 Good afternoon. On behalf of the McLean Center for Clinical Medical Ethics, I'm delighted to welcome you to today's lecture in our series on ethical issues in health care reform. Today's talk is cosponsored by the University of Chicago's Institute of Politics. I'm looking for some of the leadership, but I don't see them at the moment. But the IOP is cosponsoring as they have eight or nine of our talks this year. Next week, I hope you can join us next Wednesday for a talk on the implementation of the health care exchanges under the ACA, a talk given by an old friend of mine and Mike's, Richard Epstein. Exactly why he chose that topic, I'll leave to speculation. Today, I'm delighted to welcome Mike Hedding back to the University of Chicago. Mike Hedding is deputy director for planning and reform implementation at the Illinois Department of Health Care and Family Services. Mike is primarily responsible for coordinating the Medicaid aspect of health reform in the state of Illinois. He oversees the changes made in Medicaid and the goal of potentially enrolling 700,000 new clients into the Illinois Medicaid program. In the past, when Mike and I would see each other many days, Mike served as vice president for planning here at the University of Chicago Medical Center, and he did that for almost 25 years. In addition to his responsibility with regard to planning, Mike also formulated Medicare and Medicaid strategy options for the medical center. He was responsible also for the process of capital budgeting and looked after house staff and medical staff affairs. Mike holds a PhD in sociology from Harvard. And today, as you can see on the board, Mike will be speaking to us on the challenges of implementing the ACA, Examples from Illinois. Please join me in welcoming Mike Hedding. Thank you, Mark. It's very good to be back here. I can't begin to count how many hours I logged in this room before, mostly on that side. But I have been on this side as well. When Mark asked me to talk about this, I said, well, do you think I could take six hours? And he suggested that probably wouldn't work. And so that left me with a dilemma. What I have decided to do is go through, at a fairly high level, some overall considerations about the ACA. And hopefully do that quickly enough that there's a lot of time for questions and answers. I understand that most of you will know something of what I say. And there will be some of you who know most of what I have to say. But on balance, it seemed to me that having an overall framework would be more useful for the question and answer period. And then I can dive into details that particularly fascinate folks. To reiterate, the goals of the ACA, they're primarily around coverage. The Call it Health reform probably is overarching. It really was about expanding access. And it set out to do that three ways. First, by changing insurance regulation, doing things such as ending the pre-existing condition limitations, other changes that allowed more people access to private insurance. Secondly, by creating a series of what were initially called exchanges. They're now called marketplaces, where people can purchase health care. And in general, if their income is appropriate, get a subsidy related to the size of their income for the purchase of this private insurance. And then third, to expand Medicaid. Many people in America think that a Medicaid covered anyone who was poor. But those of you who know anything about Medicaid know that historically, you had to be poor and fit into certain categories. And so just being poor wasn't enough. The ACA said that anyone whose income is below 138% of the poverty level will be eligible for Medicaid. And the idea was that these three coverage expansions would all fit together and provide an overall coverage for citizens who otherwise didn't have access to insurance. And then the fourth goal of the ACA was sort of to pay for itself. And then it became a collection of a whole bunch of other ideas that impact health care. And we're not going to talk about those today, although a lot of interesting and important things have come out of those. They're kind of hodgepodgey. So this is what we expected back in 2010, 2011. And I'm not going to dwell on the specifics here because most of them turned out to be not quite right. Order of magnitude, directionally correct, but not quite right. I want to make two points about this, though. One is that a lot of moving parts. We never had an expectation that this was going to be simple. We knew from the beginning that people would be moving into various categories and our big job was going to be accommodate all of those movements and keep them coordinated. The second thing that is important from this is that at the end, when you step back a little bit, a lot remains the way it was. Most people who had private insurance are still in private insurance. Medicaid was this big. Then it gets this big. There's still a substantial number of uninsured in Illinois. These would be primarily, but not exclusively, the undocumented. And we figured people would be moving among all of these categories, and we had to take that into consideration. So we'll come back and talk about where it ended up, but that's where we started out. And of course, along the way, things didn't go exactly as planned, which is no surprise. One of my very favorite mantras over the last year or so has been a line from the boxer, Joe Lewis, who says, everybody's got to plan till they get hit. And so things happened. One of the things, of course, that happened was that this was all born in America. And there