 Good afternoon. I'm delighted to welcome you to the McLean Center's series on health reform. As you know, today's talk by Dr. Pollack will be the second talk of the winter quarter. Next Wednesday, January 22, Colleen Grogan, the chair of the graduate program in health administration and policy here at the university will speak to us on the politics of the ACA Medicaid expansion. It'll be an interesting talk to hear because some weeks later, Julie Hamos, who's the director of Illinois Public Health, will speak to us about how the Medicaid enrollment is going in the state of Illinois. So we'll hear Colleen next week and then Julie Hamos later on. Today's talk, I'm delighted to say, is by Professor Harold Pollack. Harold is the Helen Ross Professor at the School of Social Service Administration. He is also the co-director of the University of Chicago Crime Lab and an executive committee member of the Center for Health Administration Studies. Harold received his undergraduate degree from Princeton University and holds master's and doctorate degrees in public policy from the Kennedy School of Government at Harvard. Prior to joining SSA, Harold was a Robert Wood Johnson scholar in health policy research at Yale and then taught health management of policy at the University of Michigan School of Public Health. Harold's published widely at the interface between poverty, policy, and public health. Some recent research efforts have related to HIV and hepatitis prevention in injection drug users, drug abuse and drug dependence among pregnant women, infant mortality prevention, and child health. Harold not only publishes scholarly works, but his writings have appeared in the Washington Post, in the New York Times, and other publications. Today, Harold Pollack will be speaking to us on the topic of two steps forward, one step back, the ACA and disability policy. Please join me in giving a warm welcome to Professor Harold Pollack. Yeah, good. Thank you. Thanks, Mark. That introduction is always a reminder of my total lack of focus when you go through my CV. Thanks, everyone, for coming today. I know there's a lot of expertise in the room about the subject I'm going to talk about, so I look forward to a conversation as this proceeds. So my basic roadmap is I'll start with some generalities about the context of disability and talk a little bit, partly by example, about the variety of disability issues that are really engaged by health reform. And the ways that ACA helps people who are living with disabilities. Some of the ways that ACA tries to help people with mixed success. And some of the ways that ACA really doesn't try to help people who actually need some assistance. Now, I should say it's weird to give a talk about disability to think about the different mindsets we can bring to this. On one view, disability is a really complex subfield in health policy. And all these really nitty-gritty issues around nursing homes and home health care aids and SNPs and all sorts of acronyms that many of us don't know. And from that point of view, in a place like this, disability seems like a small subset of what we do in health policy that's for people with specialized knowledge. I actually think that's kind of backwards. Disability is really a domain of human life. And all of us are touched by disability issues in so many different ways. And it's really not a part of health policy. It's really something that's much broader. And many of the challenges that people living with disabilities face have a health dimension, but they also have other dimensions as well. In fact, those other dimensions are often harder to deal with. So we try to squeeze them into health policy. So Medicaid does a lot of things in schools for children living with disabilities. And you say, is this education or is this health? And in some sense, that question is really hard to answer, except that we can get resources through Medicaid that we can't get any other way. I also think disability is striking for another reason. Mark mentioned that I do research in substance abuse policy and welfare and crime and violence. And in some of those areas, you really see American social policy kind of at its worst, where you see issues that are disfigured by the politics of the culture wars, where you see sort of racial and economic divisions that really disfigure the conversation that we'd like to have about poor single moms or people who drink too much or use too much cocaine or whatever the issue is. And I can get pretty pessimistic about American public policy when I'm thinking about our tenuous commitment to disadvantaged people in these other issue domains. Disability is really not like that. I would say that if you had to look over the past 30 or 40 years, is the echo distracting? Can you hear me okay? Do I need to stay in one space? Let me know. If I can improve your listening pleasure, let me know. If you look over the past 30 or 40 years, I would say in general disability policy is an area of remarkable policy success in America. And it's all that more remarkable because we don't really notice it. But when I think about other areas where we've made equivalent progress, the only area I can really think of is maybe LGBT issues where there's been such a sea change in a variety of ways. But in general, I like the work that I do on disability because it really is an area where things are getting better. And I'm gonna say some bad news today, but on the whole disability policy is one where America's actually doing pretty well in some ways, despite the glaring shortcomings that we also have in this area. So what do I mean by a success? It's really remarkable how much we've opened our hearts and our wallets in this area. So one of the most striking things, especially if you travel to other wealthy democracies is just the physical accessibility of common spaces in the United States. If you go to London, Paris, Amsterdam, many places, Scandinavian countries, it's actually easier for people to get around in the United States in many ways if they have physical mobility issues. And that didn't just happen. And there's also the Americans with Disabilities Act in a wide range of changes brought about by that. The idea, individuals with disabilities, Education Act, the Olmsted Decision and related litigation, which is really something that has to a great extent ended some of the worst abuses of institutionalized care that we've seen in the United States and deinstitutionalization efforts. I think many people, when they think of the term deinstitutionalization, they think of this as a great policy failure. And we think of homeless people with severe mental illnesses standing by the roadside. But actually, this story is really much more complex and much more successful than you might think. And also the SSI, SSDI programs to provide income maintenance and just changes in popular culture that have accompanied the last 30 or 40 years. If you actually looked in a newspaper in 1960 and you looked at an issue like intellectual disability, what you would find is a lot of really freakish imagery and negative stereotypes. And that has really changed quite a bit. And the reason I put this up is to point out that health reform is only one piece of the puzzle and it's actually in some ways a small piece of the puzzle when we think about disability policy in America. Now the success or failure of American disability policy will not be shaped by ACA, but ACA is a very necessary component and its shortcomings create very important holes that have to be filled as we think about this. And so by the way, my criteria for success in disability policy, I would say, would include a set of these criteria. Are there, is there social acceptance and support that's reinforced through public policy? Do we, is this acceptance reflected in our daily lives? Do people have legal protections so that it's not just that we are being compassionate and charitable to people living with disabilities, but people have real rights of equal citizenship? Do people have entitlement security so that their economic needs are met? Are we spending the money that we need to spend? This is a weird one to put up because we live in a time where the idea that we should be spending more money seems very counterintuitive. But you know, we have to make sure that the resources are there. And also making sure that people have appropriate services across a continuum of care so that people can choose the kinds of living arrangements and service arrangements that suit their circumstances. Now disability itself, I'm not, if I said I'm going to define the term disability, we would then go to the end of the lecture with me trying to figure out a coherent definition. And I think that that's a very difficult thing to do. But I think one of the most important insights for public policy is to note that disability is really an inherently continuous and multi-dimensional measure of human capability, functional impairments, and limitations that interact with a particular environment. You know, I have a pretty weak back and that has almost zero impact on my life as a University of Chicago professor. If I lived in West Virginia and I worked in a coal mine, be a little bit different situation or if I worked in the city of Chicago picking up big cans of trash and carrying them to a garbage truck. And that was my job. We would think about