 Okay, so welcome to our health policy and bioethics consortium for March. My name is Eric Kessler. I'm a professor of medicine at Brigham in hospital and a director the program on regulation therapeutics and law, and also faculty member the center for bioethics and with my co organizer, Leah Rand. And thank everybody for joining us today for what I, what I know will be a very interesting and extremely timely discussion about about the ACA and and national health coverage. Just as a an overall reminder. Questions, questions at any time you want and using the Q&A feature. And we're going to hopefully reserve about about 20 25 minutes or so at the end to try to address address your questions so please start getting those in and we can start to start queuing them up. We're going to talk about their tweet at all about this event as it's going on. You can use the hashtag hashtag policy ethics meanwhile we're also live streaming on Facebook as well. So you can also have a conversation and through that portal. If you have any technical issues do let us know. And if you are interested in this series please check out the the bioethics website and you can subscribe there. You can reach us at the portal website at portal research.org. As always the goals of the consortium are to try to articulate key issues in the healthcare system that involve ethically challenging policies or practices bring together experts with different perspectives and experiences to continue to consider and propose solutions and to stimulate conversation and academic study to to advance the field and I'm really extremely excited about the experts that we've got that we've got today. Just to look ahead. We're going to be talking about equitable care for incarcerated individuals in April. So you can put that on your calendar and even as I said register early on the on the Center for bioethics website. This session is about the ACA in the 2020s. And what I'm going to I just want to introduce our moderator for today and Michael will provide some additional context and then introduce our expert discussions. Michael Sinah our moderator is a physician a lawyer and public health expert, who is a fellow at the Harvard MIT Center for regulatory science and teaches public health law at northeastern. And is a great, a great colleague and knows a lot about a lot of different stuff and it's going to help introduce today's topic. Michael, thank you very much. Thank you and pull this up. All right, so in on March 23 2010 the patient protection and affordable care act was passed and signed into law by President Barack Obama you see here at the signing ceremony. Since then, a lot has changed, but the ACA was really one of the landmark healthcare reforms, really in terms of reducing the uninsured rate in the United States, since the creation of Medicare and Medicaid in the mid 1960s. Now, since it was signed into law. The uninsured rate has dropped fairly dramatically it reached a peak of about 18%. Just after it was put into place and dropped to just below 11%. Since the election of President Donald Trump in 2016, the laws faced challenges. It's also faced a series of court challenges, and you'll see that the uninsured rate has been trickling up in the last couple of years. This was the repeal effort. And these are a series of bills that were proposed in the US House and Senate, trying to repeal the Affordable Care Act in whole the current law here you see that still there are 28 million people at the time that were uninsured. Repealing of the mandates which actually did happen under the tax cuts and jobs act, potentially was going to add 15 million people to the uninsured docket by 2026. And then you see a variety of bills here that were proposed by a Republican led Senate seeking to overhaul and repeal the Affordable Care Act. This is the famous 129 am thumbs down from the late Senator John McCain on July 28 2017. This essentially put a stop to any major efforts from the Republican Party to repeal the Affordable Care Act. Now this doesn't mean that the act didn't face a considerable legal challenge. It faced its first legal challenge in the Supreme Court in NFI BV Sebelius in 2012. In that case, the individual mandate was upheld essentially as a tax, but the Medicaid expansion which was initially sketched into the law as a mandate became an optional decision for states. And so this really shaped the way the ACA has been implemented in the last several years. The Burwell v Hobby Lobby case allowed closely held corporations to be exempt from contraception rules. King V Burwell was upheld. There was a question of whether tax subsidies in states with federal insurance exchanges could be upheld. Really, it came down to a technicality in language in the case. US House versus Burwell price and then ASR question and challenge subsidies for cost sharing reductions. This case was eventually settled. And then finally we have a case that's pending before the Supreme Court right now in California v Texas. Looking at whether the individual mandate is a core element of the entire Affordable Care Act and the fact that the penalty in the ACA has essentially been zeroed out. Does that render the individual mandate ineffective and therefore render the entire law invalid. So this is a lot forthcoming. So I'd like to start here and introduce our esteemed guests. We're lucky in the zoom era to be able to recruit guests from across the US, some extremely talented folks to like our speakers today. Our first speaker will be Dr Jonathan Oberlander, who is Professor and Chair of Social Medicine and Professor of Health Policy and Management at the University of North Carolina. Chapel Hill. He also holds an adjunct appointment in the Department of Political Science. His research and teaching interests include healthcare politics and policy, healthcare reform, Medicare and American politics and public policy. Dr Oberlander is author of the political life of Medicare and co author of the two volume series, the social medicine reader third edition. His recent work explores ongoing political fights over and implementation of the Affordable Care Act, healthcare cost control, Medicare reform and the fate of the Children's Health Insurance Program and independent payment advisory board. Our second speaker is Professor Aaron Fusse Brown, who is an associate professor of law, the Kathy C. Henson Professor of Law and Director of the Center for Health Law for Law Health and Society at Georgia State University School of Law in Atlanta. Professor Fusse Brown's area of research and expertise include health law and policy, healthcare finance, the regulation of healthcare markets and competition, the Affordable Care Act, single payer and public option health reforms, ERISA preemption of state health laws, consumer financial protections for patients, healthcare consolidation and prices and surprise medical bills. Professor Fusse Brown is one of five new casebook authors for the eighth edition of health law, published in 2018 by West Academic. Her scholarship has been published in top tier law health law and medical journals, and she is co author of a terrific new article titled health reform reconstruction. So with that, I will turn it over to Dr. Oberlander. All right, thank you very much and it's great to be with you all I'm going to try and share a screen here. So, those of us who have been living our lives on zoom and I know that's many of us, I'm going to have to really resist the temptation to just stop talking and put you all in a breakout room, but I will try not to do that. So, I want to start off with the observation that we have had for the last decade a partisan war over healthcare reform in the United States a partisan war over the Affordable Care Act and it has been fought in Congress. It has been fought as you just heard in the courts repeatedly, and it has been fought often they're not always in the States. When the Affordable Care Act was enacted nearly 11 years ago. It is not, I think the, certainly not the intention of the advocacy affordable care act. And I think a lot of folks like me who observe American healthcare policy would not have predicted what the next decade would look like. When the Affordable Care Act was enacted it was very much regarded as a starter home. It had limitations. It had problems. There are aspects of the Affordable Care Act that clearly we're going to need improvement over time. And the architect's the Affordable Care Act had good reason to believe that they would get those kind of improvements. Generally in political science what we teach our students is when you enact a program that's a broad program and has diffuse benefits as people get those benefits the program becomes more popular. It builds a political constituency, the whatever controversy surrounded the program tends to fade away from its enactment, and it really becomes institutionalized. That was certainly the case, if you think about Medicare back in 1965 Medicare there was a bitter debate over the enactment of Medicare it took over a decade to enact Medicare in Congress it was a partisan debate it was an ideological debate, but after Medicare was enacted, there was no longer a question of were we going to have a Medicare program. We still talked about what should Medicare look like, what should its benefits be how should we control costs, but the question about should there be Medicare was closed, essentially, after 1965 and Medicare became remarkably popular in some ways developed a bipartisan constituency in Congress. That has not been the path of the Affordable Care Act. And so, as a result, the expectation that over time the Affordable Care Act would be improved that it would be strengthened that it would be reformed really did not come to pass in the last decade. Likewise, Republicans also had an aspiration about Obamacare but it was the opposite. From the get go, the ink was not dry and they were already talking about repealing and replacing Obamacare and they have fought over the last decade to try and do just that. And when Donald Trump is elected president in 2016 and had Republican majorities in the House and the Senate in 2017. It seemed to many like this was going to be the end of Obamacare. It turned out that repeal was trickier than a lot of people