 All right. Hi, everybody. I think we're going to try to get started since we have such a great program today and only, unfortunately, until 2 o'clock in which to run through it. So thank you all very much for coming. OK, so my name is Aaron Kesselheim. I'm an associate professor of medicine at the Brigham Women's Hospital and Harvard Medical School. And I run the program on regulation therapeutics and law, which is partnering with the Harvard Medical School Center for Bioethics to bring this series of health policy and bioethics consortia. I have up here also the Twitter hashtag because we are live streaming today's discussion for the first time. And so we're going to also try to have some conversation on Twitter as well. So please use this hashtag if you have anything that you want to add. Just to give you some background on the program on regulation therapeutics and law that I run, Portal is a research core based in the Division of Pharmaco Epidemiology at the Brigham where we focus on studying the intersection of law therapeutics and public health. We have three full-time faculty members, seven postdocs and numerous students. We focus on developing empirical and policy analyses usually related to pharmaceuticals, medical devices, other FDA regulated products from all the way from development through approval and their evidence-based use. And develop work for the peer-review medical literature as well as op-eds. And we are also often testifying before Congress on some of these issues because in the last couple years, pharmaceutical policy matters have been very popular. We run courses at the HMS Center for Bioethics. And you can find us on the web at portalresearch.org or follow us on Twitter as well. The objectives of this series of consortia this year that we've organized is to try to articulate key issues in the health care system that involve ethically challenging policies or practices, bring together experts. And we've got two fantastic experts today with different perspectives or experiences to consider or propose solutions and stimulate conversation and further academic study of the topic to help advance the field. And so just to mark your calendars for the upcoming ones this fall that include caring for high-need patients in October, gender equity and academic medicine in November, and revolutionizing delivery of health care with former CMS administrator Don Burwick in December. So right now, though, I want to focus on today's session and I want to introduce our moderator who'll give a little bit of the lay of the land. Michael Sinhai is a physician and lawyer who works as a post-doctor research fellow in our group and has a little bit of introduction before we get to our expert speakers. So thank you very much and please enjoy. And Mike. Hi, everyone. It's a pleasure to have a great crowd like this here. I'm just going to do a quick fly by a day here covering seven years from the enactment of the Affordable Care Act in March of 2010 until now. Many of the details will not be discussed thoroughly here, but I hope we can expand on some of these topics with our experts. The Affordable Care Act was drafted in March of 2010. As you know, it's had a significant impact on the way we deliver health care in the United States. Perhaps the most prominent impact, though, is the fall in the rate of uninsurance in the United States, precipitous drop that had not been seen since the creation of Medicare and Medicaid in 1965. And we're now at a level where this is unprecedented. We have the lowest uninsurance rate in the history of the country. Now, this has not been without a struggle. There have been several legal challenges to the ACA. The first was the US Supreme Court case, NFIB versus Sibelius. This was a case challenging the individual mandate and also the Medicaid expansion, which was, as written in the ACA, mandatory for all states. The court at the time upheld the individual mandate but ruled that the Medicaid expansion would be unduly burdensome for states if mandated. So the Medicaid expansion became optional at the time. And as we know, there are several states, large states, including Texas and Florida, that have not expanded Medicaid. There are a couple of other cases that looked at the finances. The first was King v. Burwell in 2015, US Supreme Court case looking at tax subsidies. The Obama administration won that case. And then a current case, US House of Representatives v. Burwell, which discussed cost-sharing reductions, now cost-sharing reductions, are additional sums of money that are provided to people who purchase silver plans to help offset costs of deductibles, copays, and coinsurance. This case is currently being appealed. But with the change of the new administration, it's unclear as to what the status of that appeal is going to be. Now, the ACA obviously reached an uncertain future after the presidential election. President Trump, as one of his campaign promises, stated that on the first day of the Trump administration, we will ask Congress to immediately deliver a full repeal of Obamacare. Now, they started out in the US House with the American Health Care Act, or the AHCA. They wrote the bill. They were getting ready to bring it to the floor. And Speaker Ryan was unable at the time to come up with enough votes. He said that we came really close, but came up short. And at the time stated that Obamacare is the law of the land. Not six weeks later, the American Health Care Act was passed in a very narrow vote, 217 to 213. President Trump held a ceremony in the Rose Garden of the White House declaring that Obamacare is, quote, essentially dead. Now, the next step was to move the HCA to the Senate. The easy solution at that time would have been for the Senate to pass the HCA. It would have gone directly to President Trump's desk for signature. A lot of the people in the Senate didn't agree with certain provisions within the HCA. So they proposed a series of other bills. You'll see all the acronyms here. But the RA stands for Reconciliation Act. And that just means that each, the Senate and the House, can separately pass legislation. But then they have to reconcile it through the budget. And the deadline for that is September 30. And there are a lot of protests at the time. This is a woman being dragged away from Senator Mitch McConnell's office in June. Now, why the protests? I think we all know under the current law, there are currently 28 million people who remain uninsured in the United States. Each of the various forms of bills that were being proposed would have added between 15 and 32 million more uninsured people in the next 10 years. Now, each of these bills did finally come to a vote. It came to a halt on July 28 at about 1.30 AM. I was certainly tuned in. John McCain famously gave his thumbs down to the final bill, which was known as the Skinny Repeal and Health Care Screech to a halt at that