 Ladies and gentlemen, on behalf of the McClean Center for Clinical Medical Ethics and the University of Chicago's Institute of Politics, Steve Edwards and I are delighted to welcome you to today's lecture in the series on ethical issues and health care reform. Today's talk is the eighth talk co-sponsored with the Institute of Politics in this year's series. We at the McClean Center have been delighted with that arrangement and Steve tells me that the Institute of Politics has been very pleased with it also. You remember I talked to you last week about our final two talks in this series, two talks that are not advertised in the program. Next week, Jeff Goldsmith, a health care consultant from Virginia, will be speaking with us. And then the following week at the invitation of the Institute of Politics, Zeke Emanuel will be coming to campus on June 3rd. And that meeting will be at five o'clock in the afternoon at the Quad Club. I'm sorry, the meeting on June 3rd will be at six o'clock in the afternoon at the Quad Club. We understand that tickets for this event are very tight. The Quad Club is a relatively small venue. But if you want to get your name on the list of people waiting for tickets, it would be good to sign up now. Now let me turn to our speaker today, Neera Tandon. Ms. Tandon is the president of the Center for American Progress, a think tank in Washington dedicated to improving the lives of Americans through progressive ideas and actions. Ms. Tandon previously was senior advisor for health reform at DHHS, where she advised Secretary Sibelius and worked on President Obama's health reform team to develop and then to pass the Affordable Care Act. Before that, Ms. Tandon was the director of domestic policy for the Obama-Biden campaign. She had served as policy director for the 2008 Hillary Clinton presidential campaign and was associate director for domestic policy and a senior advisor to Mrs. Clinton during the Clinton administration. Ms. Tandon was recently recognized by Fortune Magazine as quote, one of the most powerful women in politics. Today Ms. Tandon will speak to us on health care reform moving forward, policy changes and cost containment strategies. Please join me in welcoming Neera Tandon. Everybody, thank you so much Dr. Sigler. I'm honored to be here and I've done a few health care talks in my time, so I always find it that I always find the most interesting part of the time is the Q&A and discussion. So I'm going to talk for a little bit, probably about half an hour about the changes in the health care system, what we're trying to accomplish, what we've seen so far. Some of this I know will be familiar, but hopefully some of it will be fresh. But I really want to hear from you and get questions and answer any questions about the Affordable Care Act because oddly enough, five years after passage, four years after passage, there are still a lot of questions. I was on the President's health care team, so I did help write the legislation, and before that I had served on President Obama's general election campaign and did a lot of work defending the law or defending the President's plan in the general election and then before that had worked for Hillary on her campaign. And I do think it was vital that we had a two-year debate on health care in the presidential campaign to get to a point where we could actually pass the law when the President became president. So this is a representation of our health care system before the Affordable Care Act. I don't think you can read the type. I can't really even read the type, but it is to denote that it has been a relatively complicated system and it really denotes the kind of challenge with reforming the health care system. I now have the privilege of working on all kinds of policy issues, energy policy, financial regulatory reform, education policy, and so one of the big challenges in health care is to reform a relatively complicated system. You have to do it in a comprehensive way because when you do one specific thing, it can have consequences on other elements of the health care system. And so that's why that's been a challenge for health care policymaking over the last several decades and one of the reasons why there was a lot of pent-up push for transformation of the health care system. Obviously, it's a big thing to take on because the health care aspect of our GDP is almost 20%. We stand out from other countries in this way. We spend a lot more on health care and I'll come back to this. Later, we spend more and get fewer results, but it is a big piece of business. Now, a lot of people like to talk about how the Affordable Care Act transforms the entire health care system and I do want to say that while the health care portion of GDP is a large section of spending for our economy, one of the challenges with the Affordable Care Act is to build on the current health care system, make changes in the way, excuse me, we pay for health care, but for the vast majority of people, keep the health care that they like through the employer-based system. So the goals of the Affordable Care Act, as the President talked about actually way back in the general election, where it was to provide more access to health insurance. Actually getting more and more people covered was a huge part of the thing we were doing, but I really wanted to note that for the President getting health care costs down was almost as important to him. The reason why that was so critical and is so critical is that rising health care costs are a real drag on our economic growth. The United States is different from other countries. We have health care basically for the most part in the private system, it's basically run through employers, the vast majority of other countries have it directly from the government and the single-payer system because it's run through employers and employers offer health care. When health care costs go up, it's a drag on employment. So it's not only a drag on employment, but growing health care costs are a drag on the federal budgets, state budgets, and really also, as importantly, a drag on families budgets. And we had unsustainable growth from 2000 to about 2008, premiums in the United States doubled. If they doubled again, that would make it really difficult for employers to offer coverage. So that was a huge issue for the President. In our early discussions on the Affordable Care Act, the economic team, our OMB Budget Director, Peter Orszag, Larry Summers, others, Tim Gatner, were really focused on lowering health care costs. And as