thought they were unable to repeal the law and it continued on. So if you think about the last decade, the way I would put it is the politics of stalemate have governed the Affordable Care Act in the last decade. Democrats have not gotten what they hoped, which is to build on the law to expand the law to reform the law to strengthen the law. And Republicans have not gotten what they wanted, either, they have not been able to repeal the law in any meaningful sense it's still standing. So really, both parties have been frustrated over the last decade and that has led to a stalemate and the Affordable Care Act in 2020 looked not exactly, but largely like it did when it was passed in 2010. The question is, with the election of Joe Biden and the Biden administration coming to power in 2021 what are the new politics of health care reform look like. Have we broken the stalemate, what is the trajectory of the politics of health care around the Affordable Care Act and more broadly. I want to say a word about what the Biden administration faces and as you just saw a couple minutes ago, in some respects the Affordable Care Act is a great success. About 20 million people gained insurance coverage from the time the Affordable Care Act was enacted. And given everything that's gone on with the law, all kinds of problems some of them self imposed, all the opposition to the law, all the confusion about the law. And that is a substantial gain in insurance coverage in a short period of time so that's the good news. The bad news is, there's only one rich democracy in the world, where I could appear on zoom and say I've got great news. We've got about 30 million people who are uninsured, and that's the United States of America. Obamacare certainly has not been universal really was not designed to be universal and as you can see, we still have 10s of millions of people in this country who don't have any health insurance. And as Michael just pointed out, we have actually had an increase in the uninsured population, even before COVID hit. And that really is disturbing because in these years from 2016 to 2019. The economy was in good shape. And generally when the economy is in good shape, the uninsured population does not go up. And of course, now with COVID we expect that the uninsured population has grown over the last year. So, in short, we've made a lot of progress in making health insurance more accessible in the United States but we've got a long, long way to go. I can show you lots of statistics and put you to sleep just like I put my students to sleep every week on zoom, but instead I wanted to show you a couple stories because you can pick up a newspaper, and that sounded kind of antiquated 20th century, you can scroll through a newspaper on your phone. And any week and find these kind of stories and you know New York Times has been running a series with Sarah Cliff who's terrific about billing in American healthcare and this is a story that just appeared a couple days ago actually. And it's about a guy, John Jewish it's out of Texas who exhibited symptoms that seem consistent with COVID, as you can see in April so early, early on in the pandemic. And there was, you know, mixed results on his lab some tests positive, some tests negative, but he had an irregular heartbeat he had blood clots in his lungs. They sent him home on oxygen, and but didn't give him the coronavirus diagnosis, because of some of those negative tests. Well, it turns out that because they didn't give him the coronavirus diagnosis the hospital couldn't access the special federal funds that would pay for that case. So he later on received a bill of over $22,000 for his time in the hospital. And this is a mistake by the way I should say he was 64 years old, not 66. So he was, he was literally just a little bit away from qualifying for Medicare. And so that this story is one of the many stories we hear in American medical care that should not happen. In this countries in the world, something like this should never happen, it makes no sense that somebody paid a $22,000 bill was charged $22,000, because of a diagnostic code that makes no sense. It makes no sense that this man would face this kind of bill because he was just short of Medicare eligibility, but, you know, 23 days later, he would have been eligible for Medicare. That makes no sense and it really speaks to the insanity of our non system in the United States. One other piece of the story that I want to mention, he had private insurance through the Affordable Care Act, but because he was starting Medicare, he canceled that insurance and it turned out he made a mistake and canceled at one month early. And that's where, when he got COVID, and it really speaks to the experiences that unfortunately lots of uninsured Americans have. And many Americans who are underinsured as well. COVID has highlighted a lot of things about American healthcare and a lot of things that aren't good. And so here's another story from a few months ago out in California and there were hospitals when COVID was overwhelming. There were a lot of hospitals, there were hospitals that wanted to transfer their patients to hospitals in Los Angeles, who had more resources had more beds, and weren't being overwhelmed at that time, in the same way. And in some cases those hospitals refuse to take the COVID patients, because they were on Medicaid or because they were uninsured. So there is nothing more you really need to know about the moral illogic of US healthcare and I know this is a bioethics seminar than the slide. Lots of countries were overwhelmed with COVID countries who have universal healthcare systems, like the United Kingdom, like France like Italy, but there's no country that I know of. There's a lot of other countries in the world, at least democracy at least, that had hospitals that were refusing COVID patients, because of their insurance status that is a uniquely American problem and it's a reflection of what we have and you think about it as being made into the Affordable Care Act. And while we've made lots of progress in covering people, the sort of fundamental values that underlie our system are still not really where they should be. They really aren't. So what has Biden done so far and I think Erin is going to talk about some of this, maybe in a little more detail so I'm not going to spend a lot of time in this but you know, President Biden is using a lot of executive orders, a lot of executive actions that's a trend in the presidency and it's a trend in the presidency because presidents have a hard time getting everything anything through Congress. So President Trump did the same except in the other direction. And essentially when you when you look at these, what Biden is trying to do in some sense is undo damage that the Trump administration tried to cause to the Affordable Care Act. And, you know, the Trump administration did not want the Affordable Care Act to work. And they tried to do things to set up a self fulfilling prophecy to weaken the law in certain ways, and then that would allow them to say look it isn't working. The Biden administration wants to see if they can actually make the law work and so they've taken a number of steps, including opening back up the Affordable Care Act Marketplaces and reinstating advertising and so on and so forth to try and make it work, undoing some of the policies from the Trump administration to restrict access to health insurance and we may see some additional action as well down the line via executive order and regulation. There is a law that just passed this week. And that you know this law had a lot in it but it had healthcare provisions that I wanted to mention just briefly that are really important and you know this law really represents the first significant improvement to the Affordable Care Act in over a decade. This is the first time Congress has passed a law that really strengthens the Affordable Care Act since it was enacted in 2010, and the Affordable Care Act got a lot of problems. There are a lot millions of Americans who can't afford coverage under the Affordable Care Act. The Affordable Care Act is a really good deal if you are low income and live in a state that expanded Medicaid, or you qualify for subsidies, but if you're not low income, and if you don't live in a state that expanded Medicaid, and if you're middle class, the Affordable Care Act is not such a great deal. And really the policies that have been available to people are high deductible high premium policies that really are unaffordable. So what they've done in this law is first of all to try and patch some of the bleeding so to speak that the health insurance system is experiencing right now. We have an employer based insurance system, because of the lockdown because of the pandemic because of the recession, millions of people lost their jobs and many of those people lost their health insurance. They're going to subsidize COBRA, which is a program that allows people to stay on their employer coverage. The other things that you see here, the next two bullet points are really aimed to address that affordability issue with the Affordable Care Act, to make it more affordable, to make it more affordable for the middle class, to make it more affordable for lower income Americans, and to try and get it so more people are able to sign up for coverage. And this is a big deal. This is a really important step. There's also an effort to try and offer states that have not expanded Medicaid, there are about a dozen nationally, including my own here in North Carolina, to try and offer them some new financial carrots if they do that. And finally, I just want to mention this briefly because it hasn't gotten a lot of attention. There is a expansion in the law of postpartum coverage for pregnant women under Medicaid. Right now, it can only get that coverage for two months. That's going to go up to a year, which is incredibly important given the problem we have in the United States with maternal mortality. Note that these provisions are time limited, the ACA provisions are temporary. They're only for two years, which is something I'll come back to a little later. We also have, as Michael mentioned, another name that I call the Affordable Care Act is the Lawyer Full Employment