time. This week, it's certainly timely. This week, Bernie Sanders introduced a Medicare for All bill with the support of several Democratic senators. And Lindsey Graham and Bill Cassidy are looking at reviving some of the elements of the American Health Care Act and looking to bring those to the floor for a vote prior to September 30. So with that, I'd like to introduce our experts for today. Our first speaker will be Dr. John McDonough, who's a professor of public health practice in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He serves as a director for their Center of Executive and Continuing Professional Education. From 1985 to 1997, he served as a member of the Massachusetts House of Representatives, where he co-chaired the Joint Committee on Health Care. Between 1998 and 2003, he worked at the Heller School for Social Policy and Management at Brandeis University. And between 2003 and 2008, he served as executive director of Health Care for All. And while there, he played a key role in the passage and implementation of the 2006 Massachusetts health care reform law. Between 2008 and 2010, he served as a senior advisor on the National Health Care Reform to the US Senate Committee on Health Education, Labor, and Pensions, where he worked on the development and passage of the Affordable Care Act. His articles have appeared in health affairs in the New England Journal of Medicine, among others. And he has written three books, including Experiencing Politics, a Legislator's Story of Government and Health Care, published in 2000, and Inside National Health Reform, published in 2011. Our second expert is Dr. Raul Ruiz, a physician and US Congressman from California's 36th congressional district. He was elected to Congress in 2012 and re-elected in 2014 and 2016. He attended UCLA as an undergraduate and subsequently earned three graduate degrees from Harvard, an MD from Harvard Medical School. So I assume this room looks very familiar to you. A master in public health from the Harvard T.H. Chan School of Public Health, and a master in public policy from the Harvard Kennedy School of Government. He completed his residency in emergency medicine and his fellowship in international emergency medicine at Brigham and Women's Hospital. As an emergency room physician, Dr. Ruiz founded the Coachella Valley Health Care Initiative in 2010. He later served as senior associate dean for the School of Medicine at the University of California Riverside and earned distinction for his humanitarian efforts for victims of the earthquake in Haiti in 2010. Dr. Ruiz continued his work as an emergency room physician until he was elected to the US House of Representatives in 2012. And with that, I'd like to turn the floor over to Dr. McDonough. Thank you. Thank you. Is there a hand now? Turn around for the slides. Oh. OK. Hi, everybody. Nice to be here with you. So I kind of started my career in politics and then moved out of it. And Congressman Ruiz kind of had a career and then he's moved into it. So I sometimes refer to myself as a politician in recovery so I can empathize with the stresses and challenges. So I'm not going to talk about ethics so much today. I thought instead that it'd be more helpful if I talked about behavioral economics. And in particular, one part of behavioral economics that I think provides a thread that can link together 70 years of health reform in the United States, not just the past, also the present, and also a tool that may be helpful in the future as well. So let me take you on this journey. I'm going to go very fast because I only have 15 minutes and I'm going to talk about 70 years or so. So the theory, the basic tenet of behavioral economics is a tenancy for people to behave differently when they face a potential loss. Hey, sir, I think you're kind of blocking the screen if you want to. That's great. Thank you. The tenancy for people to behave differently when facing a potential loss for a potential gain. And loss is loom larger than gain. So if I tell this half of the audience that at the end of this session, I'm going to take you all for ice cream. And I'll pay for it. You're probably going to say, well, that sounds good. I'll believe it when I see it because I don't trust this guy. And if I tell these folks over here that at the end of this forum, I'm going to ask you all. I'm going to tell you all you have to contribute $5 a piece to pay for the ice cream that I'm going to give these people. These folks are going to sit on their hands. And you folks are going to grab for your pitchforks and start coming after. And so that's been tested. I think it's been pretty well documented. And it's something that I have seen over and over again in all realms, very much including health care policy and health care reform in the United States. And so let's just take a quick journey on this. And let's start way back late 1940s. President Harry Truman proposes a national single payer health insurance plan modeled on Britain, other things developed by Franklin Roosevelt. And he picked up the plan. And he kept moving on it. Initially, the support sounded pretty good, about 58%. By the time it really became hot, and there was a push in Congress to try to pass it, support had dropped to 36%. And when people were asked, only a third of the public said they thought it should be public. And two thirds said they thought it'd be better if it were a private sector plan. The American Medical Association took the lead in fighting it, claiming it was going to make doctors into slaves. And they actually assessed every member of the AMA $25 to pay for a public campaign to convince Americans that it was a bad idea. And it was the largest public campaign, the largest, that biggest financed publicity public policy campaign in the history of the country up to that point. It also got caught up in the Cold War and the McCarthyism period and the Red Scare and all the rest. And it died. And ignominious death didn't move anywhere in terms of actually becoming realized. And that was really our first major experience with the politics of health reform and just how difficult it was. Jump forward to Lyndon Johnson, who signed the Medicare and Medicaid law. The roots of Medicare and Medicaid actually started in the early 1950s with the collapse of the Truman Plan. And the people who were pushing it said, you know, we probably ought to narrow our sights and started in the early 1950s to start to do the work and the advocacy and the pushing to push for health insurance for all senior citizens, for just the elderly, trying to restrict it. They were helped because big corporations saw a huge advantage in this because many of them were now paying increasingly expensive bills to provide health care for their retirees. And this was a way to be able to get out of that. So there was a big business connection that was actually quite advantageous. Again, it was bitterly opposed by the AMA. By the way, here's Harry Truman watching Lyndon Johnson sign it in Independence, Missouri. And I think it was July 31, 1965. The interesting and the initial thrust of it was that Democrats were just pushing for insurance for hospital services. And Republicans opposed them, but they realized they had to put something out. So they said, no, we don't want to pay for hospital services. We want to pay for physician services, for outpatient physician services. And so it became one versus the other. And it was the brilliance of Wilbur Mills, the chairman of House Ways and Means from Arkansas, who said, let's not do one or the other. Let's do both. And that's what happened. And so we had the three-layer cake, Medicare Part A for hospital insurance, Medicare Part B for outpatient prescription drugs, and then they put a third layer on the cake, Medicare. Kind of the caboose on the train. And of course, today, the caboose is bigger than the whole train. 