I'll come to you later, we've had some important progress on that issue. And finally, to have a system that's more patient-centered and less fragmented. And that's where a lot of people in this room come to come in contact with the Affordable Care Act. The goal of the Affordable Care Act was to have a system in which we basically have more value in the health care system where the patient has a better experience in the health care system and yet we pay for better care, not just more and more service. So I have to say, coming back to going through the last couple of years of the Affordable Care Act, we've definitely had some up-moments and some down-moments. Say, the rollout of the Affordable Care Act Health Exchange and healthcare.gov was definitely a low moment. But I'm pleased to talk about these numbers, which is really how the Affordable Care Act has benefited people. And the fact that we have 8 million sign-ups through the state and federal exchanges, 3 million young adults covered under their parents' plan, which has been happening over the last several years, not just this year, 4.8 million low-income adults covered through Medicaid, 10 million, close to 10 million previously uninsured individuals now covered, and 12 million predicted by CBO this year. These are real people who have tangible benefits from the Affordable Care Act. And going through the politics of this, and I don't expect the politics around the Affordable Care Act to ever entirely end, but the fact that we actually have real people benefiting, people who are working, people who, but for the Affordable Care Act, would face medical bankruptcies, a whole host of other challenges if they didn't have health insurance. You know, I think this kind of made the whole experience worth it for policymakers who've been working on this for so long. Just to specify a little bit more, we know that we are actually making real dense in the uninsured. We have the largest drop in the rate of uninsurance according to the Gallup poll in the first quarter of 2001, and these just go through the numbers again of uninsured non-elderly adults and what we expect to happen over the next several years. This is really to say that we've met some important targets. CBO had estimated that we'd have $7 million this year. We surpassed it by getting to $8 million, but there's a lot of work that still needs to be done to get more and more people covered. And the true benefits of the Affordable Care Act will really be operationalized when almost everyone is in the insurance system, and then we are taking away from some of the rising costs that we have from so many people still going to emergency rooms, et cetera. We'll have a more rationalized system if people have coverage and can regularly see a doctor, and some of the benefits of preventive care will really kick in. But again, it wasn't just the goal of the Affordable Care Act wasn't just to get more people covered, it was to have higher quality of care as well. And these are important elements that people have got lost in a lot of the headlines, but we've made some real progress on improving the quality of care. Important for hospitals, we've had really big challenges in the United States around high hospital readmission rates, and those numbers are coming down. And we've had particular benefits from lowered infection rates. This was a big push in the Affordable Care Act. Some people thought it was pretty prescriptive to essentially create a system by which hospitals would be held accountable for higher readmission rates. And it does seem to be working to create real incentives for hospitals to lower their readmission rates. And of course, when we do that, we save money. Three billion dollars have been saved on reduced hospital-acquired conditions so far. The final area that, and I'll spend probably the most time on this, because this is the area that the Center for American Progress spends the most time on, is reducing health care costs. The United States spends a lot of money in health care. 18% of GDP translates to almost $3 trillion, which translates to $8,000 per person. And we stand out across the world in spending so much money on health care. As you can see, we spend 50% more than the next most expensive country. And our outcomes really aren't so fantastic when it comes to those issues. As you know, we have lower life expectancy writ large. We obviously have some, I do want to say, being at the University of Chicago, we have amongst the best care in the world. We still do attract people from around the world to use our health care system. But when you look at our metadata, if you look at our averages across the country, and you look at both how the wealthy and the poor treated and averaged them, we have lower life expectancy. We have higher child mortality, higher maternal mortality than other countries do for the amount of money we spend. This just gives you an example of how states are allocating money and why the challenge of higher health care costs is one that can really translate to state budgets. Medicaid expenditures have been going up, while other things have been going down because health care is consuming more and more of the budget. And again, this is one of the reasons why the President took on health care. I get asked this all the time, why did the President decide to do health care in the beginning of his term? There are so many other easy things to do. And I would say that, you know, honestly, I had the experience of working for, as was said in my bio, work for Hillary Clinton in the primary. I came over to work for President, then Senator Obama would be President Obama in the general election. And our first, my second day there, we had a meeting about the issues that had come up in the general election. And a lot of his advisors had said, you know, maybe we should move on health care. It was a really important issue for Democratic voters. Not as important issue maybe in the general election. McCain will attack us a lot. But the President was really forceful. Senator Obama was really forceful. He said, if I win, I want to pass health care reform because we haven't done that. It's a huge issue. We talked about it for a year in the campaign. I made a promise I would do it and I want to keep that promise. And if I keep that promise, to keep that promise, I'm going to have to campaign on it. So he spent a lot of time talking about health care in the general election. And he wanted to do it because costs have been rising for a long time and no one was paying attention in