 So our last speaker of the session is Harold Paula who I think is a really one of the gems of the University of Chicago Harold is the Helen Ross professor at the School of Social Service Administration and co-director of the crime lab here and I think actually one of the themes of the panel for me introducing my fellow speakers is how so many of my colleagues are Paul Thomer like Harold has this ability to Combine like the understanding of the individual with the policy ramifications And besides being like a tradition an amazing traditional academic He is an amazing communicator that I think if you want to learn how to write an op-ed or a blog piece Just Google Harold really some of the most amazing pieces I've seen in terms the ability to to capture the essence of an issue using common sense and the understanding of the individuals involved and to be able to communicate in a way that Anyone can get it in a very interesting lively writing style So it's also a very thoughtful speaker So we have the big expectations of you and this is a talk here Harold on Medicaid is the unlikely future But parts of health policy Thanks Marshall for that setup. I think there I hope I I live up by the way as he's saying that I'm dropping the battery out of the clicker just so that So I've already failed there I want to talk today in some ways the talk today Describes how Medicaid Imperfectly in an unlikely way is emerging as a vehicle to deal with a lot of the issues that have come up earlier today And I should say that I'm I'm I'll start by mentioning some of the work that I do at the University of Chicago crime lab and the University of Chicago Health lab I co-direct growth. I'm really I'm the Joe Biden of both efforts the That's me actually at the podium the I should say Barack Obama is sitting over there for the health lab David Meltzer and Jens Ludwig is the Barack Obama of the crime lab and and the work that we do is To do randomized trials for individuals who are really at the interface of health vulnerability Social vulnerability often in my case Particularly involving criminal justice system or addiction So one of the trials that I'm involved in is something called the West Side narcotics diversion initiative in which non-violent drug dealers and drug buyers are Instead of being arrested formally. They are Sent to addiction treatment to see if we can improve outcomes for those people a Major effort that the David's the PI on the supportive release center Is designed to prevent homelessness and other adverse outcomes among detainees who leave the Cook County Jail And the challenge there is that there's this moment of maximum vulnerability that occurs just when people are passing between Administrative systems and they're the most likely to slip through our fingers and have some some really horrible outcome When no one is really? In charge of their fate and or paying attention and then another Project I should mention is something called the 9-1-1 project where we're we're trying to improve Chicago's response to People in behavioral crisis who encounter police people with severe mental illness people with addiction people with intellectual and developmental disabilities Such as in the Laquan McDonald case Here's just the supportive release center is is I'm also by the photography nut, but This is a set of trailers that our team has put up just off of the grounds of The Cook County Jail and and the and the staff of task and and Heartland Health Outreach are trying to Assist individuals leaving the jail as I just described and the thing that is really important about about these Efforts that relates to today's theme is that five years ago We've been very difficult to do every one of the things that I just described for one simple reason Which is that almost everybody was uninsured So five years ago the great great majority of detainees who left the Cook County Jail had no health coverage Today about 80% of them are insured and almost always through Medicaid not all not entirely but almost always and and What's striking is there is a tremendous amount of Bipartisan support for those kinds of efforts actually in some of the research that I do that's not in the urban lab We actually deal quite a bit with addiction treatment providers and policymakers around the country who are concerned about the opioid epidemic and It's really amazing. You know many of many of my progressive students think of the Republican Party in As exemplified by the unworthiness of the Trump administration And that's just not what it's like when you call up someone in Ohio And you say what are you doing about the opioid epidemic and they say well? We're trying to get the Medicaid regs to match the American Society for Addiction Medicine criteria for residential treatment And then you talk about the work and you say to the person well What about all those politics in Washington and they say well our governor has told us not to worry about that that our job is to figure out how to deal with the opioid epidemic and In a really striking and admirable way when when ACA was passed and when addiction and mental health parity was passed a lot of us Worried that we were creating the Willie Horton Vulnerability in health reform, you know anybody who studied health policy knew that one of the key Populations that was going to be insured in large numbers were adults involved in the criminal justice system And one of the interesting things is that has just never happened That all around the country Republican policymakers Politicians are trying to make Medicaid work for this population not Trying to use that as a political weapon to undermine Health reform these are people by the who