are things about the American political system that most of us take for granted. We just assume that's the way things are. But the fact is that, measured against any kind of international comparison, they're remarkably aberrant. And they all played a part in making this a real difficult implementation. First, the vision of responsibility between the executive and the legislative branches in America, they are at war with each other often. And they have been at war with each other often over many, many, many years. And one of the consequences of that has been that the legislative branch keeps trying to make laws more and more and more and more specific to try and corral the executive branch. And the executive branch, of course, tries to figure out ways around these laws. And this accretion of moves and counter moves over many years leaves a mass of laws that have to be negotiated, not all of which are consistent with each other. Surprise. Secondly, America has a judicial system that is more political than the judicial systems in other countries. It gets more involved in the details of things than in other countries and takes longer to make up its mind than in other countries. And this is really an important factor in the implementation of the ACA. If I had a dollar for every time I heard someone say, oh, let's just wait till the Supreme Court decides it, I'd be in Starbucks for a long time. So good deal if that were the case. But it really had an enormously chilling effect on day-to-day operations. And then third, the American federalism, where there are 50 states, which actually translate into 54 separate Medicaid programs, which all have their own ideas about what should happen. And each one has its own accretion of laws, policies, and regulations over many years. And all of this had to be fit together, which was very difficult. So even within this already difficult context of the American political system, things didn't go as well as one might have hoped. First, the ACA did not follow the usual path of a law getting passed. Usually what happens is the law goes to one house, and they pass something, and then it goes to another house, and they pass something, and they get together and have a conference committee and work out a lot of the messy details. Due to the fact that Senator Kennedy died and Scott Brown won the election to replace him, who was a Republican, it was impossible to get the bill back to the house. Once they got the bill out of the Senate, they couldn't get it back from the house to the Senate and have it passed. So the bill got passed without a conference committee, and that led to a lot of things that would have ordinarily been worked out in a conference committee unresolved. Also, it's typical in a big, complicated piece of legislation, and this was a big, complicated piece of legislation, that there would be cleanup legislation. People would look at the law and go, oh, that's not what we really meant, and they'd pass a piece of legislation to do it. The atmosphere in Washington, as we all know, is so toxic that no one would even think of introducing a cleanup bill. So there are a fair number of things strewn throughout the ACA that people on both sides of the aisle agree weren't what they intended and weren't right, but nobody can even think about running cleanup legislation, so that became another implementation obstacle. It's also the case, and I can't tell you how distraught I am over the fact that the Republicans simply did not participate in this discussion. They utterly failed and continue to fail the test of being loyal opposition. They've simply withdrawn and sit there saying, no, that's not a responsible position. There is no question this would be better legislation had the Republicans participated responsibly. It might have been different, but it would have been better legislation if it is not good legislation when one side side completely writes it dealing with its own problems. So that's the sort of context of the ACA. When you get to the substance of the ACA, there's a fundamental problem in the ACA, and that problem is that the only way it could have gotten passed is if it built on the current system. That it minimized the amount of change because there was no way they could have gotten enough votes without that. Had you the opportunity to start over, you probably would have come up with something very different than the ACA. But starting with the constraint that you were going to build off the existing system, and that was a very real political constraint, you're left with a couple of really big problems. The two biggest being that the current system is so fragmented that anything built on top of that would be inherently difficult. And then the second issue is that things are so connected that it's highly unlikely that you could actually make a change without having all kinds of collateral impact, some of them intended, some of them not intended. I don't have to go on at great length about the fragmentation of the existing system. Most of you experience this on a day-to-day basis in the work you do. Employer-based individual purchase, Medicaid, there are all of these different systems out there, and even when you take Medicare out of the mix, and the ACA does take Medicare out of the mix, putting all of these pieces together is stunningly complex. And it is not the kind of foundation one would have chosen for trying to do the ACA. It's also gonna be the case that when you make a change that impacts this many pieces of the system, there are going to be collateral impacts. And one of the biggest is the