Washington. And it was eating more and more of the budget and it would just not be sustainable. And it is a tragedy that we spend so much and had such a high uninsurance rate in the country. And both of those forces together, I think, were central reasons for him. Now, we do have some very good news on lowered health care costs. Health care is going down. We've had the lowest rate of growth in health care costs in the last couple of years ever recorded in history. I mean, we've only been recording it for 50 years. But in our time, you see dramatic slowdown. Now, I want to be clear that there's a variety of factors there. It's in part because of the economy. But I also think, and a lot of health care experts believe, it's also because of the Affordable Care Act. But this really means that as we go forward in the Affordable Care Act, it is vital that we keep these health care costs down. Because they are too high of a burden. You see, this just tells you how much post-ACA we've had rates of growth. And across private insurance, Medicare and Medicaid, they are all coming down post the passage of the Affordable Care Act. So just a few ideas about how we have lowered health care costs. And then I'll get into how we can continue. And I want to say CAP is a progressive think tank. But after the Affordable Care Act passed, we focused most of our energy on lowering health care costs. You're going to have Zeke Emanuel here in a few weeks. And Zeke is a senior fellow at CAP. And I worked with Zeke on passage of the Affordable Care Act. And Zeke's focus was very much specifically on health care cost reduction in the Affordable Care Act legislative process and since. Because it's really a system in which we're paying so much will be unsustainable. So if we care about having access over the long term, and we care about economic growth and competitiveness, these are all reasons for us to focus on it. The most important issues here is really how to pay for health care, changing the way we pay for health care, and creating marketplaces where competition itself works. And so the way that works is... Oh, I'll move to this slide. We had some increased cost in the last couple of... It seems like in the last year or so. Now, we have to make sure that this could just be because we've expanded so much coverage. This is something we definitely need to monitor. A variety of experts think that it will continue to go up, but we're hoping that through policy we can keep the numbers down. So some of the ideas in this space is writ large moving away from how we pay for health care from a fee-for-service model. So as everyone knows in this room that you get mostly reimbursed in the Medicare system and your private health insurance. Every time you go to the doctor, the doctor gets reimbursed. Every time there's a test, the test gets paid for. It's the baseline of the fee-for-service model. We believe we need to change the way we pay for health care, bundled payments, accountable care organizations, patient-centered medical homes are ways to do that. A bundle payment, I'll just use that as an example as you pay for an episode of care. So you have, you know, you have even say an episode of cancer. The insurance will pay for the entirety of that episode. And if the hospital or doctor saves money in the process, they will share some of the savings, it will incentivize folks not to overtreat. One of the things that we're particularly focused on, and I think these are new ways to think about how to lower health care costs, are the exchanges. The exchanges themselves will be a way in which states and the federal exchanges can use to leverage lower costs. And what do I mean by that? In Illinois, 250,000 people enrolled, hopefully those numbers will grow. That is a pretty big market. And so if the insurance exchanges use that pool of people, the exchange itself to negotiate lower prices, that will also create incentives for private insurers to use those, to follow along to lower prices as well. We hope we'll get more price transparency, exchanges will push for price transparency, and then tiered networks. Tiered networks is a way in which you have kind of options for paying more for a greater list of doctors. I will say there's a lot of blowback around this issue right now, a lot in New Hampshire, because the networks are so small and a lot of doctors aren't in them. So we have to get a right balance, because we don't want to have a system in which doctors are excluded for any arbitrary reasons. As we go forward, we've put forward a few ideas to lower health care costs. Comparative effectiveness research was part of the Affordable Care Act. It hasn't been working very effectively. Comparative effectiveness research really is a means by which we learn between two drugs, which one's more effective, between a drug or a surgery, which one is more effective. We don't have a very good means right now of understanding that, because there are not very many incentives in the system for people to figure out what's the lowest cost. With the highest value effect. And so there was something set up called the Patient-Centered Outcomes Research Institute. Something rolls right off the tongue, PCORI. That's the beauty of health care. There are so many acronyms that, like, it's hard to keep track. And that's something that so far hasn't been working very effectively, but CAP and others are really pushing to make it more effective. We need to ensure future providers are equipped to work in the evolving delivery system, in the system that's going to come up. And this is a huge issue for doctors, nurses. The health care system needs to transform itself and needs to move from this old model to a new model. And that not only means changing the way we do reimbursements, but it actually means changing the way doctors, nurses, providers are delivering care. And we want that system to be one that's most focused on getting the patient healthy and driving towards that model. And I know everyone in this room is really trying to do that every day, but we need more incentives that drive towards that value. And that's going to mean some changes in the way people are held really more accountable for the health of the patient versus just having a system where doctors, nurses, et cetera are providing some care and then getting reimbursed for that care. We want a major system where there's a point where someone is really in charge of moving a sick person to health. And that's a system many parts of the country have moved to already, but we need the entire system to