Act of 2010. I hope my health law colleagues don't mind that, but there's just one case after another going on here and we've got this case. As you just heard, hanging over the law and we expect any day now, any week now that the Supreme Court's going to rule and it's tough business trying to guess what the Supreme Court is going to do. But based on the oral arguments, I think there is a lot of expectation that the Supreme Court is going to turn down the case brought by Republican-governed states and they're going to uphold the Affordable Care Act. If they don't uphold it, then we're going to have to have a whole other seminar if this total chaos is going to break out. If we take those two things, the fact that we just got this ACA 2.0 legislation, I'll call it this week, this ACO patch legislation, and we're likely, not guaranteed, but likely to get a ruling from the Supreme Court that turns back another legal challenge to the law. I think it's worth asking if we're about to enter a new era in the politics of healthcare in the United States and the politics of the Affordable Care Act, is the war, the decade long war over Obamacare, is it about to end? In addition to those two developments, there are other reasons why you might say the war is essentially over. One is Republicans had a chance to repeal it. They couldn't do it. And even when they had majorities in Congress, and since then it has not animated the Republican Party the same way. The issue doesn't have the same resonance that it did five, six, seven years ago, and Republicans still face the same political problem, which is you can't repeal without replace, and they don't have replace. There is no agreed upon Republican replace plan. Meanwhile, the law has been gaining in popularity, thanks in part to efforts to repeal it. So now we're a decade into the law, tens of millions of people are beneficiaries of the law. The law is more popular than it's been. And that, you know, that changes the politics. So can we say that the Obamacare wars are essentially over? Well, if they are, it would mean that the Affordable Care Act has had a delayed progression. The natural progression of programs, even ones that are controversial like Medicare, as I mentioned before, is after they're enacted, we move into a politics really of rationalization and reform and we think about how to fix them, how to reform them, we fight about them, but we don't think about repealing them. Is the Affordable Care Act headed in that same trajectory now? And I think the answer to that is sort of, I think the existential war over Obamacare, it could be that that's about to end. In other words, the fight over whether we're going to have this at all or not. We're not, I think, ever rolling back the clock to 2009. It's too late for that. It's just not going to happen. And I think as long as the court ruling goes away that people expect that you would probably be on solid ground to say that the existential war over Obamacare is over. But I don't think that means that all the conflict over the ACA is over. Remember, we still have a dozen states that have not expanded Medicaid and lots of battles at the state level to come over expanding Medicaid. But if you think about the political alignment right now, Democratic president, small Democratic majority in the House, even thinner Democratic majority in the Senate, those will change. And what would happen if you got a Republican majority in Congress in 2023 or a Republican majority in Congress in 2025 and a Republican president in 2025. I think there's a good chance they would go after the Affordable Care Act, not to repeal it entirely because I don't think that'll be possible, but to weaken it go after it through regulation go after it with legislation where possible. But in other words, instead of an existential war, a war of attrition, and I think that's likely where we're headed. And so I want to explain why it why is it that we just can't get past this conflict over the Affordable Care Act. This is a really popular chart in political science. As you can tell from that we don't have a lot going on with our lives really. So what this is showing you is a scale of ideology and a house of representatives over time. So up is conservative down is liberal. So the average of Republicans is higher up meaning there are more conservative party than Democrats are in a political scientist Excel at telling you obvious things in really complicated ways. What I want you to pay attention to is what has happened since the 1980s by this measure and not just this measure there are other measures that show the same thing. Republicans in the house to representatives have becoming much more ideologically conservative party and Democrats have become a bit more liberal party. So what we have here is we have this chasm this ideological gap between the parties, and it's bigger than any point we can measure, even in the 1870s, after the Civil War. So if you want to know why we fought over Obamacare in the last decade, and why that fight just has not seen to want to end if you want to know why we've had all these court cases, many of which are more about the politics than the law. So the parties are so far apart ideologically right now, and really a lot of the fight about the Affordable Care Act is not about health care. It's a reflection of the broader division and American politics. This is another political science chart once I once I start, I'm just not going to stop with these. Okay, so here's another chart in political science. So it's a little more complicated. And it's showing us this by Francis Lee University of Maryland. It's showing you by decade how competitive are national elections so if we go right here on this access, even would mean each party is getting about 50% of the share of the vote. So you can see in the 1880s elections were very competitive. Now, when you see one of these columns up high. That means a party was dominated. Abraham Lincoln the Republican Party, obviously dominated into in the 1860s, Franklin Roosevelt in the 1930s so in other words Democrats dominated, not just a presidency but elections for the House and Senate. Take a look at the last three decades see this here close to the access. What this is telling you is, we have had the most competitive the closest series of elections for the presidency and majority control of the House and Senate in US history. There are a lot of political scientists like Francis Lee, who believe that when you have super competitive elections, it increases polarization between the parties that polarization that I just showed you was ideological. This is about power, because if a party believes it can win a majority control, or the presidency in the next election, it has a greater incentive, not to cooperate with the party that's in power right now, but to do everything they can to stop them so they can get back in the majority because they can see it in reach. In other words, there's an incentive not to be bipartisan, and that may be driven by the close elections that we're having. That growing partisan division is seen, especially in the Senate, you know the Senate and a lot of ways has become ungovernable. It has become a 60 vote Senate there was a time when the filibuster we talk about the, you know the filibuster used to block civil rights legislation which it certainly was in the 1960s, but look at the overall the use of the filibuster in the 1960s and look where we are now. Look where we are now the Senate has become a super majority institution, ungovernable in many respects and that is again a reflection of the partisan divisions in Congress. One other slide I want to show you. This is split ticket voting so if you have somebody who votes for a president of one party and a member of the House of Representatives from another place so if they voted for Joe Biden for president and a Republican for the house that's what we call split ticket voting split ticket voting was the norm in American politics I mean if you look back here not too long ago, it wasn't unusual for 30 or 40% of the House to be from the opposite party of the president. See where it is after the 2020 elections, there are currently only 16 members out of 435 in the House, who were elected in a district that voted for the opposite in other words a Democrat, where district voted for Republican or vice versa, we are down to 16 in the Senate and only six in the Senate. And so the parties have become more homogeneous over time, they've become more polarized over time, and it again makes it very hard to have any kind of bipartisan compromise. It's not just what I've shown you is about Congress. And there's a lot of evidence that we've had this polarization and ideological polarization, a partisan polarization among members of Congress, but it's not just about Congress it's about the public. This is how do you view the Affordable Care Act. And look up here. This is just from a year ago, you can see 80% of Democrats like the Affordable Care Act, 20% of Republicans. So, the perception of the Affordable Care Act varies greatly by partisanship. And if I had time I'd show you a whole bunch of other slides that would show you that increasingly Democrats take a very dim view of Republicans and Republicans take a very dim view of Republicans taking a very dim view of Republicans, again, speaking to the fact that this polarization is not just a congressional polarization. We in fact have seen it, we're seeing it right now in COVID and this is a tragedy, it's an American tragedy because we know a public health emergency should not have been a public partisan issue, but it has been. We see a lot of attitudes towards vaccination. You see it from this survey that was done earlier this year about concern over COVID social distancing, masking, etc. Very different views, blue and red very different views between Democrats and Republicans. We don't live in the United States of America right now we live in a very divided country and that is a problem. And in terms of healthcare politics that there has been no bipartisanship, essentially on Obamacare. There have been a few issues in the last decade where Democrats and Republicans agreed to subtract to get rid of things that were controversial or unpopular or the healthcare