fewer over the fundamental benefit design in the ACA, whether it's Medicaid or as it's gotten much more press in the marketplaces, in people say, well, gee, the cost of individual coverage has gone up. And why is this? The ACA is supposed to drive the cost down. Well, because we were building on the existing system where the commercial insurance for individuals, not for business coverage, it's a totally different market, for individual coverage, that insurance mechanism had become superb at filtering out anybody who might really be sick. A large percentage of the people who filed for bankruptcy for medical reasons had some form of insurance. So it not only filtered out people who might be sick, once you got sick, it didn't pay all that much. And so, setting up the marketplaces, there's this fundamental dilemma. Do you want to try and match those prices, which are achieved by keeping sick people out and then not paying for them? Should they become so foolish and bold as to actually become sick? Or do you try to put together a system that's going to cover everybody? Well, if you are only covering people at the high end, then the cost of insurance becomes really, really very high. So in order to achieve coverage, you need to have a system that requires everybody to pay in. That causes the cost of individual policies to go up because you're now including in individual coverage lots of people who previously were excluded. You brought the expensive people into the tent and it made the tent more expensive. I don't think there is any better design than what the framers of the ACA came up with given their preconditions. They also use a relatively high level of co-pays and deductibles, which is something else that people have complained about, but that's necessary in order to really focus the care on people who are truly sick. And they've tried to counterbalance that with a set of subsidies, not just for premium costs, but also for co-pays and deductibles, for people at the low end of the poverty range. All the right things to do, all of them made it much more complex. Also, it would have been unrealistic to expect that you could make all of these kinds of changes and not have impact on employers. It's just when you say that all employers have to cover their employees, employers are going to react. So not surprising, but it adds to the confusion. It's certainly added to a number of issues as the administration has tried to work through how you deal with the problems created by interfacing to employer-based health insurance and basically have done that by saying, okay, we'll solve that problem another year. So big parts of the ACA got postponed for a year and we'll see how that works out when they get around to working those parts of the process. This is one that's particularly important to me is that the implementation of this was very rushed. People who don't have to deal with these issues on a day-to-day basis say, what do you mean? They had three years, why is that so hard? Well, it's that hard. And it's that hard for a number of basically good reasons and some reasons that are not as good. But we're talking about very, very complicated computer programs. People say, well, why can't it be as simple as my MasterCard? And I read in a quasi-respectable place and I have no idea where they got these numbers and I just don't think they're anything close to, I mean, I think they're made up numbers, essentially. But metaphorical numbers I think are kind of useful. The average business transaction requires 74 pieces of information. The average medical transaction requires some hundreds of pieces of information. And it is that we are dealing with a very contingent set of thoughts which are being layered on top of this 45 year, getting closer to 50 year accretion of various laws being played out in courts, in Congress, and in 50 different states. And the complexity had to be dealt with in that sort of, that rarefied political environment and that extends not just to the politics in the narrow sense that it gets covered in the newspaper, but it includes the fact that government space is crawling with internal auditors and people who are looking over the shoulder of the person, looking over the shoulder, looking over the shoulder of the person who's trying to do something. And every one of these things, running the risk of being a political embarrassment while we're trying to get this whole process off the ground and the Obama administration is at the same time running for office, running for reelection. Therefore, a lot of reluctance to do anything that wasn't scrupulously following all of the details and all of the stepping around, all of the different possible landmines, which just adds enormous amount of time to things. This led to a vicious cycle that everybody who looked at, an uncertainty when the administration said, well we're not sure how we're going to interpret that law, which of course we all knew had the subtext of, we're not telling you until after the election, then other people jumped on that and made it into a bigger deal and there was this constant cycle of anything you did drawing opposite and annoying reactions. A judicial review, which took two years after the law was passed to come out and then undid a key piece of it in the requiring of Medicaid further scrambled what was going on in Illinois, fortunately had the good luck or the good insight to say from the outset we're gonna figure out how to expand Medicaid and plan on a Medicaid expansion and took off on day one and never paused waiting for a Supreme Court decision or anything