move in that direction. And as we move forward with the Affordable Care Act, it's a very complicated bill. There's a lot of elements to it. Things like free preventive care. We need to get more and more of the word out around those issues so that the benefits of better prevention can be realized. And with that, I hope we can take some questions. I usually find the questions are much more interesting than the presentation, so I will look forward to that. Thank you. Thank you so much. I'll start with the first question. And that is, as you were working on the campaign and deciding that health care reform would be one of the priorities and early in the administrative program, did you anticipate this amount of political problems going forward? So the short answer is no. I mean, we anticipated political problems and polarization, but not this level of opposition. I'd say, I mean, there's a level of opposition that's been created in the last few years that's different from, not just in the Affordable Care Act, it's writ large, that's different from anything we experienced, say, in the 1990s. And that wasn't like a moment of kumbaya every day, either. But as I would tell, I mean, I would tell my Clinton alumni friends it's much tougher in Washington than it was back then. So, I mean, the evolution of what really actually happened is that we had the, we were going through the legislative process really early on. And in fact, in March of 2009, the president had a White House summit on healthcare in which, you know, Mitch McConnell came to the White House. It was bipartisan House and Senate leadership. And, you know, they were talking about the cost being too high and not wanting a single payer option, a public option, sorry. But it was, it wasn't, there was not a debate about whether we'd pass a bill. There was a debate about what kind of bill we'd pass. And then in June of that year, Frank Luntz did a memo for everybody basically saying, you know, we have to stop the bill. It'll be, it's our ticket to come in, winning the House and Senate back. And Frank Luntz, who's a famous GOP pollster and more strategist who does a lot with wording. And he, you know, he sort of started talking about death panels, et cetera. And that's when it really polarized. You know, to me it's kind of an extraordinary moment. The extraordinary moment has really come, though, in the passage of the bill. Because, you know, throughout our history, once a bill gets passed, people work to make it better or, and there are definitely ways to make it better, make it better or to tweak it. But the whole tragedy of the Medicaid system where we now have a system that in many states, you know, there's kind of this gaping hole and if you're middle class or lower middle class, you have coverage. But if you're below that number, you don't have any coverage unless you're in Medicaid. So, you know, sort of the most deserving, which is lower income working poor folks, not getting Medicaid coverage because the governor hates Obamacare, even though it's huge reimbursement to the state. That I think is kind of unprecedented level of, you know, almost vitriol. Versus, you know, anything, any level of obstruction. And we, we, I can honestly say no one anticipated that, that level. Thank you very much for allowing us much time for questions. I appreciate it. Sure. I wanted to ask, first, when Dr. Siegler introduced you, he described the Center for American Progress as an institution that works to find progressive solutions for Americans. And I wonder how as a representative of that institution, that organization, you can be supporting an act that is very non-progressive, let me say. It seems, again, let me, let's talk about one dimension on which I think it's very non-progressive, this act that was created by the insurance industry for the benefit of the insurance industry. If you have a... Let me ask the question, please. Please. If you have a four-tiered system, that you've got the bronze, silver, gold, platinum, it seems to me that, isn't it true that most people who are not fairly well off are going to tend towards the lower tiers of that system, which means they're going to be responsible for something like 40% of their medical bills. That is more than enough, isn't it, to put people into bankruptcy. So how do you see this as progressive? Why aren't you instead supporting a single-payer system? So, I think I would say to you that we've worked on healthcare for 70 years, 80 years. We haven't had a single-payer system. We have 8 million people covered today through the private exchanges that didn't have health insurance before. And for each of those 8 million people who have health insurance, you didn't have it before the Affordable Care Act. I would say to you, it is better to have health insurance today than to wait for whatever date you believe we were going to get a single-payer system. I would say, myself personally, if you look at other countries, they have good healthcare systems through single-payer. I'm not in opposition to single-payer system. But having gone through what one could argue is a very difficult process to get the Affordable Care Act, the idea that we were going to pass single-payer anytime soon is very optimistic in my assessment. And in my view, and a view of a lot of progressives who fought very hard for the Affordable Care Act, including Ted Kennedy, until his dying day, doing something for people today versus waiting forever for our ideological beliefs was not what a real progressive does. A real progressive tries to make positive change where you can to improve the lives of people who need it. And so I don't apologize for supporting the Affordable Care Act. And I will say that the vast majority of folks are actually getting the silver plan. They're not picking the browns plan. Even low-income folks are picking the silver plan. I think I had a question about the cost piece of this because many analysts who have in fact been in the dark months of legislation can see that while this bill does it, this legislation does a tremendous job of expanding the coverage pool, the cost questions are still open once. So in the midst of possibilities, the midst of strategies that this law allows you to try, where do you see the best progress coming in reducing costs over time? So cost is a really tough issue because if you look at the national numbers, costs are coming down. The challenge is people feel like costs are going up, right? Because we have had a 12-year, I mean since 2000 we've had rising out-of-pocket costs for