industry didn't like, but there's been no bipartisanship, none on adding to the Affordable Care Act. And so I think that what that tells you, going forward, coming out of the Rescue Act is, well, maybe the existential war on Obamacare is ending, but it's going to be really hard to go towards a bipartisan politics around the Affordable Care Act anytime soon. What about the rest of Joe Biden's agenda? So, and we can talk more about this in Q&A. Of course, he had aspirations in his plan when he was running for president about creating a new Medicare like public option, expanding Medicare eligibility down to age 60. That's going to be really hard to do, really, really hard to do. And largely because of the Senate. And I don't think this is primarily about the filibuster, which is a convenient scapegoat, sometimes from majority parties, it's because Democrats have a majority of 50 plus vice president Harris. So if you want to enact a public option or if you want to expand Medicare eligibility, you've either got to get Joe Manchin and Senator Sinema on your side, or you've got to pick off a couple of moderate Republicans like Susan Collins, and Lisa Murkowski. So the sort of bolder part of Joe Biden's agenda for the next few years, it's going to be really difficult to pursue that. So keep your eyes on expanding Medicare eligibility, which probably has a bit more publicly, a bit more political legs in the short term than the public option does. Beyond 2022, 2022, you know, then we start talking about what is the future of healthcare reform. And we're talking about a new Congress and eventually a new president and I think it gets very, very murky. We can talk about Medicare for all, which has a lot of policy advantages and an equal number if not more political disadvantages. But the point I would make to you is, it's really hard to know what's going to come next. I mean the last decade was certainly a surprise in many ways. And I think right now sitting here in 2021. Hopefully at the light at the end of the tunnel of this pandemic, really hard to say where we're going to be politically in 2023 2024, let alone a decade from now. So I think we're at an inflection point in the politics of healthcare we're likely to see transformation in the politics the Affordable Care Act but beyond that I think there's a lot of uncertainty. Great. Thank you, Jonathan. That was a really fantastic overview both in terms of the history of the Affordable Care Act, as well as a hazy forecast as to where we're going. And I pretty much agree with everything Jonathan said so in some ways there's not going to be a lot of debate back and forth in terms of his assessment and my assessment of where things are going. And I think that in some ways I just want to pick up on some themes that you know that we can talk about a little bit further. So one of the things that we are trying to gauge right as a public is what is the bite what is health policy going to look like under the Biden administration and what is still early days right the Biden administration has been very busy however on the policy and even setting aside the pandemic, which of course is taking up most of the energy in terms of policy. How should we think about what the administration has already done and what that signals for what we can imagine the Biden administration might lead or head in the future. And what do we think we should where do we think we should go from here. So it may be a bit cute but I when I reflect upon President Biden's health policy moves, you know it's only been 51 days since he took office, you can see some themes and I cluster these into certain categories one like Jonathan. I think about it in terms of the things that the Biden administration had to do just to restore and reverse whatever the damage the Trump administration had done both to the Affordable Care Act but also just to health care markets overall. And the second category would be steps affirmatively taken to reinforce the functioning of the health care market to make it more affordable and that I think a lot of what we saw in the American Rescue Plan that was passed this week would fall into this category but there have been some other efforts as well and I'll talk about those. And then there's the less talked about things that the Biden administration might retain right it's not, you know it's there's not a whole lot of things that fall into this category but there are some policy moves of the Trump administration that I don't know whether or not the Biden administration is going to reverse it or replace it with something else or whether it's going to keep it and build on it for the future. And then finally there's what kinds of reforms can we hope or expect to see out of the Biden administration and I largely agree with Jonathan here that there's it's a really tough road so we may not actually see much more in the way of reform, but what could we imagine would be some So on that first category, you know a lot of the president's initial moves including all of the executive orders he signed in the first week or first couple weeks in office, and statements of enforcement policies were all steps to reverse the bleeding right to staunch the bleeding to reverse Trump administration policies, and many of these changes are the ones that could be initiated by the executive branch unilaterally they did not require congressional action. And this is because, you know, if you think about it Trump actually did very little health policy through Congress. You know, again, other than the 2017 failed effort to repeal and replace the Affordable Care Act, almost all of the health policy that the Trump administration did was through executive action, either through executive order, or through administrative rules, or other sort of administrative documents. And these are all things that can be reversed by a subsequent administration. So the speed at which a prior policy can be reversed really depends on the whether you know the form of that prior policy so if it's an executive order, well that can be you know erased in one stroke of a pen by a by a subsequent administration. The same thing with guidance documents those can just be, you know replaced by a new guidance document a new memo, stating policy of enforcement, for example. However, if it's a rule, like a regular regulation that was issued through notice and comment rulemaking process. A president, an agency can't, you know, President can't just announce that the rule doesn't exist anymore through an executive order. The agency has to go through a notice and comment rulemaking process to rescind an existing rule. So the same process that you need to put a plate in place a new rule or amend a new rule. You actually have to use that same process to, to rescind it. So, if they're, you know, the executive orders, a lot of them took the form of instructions to the agency and that's fairly typical that's usually how executive orders are used in the sense that they are really marching orders to the agencies to take a look at certain policy priorities, and to take certain steps to effectuate eventual policy it doesn't make they're not self executing in the sense that they don't make those new policies come into be overnight. So we saw a lot of that type of action. One of the first things that that the Biden administration did was to freeze Trump administration's midnight rules and meaning the rules that went into that had been finalized but had not yet gone into effect. This is very typical whenever an administration changes parties, it gives the new administration time to review them see which ones they want to start to unwind and which ones they want to adopt. It also gives the Congress time to use the Congressional Review Act maybe undo problematic rules as well. So it is that's typical but all it does is it delays the effective date of these, you know, this category of rule for another 60 days. One of the biggest things that the Trump administration had done to really undermine some of the gains and the Affordable Care Act was to really reinterpret what Medicaid meant by allowing states to apply for and secure approval for Medicaid work requirements and of course this became a very big hot button issue in the courts. We saw Arkansas, you know experiment with this and throw 18,000 people off of their Medicaid roles. This was a big, this is a big policy debate about whether or not that's an appropriate use of the Medicaid waiver process, whether states can do this under the Medicaid Medicaid Act. And it was about to be heard by the Supreme Court at the end of this month on March 29. And just yesterday, the Supreme Court actually announced that it's canceling the hearing and oral argument on the case because early on the Biden process started the process sent letters to all the states that had existing approved work requirement waivers to say that we are going to start the process of undoing these work requirements. And we can't again we can't just yank our approval overnight partly because of some of the, the sort of gumming up the works of the bike that the Trump administration did on the way out the door. They would have to slow down that process and say are the work requirement approvals can't be, you know, removed overnight by the subsequent administration, they would have to go through this long process that takes up to nine months. But the Supreme Court has basically seen the writing on the wall and says there's not going to be a controversy for us to weigh in on if the Biden administration administration in fact undoes all of these Medicaid work requirements. We're going to hear the case argued before the Supreme Court at the end of the month. So that was an important step, something similar happened with something called the public charge rule. So the public charge rule was this very controversial rule that was actually immigration policy by the Department of Homeland Security under the administration that had health impacts in the sense that it told it said to immigrants that if you want to apply for green card if you want to come, you know apply for legal status, or if you want to apply for, you know, just apply for citizenship and you're an immigrant. Immigrant have taken advantage of and you can't use any public