else. A lot of other states didn't take that attitude and a lot of people in a lot of different institutions were left somewhat flat footed while they waited for the Supreme Court to decide what was going to happen and a lot of states were just totally confident that the whole thing was going to be thrown out and didn't do much at all. And then government procurement rules, I just couldn't do this lecture without a special call out for how awful they are. It is just remarkable. In Illinois to get a procurement approved there are 57 sign-offs that are necessary. And there are days when I can't find anyone who can tell me what are all the different 57 steps but eventually you bumble through them but all of this adds to time. So what happened? Given all of these obstacles, I think most people have a general sense of how this went. The federal marketplace got off to a horrendous start, big disaster. The truth is that they were just six months away from when they were ready to start. We all knew it. They were six months away. There are a lot of reasons about that some of them involving federal procurement rules but they were just six months too early. I have relatively high degree of confidence that they would have all been a very different story with just six more months but it was what it was. And at the end it came along in the vicinity of respectable about 7.5 million people have been enrolled through the marketplace. That's a little more than the congressional budget off as predicted. However you look at it, it's a lot of people. And remember that this was achieved despite active opposition in many states where all kinds of roadblocks were put up. There was no attempt to make this law work and make it accessible to people. Other states embraced it and tried to work with it. But 7.5 million is a lot of people. There is no reliable measure at this point impact of the other insurance provisions in teasing out those impacts from all of the other things going on in the ACA and this whole market upheaval. It's gonna take a while and it will be good work for academics when they get around but it will take a while. Medicaid expansion. There are 23 states that have not expanded. There will probably be more through do expand their expansion discussions going on in a couple of other states right now and in some of the states that didn't expand there's, there are interesting political pressures. For instance in Texas, the county boards from the big counties around Houston, San Antonio and Dallas have said to the governor, are you nuts? So that's an ongoing discussion. I mean the answer is yeah, of course, it's Texas. But all together now the feds are saying about 3 million people enrolled additionally in Medicaid. That number is wildly too low. I don't know what the right number is going to be. We know from our conversations with other people that between Illinois and California alone the federal numbers are understated by somewhere between one and a quarter and one and a half million just in those two states. I don't know what the final number is gonna be. In Illinois, the legislature did authorize expansion of Medicaid. I mean sorry, it did, that's the last point that did not authorize the creation of a state-based exchange. But because the administration supported it strongly it took advantage of what the federal government offered to become a quote, partnership state. And what that meant is that we worked very closely with the federal marketplace, received money for grants. We used that money to fund the Get Covered Illinois campaign if any of you haven't seen the ads from that then you've been living in a cave I think, certainly a media cave. But a lot of advertising, over 1500 navigators on the ground helping people getting enrolled in the marketplace or in Medicaid is an important part of the Medicaid expansion. And we had good participation by insurance companies in the marketplace. And as I said earlier, the legislature did authorize the Medicaid expansion and that has been a big undertaking which I've had the privilege of being oh so remarkably involved with. The official numbers for enrollment and there are no official numbers for enrollment in the marketplace for Illinois. The congressional budget target for Illinois of what they thought we would get was 145,000. We will exceed that number. Not sure by how much. And anticipate that enrollment will continue on into the next open enrollment period. In Illinois, the official estimate of the number of people receiving Medicaid as a result of the ACA is 430,000. I'm not authorized to say it, but the actual number will wind up turning out to be much higher than that. We've had just amazing response to the Medicaid opportunity. We received more than 50,000 applications in the month of March alone. All together, when the smoke clears in Illinois, more than 4% of the entire state's population will receive coverage through the ACA. That is a big chunk. And this is huge progress and a lot of people getting coverage. There are still problems. There's still a number of uninsured. There are a number of other issues that have to be worked through but a big step in the right direction. One of the things that's important for people in this room in their role as academics and practitioner academics is to inject sanity into the process of trying to evaluate this. It's just nuts to think that you can look at what's happened in the first couple of months and somehow divine from that what the actual impact of the ACA is. You know, this is the biggest shift in American healthcare, at least since the advent of