oppose the ACA and who are certainly not you know not herald pollock Ideological allies on things, but they're trying to figure out a way to help people in very difficult circumstances They're And it's a really striking thing that points to the Unlikely political trajectory that we're on and the tools that are likely to be effective to reduce disparities That are kind of at that interface of politics and policy where you need to operate to help people So you know the Medicaid expansion has really been entrenched. It's helping millions of people Albert gave you some statistics I'll give you more and it's reduced Medical debt it's improved mental health in various ways. It's subsidized the ecosystem of safety net care many many problems with it But it is the platform at this point that we have and one of the striking things is that many many State and local officials around the country in both parties have embraced it and now and and Interestingly enough by that has not happened with the ACA marketplaces around the country the same people that we talked to who will talk in great depth and Sophistication about how Medicaid is how what they're trying to do for addiction treatment We say what about addiction parity in your in your exchange in your state and they did why are you asking me about that? There's one politician in America who owns those exchanges anybody know who that person is his name is Barack Obama and he's not an office anymore and None of the officials that we talked to are particularly knowledgeable or invested in making those exchanges work to deal with disparities in the way That that that most of us would like to see so And those marketplaces are not working real well And in particular they work they work actually pretty well for people with incomes below about 200% of the federal poverty line But a communication tip don't say FPL when you're talking to actual human beings because no one knows what you're talking about But that's the federal poverty line and and people have high premiums and high out-of-pocket payments very often If you talk to just working-class people middle-class people and particularly in rural areas these exchanges are not working real well They don't particularly control costs and so and that's one reason premiums are high And one of the striking things is that a lot of non-poor people are very resentful of that So Sarah Cliff went to Kentucky which as far as I can tell Sarah Clips a reporter for box And as far as I can tell that Kentucky voted unanimously for President Trump in the 2016 election and one of the striking things with a lot of people that she talked to said, you know I'm in this exchange and I've got all these it's it better than if I didn't have insurance But I'm talking about my but I'm working really hard at my job And if I go to the emergency room, I'm gonna get a bill for $700 and my screw-up cousin Who shouldn't even be on Medicaid in the first he can go to the emergency room for free and You know and he doesn't deserve that and and and and that's and that you know in the short term, of course that leads to You know that makes ACA more difficult to sustain politically But in the long run think about what that's headed for in terms of the politics of American health insurance that basically people prefer Medicaid to private insurance in a lot of ways And if you look at polling met majorities prefer Medicaid I won't go into too much detail, but it's striking how many Americans value Medicaid But let me say that this is I'll just say something about some of the progress in ACA I should buy what I love us my audience always laughs at this picture the Democrats and the Republicans for opposite reasons The Republicans assume this is a joke You know, I'm sort of teasing President Obama that my Democratic students think this is just a real picture You know like they're like he screwed up the flash, you know what happened to the rest of President Obama's body there they're So, you know if you look at the percent Yeah, Albert's already given you some of that the percentage of the population or covered is had you know increased dramatic There's sometimes a debate about whether ACA actually improved insurance coverage I think that's kind of a stupid debate if you just look at the picture it obviously did and And Medicaid is really doing most of the heavy lifting in that at least in the states That embrace it and one of the striking things is there's a lot of bipartisan work on Medicaid It happened in the states that expanded Medicaid It actually happened in the states that didn't expand Medicaid also If you look at issues that are not on the front page that are not politically polarized the same states that wouldn't expand Medicaid They were working with the Obama administration about disability about quality improvement about all sorts of Medicaid initiatives They needed the federal money and they had populations and rural hospitals Places that that they really needed to to work with and there's a lot of constructive difficult bargaining that occurred and a sense of ownership On both sides of what was of what resulted So here if you look at just trends and uninsurance obviously it was The uninsured went down a lot more in the Medicaid expansion states. There's lots of ways to show that There's been a decline in bankruptcies and medical bills and Medicaid is it is really the key the key lever there About 9.4 million fewer families have problems paying medical bills and if you look at the health impact of Medicaid since ACA The most readily documented thing is just improved mental health reduced stress Basically because people have financial security That's the first thing that you're