benefits, meaning food stamps, or the Medicaid program. And of course what this does is it sends a huge chilling, you know, message to the immigrant communities. Don't use Medicaid even if you're eligible because if you do and you ever are up for to secure your immigration status then it's going to be held against you. The public charge rule was seen as a, you know, certainly by Medicaid providers and hospitals and safety and hospitals that require Medicaid payment to stay afloat. This was seen as a significant effort to undermine the reach of the Medicaid program. The same thing happened though the public charge rule was scheduled to be heard this week. The Supreme Court decided to dismiss the case to determine the legality of the public charge rule, because the Biden administration said we're not going to defend it anymore, you know, we basically switched positions. And so they're again, both sides of the parties, both parties to a controversy agree there's no controversy, and then the Supreme Court arguably doesn't have any reason to hear the case. So these are the types of actions that the Biden administration could take right away and has done. And some of the other ones that the that Jonathan pointed out that there are, you know, lots of steps to start to undo the rules that undermine the preexisting condition protections and allow the sale of skimpy plans those were done through rulemaking under the prior administration so they're going to have to be undone through rulemaking as well so that's still forthcoming but we would expect that to happen under the Biden administration HHS. And of course California versus Texas that you know you might be wondering well why if the Supreme Court can just decide not to hear the Medicaid work requirement case or the public charge case. Why can't we do that with the California versus Texas case, because the Department of Justice also reversed its position on the Affordable Care Act challenge, the prior Trump administration had agreed with the Republican state challengers saying that the Affordable Care Act was unconstitutional. However, the case was heard the oral arguments already heard back in November right after the election, it's been fully briefed, and the parties to the case, it's not really against the federal government so they can't unilaterally decide to drop the case by switching their, their position on the legal issues, because it's really a case between the, you know the states that are defending it the California's of the world and the states that are challenging at the Texas's. So that case is, you know, unlikely to be, you know, dropped from the Supreme Court's opinion calendar unless the Congress, and I don't think it necessarily has the ability to do so politically but unless Congress were to step in to moot the case through legislation by, you know, by making there are lots of a few handful of changes that the Congress could do in a sentence essentially to make the issue the legal issue in the California versus Texas case go away. For a lot of the political reasons that Jonathan pointed out, including the filibuster and all the other requirements, some of these even one sentence changes are unlikely to happen politically. And so, I think we're likely to see the Supreme Court weigh in and agree with Jonathan. Most, you know, folks who listen to oral argument and are watching the case anticipate that the Supreme Court will uphold the Affordable Care Act and not strike it down. So beyond reversing Trump administration policies, the Biden team quickly sought to restore and return us to some of the pre Trump status quo in terms of the Affordable Care Act for example we're storing funding and outreach and funding for the navigator program for the ACA marketplaces, which were axed to almost nothing by the Trump administration, also reopening the Affordable Care Marketplaces for a special enrollment period that lasts from, you know, February until May, in response to the pandemic, largely but also just to sort of give people away into the marketplaces if they don't have a good source of coverage otherwise and in the first two weeks that the special enrollment period was available. So 1000 people signed up across the 36 states that use healthcare.gov so that you know the word is getting out and people are taking advantage of this. And then there are other things that the, you know, the Biden administration is doing to restore sort of the Obama era interpretations of the Affordable Care Act including rules to prohibit starting to move toward rules to prohibit discrimination and healthcare based on sexual orientation and gender identity. The Obama administration had interpreted the section 1557 of the Affordable Care Act which is the healthcare anti discrimination section passed by the Affordable Care Act to basically prohibit healthcare discrimination against LGBTQ people on the basis of their sexual orientation or gender identity, and the Trump administration basically reversed that policy and said, no, there is no prohibition against such discrimination because the only prohibition under the law is discrimination on the basis of sex and that's not how we interpret sex discrimination. And of course last summer the Supreme Court announced a landmark case in Bostock versus Clayton County, which determined that discrimination against LGBTQ individuals under civil rights law is discrimination on the basis of sex and so in some ways the, the, you know, what the is doing to sort of realign healthcare anti discrimination law with this sort of larger civil rights decision is what's sort of happening anyway we probably would have happened. Eventually but they're sort of accelerating that process and restoring that interpretation under the law. So those are the sort of just pat you know fixing the broken, you know the damage done by the prior administration. There are some ways that the by demonstration of course is now reinforcing and building upon the Affordable Care Act itself and as Jonathan pointed out this is unique in the sense that this is the first time we've ever seen in the 10 years to 11 years since the Affordable Care Act was passed a significant effort to build upon and reinforce some of the known holes gaps and shortfall shortcomings of the Affordable Care Act. So the biggest ones here are the ones that Jonathan put on the slide but really they wouldn't come to coverage. There are three ways that most people get their coverage that they either get it through the their employer through employer sponsored health insurance or that they get private insurance on the marketplaces or in the individual market that's the you know another smaller but still significant way people get coverage, and then public coverage and particularly Medicaid and Medicare are the biggest sources of public and the American Rescue Plan passed, you know just a couple days ago and signed into law are contained significant efforts to increase support for people in all of those segments of the insurance market. So on the marketplaces, it ended what is known, you know colloquially as a subsidy cliff for those who earn more than 400% of the federal poverty level so these are sort of middle income families who essentially had no help to go buy insurance coverage on the marketplaces and were priced out through the premium increases that had happened over the course of the last few years. So what now we see is that the American Rescue Plan limits ACA premium costs, if you're shopping on the marketplace to 8.5 of household 8.5% of household income for the next two years. So this goes through the end of 2022 this is a significant increase in the amount of subsidies and support, and it really strengthens the power of the individual marketplaces in the sense that you see some talk amongst the insurance plans that if they had been sitting it out or had left the market and exited as participants are now contemplating coming back it's it's about to grow significantly. And I would imagine I'd like to hear Jonathan's thoughts on this I think because of the endowment effect and the way politics works once you give this population this type of subsidy support you can imagine there's going to be a lot of political pressure in the 2022 midterm elections for Congress to extend these subsidies into the future and just not throw people off their insurance which is how it will be calculated characterised at that point in time when the public health emergency expires, and when these provisions under the ARP expire. So for people who, you know, as Jonathan mentioned already get their previously got their coverage through their employer. There is this provide, you know provision that up that pays for cobra, or the extension of your premiums to buy your employer based coverage. If you lose your job, you can pay for the, you know to keep your insurance plan, and that cobra coverage is paid for by the federal government 100% for those laid off from their job through the end of September of this year so it's not a forever capacity but it is a way to sort of stabilize people who might still be, you know, just say, you know displace from their job because of their effects of the pandemic. And then finally the, I think one of the ones that's a big question mark in terms of how many states will take it up, but the Medicaid expansion has been one of the single most important ways to not only cover low income people but also those racial and ethnic disparities and healthcare, the gaps in healthcare and health, not just access but actual health outcomes. And so the, the Medicaid incentives to sweeten the pot for the non expansion states to expand Medicaid. That's a significant, it's a significant financial commitment by the federal government to basically add 5% to the existing 90% federal matching rate, increasing the federal contribution to 95% for two years for any state that really expands their Medicaid program. Of course, you know there's a lot of debate right now about like well if a state didn't expand when it was 100% of federal match then why would they, you know, take it up now if they've been holding out for political reasons since then. But I think, you know a lot of states are seeing their budgets, you know, strapped by the pandemic and so this might be in a very