Medicare, maybe even bigger. It's gonna be at least a year before we even sort out the numbers of what actually happened in the first year, let alone start to figure out what the impacts are. I would say that even assuming that there's no major change in direction, you can't take that as a given, but assuming that there is no major change in direction, you don't take two, three years just to get the outlines of what the impact of this is. In a lot of ways, the ACA is like letting the three-year-old in the cockpit of a 747 in spinning every dial all at once. And let's see what happens. And so teasing out these effects and really getting to any honest sense of what the impact is, going to take some time. I would also urge that one consider these in the broader context. I don't think healthcare should have been the most important item on the American political agenda for all kinds of things wrong with healthcare. I've done a whole career in it. I know a lot of them, but there are many other issues that I think are probably more pressing in America, but this is the issue that got delivered to us. And for reasons I kind of tried to outline earlier, I don't necessarily think the ACA was the optimal solution, but it was possible, which is a good thing. And the biggest problem, there are a number of other problems, is that it didn't directly address what's the biggest problem for healthcare in America. Not just too doggone expensive. America spends a much bigger share of its resources on healthcare than other countries where you wouldn't mind getting healthcare. It's too expensive. It's a jobs program now in America. It turns out that the difference between the expenditures for healthcare in America and what the expenditures would be if they were at the same level in the other countries that have good healthcare systems, turns out to be just about the same size as the stimulus bill. Each year. So a big problem, not squarely addressed by the ACA, but the ACA didn't claim to him. He claimed it was about coverage and it did that. It's also the case that for whatever the flaws, I suspect that the ACA is gonna be here for a while. I don't think that the country has the right political chemistry or the moral stomach or any of the other attributes necessary to fix it. So I think that the Republicans will continue to try to make political hay out of it, not that they're putting any alternative on the table. They've just done what is now what? 39 repeal votes in the House. Not an alternative, just get rid of it. And that's a good posture from them from a political perspective. They don't have to have the onus of dealing with what actually happens if they were to do that. I suspect that's gonna be around for a while. So unbalanced while what we have seen is not pretty, it does turn out to be a pretty big deal for those people who got health insurance. When the smoke clears, more than 10 million Americans will wind up having been enrolled in ACA coverage in a six month period. Might not have been pretty, but this is a remarkably effective thing. So I'm happy to answer questions. Question, are you prepared in Illinois to measure the public health effects of Medicaid expansion over time, citing the previous data from a combined study in New York, I think it was New York, Maine and Arizona, all with different political chemistry, showed the positive association between higher Medicaid coverage and population mortality, which is associated with more as a positive effect? I understand the question. I don't have, I don't know the studies in any great detail, certainly willing to look at them. It ought to be looked at as to what are the effects of the legislation. Well, what about you, are you prepared in your office to measure the effects of Medicaid expansion over the next couple years? Public health effects. Yeah, to the extent we can remember, we are a Medicaid program and we provide insurance for a set of people. Our office would not necessarily have the corresponding data on people who are not Medicaid enrolled. So it would require work with other people, but I think that that would be something that the academic enterprise largely thought of should undertake and it should be done. And to the extent our data is necessary, it's available. Do you think that unexpected increase in Medicaid enrollees is due to people applying for the workplace and finding out that their income was low enough to kick them into Medicaid so that it was a secondary outcome of the whole system being implemented? Yeah, there's no question that that happened, that the group of navigators who were focusing on trying to enroll people into the marketplace wound up sending more people to Medicaid. One of the things we did in Illinois, and this gets a little bit into the weeds, but it's kind of worth mentioning, is that in the spring of 2013, we said, hmm, we're not so sure that this federal marketplace moving applications back and forth is gonna work real well when they open up. So we used some of that partnership money to create an umbrella that covered both Medicaid and the marketplace. And so when you go to the Get Covered Illinois website or you go to a navigator, the first thing that happens is you answer a series of very simple, straightforward screening questions about whether you're more likely to be eligible for Medicaid or the marketplace to get you to the right place, so as to avoid getting caught up in all of these transfers. And when that happened, a lot of people got referred to Medicaid. I think that's a great presentation. There was one area where there is, by part, is the