disabilities is a little different for me. So the particular environment always matters but also public policy requires us to map this multi-dimensional and continuous thing onto a binary determination and some administrative process. That's just a reality. Either you're eligible for SSI or you're not. And in the real world, people come in all sorts of different flavors and it would be nice if we didn't have to always make these binary determinations but we have to do that. And we have to do that in processes that have some administrative predictability and consistent fairness for millions of people across the United States every day. And you can't stop and run an OJ trial every time someone applies for SSI. That's a dated, I think that metaphor is now dated since some of you were not born when the OJ trial occurred. There was this guy named OJ, I'll tell you later. So, the other thing to notice, disability services cost a lot of money. Now when we get into the realm of health policy, this is one of the most fundamental realities to it. If you think, for example, about the dual eligible population in Medicare and Medicaid, these are people who are eligible often, but not always because they're in nursing homes or they have a particular disability. People who are eligible for both the Medicare and Medicaid programs, this population accounts for 34% of the spending in each program. And all together in 2009, which is actually the last year that I found with this really good detailed data, $272 billion, and it's now, I'll let you know in secret, it's more than 272 now. And this is really where a lot of the money and a lot of the challenges in American healthcare, both in terms of improving the quality of healthcare and improving the economy of healthcare, we've gotta deal with this group of people. And for example, there's a lot of discussion in health reform, it's really costly to cover those 50 million uninsured people. I assure you that if we covered every uninsured person in America, we're talking about a heck of a lot less money than we are when we talk about the people who already are covered who are dual eligible. So when we think about the dollars involved, that's a very important element. And I should say it's also something that everyone in this room will be faced with or is faced with either directly or indirectly. One of the statistics that, the several scarce statistics that you can pull out, but one is just one third of today's 65 year olds can expect to enter a nursing home for three or more months. And I yield, you know, we have a super expert on disability policy later in the term. Temer is gonna tell us in detail about it, but it's really striking. You know, we often talk in the health reform debate, how do you get these young invincibles to sign up for health insurance? All these college students who think they're invincible. When we think about long-term care and disability issues, that issue is even more profound. I mean, how many of us really think about, someday I might need to be in a nursing home. That's just such a bummer that how many of us wanna focus on that. So one of the striking things, by the way, is how much money is spent in the under 65 population in this group. You might think Medicare is a program for seniors, which it is. But you know, for example, my brother-in-law is on, is a dual eligible Medicare Medicaid recipient, and is very proud contributor to much of that bottom bar right there. And so we're talking about some pretty serious money in making the economics work in health reform. And one of the challenges in disability policy was that when health reform was passed, there's a window of opportunity to do a lot in health policy, but there was also an incredible politics of deficit and constraints on what could be spent. And whatever you wanna do in this arena is very costly. So I should say that a lot of what's most valuable in health reform is in what you might call the junk DNA of the Affordable Care Act. Anybody read the Affordable Care Act besides Elbert? So I should say it's actually shorter than Sarah Palin's memoir, if you can't. It's, because they've actually padded, it's got narrow, the margins have been padded and there's big print, it's like a student term paper that's been, but there's a lot in the 2,500 pages or so that might be described as junk DNA. And that's really where a lot of the most interesting stuff is, and by the way, a lot of the most bipartisan stuff. And most difficult stuff in health reform is gonna show up. So there's a variety of things at the Innovation Center that Elbert talked about. State waivers to try various things, to improve the quality of care. One of the things that seems particularly pertinent here in Illinois, why don't you come on and if you're sitting in the back, if you wanna come and find a seat, please feel welcome to wander down. There's plenty of seats. The 16 States are now participating in an initiative called the Balancing Incentive Program, which will actually increase the state's Medicaid match rate as part of an effort to help states give people more options outside of institutional care and in home and community-based care. And so some of the things that states agree to do in the Balancing Incentives Program is improve the services provided to families for care planning, have common assessment tools for people so that we can streamline this process. And it's particularly pertinent in Illinois because we tend to lag behind in our over-reliance on institutional care and there's actually quite a few lawsuits going on related to the Olmstead. If I say the Olmstead decision, shall I explain what that is? Yeah, so the Supreme Court in 1999 ruled that it is discriminatory on the basis of the Americans with Disabilities Act to place someone, the people have a civil right to be in the least restrictive environment that is appropriate for them. And so the state of Georgia was sued and said basically our public policy is most efficient and streamlined if this particular group of people are in an institutional setting and these people wanted to be in a community setting that was not financially supported by the state. And the Supreme Court said that there was a right to be in the least restrictive environment that was appropriate for these people. Justice Ruth Bader Ginsburg wrote that decision and it's probably the most important Supreme Court decision that most people have never heard of. And since that time it's really solidified the closure of many large state institutions around the country. And one of the interesting political issues that comes up a lot in disabilities is how much should we rely on the courts versus how much should we rely on straight up political mobilization to make progress? And Olmstead is a great example of something where the court decision really made possible a whole politics around creating community options that might not otherwise have been available. And litigation was a compliment rather than a substitute for a lot of the advocacy work that needed to be done. And so as part of the balancing incentive program states, Illinois and other states are doing a lot to try to improve the processes of disability services. Also money follows the person. Another set of somewhat intricate initiatives that are designed to help people live successfully in the community and have proper financing for the care that they need. I think one of the positive developments with many of you noticed that healthcare.gov was completely screwed up when it was rolled out. I don't know if anybody noticed that. And one of the interesting things about the debate over the ACA now which I think is useful to think about in this context is the blocking and tackling really matters. There's actually tremendous consensus in America that we would like people to be living in a community setting on a human scale when they have various intellectual, physical, behavioral challenges. It's really hard to do. And one of the challenges that we have in a state like Illinois is actually making real what we all would like to do. And things like money follows the person will be a success or failure based on the quality with which the work is actually done. And I think it's actually been very helpful as we've watched the ACA roll out to see that a lot of us who favor health reform are actually looking at how hard it is and are being forced to confront. You know, how do we actually do this well? It's not an ideological debate only. It's also a performance debate, institutional capacity debate and so on. So just to show you how, oh, sorry. To show you how disability services cost a lot, let's just look at the state of Illinois. So if you look at the Medicaid expenditures right now in the state, it turns out that here's what the histogram looks like. This line here is the cumulative distribution. So it starts at zero and it goes all the way up to 100%. And this weird looking thing here is the average that's spent within each of these little percentiles. And here's the point of this graph. The top 3.2% of Illinois Medicaid recipients spend half the money that we spend in the state on Medicaid. The bottom 72% spend about 10% of total expenditures in the program. So when the typical Medicaid recipient is actually a pretty healthy low income adult or child, the typical Medicaid dollar goes to somebody who's pretty sick. And that's a really