people, like a good example is deductibles. In 2000, very few people had to pay a deductible over $500. Now that's 70% of people have a relatively large deductible, $250 or above. So people are actually experiencing greater costs because employers are shifting costs. In order to deal with the burdens of premiums, they're shifting costs to individuals. So the cost issue is front and center in a lot of people's minds. And to me, I think there's really two areas of opportunity. One is moving, I'm a big fan of bundle payments. Other people will have greater expertise in this room about how effective these programs are. But I think moving to a system where you're actually paid for the episode of care will help create incentives for less volume. We have to be careful, though, and I want to say policy is about the details. You have to be careful that the bundle payments take into account how sick a person is, et cetera. So they're right incentives in the system. But I also think going forward what particular states, California is a great example. They use active purchasing. So they really use the power of their market to negotiate prices really effectively. And one of the reasons why California premiums have been lower is because now they have a large market, a large group in the system in California, which is really pushing prices down and private insurers are following. So I think that that is a good opportunity. The truth is none of the stuff is sexy or as interesting as death panels, or I should just be clear, the lack thereof of death panels. But I think this is really important to get right over the long term. Thanks for being here today. I certainly thought the group away from feedback service. Right now you're on more of the education side of things. You're also seeing kind of on the fringes and startups around cost transparency and some insurance demands going forward is more high about both demands. How to see maybe the success of that kind of side of the industry and what to do from a policy perspective maybe to research that. I'm sorry, before you said price to insurance, you said with patience at the fringes you're seeing. I'm sorry, I just didn't hear what you said. Yeah, just there's certain sort of like cast lights. Startups, yeah. Just to increase the ability to patient function what the real costs are. Yeah, so that's a great example. Cast light is a system that's basically trying to make it much more transparent what hospitals are paying for, what you're paying for in your premiums and in your costs. And we are a strong supporter of transparency. This issue I talked about a minute ago of costs going up and cost shifting is a double-edged sword. So because you have high deductibles, there is some evidence people are using the health care system less. On the other hand, it's also the true that people are getting less preventive care because they have high deductibles that they're anxious about. So it's really hard to navigate. I think when you have a $1,000 or $2,000 or $3,000 deductible, that's a lot of cost. And I agree in the Affordable Care Act we want to move in a system where there's some skin of the game but people aren't so burdened that they're not using the insurance that they have. So it shouldn't just be catastrophic, it shouldn't really just be catastrophic health insurance. You should get some help for when you use health insurance regularly. So I think there's a variety of issues. You should probably have deductibles, not huge deductibles. We should have greater transparency in the system. There's a lot of fighting about that. Hospitals right now still have a lot of uncompensated care. So their argument for some of the costs, some of the difficulty with transparency is that they have to cost shift to take care of that and it's unfair to burden them with that. If it's totally transparent, then people will think I'm getting really burdened. You're getting benefits from your experience with the health care system. So these are important issues. We push a lot on transparency and I think we are getting more and more and more of it and hopefully with the advance of technology you'll see much more use in the coming years. You mentioned that it's difficult to have public perception experience and perception with that. I'm happy to talk about that all day. I think of health care cost issues. This is really such a tragedy from the polarization because if you actually think about, for most of the late 90s through the 2000s, it was moderate and conservative health economists who really focused on issues like getting more efficiencies in the health care system and lowering health care costs. Mark McClellan is one of them, but there was a whole range of substantive, serious thinkers and they did a lot of work in the Senate. The truth is that comparative effectiveness research was something that was very bipartisan. I think probably more conservative-supported compared to effectiveness research than progressives really. It's been a lot of progressives in the past who've raised concerns about high deductibles and things like that. I remember I was on President Obama's transition and Mike Enzi who was then ranking in the health committee. We looked at everyone's record. He was a huge supporter of comparative effectiveness research. Then when we went through the process, there was a political argument made that you could translate health care cost reduction to rationing, health care rationing. The truth of it was all these people who've been really concerned about health care cost reductions a minute ago started hitting us on rationing health care through the precise means they had championed a year ago, a year previously. I believe consistency can be the hobgoblin of little minds, but that was a little much. I think that my experience with the Affordable Care Act, which is I still have the scars to show. I went through it and my PTSD from the experience ended just about a month ago, but really at the end of the day, you kind of have to do the right thing. The truth is you're going to have to live with the law. We're going to live with this law. People ask me all the time about why Obama did it, and no one was thinking. Susan was there, too, at the time, but I certainly wasn't going through this experience thinking this was going to help us politically. The President did it because he thought it was the right thing to do. Believe me, he had a ton of advisors all throughout willing to do something else instead of healthcare. This is a cynical age, and people think the worst about