negotiation and conversation which is between the Obama administration and the Republican governments. And I'm wondering if you're seeing anything coming out of that that is being fruitful until the morning because some of the information about all states are perhaps in front of you both where there isn't a kind of conversation about that. Yes, there has been that cooperation and that's one of the reasons I believe that Medicaid will continue to expand because governors look at this and say, well, wait a minute, this is an opportunity for our state that's awfully hard to walk away from. The specific things that are coming out of that are typically relatively tailored to those individual states. And it continues in that sort of theme of having so many programs out there that makes it hard to walk from one program to the next. There are some elements of the discussion, particularly around what's known as premium support or some version of premium support, that over time we might embrace. But right now we've got our hands full just working through what we have on our plate right now. Hi, thanks, Mike, for a really good explanation of the context of the political background. I suppose that was very helpful. If you're following up on Harold's comment, what can we as an anti-medical community do in the current context, you know, besides the fact that we were doing studies and demonstrations and we're trying to flesh out care in the current environment, what can we do to help inch our society towards, you know, this bigger vision about it should be? Well, there are two roles. I mean, this is one of the things I was loved about the Medical Center and drove me nuts about the Medical Center is that as you implied, you've got two roles. One is academic and a responsibility for taking hard looks at what the data shows and the other is delivering care. One of the things that I often say about the ACA is that as important as the ACA expansion was that it's adding 400,000 people to 2.7 million people. We have to keep focus on all 3.1 million people. And as a consequence of that, a parallel initiative in the Medicaid program in Illinois is to move as many of our patients as possible into some form of managed care over the next two years. Now, we're very agnostic about what kind of managed care. We're not, we have no belief that it has to be a for-profit HMO in the traditional model. We have more models than you can shake a stick at. What we do believe strongly is that unmanaged care is not a sustainable position for the future. And so the Medical Center as a delivery entity has to decide how it wants to work in that. And that's part of a bigger set of changes that are going on in healthcare and that most of you have encountered in various places that are a response to the fact that I'm not the only person noticing that healthcare in America is very expensive and that over time, and I think time's gonna turn out to be a shorter time than people sometimes think, the demand for more value out of the healthcare dollars is forcing a radical realignment and a radical restructuring of how the healthcare resources get used. And I think the Medical Center has to decide how it wants to fit into that. And it's a unique set of challenges which I doubt have changed that much in the six years I've been going on. So it'll be very challenging for this place which really has historically had a bipolar organization or a bipolar mission of providing healthcare, pretty basic healthcare to a large group of people and then providing very, very, very specialized care to an even larger group of people. But the whole financial structure resting on that. Yeah, Mark. I just want to get clear. Are you expressing confidence that we are going to bring the cost of healthcare under control over the next five or 10 years? I mean, is that your position that we're not gonna go from 18 to 20 to 22% of GDP? That's my position. I don't, confidence is not a word I would use in this context, but my position is not because I've studied it in the same way that certain academics have, but because I live in a political environment and I say, okay, we have GDP growth of whatever it is and we've got a few other needs on the horizon. Like sooner or later, we're gonna have to do something about global climate change. And I don't think that's gonna be cheap. Somewhere along the line, we probably might wanna think about how we educate people. I think in balance, we put enough money in education, but I'm not sure it's, we've got to do something about the nation's infrastructure. We have many other needs and at some point, the reaction, and I think it's already started to happen, that says, why are we doing a special stimulus program for jobs and healthcare? Let's do those stimulus in other places, spread them more broadly in the economy, and it simply isn't sustainable to keep growing healthcare at the rate it has grown. Now, drop off over the last couple of years, there is a lot of academic discussion about what exactly is the cause of that. There can't be any question that a material contributor to that is just the general economic malaise. Now, although one might say, well, why are we sure there's gonna be a period real soon where there's not economic malaise? But even setting that aside, there are other factors at work here that are causing people to demand greater value for their healthcare dollars. And I just don't think those are gonna go away. What kind of pressure do you think the Medicaid expansion in Illinois will put on those five providers? Is there a mismatch or are there enough providers