75 million Americans versus 55 Americans. Irony's just a bound in this business. But so fierce opposition helped by, by the way, super, super majority of Democrats in the House and the Senate, more than two-thirds majority that enabled them to get this through, be able to avoid any filibuster wasn't an issue. So I think the lesson, narrowing the scope, narrowing the scope of conflict, was able to get it through in spite of intense opposition. Let's flash forward, Ronald Reagan. I just have to put these two pictures up here, because they're so wonderful. 1983, 1983, legislation passed to revolutionize hospital payment in the Medicare program, to create a program of regulated pricing, still based on fee-for-service, but with new levels, so the prospective payment system, with the heart of that being the DRG system, the diagnosis-related groups. Big change for hospitals, not big change for anybody else, happened significantly because they front-loaded the financing of the program so that in the first few years, all hospitals were significant winners. They got significant financial gains that made them encouraged, and so every hospital got into this thinking they were going to be winners, and then it was only three to five years down the road that they started feeling the squeeze, and by then they were all sucked in and it was too late, and they couldn't get out of it because this was the new model. So again, something happens when it's a narrow scope, when people are much more constrained in terms of what they're moving for. Late 1980s, Ronald Reagan was president. He had a problem. The problem was called Iran Contra. Iran Contra was selling, giving arms to the rebels in Nicaragua who were called the Contras and making a deal with Iran that involved chocolate cake and other things like that. Won't mention it, Oliver North. And people talking about impeachment of Ronald Reagan and he asked the cabinet meeting, he said we have to do something to change the subject. Does anybody have any good ideas? And his secretary of health at the time said yes, let's create a catastrophic coverage program in Medicare. And everybody said sounds good to us, and that's what they did. So in 1988, President Reagan signed the biggest expansion to Medicare since it had been created 23 years before that called the Medicare Catastrophic Coverage that eliminated many of the co-payments, created a long-term care benefit, prescription drug coverage, all kinds of things that people thought were missing in Medicare and wanted to see. And it was financed in part by new premiums on higher income senior citizens. And those senior citizens, the ones who were affected by it and started getting the bills for these payments started getting really angry and agitated. There was a famous scene, the head of the House Ways and Means Committee at the time was a guy named Dan Rostankowski from Chicago, later a resident of one of our finer federal correctional institutions. He was going to a senior citizen center in one of his neighborhoods in Chicago to have a celebration with his senior citizens and when the car was driving up, he saw this big crowd out front of the center and he thought, oh, isn't this great? They're so excited to see me. They had to come out and greet me. And when he got there, they surrounded the car. They started beating at the car, complaining, yelling at him, almost like US politicians in Latin America in the 1950s surrounding slam, all these senior citizens saying, how dare you, you have to get rid of this and created this immense controversy over this law because of the small number of senior citizens who were able to convince other senior citizens that they were gonna have to pay this too, even though it wasn't true. So much controversy that 16 months or so after the law had been signed on 1989 November, President George Herbert Walker Bush signed a new law repealing the whole Medicare catastrophic coverage act. Bill Clinton, 1993, 94. He came in with the first lady, Hillary Clinton and they were proudly going to transform healthcare for all Americans except for senior citizens on Medicare. And so came up with a gloriously complex plan that Robert Reich, who went around the country campaigning for it, said he never really understood what the heck it was. But, and polls showed that many Americans wanted to see health reform happen. And also at the same time, though that more than 80% really liked the health coverage that they had. And when they realized that the health coverage they had would be changed, it was a little bit like the ice cream in the room and who's gonna get one. All of a sudden people started and the polls started dropping and dropping and dropping. And in September 1994, the plan, the effort, the campaign entered in utter collapse, utter collapse because and never even got a vote in either chamber. Was never brought up in the Senate, never brought up in the House, ended in Ignomini's defeat and to add kind of a cherry on top of the cake in November, literally two months after the collapse of the plan, Democrats lost control of the House and the Senate and Clinton spent the rest of his six years as president with Republican majorities on both sides. George W. Bush, 2000, he campaigned, he would create an outpatient prescription drug plan in Medicare, he made that as a promise and he delivered in the 2003 Medicare Modernization Act. Question was, how was it gonna be paid for? So the formula ended up about 12.5% from state governments because they were gonna save a lot of money on the Medicaid program because of this and that was called the Clawback, 12% financed by premiums from the millions of senior citizens and disabled who would get benefits through this and paid premiums to these outpatient prescription drug plans but 75% of it paid for courtesy of adding all the cost to the national debt. How many minutes left? Four minutes, three minutes, okay. Barack