important distinction. So what, by the way, a pop quiz for you. We often talk about trying to use cost sharing so that we can more efficiently use dollars. If patients had more skin in the game, they would spend our healthcare dollars more efficiently. We would all spend our healthcare dollars more efficiently. And there's certainly some truth to that. If Mark and I had health savings accounts and Mark's knee was bothering him, it would be kind of useful from an overall system perspective. If he thought, you know, I have $10,000 in this health savings account. Let me buy my knee replacement in an economical way and actually do some research to figure out how much does this cost, can I do it better? But what does, but when you look at this graph, what does that suggest to you about cost sharing as a larger strategy in Medicaid? What's that? So say more. Well, you could have a, you could say, well, Medicaid will impose a deductible for the service or copay, say to families. So one issue is, of course, these are low income people. Let's even leave that aside for now. For the typical person, how much can we save money for the typical Medicaid recipient if we got them to use health services more efficiently? Nothing. Their average, the average spending in that bottom of 72% is $560 a year. So it doesn't matter what we, in a sense, the incentives that they face are basically irrelevant in terms of the overall program costs because they're just not sick. I mean, some people, I guess, enjoy coming in for an MRI, you know, for the heck of it, but it's not, you know, so you don't see a lot of sort of the, you don't see the frequent flyer colonoscopy problem too often. And then you have this group of people that really are where the money's being spent and they can't, first of all, they're low income, but secondly, their bills are so high, they can't really share those expenditures. So the idea that we could use cost sharing and some of those people have, by the way, dementia or have other issues, some of their end of life care. So the idea that they're in a position to really be intelligent shoppers for this is questionable. There is a role for cost sharing, but it certainly, as this histogram shows, people haven't really addressed that the people that we're most concerned about are really high ticket people with very complicated problems. So, and I should say, by the way, one of the most promising things in health reform is the attention, okay, we can't really use cost sharing for these people, what can we do? When I think about things like David Meltzer's CMMI grant, we're really trying to help patients with complex problems. One of the things that's really going to determine whether or not we can improve the economy of care is bringing the social service system and social services that could be provided in cooperation with the healthcare sector, bringing those two things together with providing healthcare. Many people have housing needs, other kinds of social service needs, mental health needs, and if you really want to address the really expensive people, A, you have to deal with those issues, but B, it becomes economical once you're focusing on these really expensive people to do things that you couldn't do for the overall population. If you said we should give every poor person a home, that's pretty expensive, but if you have a guy who's spending $250,000 a year because he's really sick and part of his problem that brings him to the emergency room is housing instability, all of a sudden it becomes a lot more sensible to say, where's the housing program for those people? And Heartland Alliance and others in town are doing some really interesting work to try to deal with some of the high expenditure Medicaid folks to say what can we do in the social service realm for them that would end up being economical? I should also mention not all disabilities bring the same challenges or stigma. One of the, when I give this talk and I say everything's looking up in disability policy, there's always someone in the audience who has a relative, who has a significant disability for whom things are not getting better. And I wanna be sensitive to that because a lot of my own work in particular is in intellectual disability, which is probably the area where we've made the most progress in a lot of ways. So if you think of these two people, that's my brother-in-law Vincent on the left and that's a man named Paul Flannery on the right. Vincent lives in a group home that is paid for by the state of Illinois, has a whole series of services that are very well supported and is supported by the way by a very powerful political constituency that can scare the daylights out of elected politicians when things don't go right. And if he were born 30 years before he was, he would have spent his life in an institution. In fact, if he were born five or 10 years before he was born, that's where he would be right now. That man on the right is Paul Flannery. He, and that's his sister who took care of him. He actually died recently. He lived a very harrowing life, teetering on the edge of homelessness, did not have access to the same services and really only got adequate housing and healthcare and other services when he was diagnosed with a very serious, what became lung cancer. And ironically, he got excellent medical care the last six months of his life, but the previous 20 years, he was cycling around being profoundly ill-served. And so there's a tremendous difference in social stigma and in everything else between these, between severe mental illness and intellectual disability, just one symptom of that. I'll show you two things. One is just, what are the images in popular culture? Here's intellectual disability. Life goes on, remember that show? Am I dating myself? You can get on Netflix and find it. This is, I think this was American Idol and here this was a nice story in the Washington Post about this young couple that got married and they're both intellectually disabled. The severe mental illness folks have a somewhat different set of media images to struggle with and this matters. Not entirely negative, Jane Pauley's memoir being an example, but one where there's an element of public fear that matters. And one place where this really shows up is the not in my backyard problem. This is a very nice GIS analysis done by Wong and Stan Hope in social science and medicine where they just mapped out in the city, anybody recognize what city this is by the way? This is Philadelphia. And the blobs on the left are the location and size of homes for basically group homes for people with intellectual disabilities. You see there's lots of small dots in basically every community in Philadelphia. If I asked any of you right now, is there a group home for people with Down syndrome near where you live? Many of you would probably say, I don't know. I mean, you might say yes or you might say no or you might say, well, I suppose that probably is I never really thought about it. I assure you if somebody said we would like to build a home for people with schizophrenia that there would be a different reaction. And in fact, if you look across the city, what you find is big dots in low income areas. And if you do various neighborhood analysis, you see what we all know basically looking at that map which is much more concentrated in low SES places and at a larger scale. And you just cannot achieve the kind of true community integration that you see in the left blob. So now let's think about who's helped. You may say, when is health reform gonna come into this? I mean, you go like, well, I thought I was gonna learn about health reform. Sorry, we're now getting to it. Let's think about a bunch of different people and let's think about who was helped and who's not by the provisions of ACA. So has anybody ever had the experience when you go to say Medici's and someone asks you for money outside of it or walking around Chicago someplace and someone asks you for money? I guess no one. I've had that experience. And you ever have this thing, maybe is there something that is, does this person have some sort of a maybe substance abuse issue or a mental health problem as I thought ever come into your mind? That's one person. Another person, how about the liver transplant patient? Actually, I did a lot of campaigning in 2008 and 2012. I just walked around going door to door doing campaigning. And in the process of that, actually I met a decent number of people who were in very serious financial problems due to chronic illnesses. And two things that were really striking about that to me, most of those people were insured, not all of them, but most of those people were insured and quite a few of them were actually already accepted into federal disability programs. Now if you're already accepted into SSDI, how can you be heading towards medical bankruptcy? That's a question question. Doesn't that seem sort of bizarre that you'd be accepted into, that you'd be deemed eligible for SSDI and still headed towards a very serious medical bankruptcy problem? The two year waiting period. And by the way, there's a long process that you've gone through to get to that point. So I met one man, actually went through a part of Northwest Indiana. And I went through this neighborhood. Everybody had a, this was then, everyone had a McCain thing on the front of their front yard. One house is