politicians, but the Affordable Care Act was an experience where the President really was trying to do the right thing and thought it was the right thing to do for the country. Members of Congress, some of them were kind of lame, I will admit, but most of them, we were going in there and telling them they wanted to know what the bill would do and they basically wanted to do the right thing. There was all these side shows, but the vast majority of the interactions on that bill were about how it would work and what it would do for people. We have a challenge in a media environment where it's much easier for reporters to report on a cornhusker deal that's actually not in the legislation itself. Versus reporting on what an exchange is, which is the heart of the legislation. We're not going to change that game. You have to just live in the game that you're in. But at the end of the day, I honestly think people were trying to do a very difficult thing to reorient a significant change at a time where people have deep skepticism about government and its ability to act, and we faced a lot of headwinds, but the goal was really to fix this problem that we are unlike almost any other country in our inability to fix it in the 21st century until today. I'd love to have you say a little bit more from an insider's point of view about the death panels. I ask that because this series next year, for those of you who might be around and interested in coming, we'll be on end-of-life care. And the McLean Center, I hope with the involvement of the Institute of Politics, we'll be supporting again as this year, about 25 or so talks on Wednesdays on end-of-life care. I mentioned that to Nira on our way into the lecture today, and asked her if she would say something from an inside perspective about the death panel problem. So on end-of-life care, it's obviously a huge issue in the healthcare system. A lot of costs at the last couple of months of life. I think it's like 30% of costs at the last three months and even higher in the last six months. So from a policy perspective, people are relatively interested in how to deal with that challenge. We had something in the House version of the bill, which I will literally describe it as, if a doctor tells you about alternatives, alternative end-of-life issues, and not prescribing anything, just tells you about them, hospice care, other things. Just the availability of alternative end-of-life options for you. That doctor would get reimbursed for telling you that in the Medicare program. And that is what became the death panel praise. That was literally what Sarah Palin was saying, was going to create death mills. Honestly, I think she did get confused between comparative effectiveness research, which is a whole other attack, and this one, but I remember it so vividly, it was like the crazy wingnet blogs had it, on like a Thursday. And by Wednesday of the next week, it was in a Robert Perry story in the New York Times. And, you know, he protected himself by saying there is an accusation, but once you have it listed as there is an accusation in the New York Times, there's like full sanction for going whole hog on it. So, you know, this is the, again, I probably could spend every topic I discuss going after the media, but I don't want to do that. This is a huge challenge in a, he said, she said world of media coverage. Because he said, I mean, literally, I say death panel and someone else says, not death panel. And then, like, what do you have in your mind? A death panel, right? Or if I said, you know, like, murderer, and you said, no, I'm not a murderer, I'm a murderer, right? So, I mean, in any complicated public policy issue, it's really easy. And, you know, I'm not saying only one side does that, you know, kind of attacks the motives of the other side or makes crazy accusations. But it is, I mean, one of the hardest things about the Affordable Care Act is it's a complicated policy as demonstrated by my wonky talk about it. It's not easy to describe or communicate. And what was kind of the most disheartening thing to me about it was, went through this full year of a legislative process. And people's, and, you know, there's coverage of elements of it almost every day in the press. And then if you did public polling or public research or research on people's understanding of the Affordable Care Act, everyone could understand. Everyone, like, almost everyone had heard about it, like the Cornhusker deal, which was actually not in the final bill, and was admittedly a completely stupid thing. But nobody knew what an exchange was or what the Medicaid expansion was or that people didn't even understand that you were going to get subsidies for coverage. They just thought there was a mandate to get insurance and no one was going to help you buy it. I mean, it was just, like, the most basic information. And, you know, I just think people kind of fell down on the jab because it's not interesting. You know, health exchanges aren't sexy until they're not working, right? So it's really a tough issue to make public policy. You know, it's one of the reasons why it's harder to make change today than it was, like, say, 50 years ago. But that doesn't mean we shouldn't try. I want to reiterate the point that Ms. Tanden just made. And that is, you saw from the slides that the U.S. health system is a $3 trillion operation consuming 18 percent. And it's not clear that it's going to stop at 80 percent. Right. And this end-of-life question becomes really a major political matter as you think of perhaps a third, maybe even more than a third, of healthcare expenditures being utilized in the last three to six months. To give you an idea of what $3 trillion is, when I checked a few years ago, there were only six economies in the world. I'm talking now about Japan and Germany, the old Soviet Union, but not modern Russia. Japan, Germany, only six economies in the world that cost more than the U.S. health system. Yeah. That's, I mean, it's a staggering thing. We compete each year for 6.7 with Italy, for example, which is bigger, the U.S. health system or Italy. So this end-of-life matter is really a major political problem. And let me just say one final word about that. You know, having gone through it, the issue that, you know, again, I have the privilege of working now on a whole host of issues and used to work on a whole host of issues as well. And healthcare is very different than every other issue. I mean, that's the benefit and cost of working on healthcare policy is, you know, unlike financial