Obama, I can tell you because I was in a lot of these meetings that Democratic strategists spent enormous amount of time between 2007 and eight through 2010 learning about, talking about, reflecting on, remembering the lessons from 88, 89, 93, 94 and other health reform episodes but particularly from 93 and 94 of the failure of the Clinton plan and what that meant in terms of trying to advance some kind of comprehensive reform in 19, in 2009, into 10. And one of the lessons was that you had to narrow the scope that we couldn't repeat Clinton's mistake of saying we were going to change healthcare for everybody and so instead we said we've got about 50 million Americans who don't have health insurance and we're gonna cover as many of those folks as we possibly can and try to improve coverage for everybody else. Barack Obama almost famously said if you like your health plan, you can keep it. If you like your doctor, you can keep it. If you like your girlfriend or your boyfriend, you can keep that too. Whatever you wanna keep, right? And again, the expansion passed with no votes to spare, needed 60 votes in the Senate. It got 60 votes in the Senate only because Democrats had for a nine month period between 2009 and 10, 60 Democratic votes in the Senate. Not a single Republican came. So narrowing the scope, narrowing the field of conflict in terms of who's upset with it and who wants it. Now we have this year and I would say that the thread extends through this year but it extends in a way that's just remarkable how the tables were turned. How the tables were turned because now it was Donald Trump and Congressional Republicans promising ice cream, promising good things to happen. Only 22 to 30 million Americans would lose coverage. Only this amount would be affected on health insurance premiums but come along folks because it's good as Donald Trump said, believe me. Trust me, healthcare is complicated. So trust me, right? Repeated CBO analysis documented the coverage losses and remarkably, and this was just for someone who'd been waiting for about seven years to see Americans start to appreciate some of the things in the ACA in starting on November 9th, the day after the election Americans all of a sudden started to have a different orientation and idea and thought process around Obamacare. My goodness, you're gonna take away my Medicaid coverage, you're gonna take away my health insurance coverage, you're gonna take away my protections from pre-existing condition exclusions. Here's my pitchfork, come and get me. And that's what happened and so it's remarkable the switch in public opinion, the switch in public opinion that entirely reflects the basic core dynamics of behavioral economics. So which way now? Which way now? There are two paths for people who care about health reform. One is to try to build on, improve, expand, extend the benefits of what's been created through the ACA and the other is to try to throw it all away and let's create a new comprehensive plan that will change the health insurance for everybody, for everybody. So that's the question, that's the challenge moving forward and I won't give you an answer because that'll come in the discussion and I'll turn it over to Congressman Ruiz. How'd I do it? Testing, testing, can you hear me? I don't have slides so you can just, I just want to go back to the front page if you want. So that is the question and I guess politics is where the answers come and where we have to make the tough decisions and determine where that path will lead us and then wholeheartedly accept it and build the coalitions and the political will so that we can get there. I want to thank everybody first of all for having such a wonderful lecture series, great job. I think that politics is the war of ideas and there certainly are a lot of ideas in this room and throughout America and this is the nexus of that war so that we can really wrestle with these ideas. Before I tell you what I think that you care about I want you to know why I care personally about this issue. So that you understand where I'm coming from my life story is a little different than most politicians who go into Congress or the Senate or whatnot. You see I grew up in a very poor farm worker community of Coachella with very high disparities, very underserved, under resourced and there's a lot of issues with health inequities in the area. There's a dichotomy of worlds in the Coachella Valley. My parents are farm workers. We lived in a trailer. My older brother was the first to graduate from high school and the whole family and it was a high school counselor that paid for my college application and I knew since the age of four I wanted to be a doctor and did everything so that I can go to college and go to medical school. I went to UCLA. I went to here Harvard Medical School, Harvard Kennedy School, Harvard School of Public Health. I did my residency at the University of Pittsburgh in a fellowship with a Harvard Humanitarian Initiative at the Brigham. I graduated, I finished 2017. I was probably the guy at the Kennedy School voted most likely not to run for office. And so I went back home and I started working in the community. I started using all the skills and talent that I had in order to improve health care access at the local area, the regional area. Started free clinics, led health care initiative to address health care access barriers. Started pipeline programs for underserved kids who want to serve in those underserved areas. Really brought back the coalition of stakeholders to really address our most pressing health equity problems as a practitioner in the field. And then all of a sudden I wanted to run for Congress to make a larger difference. And I had a huge pay cut and gave up my passion of emergency medicine in order for the common good and to be a team player on the inside of government because I believe it's not working. It's a disaster. And we need more of a pragmatic approach to get things done for the American people. And when I ran so that you know I'm not an ideologue, I told the Democrats in my district that I'm not running for the Democratic Party and I'm not running against the Republican Party. I'm running for the people in my district. And sometimes we get caught up in the ideologies where we cannot come together and negotiate a good deal for our patients. And as physicians, what is the most important thing that we care about? The outcome, the patient, to make sure that they walk out of the hospital, that they have a sense of health and wellness and that their pain is relieved and we add more health, more years to their life and not take away those years and their ability to live happily and longer. So now I'm on the Energy and Commerce Committee where we deal with healthcare policy. And this is where the battleground was with TrumpCare's repeal efforts. They're in the Energy and Commerce and the