a little Obama thing. And I walk up to the front door and actually there's a bunch of trinkets out on the lawn. They're having a garage sale. One of the things that I spent a lot of time just walking around to garage sales and things like that just to talk to people that's sort of a more friendly way to approach people in retail politicking than to knock on their door. It turns out that they were having a garage sale because the son-in-law of the owner, he was actually getting care in Northwestern Hospital at a very serious liver problem. And he was on this waiting list for Medicare and he was running out of money. And maybe they had a couple thousand dollars worth of trinkets on the lawn that they were selling, which I'm sure was a couple of visits and some medication, not a whole lot. So that's a different face of, sort of illustrates how the line between chronic illness and disability and policy lexicon is not obvious. Another person, anybody here that, anybody that listened to this American life about disability recently was called Trends with Benefits? Great title. This is basically about the growth in SSDI roles. That's Social Security Disability Insurance. And a typical person that they were concerned about on this show, a guy who was about 56 and he worked in a lumber mill in Washington State that closed. And he had a heart problem and he went on, he started, he applied for SSDI and a lot of people in that plant went on disability and SSDI roles have increased during the recession, particularly based on diagnoses like musculoskeletal problems and mental health problems. There hasn't been much of an increase in things like cancer. But here's a guy, he has a very legitimate physical health limitation, but he went on SSDI basically because his plant closed. And that's causing a lot of discomfort among people because we don't have quite the same social consensus about what to do with these near retirees who have real health problems but who would still be working if the plant hadn't closed. Another example, Rocky Clark, anybody here a football fan around Chicago? So who was Rocky Clark, anybody know? He was a big star at Blue Island High School, at Eisenhower High School. But I think the last person who voted Republican in Blue Island probably moved away long before that. But he actually was paralyzed in a football game. And illustrates another set of issues. And then there's a young woman named Marcella Wagner, who's actually the sister-in-law of Colleen Grogan and I have a colleague Andrea Campbell, who's a professor at MIT. And her sister-in-law, Marcella, was basically uninsured and pregnant and was in a car accident and she was rendered quadriplegic. So this kind of a talk is really, it's like you walk out, oh my God. And so there's a set of issues that she faces. And then there's a child of working parents who just has very significant disability. So some people, they're kids that, Peter probably has some of these kids in your clinic that are, so they're working parents and they have kids with really profound health needs that are also really expensive and challenging. And then there's just in case you're not freaked out enough, there's the professor who just walked out of his house one day to get the paper slipped on the ice and ended up in a wheelchair. Still a professor, but is in a wheelchair. The availability heuristic is a really interesting topic for another talk. The more you make these things vivid, the more they seem more likely. So who was helped by health reform? The answer is some of the people on this list are and some aren't. The guy who's asking me for money outside Medici, he's definitely helped. The liver transplant patient, definitely helped. The blue collar worker, definitely helped. Rocky Clark would have been helped. Marcella Wagner turns out not so much. And the child with cerebral palsy, we actually don't know the answer to that question yet. The professor that slipped, we were gonna help that guy, but it turned out we didn't. So basically, no. So let's think of, let's go through these. So the beggar, and by the way, the beggar of Medici faces a set of challenges that are more representative of other people. So most people who live with disabilities are not formal beneficiaries of disability programs. So for instance, if you look at kids, about 30% of the kids on Medicaid who have various, by various definitions of functional impairment, only about 30% of those kids are on SSI. So a lot of people who meet common sense definitions of disability would not be on any disability program. And in the case of our beggar at Medici's, one of the conditions that is specifically excluded as a qualifying condition is substance abuse. So if you have a serious substance abuse disorder, that will not contribute to your eligibility for disability programs. So here's a guy who's just poor and he's not a vet, he's not a mom. So he doesn't have any qualifying diagnoses. Pre-ACA, that person is uninsured. And if you say, who's gonna pay for that person's substance abuse treatment, mental health care, whatever he needs, whatever the answer is, it's not Medicaid. 41 states in the United States, pre-ACA, the income threshold for a low income adult to get on Medicaid is $0. So you can have zero annual income and not, and people often think you're eligible for Medicaid just because you're poor, but that is not the case. And so ACA immediately changes that by saying anyone with an income below 138% of poverty gets on Medicaid and so that's how now we can help that person. And you magnify that story for detainees in the Cook County Jail. I talked to Sheriff Dart and he considers ACA to be a game changer because almost all of the people in the jail are uninsured. And 20% of those people, by the way, have serious mental health issues. So people in the jail, people who are just low-wage workers, suppose you take someone who has been in special education when he's been in school, has some serious literacy and numeracy problems, is not intellectually disabled by the usual diagnostic criteria, but it's gonna be a really low-wage worker. That's a person who benefits from the Medicaid expansion in a state that actually takes it up. And so one of the challenges that we are gonna face around the country is what happens to people with these sorts of challenges who live in states that have just not taken up Medicaid. And that's going to be a big challenge. I should say also that in addition to the Medicaid expansion, the content of coverage through substance abuse and mental health parity and the definition of an essential health benefit is going to be important for those folks as well. So I mentioned children before. The important thing about children is most children with disabilities are getting help through Medicaid or CHIP if they have low income. So I'll give you an example of why this is such a big challenge. So this is the world's worst graph. So the solid lines are all numbers of kids and they correspond to this axis and the dotted line represents the percentage of poor kids who are getting cash assistance. And what do we see when we look at this? Over time, so the 1996 welfare reform is right about here. So what we see over time is that the number of kids on SSI has actually stayed remarkably constant. There's a real increase and then the increase really leveled off. But what's happened is the number of kids on TANF has absolutely plummeted and the number of kids in poverty has gone up. So the percentage of poor kids who are on cash assistance programs has really dropped. And that is where most disabled kids are actually gonna be. So this puts a lot of pressure on Medicaid and CHIP to fill that gap. Now fortunately Medicaid and CHIP have expanded for kids. But CHIP is actually up for reauthorization in 2015 and that's going to be a big issue. Now we get to our displaced worker. So this is a person that has a genuine problem. A person has a host of labor market problems and you say what should we do for this person? The real answer might be help that person get a job with a decent wage, that's out of my department. I don't know how to get that guy a job. But one thing about ACA is at least that person can get health insurance and then maybe that person is more able to take a low wage job that doesn't come with benefits which may be what that person can actually get. So at least we have decoupled the health insurance issue for that man from the should he get cash assistance question for that man. And you could very well come up with different answers. You could very well say, you know, I really don't think this man should be getting cash assistance if he's capable of working but just has to take a lower wage job. But if he has a heart condition, I want to make sure that his heart condition that he can get the care he needs for his heart condition and that he doesn't have to pay a really high health insurance premium because he's got a preexisting condition. So in some sense ACA may lessen the pressure that the administrative law judges who run SSDI feel to get people onto the program because they just want to make sure that person can get health care. And now how about our severely ill patient? So the liver transplant patient on SSDI, the reason that that particular person was put on SSDI was he actually had private insurance and he just blew through his lifetime cap. And that's exactly the