attractive source of money to supplement their state budgets. I think as Jonathan pointed out the, the extension of the, the Medicaid coverage for postpartum coverage from 60 days to a year could also have a significant effect on not just postpartum health and maternal and child health but on racial disparities as well because some of the biggest effects of those racial disparities are seen in the maternal mortality statistics. You know that's the building upon and I think that that's it's pretty exciting and I think that that you know of course the American Rescue Plan wasn't just a health, health law but it was similar to what we saw in the how the surprise medical building federal law, no surprises act was passed as part of the COVID relief package at the end of 2020 in December. It must pass as part of the American Rescue Plan part of this like broader anti poverty and stimulus bill. It's must pass spending, it's something that can be done through budget reconciliation and so that seems to be the way to make health policy these days is you have to attach your health policy and tuck it into a must pass spending bill. And that's the only way to get anything done, but there are limits to that strategy and it means that we have some, we may be approaching the end of the ability to pass sweeping reform if that's the only path forward. So that brings us to the bigger question of whether the Biden administration will be able to pursue this bolder health policy agenda. Beyond just reversing Trump policy or restoring and reinforcing this, you know the ACA to its sort of pre Trump status quo, will Biden be able to usher in any sort of sweeping health reform. And what could that look like. And obviously that you know sweeping health reform in the in the election in the run up to the 2020 election took the form of debates about Medicare for all versus a public option right Medicare for all being Bernie Sanders and other single payer plan that would cover everyone with Medicare or Medicare like plan and replace largely the current fragmented landscape of public and private payers. And the public option which is the one that you know candidate Biden adopted or embraced was the idea of providing everyone an option to purchase a public plan, a Medicare like you know maybe a Medicare Advantage like plan, whether on the ACA market places or elsewhere but just again not sort of forcing people into the public plan but allowing them to opt into it over time. So what these two reform concepts have in common is that they are a major structural reform because they would begin to untether or completely untether health coverage from employment. And that was one of the biggest vulnerabilities I think revealed by the pandemic is when you're, you know your coverage is tied to your employment then when there is an economic recession, or worse a pandemic caused economic recession, which is a crisis, then at the same time you're losing your job you're also losing your coverage. So that's a major structural reform that I think there is a greater I don't know if there's a greater political appetite for that but there's certainly among the public, a greater appetite to untether or uncouple health coverage from employment. The second would be you know the second major structural reform again is that is aiming more toward the universality that the Affordable Care Act never was able to fully accomplish. It would also apply publicly determined rates to what is now the private insurance market so this is the cost control side. The idea that the private market isn't controlling healthcare costs anywhere near enough competition isn't really functioning in the healthcare space. And so the only way to do that would be to use the the great buying power of a public plan like Medicare for all to control the rising healthcare costs for everyone in the private market. So, I think it's tough to imagine a way forward for a federal, certainly before 2022, a federal level of any sort of health reform I think Medicare for all is already more or less, you know, a pipe dream it's, it's, it's a conceptual and it is not necessarily a live policy proposal at this point for a public option even that would be very hard to do under current Senate rules regarding the filibuster again Jonathan says it may. It's more than just a filibuster is actually the politics to and I think that's that's correct. If Democrats do control the presidency, and the both chambers of Congress. It is, you know, certain types of reforms are possible, but other types of reforms are just beyond reach because Democrats only control 50, 50 votes plus vice president Harris. 51 votes is not enough to get something sweeping, like even a public option to pass through the Senate so maybe a filibuster reform would change that maybe not because the politics don't don't change even if the filibuster goes away. You know the idea that it takes 60 votes to pass anything other than a bill that affects the budget right means that the only type of health reform we get our health reforms that directly are spending provisions or tax changes. So that is, it sort of limits how much reform you can do because the healthcare system is complex. It involves a lot of different parties involves a lot of behavior changes and nudges and regulations and you can't get all of that through the budget reconciliation process and through the rules that require the bill to actually affect the budget in order to pass through the budget reconciliation process. So even though we saw Congress just pass the American rescue plan so we may have some hope that there is the ability to pass bold new policy, not there were zero Republican support for that, for that bill and it did pass through the reconciliation process. So, again, once you run up against the limits of the reconciliation process you run up against the limits of what is possible for health reform through Congress. So, looking ahead, it's, it's looking not particularly promising that the, the Biden administration could get sweeping health reform through Congress under the current rules, and the current sort of political makeup of the Senate, but there is no way. And that is, if, you know, even under the current status quo, one alternative path to more structural and sweeping reform maybe actually through the states. And so here's what I mean by that. In the United States we have a federalist system, which is the system in which the power to enact policy and governance divided between the national government and the states. One of the benefits of course of federalism is the laboratory of the states we can test policies at the state level. And if we can establish a proof of concept there. The next step is you is often federal reform, or national reform so for example the affordable care act was patterned off of the Massachusetts health reform in 2006 Romney care was the precursor to Obamacare that established the Massachusetts health connector your exchange in Massachusetts. Similarly, you know we actually see this happening in other countries with a federalist system so Canada established its single payer system confusingly called Medicare at the national level after one province the sketch one proved it could be done at the provincial level. Sometimes it's not just one state proves it and then the next step is national reform it takes sometimes more than one state in the case of surprise medical billing 33 states passed laws protecting patients from surprise medical bills, before Congress finally got the political will to pass the federal surprise billing ban in December. The benefit of that is is that we actually get to benefit from a number and diverse state experiments about how does, you know how to solve this policy problem. If we can learn from that sometimes it does shape the ultimate national policy. And I think it's very helpful that one, it's not, you know one route to national reform is for a state to do it first. The political will in some states is actually quite high to, to, it's not easy, I'm not saying it's easy but it is higher and it's easier to kind of pass systemic in a state like Oregon, or, you know, even a state like New York that has been debating it but there are there are ways that states can make further strides and start the experimental debate about what's possible. Before the national government. So first states face additional barriers to passing state level reforms. Some of these are fiscal right states cannot borrow they cannot deficit spend. So they cannot raise the funds necessary. Like the federal government so they are highly dependent on the flow of federal funds to fund any, you know sweeping reform at the state level, and then there are legal barriers so if you need that's federal those federal dollars to come into the state. They are however limited by the variety of federal laws that govern those federal funds, whether it's the Medicare laws, the Medicaid laws, affordable care act law, and also Arissa which is the, the law that governs employee benefits. And these really constrained the degrees of freedom states have to design a single payer or a public option planner any other sweeping type of reform. We researched looking at state single payer and public option proposals and found that since in the decades since the ACA was passed. There's been quite a bit of state action in the sense that legislators in 21 states have introduced 66 single payer unique single payer bills. That's a lot more activity at the state level than we generally hear about on the public option 20 states have introduced 38 unique public option bills including one in Washington state that was actually signed into law and went into effect this year. So, where does the federal government come in, although a lot of policy innovation in health care is happening at the state level. And then can do a lot to either grease the skids or throw sand in the gears of the states. And the first and easiest thing that the Biden administration could do here would be for HHS to adopt a policy to approve very broad or comprehensive waivers under the Medicare Act under Medicare and Medicaid for states to pursue systemic health reforms and avoid some of the legal barriers of existing federal law when they're trying to pursue either a single payer or