regulatory reform or foreign policy in any way or energy policy, almost every person feels like a healthcare expert because they have some interaction with the healthcare system. And it's not just an interaction. It's the most profound choices you make as a human being are interacting with the healthcare system, like the anxieties you have as a mother when your child is sick or as a wife or as a daughter. These are how you interact with the healthcare system. So the challenge from a policy perspective is people are very anxious about healthcare and can get very scared about it. And that's, I think, what happened with death panels. There was an opportunity to make people really scared about this big, crazy thing that could happen to you and people took it. And, you know, I don't think you could do death panels for financial regulatory reform in the same way. But I do think it makes it very challenging to tackle from a public policy perspective this challenge. And that's why I think it's really important to have also private sector efforts to inform consumers. The truth is, consumers want information about end-of-life options. So I just wanted to say that. I want to thank you for your presentation and also for the work of the Affordable Care Act to come along despite all the challenges. I live in urban Kentucky. Kentucky is a success story. Yeah, fantastic. We reviewed some of those, in the beginning to make a real inroads in eastern Kentucky by 40 percent. I know. That's a staggering number. And I think it's testament to the courage of the Democratic government and the state of red states to support it. Last night, Alison London-Grimes, who's challenging Mr. McConnell this fall for the U.S. Tennessee, gave a fiery, very well-educated, post-election victory speech. And she articulated all her political positions in which Mr. McConnell is quite vulnerable. And she's got a real shot at winning. She didn't say a word about the Affordable Care Act. It's a success story. And my question to you is, why are not Democrats in states like Kentucky running on the Affordable Care Act? My second question is, if your own boss runs for president, will she run on the Affordable Care Act? You know, I have to say, you guys are really slowing down on the jab here because usually that's my first question. And it usually comes not in, and if she runs, will she run on the Affordable Care Act, but is she running? So I appreciate the health care related on to right into that. You know, we actually had President Clinton at CAP last week. We have an annual Gala, which we're very honored to have him speak at. And at that Gala, he made the point that Democrats wherever there are should run on the Affordable Care Act benefits. And you know, my, I have worked in policy and I have worked in campaigns and my view of this is that people smell fear. And when you refuse to talk about something that everyone sees and knows in the room is there, people can sense that they'll just think it's a terrible thing and they'll think it's a worse thing than if you had bothered to defend it. Now, there's been, I think there was a research that came out last week that shows it was like there's been $400 million spent on the Affordable Care Act, 90% of it negative, only 10% of it positive. So, you know, it has a negative aura in states that have done a great job. And I want to, I have to single out Steve Beshear, Governor of Kentucky who has done a phenomenal job. Jerry Brown has done a phenomenal job and Steve Beshear has been in a sea of red. Senator Beebe has done a great job in Arkansas as well, but Kentucky's numbers are really a model for the nation. I mean, they've literally halved their uninsurance rate which is quite an amazing success. And, you know, I'm not advising Allison Linder or Green Grimes. I do hope she wins, but I'm still to see that I would take a different course. And, you know, we talk about I think it's not a problem to talk about the benefits to the law and things that need to be fixed going forward. And health care costs are an area that I think everyone sees as something that needs to be fixed. But I agree with President Clinton on this one until I hear you. And on Hillary on health care, I will just note that the law did have an individual mandate like she had her plan in 2007, but I've now gotten over that primary. You know, she's a huge champion of health care. And I mean, I actually expect her to talk about the Affordable Care Act, things that should be fixed going forward to make it better, but that, you know, this is a huge achievement that this country hasn't been able to do. And she, you know, she worked her heart out and failed and recognized every day how important it was to have success. So I imagine she would be doing if she runs. I see a lot of hands still up. About the problems we are having regarding contraceptive coverage. contraceptive coverage. I mean, what's happened with contraceptive coverage is that the Affordable Care Act had preventive benefits specified that there would be no reimbursement, full reimbursement, no cost for preventive benefits. And then the Institute of Medicine and it was let in the bill was said the Institute of Medicine, which was a group of medical experts would decide what preventive benefits, how to define preventive benefits. And it was the Institute of Medicine that said contraception was a medical would be is a preventive benefit that should that should be covered. So I had the great misfortune of actually working on the abortion language in the Affordable Care Act but the issue around contraception wasn't litigated in the Affordable Care Act itself and wouldn't have been wouldn't have been I don't think it would have been different if we had a public option or a private option because either way employers would be just to be clear on contraception contraception issue isn't a debate just in the exchanges the contraception issue is everybody now gets free access to preventive benefits like contraception so people who have been providing healthcare all along now are getting this reimburse so it's not really a public option issue but you know I think the fact that we're litigating contraception is kind of a ridiculous thing and I hope the Supreme Court does not create a large curve out for private companies to not offer this insurance in what they're privately doing we talked about whether Democrats should be running on ACA and I actually have a question about the office which is where it's no secret that Republicans are vehemently running against ACA so my question