Ways and Means Committee and many of you probably were tuned in to the 26-hour committee hearing. I want you to know I used all my skills from Harvard Medical School to talk to all the other members to make sure they were hydrated, to make sure they were eating glucose. There were people in the bag zonks trying to sleep for a couple hours and we were trying to rotate, take turns, people were in and out and I was really doctoring the committee members during the 26-hour long nonstop committee hearing and it was a battle and we'll get towards the process later. So where are we? The Affordable Care Act and I've always said this from the beginning was an imperfect bill but a step in the right direction and if there were things that if I were in Congress during that time I would have changed some things I would have wished remained in the bill and so it is malleable and we can change and we can improve it. We know however that we have record breaking least amount of uninsured in our nation. That's wonderful, there is no public health expert and no physician or hospital or healthcare providers that's gonna prefer an uninsured patient over an insured patient, we know that. So a marker for us to determine whether a policy is smart or good is to look at where that needle moves whether it adds more uninsured or less uninsured. 20 million more gain health insurance and we have the prescription drug donut hole was closed the youth can stay on their health insurance till 26 so the millennials that are graduating from college looking for a job can still be protected. We had all these incredible amount of protections and essential health benefits people with pre-existing illnesses could no longer be denied because they have diabetes or because they have cancer. Those that are employers health insurances who run out of their coverage with a lifetime cap no longer exist so they're gonna be covered those with cancer and kids with very chronic illnesses and disabilities will no longer be denied that healthcare cover so that in itself is an incredible concept that we should take care of patient regardless and let's make it work. But there were still some challenges and some of these challenges perhaps were innate and some of these were manufactured by the once the Republicans won the house they had control and they were passing bills left and right and they had the ability to not fund certain initiatives so certain ideas were never funded that would have helped healthcare never implemented. We saw a lot of lawsuits that were against the Obama administration in order to modify the Affordable Care Act in order to weaken it in order to make sure that premiums went higher that they can claim later that it was on a debt spiral in order to gain political will to bring it in. However, their solution really wasn't a solution their solution would have augmented the public health crisis for the American people. I think that if we would have started with a sit down and understand and accept that some premiums were going up some members couldn't keep the promise that Obama made because they had to switch to different plans. Arguably one can say that those plans were like lemon plans and not good enough but they were happy with it and so there was this a lot of tugging pushback in terms of what was promised what they got and we know that in some areas and counties there were no at some point the threat of not having any health insurance and in many counties now there's only one option. And so what we want is more options more competition et cetera so there are some challenges that we need to admit and work together with Republicans to strengthen and stabilize the market and make it better and that's that there's no doubt with that but these whether you have Trump version one Trump version two Trump version three these were all disastrous to America's public health. We know that CBO scored that up to depending on which one 20 to 32 billion more people would have been uninsured that would have been catastrophic for hospitals doctors clinics for the American people. We know that they wanted to turn Medicaid into a block grant program and therefore states that were already cash straps would have then wanted to save money by decreasing reimbursements to hospitals clinics doctors to changing what they would cover so expensive cancer medications perhaps would no longer be covered under their Medicare Medicaid plans and their benefits would be changed and their eligibility would have been changed so they would have added more people to the uninsured plans and we know that they would have allowed health insurance companies to increase the cost and premiums to those that were 55 years old and older something that we call the age tax for those folks that were very high propensity donors and also the ones that utilize healthcare systems more than the younger ones so thank goodness it did not pass, right? Thank goodness that the American people as Professor McDonough said really treasured those gains that the Affordable Care Act provided and you see people activated through town halls in people's offices and making sure that their voices were heard I led letters from other members I led a over a hundred doctors and medical students and residents with white coats on the house steps to really talk about patients' perspectives I led coalitions in the house in order to not only message this bill I've been on national news in order to educate the American public but always with the caveat that it just doesn't end with the Affordable Care Act that there are things that we need to do right now in order to improve it now let's talk about process let's talk about the ethics because sometimes we wanna know what is behind the process and negotiation and one can arguably say that transparency is very important so that we can analyze what those ethical questions and the moral questions that were asked and why and whose interests are being defended when we do this and so Republicans from the get go argued that the Affordable Care Act was done behind doors I wasn't in Congress during that time but they were saying it was rammed down everybody's throats that it was done behind closed doors that it was pushed and no Republicans voted for it, et cetera and so the question is they were down and dirty and didn't follow the rules well let's compare them so the bill was online for about 30 days before the first markup 79, there were 79 bipartisan hearings over the course of two years there were 100 hours in hearings in total 181 witnesses on both sides of the aisle 179 Republican amendments in the final Senate bill so there were about 18 months of back and forth discussion well politically speaking Republicans had a field day with how long it took for them to be able to garner the Tea Party the birth of the Tea Party that came out the other side of the town halls and the raids that happened