a public option at the state level. Remember I said that federal laws create barriers because of these legal requirements but a lot of these laws also contain authority for the federal government HHS usually to waive these legal requirements. When the state can show that it's going to abide by certain guardrails to ensure the maintenance of key consumer protections key coverage goals and other types of things to protect program beneficiaries. But the waiver authority could be combined and used to enable states to access streams of federal funding in the Affordable Care Act to make the premium tax credits that are now bigger to allow that flow of funds to flow into the state and state to keep it to use to fund this larger systemic reform. Also Medicaid matching funds could be could be loosened the restrictions on Medicaid matching funds could be restrict loosened through the waiver process and also Medicare payments so the idea of combining all of these into a single public pool that combined you know Medicaid the Affordable Care Act marketplaces and even some employer based plans would be the goal. The key exception to this concept of a waiver though is ERISA. There is no waiver in ERISA, which means it's harder for states to tap into the big and extremely important employer based health care coverage market with their reforms. I've written about how it's possible but states really need to turn some results to do it. It's very complicated because of ERISA restrictions on state health plan regulation but it is somewhat possible to do. And then the other step that the federal government could take would be for Congress, if it can't do its own national reform, it could pass a law amending ERISA and these other health care statutes like the Affordable Care Act Medicare and Medicaid to create this an omnibus waiver program for states to apply for to pursue more sweeping health reforms. There have been a few proposals in Congress to do this, but they you know I think they should be revived, particularly if it doesn't look like sweeping national reform is actually going to be possible in the near term. And of course any congressional action is going to run into the same political constraints that Jonathan mentioned earlier. I think I'm going to stop there. I'm not really going to talk about the smaller and somewhat insignificant, although not always insignificant category of policies that the Biden administration might retain from the Trump administration but I'm happy to talk about it in Q&A. Thank you both for terrific presentations. I'd like to start out with a question for both of you. So, through both of your talks I think we've honed in on two primary approaches that the Biden administration can take to improving the ACA. And those are executive orders and legislation. And I guess as to your thoughts as to which of the early actions from the Biden administration, either through executive order or through provisions and the COVID relief act will have the greatest short term impact. I'll go, I guess I can go first I think it's a tough, a tough call I think the answer is a lot. Can I take a lot as an answer. Really you know the, there are a lot of people who are unemployed and really don't have affordable options for health insurance and so the extension of COBRA provisions, as well as the enhanced subsidies, I think are going to make a big difference and that's going to solve all that ales American healthcare and the Affordable Care Act know are a lot of people going to get coverage that they would not have gone in absent those provisions. Absolutely. Yeah, and I would agree with that and I think that the other, some of the things in the background, like, you know, just reopening the marketplaces, you know, advertising that it's available coupled with the enhanced subsidies I think will also just sort of give me to get essentially, you know, I think a lot of people are eligible for free healthcare on the on the marketplaces. And so getting the word out about that and reopening the marketplaces will be big. But I also think that some of the biggest changes are, you know, the things that that don't sort of tinker with the individual market although I think that's one one place to go. But I think that the potential for the Medicaid, you know, if there's any way to get the holdout states to expand Medicaid and I don't know if it's going to happen. I think that would make a huge, huge impact in terms of just the health outcomes health care access reducing racial disparities I mean that has the potential to be a game changer. Again, if it works. Absolutely. If anyone in the audience has questions please do type them into the q amp a I'm going to get to those next. But I have one other question that I'd like to ask, given that you both have such extensive experience in the ACA, since its passage have written extensively on various aspects of the law. I'd like to put yourselves you can take your choice but if you could put yourself in the Oval Office, what executive order would you draft first, or if you were in charge of reforming the ACA through legislation, which would be the first major structural improvement you would implement. I think there's a limit to what you can do with the executive order. And I think, frankly, Biden, President Biden's done all the things, you know, not not that he, not that there's anything left that couldn't still be done but I think in terms of undoing the damage. Some of it can't be done through executive order but it's underway through rulemaking things like fixing the family glitch you know but these again are tinkering on the margins. It doesn't matter tremendously to the people who are affected by it, but I don't think that you could structurally change the affordable care act through executive order, nor should, should we be able to structurally change something that is, you know, a statutory framework frankly, through executive order. But in terms of what I would do if I were in Congress. I mean I guess I'd push for a public option. I think I would want to have a wand, not a executive order because I think as Aaron just described I mean, it's kind of hard because the Biden administration is done as I just said a lot of what is the low hanging fruit and not to suggest that it was easy because but they've done a lot of the things that you would sort of do and the ACA fix up operation and then the levels of difficulty for anything else really get steep I agree on the family glitch that would make a big difference. But otherwise, I would ask the first thing I would do I don't know if you can get this in the Oval Office but I'd get on the phone to Hogwarts and I'd say give me a wand. I'd start waving it around us healthcare changing as much as I could as quickly as possible. I've got a question in the Q amp a here. And I think the key here is that they're drawing a parallel to other industries so they note that in many states and I think in most states, drivers are required to have some sort of liability insurance. The question relates to whether or not you think it would be possible to actually require some sort of minimal basic level at the very least potentially hospitalization insurance coverage. Can we create some sort of low hanging baseline that would cover the majority of costs for some of the uninsured populations. The policy of requiring people to have insurance is the individual mandate and that exists at the state level and Massachusetts, it exists right. You have an individual mandate in Massachusetts to maintain a minimal level of coverage or else pay a penalty. And many states had put in place a sort of a state individual mandate when the Affordable Care Act individual mandate became zeroed out and unenforceable. And that is that already exists as a policy option that states could do. I don't know how much it actually changes enrollment I don't know Jonathan if you've seen data on that. I don't know if it has a big impact I think the thing is people actually want coverage they don't not want it. They're very few people who who just morally object, you know object to having coverage. The thing is if you make subsidy if you make the marketplace, you know, robust enough, and you actually subsidize people you only need two of the three legs of the stool you don't need a mandate to get people into the market and to get coverage. The problem is for a lot of the remaining uninsured it's not that they're holding out because they don't want insurance. They're holding out because they can't afford it because they, you know, make too much and are beyond the subsidies or they make too little and they're in a state that doesn't expand Medicaid or they're an undocumented immigrant and nothing applies to them. Yeah, I would just say did it or what Aaron said and just add that politically mandates are difficult it's it's punitive. So the politics of mandates are, you know, the ACA's penalty was actually not that large. In the context of health insurance, you saw how much political trouble we had, abiding by that. So it's, it's just, it's difficult to think of it in that way. There's an alternative formulation which is, we essentially require workers to participate in Medicare and in social security so social insurance is another way of thinking about mandates, less in a punitive way and more in a communitarian way, and a contributory way and that that's why I think it is appeal to a lot of people and health policy as well. Thank you. Another question from the audience here so the ACA originally included the class act, which was aimed at increasing funding for home and community based care and which would have enabled more elders to age in place. Unfortunately, the policy of favoring institutional care over community based care has proven to be deadly quite literally to elders during the pandemic. So the question is, are there any indications that the new administration will attempt to significantly reform long term care policy. I haven't heard anything Aaron if you heard anything about what what Biden's plans are. I haven't heard anything either I mean there is some direct funding in the American rescue plan. You know, again this is sort of short term not long term reform for community based health care. However, I don't think that you know the class