same thing that happened to our football player and one of the sad things about Rocky Clark was that his mother actually took care of him at home and she had all sorts of home health care aids coming in to help and so on until he hit the lifetime gap on his insurance and then a lot of those supports went away. And sorry, there's a typo in there. There's always a typo in your presentation, right? When you're about to make a great point, you notice the thing that screwed up. And she really couldn't take care of him without that help and he actually died not too long after that. I don't know whether hitting the lifetime cap is what led to his death but she really wasn't able to take care of him. So the provisions of health reform that outlaw annual and lifetime caps for serious illnesses would have very directly helped both of these people. And also thinking about making sure that the essential health benefit in ACA is set up in a way that provides those health aids that are needed is quite important. That's actually, that's him. And quite a story. By another, if I were giving the football lecture that would be another talk. And it was just so tragic that his mother tried so hard to take care of him and she just needed more help than she was able to get. So that's Rocky Clark. Now how about the young woman who was rendered quadriplegic in the car accident? You might think, you know, since I'm such a pro health reform guy, I'm gonna tell you how wonderful health reform was for her. Turns out it wasn't so wonderful for her. And Andrea Campbell actually has a book coming out and I won't say too much about it. I'll let her speak for herself. But this story illustrates some of the real holes that we still have to fill in the Affordable Care Act. Now one thing is, one thing that would have helped her about ACA is she wouldn't have been uninsured before she got into the car crash. And you know, she was just one of those young, healthy people that didn't have a lot of money who took a chance and she got into an accident with a hidden run driver and that was it. But there's no real guarantee even if she were insured that her insurance really would have truly covered this kind of permanent catastrophic condition. And many people who have this happen even if they have pretty decent insurance draw on public support in various ways. She's actually now on Medi-Cal because she requires essentially permanent long-term support services. And Medi-Cal is California's Medicaid program. Now, so why isn't ACA much help? One of the biggest problems is that it's an asset tested program. So she and her husband and her child are only allowed to have $3,000 in assets, exempting their house and their vehicle. So she gets her healthcare paid for but she had to cash in her 401K and pay a penalty for that. She had to spend down her bank account and she's just never allowed to have more than $3,000. If you think about the life of a person who has a young baby and can never have more than $3,000, that is quite a burden. Her husband also faces very confiscatory marginal taxes on his own earnings. Essentially there's an income threshold for Medi-Cal and if he earns more than that he basically has to return that to the state of California. I'm skipping over some of the complexities but that's the basic picture. So for him to remain a full-time worker becomes very problematic unless of course he has a strategic divorce or moves to Massachusetts, something like that. There, an ACA really does not address that predicament at all. It really leaves alone those components of state Medicaid programs. And what's particularly galling is all the new people coming on ACA who don't come on because they're disabled but come on because they're poor, they don't have that same asset test. So for example, if you're a University of Chicago graduate student with a low income and you have a nice trust fund from your parents that's sort of sitting in the background or you own a nice house and you have some financial assets those don't get counted, your income gets counted. And there's an insanity to that disparity that's really quite striking. Now one of the good things about insanity in public policy is it tends to be politically generative. So I think what we're gonna see around the country is a real move to try to weaken these asset limits to at least make states like California follow the practices of more generous states because there's going to be this very identifiable specific constituency that's gonna be very organized around this idea that why is my life being ruined I can't save for my child's college because I got into a car accident. And particularly as we institute an individual mandate I think that will be even more powerful. Right now one of the responses that you could say to that woman is well you should have had health insurance. But at some point people are gonna say well we did have health insurance and we're still in this position. So if we had a $30,000 asset limit instead of a $3,000 asset limit make a huge difference for people. What about disabled dependence of working parents? Well some of those people will be helped because they can stay on their parents health insurance longer. You can stay on to age 26 under the new law. How many of you have a child on your own health insurance policy because of this provision? Anybody here have younger, there's a few. So I'll raise my hand. So that's very helpful if you have a child that just is gonna take a little longer getting going in the workforce. And a lot of people with living with disabilities are gonna take a little longer and that's going to be valuable. But we don't yet know how well a lot of the mechanics of ACR are gonna work for this population. So one of the big unknowns is how are these health insurance exchanges really gonna work when people have disabilities? And they're really not designed with this in mind. And one of the challenges we have is that a lot of the regulations that have currently been written are focused on the individual who is buying the coverage. Is this affordable for you as a worker? And they're really not the same level of detail and attention to what about my disabled child? And one of the challenges that we have is you could imagine that an employer offers someone benefits and they're really not adequate for their child. But they're deemed affordable under the law. Well that person can't then go to the health insurance exchange and try to buy something and get any sort of subsidy for that because they've been offered a plan through their employer. But there's a lot of mechanics of this process that really will be very messy and probably screwed up and will have to be fixed. Another problem is for, and Peter, do you have people in your clinic who have private insurance with supplemental Medicaid? So, if you're in the health insurance marketplace, you can't do that. So if you're supposed to earn 250% of the poverty level, I'm a worker, I earn 30 or $40,000 a year, I go on the exchange, I get a nice subsidized plan, but I have a kid with cerebral palsy and I say, well now I wanna go and get Medicaid help for the profound needs that we have. You can't do that through the marketplace. And that is a really serious problem that we'll have to address. Now, how about the professor who slips and falls? This is the guy that we kinda were gonna help and then we did it. So what happened to that? Boy, would sure be nice. So let's say this professor, what that person really needs is they need some money so they can rebuild their house so they have an ADA compliant bathroom and they have a ramp and maybe they need to buy a van so that they can drive to Hyde Park, although I wouldn't recommend that strategy for this person. Wouldn't it be nice if we had some sort of an insurance program that gave that person help to stay in their home? Well, this is a really hard thing for the private insurance market to do and it's worth taking a moment and then I think Professor Kanetzka's gonna say a lot more about this if I ever stop talking when she has to go in a couple months. When are you going? March 12th. Everyone come back March 12th because you'll hear a great talk. The private insurance market for these types of long-term support services are just inherently troubled. One of the basic problems is adverse selection. You know if I said right now, you know there's an insurance policy that provides these kinds of benefits, who's gonna be really excited about that? People think they're gonna need it. And the rest of us are like, that's the page in the benefit manual that I just kind of skip over and I don't care about? I mean, how many of you can carefully read your open enrollment materials? What's the overlap between that and the OCD diagnoses that... So how many of you actually purchase the Genworth option or have looked into the Genworth options available this year? How many of you have not? How many of you have no idea what I'm talking about? How many of you are afraid to raise your hand? Yeah, so my wife and I, we just got disability insurance through Genworth for the first time through the university. It's like $138 a month. So the tremendous adverse selection issues and just sticker shock issues for most people. The other thing is that... So that's one problem. The second problem is a lot of the real risks that this market is trying to insure against are exactly the