getting than the most the most solidly documented health impact right away We also see by the way supporting the infrastructure of care now This matters a lot this is these are just for health systems that found in the in one year They're uncompensated care went down by about a third in most of these places that matters for these patients but it also matters for all the other patients and You know Medicaid has an ecosystem impact that's different from its impact on individual patients Now if you look at the impact on disparities of Medicaid, and I'm happy to talk more in the questions There's good evidence for some things there's weak evidence for others and there's no evidence for still others There's good evidence about mental health people self-assessed Mental health status goes up very quickly the Oregon health insurance experiment is probably the best place to see that We often see people saying well Medicaid doesn't improve people's health. It just improved their mental health It sort of reminds me of the statement of this guy running for Senate in Alabama who said that he He says we shouldn't have any Muslims in the Senate because they don't believe in religious freedom And it's like the self-reputing statement there So there's good evidence about financial well-being and also that and I think Albert's diabetes Medicine graph starts to show there's good evidence that there's that there's improved chronic disease diagnosis and management And I don't think we've seen that yet in clinical endpoints But there is pretty good reason to think that that's happening And there's also evidence that Medicaid improves outcomes for discreet populations There was a New York Times story about gunshot wound victims in Chicago and Detroit Before ACA there were people walking around Chicago in Significant numbers who had helmets because they couldn't find surgeons to close their skull if they had a head wound and there were people with who were with You know they had they had a colostomy bag Because they couldn't find surgeons who would close up their abdominal wounds They all got treated in the emergency room when they got shot But all the post-acute care a lot of people just didn't get it and that is not happening now in the same way There is suggestive but non definitive evidence that Medicaid reduces mortality that a lot of critics of Medicaid has made This the standard by which we should evaluate Medicaid which I think given that Mortality is such a rare outcome that arises from such multiple causes That's not the right way to think about the problem But there's some suggestive evidence particularly when it coincided when Medicaid expanded for example around the time that that the heart Drugs came out you could see real differences in HIV mortality that were related to Medicaid eligibility because people could get a Powerful treatment. I think it's very little evidence that Medicaid improves health behaviors and deals with the social determinants The way that it needs to there's a lot of people trying to do that But but we have a lot of work to do before Medicaid is an effective platform for public health Let me say why another reason why I think Medicaid is the future of Bipartisan health policy, you know a lot of Americans say our health policy is broken Which it definitely is in a lot of ways. It's broken because of our broken health politics That's really one of the fundamental problems that we have You know in principle, we could have an ideologically moderate System that looks a lot like the ACA marketplaces like they do in Switzerland or the Netherlands that works very well to give universal coverage The problem is that the that these kind of an approach it's in its ideologically moderate, but it's Institutionally radical. It's they're complex and fragile things that have to be stood up They require bipartisan pragmatic problem solving and that's precisely what our political system cannot deliver It could deliver that Medicare Advantage. You cannot deliver that for low-income populations affected by Medicaid So even though there's very good arguments that we could have a good health system that's market driven that promotes universal coverage That's just not what we're gonna get Now by the way a lot of progressives say well, that's why I like single-payer Because that's gonna cut through all this the problem is that that presents single-payer as the alternative to our screwed up politics Whereas in fact if you think about it the single-payer system would have to be the product of that same screwed up politics You know it it we would have to deal with all of the reasons why our current political system is messed up in health policy That's this that's we'd have to compromise on all of these issues to pass single-payer And it doesn't emerge from the head of Zeus as a functioning You know the French system is not gonna pop up now comparing the French system to the US system is saying the French system is better That's just not actionable How do you get from here to there? and So, you know there's for just to give one example a very disciplined single-payer system that's substantially reduced health expenditures Would require a doubling of the federal income tax or an equivalent increase in federal tax revenue just to port that stuff onto the federal budget and and There's just a bunch of things that are really really a huge lift for American politics And then there's also the question of what do you do with the existing infrastructure of state? Medicaid programs, so you know we've had 50 years of disability programs And we know what the Sanders single-payer plan does with Medicaid services like Holman community-based services Leaves