act and long term care in general. I mean if we think regular health reform is hard. I think long term care is really really hard. It's just extremely expensive the market is super dysfunctional. And it's not. So I think it's, it's, if anything the idea that there was something like it in the original affordable character and then it just, it just got killed. You know, Jonathan's talked about some of the other provisions of the affordable character that have that have gotten killed along the way. And it's just really hard. And I don't know whether there's any appetite right now in the Biden administration if there is there not, they're not trumpeting it they're not because it's they're probably sort of still trying to work it out. Great, we have a brief clarifying question here what is the family glitch that you mentioned. The family glitch is part of the, the rules for in terms of calculating your subsidy eligibility is based on your income, your family income, but or your income but in terms of the family glitch some of the way the rules are calculated really what counts as affordable is based on your own individual income and and not your costs to your cover your whole family. And so obviously family coverage is significantly more expensive than individual coverage and so any rule that bases your subsidy level or your calculation of your ability on the individual costs when someone is really buying family coverage basically grossly underestimates the amount of subsidy you would need and so that has made it really unaffordable for a lot of families to access the subsidies that they need to buy coverage on the exchange. Yeah, just to give an example so here at the University of North Carolina, our health insurance is subsidized as North Carolina state employees but there's really not a subsidy for family coverage so if you have somebody from the University of North Carolina and let's say their partner or spouse has a job that does not have health insurance in it. Technically that partner or spouse is eligible to join the University of North Carolina family plan, but as Aaron just indicated it's super expensive because the University of North Carolina is not subsidizing it. And so a lot of employees at University of North Carolina, who are not well paid just can't afford to do that. And you would think well okay they can go on the ACA market places and get coverage. But in fact the way the rules were interpreted during the Obama administration they're ineligible to qualify for subsidies so it really is a policy that hopefully they're going to be able to revise it's hurting a lot of families right now. So there's a question here that relates to high premiums and subsidies. So maybe you can give us an indication. I mean I have a sense of it but I'd like to hear more about what what happens to those folks that are potentially right on the cusp of getting access to health insurance exchanges but may not have the resources to fully get access to premiums for co pays that sort of thing. What sorts of assistance, do they get from the federal government and from states to to help, because I get the sense that Medicaid, you know, a lot of the costs are covered. There's not much of an individual contribution when you're in the Medicaid program, and then there's a sizable jump in terms of the amount individuals have to contribute. Even even if it's not, you know, tremendous it can certainly be impactful I'm wondering, where can we smooth in that transition or and what's been done to attempt to smooth in that transition. You're right that, you know, Medicaid by statute doesn't have much in the way of cost sharing because it shouldn't because these are really low income folks. And so if you look at the, the sort of next step above Medicaid would be to get heavily subsidized plans on the marketplace. The problem is for a lot of low income people even modest co payments can be really difficult to pay and I remember I was part of a study years ago looking at Medicaid in Oregon. And when they raise the premium not even by that much in Oregon Medicaid expansion, they lost tens of thousands of enrollees. The dollar amounts that may not matter to people make $75,000 a year, they're going to matter a lot to people who make 20,000 25,000 30,000 a year. I think what you continue to smooth that out is what they just did actually in this legislation, which is to really try and increase the subsidies for people who are, they did it up to really increased it up to 150% of the federal level which these days would be what somebody makes $18,000 or so around there. So I think it's that that population that's just makes a bit too much money to qualify for Medicaid that you've really got to try and work on their premiums and deductibles but I do want to add this that we, you know we make a mistake in US health policy we divide Americans into two, which is the insured and we don't spend nearly enough time talking about the under insured. And this is not just a problem for low income Americans there are millions of middle class Americans who are basically one family illness away from discovering that their insurance isn't very good and they're not going to be able to afford the cost of their care. And while what was just done helps address some of those issues in the ACA. As I pointed out before, you know, most Americans working age Americans don't get their coverage from the ACA. Most of them are getting it through their employer and their deductibles have been going up and up and up. So one of the issues I think had resonance in the last campaign and continues to be something that needs action. And that is what do we do about the under insured in this country not just an ACA, what do we do about the under insured who have employer sponsored insurance. Yeah, I would agree with everything Jonathan just said and just say that the American rescue plan does contain a lot of the smoothing and it extends it up beyond, you know, 400%, which was a cliff before. In terms of cost sharing subsidies. If you're unemployed for example you get basically a zero you get a free health plan under the American rescue plan. So, you know the, there are things that are that that are being tested and you know in this in this plan but it's time and it really doesn't touch what Jonathan said is the the big, the big problem is, which is just commercial insurance in general, whether it's through the employer, or otherwise is becoming unaffordable to most, you know, ordinary families. Absolutely thank you. All of fun questions to wind us down here. The first comes from a former student of yours, Dr Oberlander. And I'm going to open it up to both of you but the question is, which 1980s music video best encapsulates the current state of health care politics. Yeah, okay so some, a lot of you at this point are wondering what kind of classes I teach here at the University of North Carolina. So I should give some context that in my, in one of my classes on health care reform. I make use of the big video board or these days the small laptop zoom board and I show a 1980s music video every week and true story that once one of my colleagues and I were walking down the street and a student stopped me and said, I wanted to tell you how much I learned about my class and I felt great. And then they said I you know I learned so much about those music videos and my colleague asked me, what's the title your course again so that's a really hard. That's a really hard question I don't know. There's a pop on my head with which 80s music video I would, I would pick to summarize where we are right now I'm gonna I'm gonna have to think I'm gonna leave it unanswered I'm gonna have to think a little more about that. Right and if you have a music video in mind Professor Fousey Brown. I don't know if it's an 80s music video I'm trying to think. Well I've got a 70s let me just give a 70s song this is what I think about as we get to the end of this week and we think about, you know US health care policy is. It's full of failure and disappointment and frustration and those of us here in it just, you know, deal with this so often and I think this has been a good week. Did it solve everything no but this has been a good week. So I'm just going to offer everybody the chance to listen to a little reggae going into the weekend and think about Bob Marley song positive vibrations and just carry that forward. I was going to suggest sledgehammer. Well that would be good and that's one of the videos I showed in my class actually suggest we didn't start the fire but I think that's a little too dour for the current moment. Yeah I didn't want to go if it's the end of the world as we know it either. I terrific and I think we've got maybe one more minute left and I'll tell you what I do in my classes I have a Twitter hashtag in every class. And I have the students engage on Twitter and engage in conversations. I try to share those tweets in class share content that's relevant to ongoing current political debates. So I'd love to have your one tweet summary that encapsulates the past present and future of the Affordable Care Act. Aaron do you want to take a stab. I don't know if this is literally a one tweet summary. But I think this week we you know we did see the first big strengthening or reinforcement of the Affordable Care Act. And I my small again caveated prediction is that these these additional benefits are very sticky. They're hard to undo once you give them to people so hopefully that lays the groundwork for future reform. That's going to be hard. I would say, and I'm a relative newcomer to Twitter so I'm still, you know, as a political scientist, I'm used to doing short things short things to me mean like 5000 words so it's a little bit of a difficult format for me, but I would say lots of progress, long way to go. Well thank thank you both very much and thank you Michael for for moderating the session, and we will see everybody next month. And we will, you know, maybe by then we'll have a decision from the Supreme Court who knows but we'll see you next month for the session on on prisons and prison health care. Again, Dr. Belander if you see around thank you very much for joining us really really great comments really interesting hour and a half. Take care everybody.