kinds of things that private markets suck at insuring against. So if you think about like, let's think about your car insurance. So every one of us in this room has a 1 in 1,000 chance this year of getting into a reasonably serious fender bender. I just made up that 1 in 1,000 number by the way. But it's pretty much independent across all of us, right? So if 1,000 of us buy health insurance, one of us is gonna have a $20,000 bill and it's pretty easy for us to pool that risk because it's idiosyncratic risk. And yeah, the young guys will pay more than the old guys for car insurance, but it's a pretty well understood risk. Well, the real risk in the long term disability market is like, how much will Alzheimer's drugs cost in 2040? And that's gonna be the same for everybody with Alzheimer's, right? And what are the interest rates gonna be between now and 2040 so that the money that's put aside to pay for that is actually gonna accumulate properly? That's gonna be the same for all of us. So there's a series of really common challenges that you just can't insure by having lots of people in a big risk pool because it's the common risk. The other thing is, how many of you really trust insurance companies? You're buying a product that, it's amazing by the way, we think insurance companies are the evil doers in health policy. If they were the only problem we would have solved this a long time ago because they basically pull with made-off as far as their public esteem. That was a funnier joke than I got credit for. You're buying a product is this company gonna survive in 2040? And what kind of premiums are they gonna charge me in the interim if I start paying them now? That's a legit question. And also there's a weird problem because there's always the thought, well if something bad happens to me I've got Medicaid to take care of me. And in some sense, what the company is selling you the cost of your care but what you're really buying is the value of what they provide over and above what Medicaid provides. And that makes it sort of a more questionable deal, right? And so one of the interesting developments in the industry is figuring out how can they interdigitate with Medicaid in a way that makes it attractive for people. But this market has really done very poorly. And I think there's one other thing which should be mentioned which is just it's a bummer to think about this stuff and people avoid it. And how many of you were like, I came to a talk so I could hear about some guy who slips on the ice and ends up in a wheelchair? Like what kind of a day is this? So the class act is one effort to deal with it. So a pop quiz, how many of you have heard of the class act? You have not heard of the class act. I mean you could say what the acronym is. A few. So the class act was actually title eight of the Affordable Care Act. And I won't give you huge amounts of detail. It stands for Community Living Assistance Services and Supports. Suppose I should check what time it is. And it was kind of the legacy of Senator Kennedy and some of the disability community really wanted. And it was bitterly fought over in the lead up to health reform. It was supported by 275 major organizations in both the disability community and seniors. The fact that so many of you have never heard of the class act is itself prognostic, isn't it? If 275 organizations like AARP supported it and most of us never heard of it, that's interesting. And one of the striking things that's kind of discouraging for those of us who do disability stuff is this just never got any buzz within like the progressive blogosphere, things like that. If you said public option, how many of you have an opinion about the public option of some sort or against many? Many of us don't even know what this major pillar was in the law, and a pillar that was actually passed. Public option didn't happen. So what is the class act? So the idea behind the class act was that you would pay a monthly premium. And in fact, if your employer elected to participate it would be done on an opt out basis. So it would just be taken out of your paycheck unless you complained. And there would be no medical underwriting. And after a five year investing period you'd be eligible for benefits that were based on your activities of daily living limitations. So that was only for workers. So if you had someone who was permanently disabled and out of the workforce, they couldn't participate. But the earnings threshold was actually quite low. You had to earn Social Security credits for one quarter. So basically $1,200 a year. So pretty minimal thing. If you were intellectually disabled and worked as a beggar at Jule you would certainly be able to participate in the class act. And after your investing period you could get daily benefits and they could cover all sorts of interesting things that you would need to stay in your home or if you needed various kinds of homemaker services and so on, the class act would pay for it. How does this sound? Does this sound appealing by the way? It's a very innovative idea to try to keep people out of nursing homes or to help people live and thrive independently. By the way it also scored very, very well because under the ground rules of health reform there was a 10 year window over which you looked at the cost. But the first five years no one got any benefits because they hadn't invested yet. So it looked really great. It actually contributed half of the deficit reduction that was found in the first 10 years. No. Yep, so the class act contributed half of the estimated reduction in the deficit on net. If you look at the net reduction which was something like 117 billion about 59 of that was from class. So it was a very imaginative thing. I should say that it was, Republicans all hated it and many Democrats hated it. Kent Conrad called it a Ponzi scheme of the first door. You see the second mention of Madoff today. But it ends up being passed as part of health reform. And one of the interesting things is initially when Ted Kennedy first started talking about it, he said that the premium would be something like $65 a month. How many of you would pay $65 a month for what I just described, by the way? I mean, you think that's sort of too much money for you. How about if I said $100 a month? How many think that's too much? This is a really big challenge because when people looked at how much the premium had to be, it had to be self-financing and actually out to 2086. Now, how we're actually supposed to forecast is another question. But when actuaries looked at this, the Congressional Budget Office said, well, about 3.5% of the workers would enroll and the average premium would turn out though not to be $65 but more like $120. And that starts to be, wow. Now there were various, if you were low income or a student, you could actually get a much cheaper premium but that's what we were up against to make it self-financing. It's one of the constraints, there's no money coming from outside the system. But the Chief Actuary for Medicare looked at this and hated it. And he said only 2% of workers would sign up and that the premium would be more like $180. And that starts to be the point where a lot of us would say that's too much. I could just save my money and if I needed some data, buy this stuff, I would just buy it out of my savings. And the American Academy of Actuaries expressed deep concern about it. And all of a sudden there was just this gang tackle by a lot of people looking at this saying the premiums are gonna have to be a lot. And actually in February of 2011, two fairly progressive or certainly nonpartisan analysts, Alicia Monell and Josh Hurwitz looked at it and they said without an individual mandate be like $190 on average for people. And if you had an individual mandate and made us all do it, the premium would be about $94, by the way, per month, which is still actually not trivial but would be a lot cheaper, but that they would just be this intense adverse selection. And the act also faced some very significant logistical challenges. You needed employers to really market this to employees. So none of these things were happening. So people understood what was going on and there were a variety of fixes proposed to this. And what was interesting about it, two things were interesting about this story. One is there were a bunch of things that could have been done that they had planned to do in the conference committee when the health reform was finally put together. But what happened in the end game of health reform politically? Scott Brown wins the election to Massachusetts Senate and there is no conference committee. And the Democrats have to do this Ungepochki procedure to actually pass health reform and there's no conference committee. And it turns out that the Senate parliamentarian says you can't put in these fixes to class because you're allowed to make certain kinds of fixes to the budget, but these didn't fall within that. And so the Democrats were trying to fix the thing and then they found they couldn't because of the weird end game to this. And so this imperfect piece of legislation gets put in. And the Obama administration almost immediately is faced with a whole series of fights over health reform and they just decide this is one fight too many. And to make a long story short, they basically close up shop on class and last officially about a year ago the