them as a separate system Completely brackets that which I think was a wise decision, but it basically was a very interesting acknowledgement We don't know how to rewire this And also we need these governors so So I'll stop in just to close out I will say the next go-round where it's a little bit like 2006 right now for a lot of Democrats They're looking at results like last night or two nights ago in Virginia say we're gonna win some elections soon. What do we do? I Think that what we're gonna see is something that is simpler Even if it's more ideologically radical and it'll have some strange bedfellows when Democrats try to expand Medicaid And when states try to expand Medicaid because a lot of state officials whatever their ideological perspectives around the country They say, you know, I can deal with disparity issues by through my Medicaid program I have constituencies that that value that and So I think the bipartisan challenge we're going to have is to a find a dignified political way to do this But be to make Medicaid genuinely work to deal with the problems We all acknowledge like low provider of reimbursement that make Medicaid a much less effective public health tool than it should be Because I think that that's the future of American health policy whether we like it or not and we should embrace it and make it work So with that I will I'll stop and happy to answer questions. Thank you Hi Harold. Thanks Debbie Stilberg from the University of Chicago. I'm a quick comment and a question I wanted to highlight one area Where there's I think pretty good evidence of Medicaid's Benefit that you didn't have on your list that has to do with family planning services and It's especially threatened in our current era It's been really cool to practice in a world in which everyone could get any contraception that they wanted and we didn't have to Really argue about that and there's good evidence from before the ACA that states that had family planning Waivers it's not causal but had an association with lower rates of preterm birth and low birth weight Largely through preventing pregnancies that were both unwanted and would have been high risk for those outcomes had they could occur had they occurred So good good additional point. I Appreciate your optimism around the politics of this, but I'm having a hard time understanding and maybe I'm missing some of the nuance of it How do you explain the Governors who have rejected Medicaid expansion despite What feels like just a straightforward gift from the federal government that their Populations want and would benefit from that. They've rejected. How do we get past that? Well, by the way, it's certainly on family planning I agree with you and it's why it's important for you know people who have different moral views on abortion and family planning Have been very active politically and have won a bunch of elections and good for them, you know I think people who think differently And who hold the values that you express which I also hold You know, we have to we we have to get out there and not just and win some state elections the question of One of the things about Medicaid that's both good and bad is it allows such variation around the country around these issues Now on the Medicaid of why states rejected Medicaid, I'll show you two maps. This is a map. This is not quite right because You know, there's been a little bit of fuzzy look at this map and you say well a bunch of states have rejected Medicaid and It's sort of the yellow the orange states are the states that rejected Medicaid expansion You look at this this map is deceptive because it's weighted by Land, you know, there's a lot of cows in Wyoming, but there's not a lot of people If you actually take the same map, this is gonna look like a bad acid trip for those of you that I just have I'm warning you I'm gonna take the same map and I'm gonna weight it by the population of people affected who are shut out by Medicaid and this is what it looks like That Louisiana by the way should be blue now. I made this map before it's a cartogram 90% of the people shut out of the Medicaid expansion in the Old South and it is it is where the poor people are non-white and it's a red state and That's a big challenge. I was actually hoping that President Trump could convince some of these states to expand Medicaid Basically say look, you know, you can do that with me even though you couldn't do that with President Obama These are gonna switch by the way. I think some of these big states are gonna expand Medicaid But it's gonna take time, you know, it took you know, Arizona 1980 and but you know, we have racial politics in America that that Is a big factor in Medicaid expansion and that's I don't know how else to say it Hi, I'm Nathaniel Meadow over Loyola internal medicine. So I have a clarification question and then an opinion question So you said that the behavior of those who received Medicaid Didn't change does that mean that they also didn't use more resources? After obtaining Medicaid and then the opinion question is what do you think about kind of hot? Nevada tried to do by having the buy-in Medicaid option So let me let me answer that in reverse order. It was very interesting Nevada passed a Medicaid buy-in the Nevada state Legislature and there was a real question about whether the Republican governor in Nevada would sign this thing and he eventually after a delay Vetoed it but think of how much American politics has moved that a Republican Nevada governor That we were all waiting to see was he gonna veto a bill that would allow anybody to buy into Medicaid You know that shows you how the ground is moving. He did not say by the way, this is