is how far back do you think we can go what's the worst case scenario about how many people work and the conversion of that what do you think is the strongest next step that we can do to maybe address some of the concerns on that side so that we can keep moving forward you know I'm always an optimist so the last two you know we got 8 million people covered in the last two weeks it's like the first time and since the Republicans took over the house there hasn't been a hearing on healthcare or some kind of investigation of healthcare so and the truth is that they are having a little bit of difficulty now describing you know there is more pressure on Republicans to say what they would do to replace it some Republicans just was in New Hampshire and said he wanted to repeal it and then also said fixes he wanted and they asked him well do you want to repeal it or fix it and he got all confused I won't say anything about Scott Brown but but so I think the most important thing for the lot to do is to succeed and to keep covering people because it will be harder and harder for people to undo it and I think it will be very my view at this point is it will be near impossible for Republicans to take away I mean let's say they magically won the president they could win the president presidency take the house and senate at that point we should be at 15, 16, 17 million people covered through the exchange they would have to come up with an alternative and what I said at the beginning is the truth about healthcare it's hard to come up with just a fix here and a fix there you know the reason why they haven't been able to come up with an alternative to just fix the things they think are egregious is that that usually drives costs up or drops coverage from the employer based system or does something else a great example is there's been all this complaint about the Affordable Care Act and the 40 hour work week and whether employers are dropping because of the restrictions on the Affordable Care Act around having to be full time and what that means and the Republicans put forward a bill to fix just that problem and it had 18 billion dollars of cost and would have dropped a million people out of their employer based health insurance system by doing that so you know it's not an easy it's not an easy thing and one of the reasons why they put forward a replacement I think is because it's difficult to do so just getting more and more people covered I hope means that we'll be able to I love that first slide you showed which was the pre-system before the Affordable Care Act it wasn't so clean and then nobody could read it but it was very simple way back, yes thank you for coming it's great to learn about ACA and what it has to offer principles about the value basically the Affordable Care Act trying to find the dollars that are out there instead of doing them to just trying to find the value over a dollar speaking of the New York Times three days ago there was an article that was published that highlighted the amount of compensation that was given to CEOs of major insurance companies I'm not sure if you had chance to admit it but I mean we're not going to their salaries are about $27,000 but they're a total compensation of the year is $20,000 so I'm learning that if you go into legislation or any kind of eyeball that's being put on the back not only for the health care workers in general but also for the patients to see that value of the dollars instead of going into that pocket at the spread of costs yeah so you know CEO compensation in the US is far out of whack with other countries I mean our lowest CEOs are paid generally 10% more than the highest paid CEOs in Europe so we have a challenge with CEO compensation at large and I think we do have a challenge which is that insurers have been and will continue to be relatively profitable and one of the things in the law was medical loss ratio which is a fancy way of saying that 85% of the premium actually that you pay actually has to go to delivering health care versus profits of the health care system so that is creating some downward pressure on payments insurance fluff but there's definitely more we can do now my view is the Affordable Care Act allows states to have a public option Vermont is going to move to a single payer option I think it's a tragedy states like Illinois pretty progressive state it should have a public option to create some of the pressure on insurance companies I fought on the public option in the legislation I think a public option should have been in the legislation because it would create some of this pressure between the public and private sector there are additional legislation on price transparency which is giving states the ability to better regulate premiums themselves and push when premiums go up a certain amount more than 5% ask for where more clarity on things like where the money is getting distributed with the insurance companies I think those are really good ideas and I think the truth is as more and more people face higher deductibles and high premiums there should be more pressure in the system and there should be on how the money is getting allocated between insurance companies and their providers as well that have a lot of high pay are you basically asking a single payer more efficient no the US heterogeneous population heterogeneous got it McKinsey did a great study about seven or eight years ago on US health care spending versus other countries we are different on a whole host of issues I don't want to say it's because we are more heterogeneous and other countries are more homogenous there are countries that no country really approaches our level of heterogeneity and they still have really low health care costs and it's a variety of things that contribute to it just having a culture of walking and not driving, having things much closer together, having a single payer system which invests much more in prevention because you have one payer who is going to be there for the life of you versus several insurers so there is a much bigger incentive to pay for things like high preventive benefits etc there is a whole variety of things and I don't think anyone has really figured out the specific reason why we are so terrible but we are pretty terrible that's a great reason for people to continue to invest and study this area and provide us great things about being in an academic institution is that you can provide us answers to policy questions like this please join me in thanking your tenant for wonderful work thank you so much