or not? And is there anything that your agency is specifically doing to try to resolve that? On providers generally or did you qualify that? I'm sorry. Yeah, we'll put some. I don't think it will be horrific. And we could be wrong here, but a lot, well, historically, the vast portion of Medicaid has been delivered by safety net providers. These safety net providers have been providing some care to many of these clients and not getting any reimbursement for it at all. Now they'll get reimbursement for many of these clients and that will make their fiscal position better. How much excess the man gets generated because people now have a health insurance card and there are a lot of people who like to say, well, in the long run, this will be less expensive because people will get preventive care. No, no study anywhere that shows anything makes healthcare less expensive on that other than changing your delivery model. So there will be additional cost associated with it. The bigger problem I think is not going to be primary care where I think that there will be enough adaptations. And again, I'm somewhat guessing here, of course, as are all of us, why say it's gonna take time? But the bigger problem will be in the specialty care where now the people who have been going to work, you think about some of the people who are going to be covered by the ACA, the 55-year-old waitress who works in a Greek restaurant downtown in the Louvre who is single, now is going to get Medicaid coverage. She's been going to work with arthritic knees forever and now has a chance to see her way to a different set of circumstances. And so I think that the pressure will come on the specialty care. Some of these specialty are already in short supply regardless of whether you're private. So there'll be some issues there but I think they're in the broader context of things that I think it will be manageable. And that's been the experience in Massachusetts after some bumps in the first year. Things started even out. You can't generalize too much from Massachusetts because it's an isolated case for a lot of reasons. But I think it will be okay. But it's something we definitely have to keep a watch on. And we have to think about longer term as part of enhancing the value proposition but also thinking in terms of just getting basic access to people thinking about can we use nurse practitioners smarter or community health workers able to do more pieces of this. So we have to keep thinking about how to work on that issue. Thank you. I love it. No. We have that. I'm in a position that works in the disability space with some of the most complex patients that cost Medicaid to us. And I have two questions. Again, the decisions that Illinois made about how to begin its Medicaid extension. One is, I agree with everything you said, but I think we've increased the fragmentation by having seven or eight different managed care companies now in this space. Each of them have different pre-approval processes and administrative procedures and covered benefits and what not. So it's going to be very complicated for providers. And I think in the end, we've increased the administrative cost. We also have more narrow networks because of the way the managed care companies are setting up and providing the workforce. I should also mention I can involve a community care audience a little bit more. So my concern is the administrative burden and the fragmentation. And secondly, why did we start with the most complex patients who would be meant to manage care rather than the less complex patients? The answer to the second question is it's the basic Willie Sutton answer. They asked Willie Sutton why he arrived at banks and he said, because that's where the money is. There are 20% of our clients who are on AABD who are seniors and persons with disabilities. Those 20% of our clients account for 56% of our total expenditures. We knew we didn't have much experience in managed care and we knew it was going to take a while to get this worked out. And so we said, let's start where the money is the greatest because once we get it worked out, we will be able to have the biggest impact on the budget. And I agree with that. But the problem is managed care has very little experience. Very little. A lot of truth services. Very little. So very little and they know that. And it's hard to get them to say that in public. But when we talk with them in private, they know that, they admit that. One of the interesting things that is happening here in Illinois is that as they have come more and more to grips with that, those community service agencies that are attuned to the way the wind is blowing have gone to the managed care companies and said, you don't know how to take care of a homeless schizophrenic who uses drugs. Let us subcontract some piece of this with you. And we're starting to see that, that Medicaid agency has made that possible because we have used some of the money in the contract now to encourage these managed care companies to make some expenditures in community capacity building. They're starting to reach out to these groups. That's a process that they don't really know how to begin, but where community groups have seized the opportunity and started having those conversations at work, there just need to be more of them. But you're right, they don't know how to do that and they're, frankly, learning on the job. Are there ways that we can try to get with synergies with administrative burdens? I'm sorry, I lost it. Well, beyond the different capable processes that we've been working on, are there any ways that