and so and we know what happened after it was passed the Democrats lost the house lost the Senate, et cetera so I think they were very astute in trying to say what did we learn from this so what did they do? They drafted the bill in secret there was no bipartisan input they posted it only for hours before our first hearing in the Energy and Commerce committee there were no bipartisan hearing with witnesses on both sides they allowed no Democratic amendments or witnesses and they drafted and attempted to pass in just a few weeks in the House and we know that it fell the first time then they negotiated and they brought in the freedom caucus to appease them they took out some of the essential health benefit coverages and protections now made it optional and they made it a little worse in our perspective as public health experts and so they were able to get some of the freedom caucus they lost some of the moderate Republicans but nonetheless they had enough votes to pass so what were some of the lessons learned from there? One is McCain had it right when before he gave the thumbs down and even afterwards and he spoke and if you agree with his politics or not you have to admire his stance, his position and you have to obviously admire I mean if this guy endured being in a POW camp and with a lot of bodily harm and torture I don't think Donald Trump is gonna intimidate Senator McCain so he was really able to be independent and vote this down along with the other senators from Maine and Alaska of course they were steadfast and everybody likes to give McCain the credit but it was the two women senators who really stood fast from the get go and received all the pressure throughout and stuck to their guns and of course I'd let them know how courageous that was to do but one of the things McCain said was anything long lasting should be bipartisan needs to be bipartisan and so if we attempt to do bills and it's absolutely not bipartisan and it's polarized in an ideological manner that it becomes the emblem on the football of whatever party then we know that the White House may change every four years that the House may change every two years that the Senate may change staggered positions but their elections are every six years for an individual so that if you change power then all those things and gains would be attempted to be reversed like we just saw here and so those are the dangers and I think that Professor McDonough said was the power of educating what the gains were so that people can push back whenever those gains would want to be taken away. The other issue was that there was a reluctance on the Democratic side to admit that there were some problems and that we could change them. I know because when I came in bright eyed and bushy-tailed to Congress as a doctor saying guys we need to figure this and that, this and that and everybody said shut up, don't say that because they want to destroy the affordable character and if we admit that there is problems then we won't be able to politically push it and that's not my approach and I continued to say guys we need to change so that we don't give them more ammunition to repeal it and now what is our message is mend it, don't end it, right? Let's mend it and not end it so I think that working on some modifications early on as Democratic proposals would have been very helpful. The other thing is that Republicans were trying to undermine the affordable character throughout the process and I don't think that Democrats did a good job at calling them out on it. The, for example, the continuing threat of not paying cost sharing reductions which leads to insurance companies saying there's uncertainty so they'll increase premiums and perhaps threaten to get out of the market is an issue and the Republicans filed a lawsuit saying Obama was not in his constitutional authority to keep these cost sharing reductions going. The other lawyers think differently and now they put a pause to allow President Trump to on a monthly basis threaten not to pay these and there is a lot of leverage in that and that affects how high premiums will go up and whether or not health insurances will stay in the exchanges. We know that there were some changes with the reinsurance programs. There was a timeline of those and so those fundings ended and that gave health insurance company some sense of security to take risks in new markets. There was a risk corridor that was changed as well. It was a program to bring stability in 2015. A lot of people don't mention this but Senator Rubio slipped the provision into an omnibus spending bill that prevented outside funding to be used on the payments to insurance companies who had higher than anticipated claims and who participate in the risk corridors. So in other words, they changed the way these were funded and therefore health insurance companies didn't get the payments that they were expecting through the Affordable Care Act. Therefore they pulled out, they said we're gonna raise prices and a lot of them pulled out of the health insurance market. And of course right now what we're seeing is there's a lot of undermining of the open enrollment periods. The funding's decreased. The time that patients have to enroll in the exchange have decreased. The outreach efforts have decreased and we know the whole concept of insurance is the larger the pool, the lower the risks. We need younger, healthier people as well to enroll in health insurance. So if you do everything possible to discourage the younger, healthier to enroll, what happens to the premiums? They go up. And if the premiums stay the same, what happens to your co-pays and your deductibles? They go up. And so these are different ways that their efforts have undermined the intent of the Affordable Care Act. So it's almost like saying, listen, if you stand on that rug, you're gonna fall and from the very beginning they have manufactured this crisis for political gains. So you're gonna fall if you stand on that rug. You're gonna fall when they stand on that rug. So you stand on the rug, then they pull the rug from underneath you. You fall and say, see, there's a crisis. You fell, right? So what we have to do is to be able to explain how their actions have permanently changed the Affordable Care Act so that when Speaker Ryan, Mitch McConnell and all the Republican leadership go up and say it was doomed to fell from the beginning or to say how it is on a death spiral or how this is a flawed bill then at what point in the experiment when you add multiple ingredients to your experience is it no longer your experiment and somebody else's experiment? And so this is where the responsibility comes in. Nonetheless, we have the responsibility to stabilize it. What do we need to do now? In my perspective, Professor McDonough, I choose the build on the ACA because we have gains and we don't wanna lose those gains. I choose that we