a socialist You know wacky thing. He just said I this doesn't seem like a very you know, this law and balance. I'm gonna veto it The ground is shifting. Yeah, as far as what's changing in Medicaid I think that you know people who face either complex social determinants or complex behavioral issues like smoking We would like to see health insurance Improve those factors and there's almost no evidence if you look at say the Oregon health insurance experiment that we affect people's Nutrition that we affect their smoking in fact by giving them more money effectively We might increase their smoking because smoking is expensive And we haven't figured out how to that that line between health insurance coverage and health Not just for people on Medicaid, but for everybody. We don't we were not good at helping people be healthier By by making sure that they're covered we can make sure they don't lose their house if they get cancer and that's great But we're not so good at preventing the cancer by getting them to stop smoking Hi, I'm Deb Bernat from University Chicago. Thank you Harold for a great talk and to all the presenters this morning for wonderful talks Harold, what do you think is the Role the most practical way for physicians and physician organizations to help bring about this vision you've put out Well, I think I think that there's a couple of things I would say one aspect is advocacy for your patients and to put a human face on issues and to do that with confidence that many many Americans both really respect what physicians have to say and other health care providers have to say and and and To also speak with integrity about what's not working and things that we could do as an institution if say Medicaid worked better You know several people today have commented that we do not Embrace Medicaid patients at the University of Chicago Medical Center as much as we would like to you know I my wife and I take care of her brother who is intellectually disabled who's on Medicaid gets very good care at the University of Chicago. We're very grateful for it. We certainly see ways that it is different for him than it is for people with The best insurance that you could get through Blue Cross or whatever And I think one of the things I'd like to see us do is to be honest to say to people for example to the people in Springfield Here's some things that we would like to do for our patients But we can't do because you're a bad customer for our hospital And so that when we talk to our financial people and they say, you know We share your values, but the University's owed 150 million dollars by the state And so it's hard for us to be as humane as we would like to be Given the financial realities of this. I think that sort of integrity and I you know you mentioned by the way No notice I said something very I Criticized I've referred to the president as unworthy. That's another aspect of integrity just to speak plainly and to say you know, there's people that are Litigating basic values that should be the foundation of American health policy and President Trump is one of those people And we're just gonna not in a dramatic way, but just say it Herald one last question one of the things that you pointed out is That Medicaid really covered vulnerable populations for substance abuse and behavior health but the counter argument About markets is that there's no private market that does a good job on let's say your Family member who has intellectual disabilities for those who? experience adult mental illness or behavioral health issues and There seems to be a gap between equity in Medicaid for basic covered benefits and non-equity in Insurance markets as we know them that should be much broader, but aren't taking place And that's a setup for just having people caught in the middle and Exacerbating disparities. Can you comment on that? There's a lot there I Mean what by one of the ironies is this implicit the human experience of being a Medicaid recipient is in some ways in some ways Better than the human experience of being on private insurance You know Vincent my brother-in-law has been hospitalized maybe 25 times since since we've taken responsibility for him We just never get weird stuff that sort of says this is not a bill that we're trying to figure out weird paperwork weird deductibles Now we can't take him to every specialist We'd like to take him to because Medicaid doesn't pay enough But we don't have to deal with a lot of this a lot of the stuff that people deal with in private insurance and I think that that That is one of the reasons Why there's such a groundswell for expanded public coverage is that people don't like private insurance? And the market does not work very well for that. I would never put him in a managed care product for example There's I I do think that the D on these disparities the details matter so much and the people in this room know a lot of the details know the Ways that Medicaid can be designed to facilitate access or it can be designed in a way that that fails to provide access and Particularly for things like addiction treatment where the populations are so politically marginalized. It's so important for us to explain Those details to people in a way that people can understand right Harold. Nobody's going to cover the Mental health or the behavior or health or the addiction stuff in Illinois because they're all going into Medicaid managed care and that's a done deal and that's another example where we have to mobilize and talk So one more quick question and a quick response Harold Notice Marshall did not praise me for my quick responses when he was so effusive when I started Hi, Karl Brogan, DePaul University School