we can decrease that? Not sure, a term, longer term it will happen. That people always think back about the Halcyon days before X or Y. When I was at the medical center and 15 years ago, utilization review reported to me and at that time we were managing 185 separate pre-authorization protocols because every company had its own. You don't know what a great job your administrators are doing for you, by the way, behind the scenes. Trying to protect you from as much of that as possible, but it is an issue, it doesn't go away. And we do add administrative costs and there are ways one could get these administrative costs better controlled and better spent, but they would require a different political system than we have. So there's been some work with the crowd recently that describes how rising reimbursement rates for Medicare and also some of the increases in the Medicaid population are causing or incentivizing hospital systems to emerge. And that type of horizontal integration is leading to or has a potential to lead to an increase in overall prices for the consumer because of reduced competition. Does Illinois anticipate any of this happening in the state? Is there anything that we think can be done to address these issues? Well, that's sort of a graduate seminar question that we could spend a lot of time talking about. First of all, I believe that the hospital mergers not as a result of Medicaid or Medicare that they are a result of the broader set of changes that are going on in the healthcare arena. And you have to trace those back to what started with the first round of managed care in the late 80s and into the early 90s where there were all kinds of notions about how this was going to work. Many of them turned out to be quite wrong and made a particular mess, but eventually people sifted through the wreckage and say, what have we learned from that? And one of the things the healthcare institutions learned from that is that we are powerless against insurers, whether the insurer is Medicaid or Medicare or Blue Cross of Illinois, which has a much bigger market share than either Medicaid or Medicare, that the only way we can get leverage is to do one of two things. Either create for ourselves a particular niche where we can defend our costs because we're absolutely essential or merge with other people in order to command a better position in negotiation with the insurers. Now, on the other side, the insurer is arming too. It's an arms race. And I believe that what we are now in the middle of is a big battle for hegemony of the American healthcare system where for the first in decades, doctors clearly were running the American healthcare system. I think that that has changed enormously in what we're seeing now is the fight between the big hospital systems and the insurers as to who's gonna have hegemony. I believe that fight, particularly if it stays relatively balanced, will have enough give and take. But there are certainly issues that arise and arise in particular markets when the hospital consolidation, health system consolidation gets ahead of the insurer power and costs do go up. But sooner or later, as I predicted, hopefully rather than confidently, that all of this comes to a head because the country simply can't keep shoveling out more money for healthcare, given all of the other needs that face it. So that's the beginning is of an even longer-winded answer, but we'll stop there. Thanks for coming. I don't see a JV after your name, but listening to your commentary on the last four slides that you had, I said to myself, Kathleen Sebelius needed you as a defense intern tonight. So my question is... Got enough problems as is. Right, my question is, not trying to deal with all the parts and you know what's going on in Washington, D.C., but as a public policy maneuver or a move and you documented well how big a move this was, do you think that some administrator had to follow the score behind this rollout or you think it could've been better explained to the public had we had a chance to do it over again? Well, you know, there's a, this is from my youth, a Bob Seeker rock and roll song and it has a great line in it. I wish I didn't know now what I didn't know then. Could it have been explained better? Perhaps. I'm more sanguine on that. My wife and I argue about this all the time about whether it could... My point of view is that there wasn't that there were just a large group of people out there who were not interested in any explanation whatsoever. And so from a political standpoint, I mean, we're at a situation now where six months into this, the fact is that the federal exchange works plausibly well, it's still got problems, it's still hiding some of the problems that really exist there, but it's working plausibly well the state exchanges mixed bag there, some of them are working really well, some of them not so well, Medicaid expansion has gone pretty well in almost any state that did it, but there are still people who say, well, they're not sure about the benefits of the ACA. I'm not sure what, sometimes I think it's like saying that the Titanic had a communication problem. No, it had an iceberg problem, guys. So I just don't, I'm not sure that communication would have helped. Now, did Sibilius run this project the way it ought to be run? I think that that's a different issue, but what we didn't know then, we didn't know then. Thank you. I did finally recognize the Executive Director of the IOP, Steve Edwards is here. Steve, thanks for co-sponsoring this with us. Mike, it's a delight to have you back. Great to be here. Thank you.