first do no harm. In other words, stop threatening the CSR fundings. Make sure that we have a robust open enrollment and funding and outreach to really bring in the lower risk people into the insurance pools. Second is stabilize the markets. How do we do that? We can do that by reinstating the reinsurance programs that we're working and also the cost sharing reduction subsidies that are at point of care that are not a health insurance bailout because the health insurance companies, mind you are not at the verge of collapse. And these subsidies go towards patient care for their co-pays and deductibles at the point of care. I've introduced legislation. Senator Shaheen in the Senate is called the Marketplace Certainty Act which would permanently fund these cost sharing reduction subsidies increase eligibility to 400 from 250% federal poverty level to give more aid to middle class families who are facing higher premiums. The other thing we need to do is we need to take care of the patient. So we need to start to make sure that health insurance companies can no longer threaten to leave a county and create a bare county where there is no option, right? Because we need to be able to take care of the patient. So we should start talking about public options, different ideas that the government as a safety net can say no patient will be abandoned in the United States. There will always be somebody in every county that will have an option. And even in programs where there are in counties where there's only one health insurance that we should look at maybe providing that public option so that at least there is some competition. And then after we stabilize the patient then we need to address the bigger problem. And this is my approach. It's like an emergency medicine doctor, which I am with that, that deals with a multi-organ trauma, open fracture, lacerations, maybe some brain injuries, and they're hemorrhaging from the open femoral fracture. So what do you do first? ABCs, is the airway patent? Are they breathing? Is there circulation? Circulation, blood pressure is going down because they're hemorrhaging from their open femoral fracture. So are you going to start talking about in the emergency room table about how you're gonna repair the bone? Are you gonna spend your time talking about how this patient is gonna need a long-term rehabilitation program in order to address the long-term issues that this patient needs or the psychosocial problems that they need? Two months from now, 10 months from now in rehabilitation? Absolutely not. You're gonna stop the bleeding. You're gonna make sure that they don't bleed to death and you're gonna protect the patient. So my approach is we just dodge the bullet. We have to protect healthcare for millions of people in the United States. We have to focus every single day to ensure that any attempt is first to do no harm. Once we can stabilize, once we can defend healthcare for the American people, protect our care, save our care, then we can start looking at some ideas that will strengthen, stabilize the Affordable Care Act, make it better, and reduce overall healthcare costs in the United States, like prescription drugs, allow Medicare to negotiate drug prices, et cetera, looking at public options and other things like that. So we don't have the luxury of being, or at least I don't, have the luxury of being ideological. It's either yes or no votes and we have to defend healthcare. I'm one of two doctors on the Democratic side in all of Congress and the Senate. I am perhaps one or very few that have a master's in public health as well. And I want to help elevate the public health voice with pragmatic solutions and pragmatic activities and advocacy so that we're at the table. And we can defend healthcare for the communities where we work. Thank you very much. Thank you. And that's it. Yeah. All right. Thank you both for a great presentations. I've got a few questions and then I'd like to save some time for audience questions as well. So the first question, it seems like one of the most challenging tasks, faking elected legislators surrounding issues like healthcare is weighing those short-term self-interest of some constituents. For example, individuals' interest in deciding whether they want health insurance now when they might be healthy as balanced against the needs of other constituents and even the long-term needs of those very same people who have an interest in a stable, well-functioning system that they can access when they do inevitably get sick. What is the role of legislators in navigating those issues and what sort of considerations are most relevant? You want to give it the first shot? So, you know, I would just say that self-interest versus public interest is a amorphous concept and that what I would view as somebody acting out of a self-interested point of view in that person's mind, they are operating very much in an altruistic level. And so we look at the same phenomenon and we look at it through the lenses of our own values. I assume that almost everybody all the time, and this includes when I was a legislator, is acting out of a mix of self-interest and public interest and interprets it in ways differently than me. And it's just, you know, I think it was Madison who said in Federalist number 10, he said, faction is to liberty what air is to fire. Faction meaning conflict and to some extent based on self-interest. It's just part of what is expected in normal and endemic in society. And so I view the dualism as kind of a little bit of a false argument myself. I want to add another complexity, another factor to that complex question. You know, you talk about the long-term public good versus the short-term self-interest of different constituents which you left out was the self-interest of career politicians and their future and their need for re-election and whatnot. And oftentimes when we look at the public good and long-term, we study evidence-based medicine. We look at an outcome and we try to figure out how do we get to that outcome? And hopefully one day my dream is that we get to more evidence-based policy. But unfortunately, policy in the United States is primarily based on politics. And the crisis of the day and the self-interest of career politicians. And so I would say that our role is to bring it more towards evidence-based and the role of government is to protect the common good for the public, right? And as physicians, we also need to know what our limitations are. So as an emergency physician, I am now gonna take a patient in to do cardiothoracic surgery and do a bypass on the patient. So I know my limitation. There are limitations to government. And so government should know how to utilize the tools that we have at our disposal but when to back the hell off and let the market and private sector do its business as well. The second question. Oftentimes, it seemed like the