class act was actually repealed. And one of the sad things was not only was it repealed but sort of nothing was put in its place. A national commission was set up about long-term care and they couldn't actually come up with an agreement on financing. So as we used to say in engineering school, their report went straight to the right only memory. If you think about that one, that's one of those delayed action jokes. So what can we say about just to close up? Tremendous benefits to people with disabilities from health reform. Most of those benefits are indirect and they arise from the non-disability specific provisions of the new law. Coverage expansion, community rating of insurance and elimination of lifetime caps and so on. And also tremendous benefits just by improving the blocking and tackling of the healthcare system. Particularly dealing with people with complex conditions. This class act, I often think about this. I covered it actually for the new republic at the time. Now I think I covered it very badly. But maybe it was inevitable that this thing would die. The key sponsor, Ted Kennedy passed away. It was a voluntary program for public benefits whereas most of ACA was a mandated purchase of private coverage so it sort of didn't fit into the political debate very well. Very uncertain how much this thing would cost. And it also, the politics of this really didn't work out well. This thing, in order to get health reform passed, it had to be passed in a very polarized environment on a partisan basis. I think that was actually what they had to do. I don't think that was a bad decision. But here you have this incredibly complicated and intricate thing that really requires a lot of mid-course correction, a lot of pragmatic problem solving and new laws passed to fixed glitches and that just couldn't happen in the real world that we lived in around health reform. If it has the name Obamacare on it, you can't tinker with it in a pragmatic way. I think it is, it's revealing that there's so little attention to it now and so many of us haven't heard of class. In some ways what we really need is a bigger social insurance program to deal with the issues class was trying to deal with but there's just no way that can happen. The way class imploded also pointed out how fragile the coalition is for policies like this. What I call the adverse selection problem is really, if you think about this in a human way instead of in an insurance exam vocabulary question way, you realize that what we mean by adverse selection is there's a group of people right now who really need help and what they wanted to see is, is this gonna help me? So the disability community looked at a bunch of the fixes to class and said, you're basically saying people like me can't sign up for it and that's how you're gonna pay for the program. And so the politics becomes very tricky because what we really need is more money to help people who need help and that's just not available. So I'll just end. First the bad news, it's just hard to see an ambitious new social insurance program emerging to really deal with some of the problems I've outlined today. I also think that we're gonna go through this really rough period that's gonna be a lot like the rolloutofhealthcare.gov when it comes to disability issues where we're just gonna screw up a lot of things in the new marketplaces for example. But there's also a lot of good news. One is that there's a lot happening right now to improve the mechanics of Medicaid and other programs to make them work better for disabled people and the politics around that is very favorable and much less partisan. And so I think we're going to see through things like the Balanced Incentive Program. Services will get better, life will get better and there's real political support and practical realism behind these efforts. So I'm optimistic that the things will get better but not in the way we originally hoped. So thank you very much. I don't know if I got it finished. I don't know if I got it finished. So you started out talking about sort of a broad definition of disability and how some of it is context specific, which I agree with, but putting that aside, there's been this longstanding sort of political divide between the sort of under 65 working age disability community and the frail elderly who have reached disability through sort of basically age related conditions. And one might argue that the under 65 working age disability community has been much more successful politically at least in achieving sort of political support for getting care in the least restrictive setting possible. And this is sort of despite AARP and strong lobbying powers for the frail elderly. So I'm wondering, and the ACA may be one sort of almost unique example where those two communities really worked together to get a class included. Do you think there are lessons that the elderly disabled community could learn from the younger disabled community in improving services to meet their long-term service and support needs? Or do you think there's potential after this experience for those two groups to work together more? Well, I think the class experience leaves me a little pessimistic because I think what happened, as people saw the problems with class, people immediately saw these two groups have very different interests in that the frail elderly are actually a more powerful constituency. But they also have more needs that are more expensive. So each one has its own challenges. I guess one of the lessons that you can learn from the under 65 experience is when you change social perceptions and social norms, a lot of things that seem politically impossible all of a sudden become politically possible. And if the American public really comes to understand that my 87-year-old great aunt really doesn't have to live, really can be in the community if we give her the proper supports, all of a sudden things become feasible that seem ridiculous to ask. And the, it really, so I think that public attitudes are really important. I also think that sometimes you have to play the inside game and I think there's a lot of valuable work that can be done, for example, in changing asset requirements that most Americans are not gonna pay any attention to, but that actually tremendously important and where if you get inside the room with a legislator who really cares about it, especially one with an 87-year-old great aunt, you can actually accomplish some stuff. And maybe mass politics to try to create some new program is not the most strategically smart way to go about this but to go in a more incremental way. Those are some immediate thoughts. There and then we'll go to the back. Thank you. As a quick question that's similar in terms of Illinois and experience as you expected in Illinois versus another Midwestern peer like Minnesota or as you mentioned Massachusetts in terms of, as I see it, I think context makes a huge difference and the difference between the states is I really think the story of the ACA going forward. Well, Illinois has a very long way to go. I actually think public policy is improving in Illinois but we've had this legacy of very strong reliance on institutional care and low quality of governance. You know, it's interesting, we are a blue state but if you look at many of the measures of service quality and the way it's affected in people's lives, we rank astonishingly low in some of the national rankings and one of the sad things that I see is for example, the number of people who moved to Wisconsin from Illinois who have a child with autism or related issues, you know, it's really shameful and so I think we're, Governor Quinn has made it an effort to really work on that but we've got a ways to go. Now we're doing much better than a comparison if you looked at say Indiana versus Kentucky where one took up the Medicaid expansion and one didn't, you'll see a much more profound contrast. Yes. Yes, you mentioned the balancing incentives program but you did not mention the community first choice option which is also a part of the Affordable Care Act and it allows for a 6% enhanced match to the state over a much longer time period than the BIP. So I was wondering what's the reason you left it out and what your assessment of that would be? My reason was neglect. No, I think those are really valuable things and I think that those are the kinds of things that will be very generative particularly because they're not so polarized and because state governments really need the money. So some of the states that have not taken up the Medicaid expansion have been taking up these disability match programs, like Texas for example and I give them a lot of credit for that, you know, that they're, so I think that that will be very valuable. We'll have to see how the evaluations turn out for these things but I think they're all positive efforts to go forward. So, I have a question. The first is that L.A. right now, if you remember the histogram, when like 3% of people occupy 60% of all the lawsuits and stuff like that, is that true in more of this L.A. Medicaid, comparable things too for U.S. Medicare or other things like that and if as I suspect there's nothing special about L.A. Medicaid, it probably is true. Is there any pressure to just say, well we could save a lot of money by not paying for 3% of people? Fortunately no, there's not a lot of pressure but there's a lot of anxiety. If you take some issue like death panels, at one level you say, wow, that was a complete BS thing that was just made up but if you say, why is it that it got such traction? People have an anxiety, they know intuitively, well that's a group of people you might go to to ration care. I actually think that what people wanna do is see good care provided to that group of people. And when I, we don't have a lot of, it's not that that money is being poorly spent and we don't know that that money is poorly spent but we wanna make sure that, you know what makes a lot of people upset about end of life care is when they see a horrible quality of life and a lot of money spent. But I actually don't see sort of a desire for sort of rationing end of life care or cutting on the disabled. All the survey data we see suggests much greater public acceptance of people living in profound disabilities than ever in American history. And so I think that that, so that's where I stand on that. Justif, how did class disappear without any of us hearing about or most of us with 275 major organizations originally supporting it? They all cut their losses. They cut their losses. There were two things that happened. One is that there was an inevitability about its death that made everyone decide, I don't wanna put any political chips on this thing. So, you know, it's like when one animal and the herd is wounded and the rest of the animals just kinda wander off and then the gang of wolves come and kill that animal. That's kind of what happened to class. You know, it happened in the context of an incredible knife fight of over the entire healthcare reform. And so AARP, for example, was thinking, you know, we have a bunch of things we can emphasize. And when they realized that a lot of seniors didn't really care about class and, you know, they just backed away from it. And the disability organizations that actually did care realized that the Obama administration just was not gonna, that they basically closed up shop on it. And so why make a big deal over something that's just gonna go away anyway? I think Colleen had a question. Thanks, Harold. I really enjoyed the talk. I heard someone nod from you, as always. Just on that point about class, that's also, you know, to me, it was just, it was a deeply flawed design. And, you know, my thinking of it was, as you said, it was inevitable, but to me it was inevitable because the design was so deeply flawed, you know? So you can't have a voluntary insurance mechanism without adverse election. It's just, I think the, you know, I'm surprised it got passed in the first place. Like how, I think there was just too much going on and somehow it got passed because as soon as you looked at it in more detail, you just knew it was gonna be astronomically expensive and the main people that were gonna sign up were really sick people. So to me, especially if I got one of the design flaws I think was that you five years, you're invested. So why not wait till you're 65 to sign up? I mean, the problem is they wanted to create something like long-term care social insurance, but they didn't volunteer even. Somebody like me, there's no way I would have signed up because I don't, there's no incentive for me to start paying them now. And so it's sort of like they were wishing to get social insurance, but knowing that, I mean, when you say that we needed some technical fixes, an individual mandate is a pretty major technical fix. I mean, that's recreating that social, national long-term care insurance. So anyway, I guess my question to you is, it's really that you have to get the non-disability and the non-elderly community to buy into the idea of something like class. And are we anywhere close to that? Because that's how you finance it, right? You don't finance it all for the people that are already sick. That's Medicaid, that's what we already do. A couple of thoughts on that. I think A, your absolute performance matters. I remember when President Obama's performance ratings and the ratings for health reform dropped after October one, of course they dropped because there's poor performance. So people's performance ratings tend to drop. If you craft a poor law, people won't, you know, you have a problem. I think many of the framers of class thought that you could get something on the books that was reasonable, that would need to be fixed, but that we could go forward with it and end up with something more valuable than if we wait. There is a paradoxical thing where the more the politics rule out bringing in money from outside, doing something straight up like a national social insurance program, the more ideological moderation and fiscal constraints push you into this institutionally radical strategy because they were gonna create this whole Ungepochki structure and try to make it work. I do think that had they tried to fix class, had the Obama administration really had its heart in it, that there were things that could have been done and it could have been crafted more carefully in the first place, but the real problem was it would have disappointed many of the disability advocates because many of the fixes, you couldn't have done an individual mandate, but if you put in a long vesting period, required people to have higher engagement in a labor force to be eligible and things like that, you would have really, those 275 organizations you would have discovered, a lot of those people would have fallen by the wayside because they would have realized you've just defined us out. And if you really wanted to reach the non-disabled, really healthy groups of people, that's what you would have had to do. Wow, that's really hard to do when the people excited about this law are exactly the opposite group. I'm very committed, I can try to talk. I think you've shown us that we need a national health insurance program, a single care program which would take care of just people with disabilities like everybody else. But that aside, I'm wondering if you could comment on what has happened in Illinois Medicaid with the so-called Smart Act of 2012 with the cuts in Medicaid, the adult dental insurance, the limitation of only four prescription drugs per month before a physician has to get free approval for adult patients, the constraints on home care for children with high levels of technical needs. Can you comment on what that has meant for the people with disabilities? Well, this is a family lecture hall, so I can't fully describe my reaction to some of the things that you've mentioned. You know, the dental program was so, is the huge failure in American health policy. If you look at any severely poor person, the problems that they have are as clear as the smile on their face. Every single severely vulnerable population I've ever worked with, everybody's teeth are messed up. My brother-in-law, we gave up on finding a dentist that would take Medicaid long before 2012. And I think that those things are, I think there's a real Medicaid cost problem, but I certainly think that many of the things that you identified are harming the lives of everyday people, and I would like to see them addressed more successfully. So I'll leave it there because we're all coast out of time, but that's my... We'll take one more question. Hi, thank you so much. I'm really interested in disability policy and health, so this was a perfect lecture for me. But I have been working with an organization here in Chicago that works with adults with disabilities. And there's been two terms that have been said a lot and I'm still trying to grab what it means. One is managed care organizations and the other is the 115, 1115 waiver. And the people with disabilities that I work with a lot have developmental disabilities and it seems that as they term it in my work, the DD world is very much opposed to it whereas other groups that fall under the disability world are for it and I'm just hoping to get your insight. It's a complex subject which I can't deal with in its full complexity. I'll just say a couple of things about it. One is it's interesting, as a family member, I would love to see truly managed care and I'm sure that we would save a lot of money. On the other hand, I'm also very risk averse and I have a bunch of things that are basically working and if someone says I'm gonna, we're gonna put your brother-in-law in a Medicaid managed care plan now, it's hard for me to be happy about that because I just now worry that there's just gonna be new constraints and complications and I think these plans have to earn legitimacy within the disability community. I think in the experience is very state specific. In some places these plans turn out to really improve people's lives and improve care coordination and people say I really wanna be in this and in other places people have the opposite experience and now the advantage that the DD community has is it's hard to ram something on the throat of the DD community because there's just the politics work out that way. I'm more concerned about some other disability populations that are just less powerful. So I think all of us, there's such a need for care coordination but there's such a fear that the care coordination process would be used to limit the care that we need and so that's what, or prevent us from seeing the specialists that we feel that we need to see. Harold, thank you so much. Thank you.