healthcare reform debate wasn't really about optimizing health. It was about differences in views over the role the federal government should play, taxes, the legacy of President Obama and other factors. Is there a way to separate health policymaking from these other political or social issues or are they inevitably linked? They're linked. They're always gonna be linked in the United States because like I said, everything is politics and you have ideology that gets in the way and you have the power interests of the powerful those that control the house and they wanna gain more power. And so this goes back to my whole point where we need to make sure that it is the interest of the public that is first and foremost. I think that it's always there and I think that it's always there not just in the United States. I think it's there in every country. However, I would also say that I don't think there's another advanced nation in the world that has a health system that is so deeply rooted into the investor-owned for-profit sector and that that creates really some compelling differences from what you see and my reference point for that is if you haven't heard of it, Elizabeth Rosenthal's book An American Sickness that came out earlier this year that basically describes the US healthcare system as an orgy of greed. There's an incredible amount of greed in this system and if you don't believe me, read the first 10 chapters of her book where she documents it to extraordinary detail. And so I think there are some real value questions that we face that are different but again the duality between the two, it's always there and you're not gonna get rid of it and what one person looks at is being in the public interest. Another person says is just a naked self-interest grab and vice versa and just get used to it because it's always there. So, that question is obviously based on ideology in terms of what's the role of government and we know that there are extremes in the spectrum of that answer and those that want government to play a larger role, those that want government to play no role and I take a more pragmatic approach, right? It's who I am, it's my training in emergency medicines and patients dying keep them alive and so I was in an interview with a Republican colleague who I work with and on the diabetes caucus and the co-chair of the diabetes caucus and we pushed legislation in a bipartisan way and we were on national TV and MSNBC and they were asking some questions about what do patients prefer and my colleague went and said, well patients don't want big government so it's always that no big government and I said, I can guarantee you that if you're diabetic and your glucose is high and you're having mental status changes you can care less about the size of government. All you want is insulin and you want to get to the hospital so what can we do to give this patient insulin so that we can take care of this patient? So let's stop talking ideology, let's take a pragmatic approach, let's say patients need care and let's work backwards from that so that we can get there. I think that's a great point and I would just like to add and build on that topic. What do you think the role is for a healthcare provider and a patient in the debate over healthcare forum? How well did that happen in the most recent debate and how can those patients and providers be more effective? Well, I think that our democracy is an absolute wonderful most advanced experience in empowering individuals to have decisions on matters that affect their own lives, right? In our country it's representative so you give the authority to your representative and you try to pressure that person or let that person on, you hope to God they have your interest in mind otherwise you vote them out of office. So I think the best way is to tell your story for doctors and patients, tell your story, talk about the care, talk about what you'd like to see as physicians, talk about your patients because at the end of the day we have that perspective. We don't protect, for example, the insurance industry, pharmaceutical industry, we advocate for our patients. Our patients come first and foremost, everything else is with locked arm with our patients to make sure they get the care that we need. I attempted to do that with bringing in more than 10 national organizations, 100 plus doctors and some nurse practitioners as well to really talk about our patients and do that narrative and to put pressure in the democratic way on your representative to make sure that they understand. Doctors are well respected in our community. They understand the interplay with the policy and patients and what they can and can't do so they have a very legitimate voice in this conversation. The question is how do you advocate for it? How do you build those coalitions? How do you join organized medicine? How do you make sure that you know the tools and politics to influence those that are going to decide yay or nay? I would just say that it was extraordinary over the past 10 months to watch the process in Congress and to observe the extraordinary mobilization of almost the entire healthcare sector, particularly providers, physicians, nurses, others, hospitals, as well as patient organizations and also just how compellingly and strangely one-sided the conversation was I can't think of a single credible patient advocacy voice from the American Cancer Society, the American Heart Association, Diabetes Association that was on the side of repeal and replace. It was the only folks I can think, the medical technology, ADVEMED, that was about as far as it went in terms of the health sector. It was quite extraordinary and frankly, I didn't think they had a lot of difficulty raising their voices and being heard. And just to build on the sentiment that you raised during your presentation that as we came closer and closer to repeal, the Affordable Care Act became more and more and more popular. Have you ever seen something like that where legislators are trying to push through measures or bills against such a groundswell of support in any other type of setting? Well, you see it in all of these other prior episodes where public opinion shifts. We see it in single payer, by the way, where, so for example, there have been, people don't remember this, but there have been three states in the past 20-something years where citizens put binding single payer initiatives on the state ballot. California 1994, Oregon 2002, and Colorado 2016. In each one of those states, when the advocates announced it, they started pushing nice polls, more than 50% of the people saying, yes, this is where we go. Final results, California went down 27 to 73%. Oregon 2002 went down 21 to 79%. Oregon, this past fall, people forget because it was the day Trump got elected, went down 20 to 80%, right? But so you see polls right now that tell you one thing, but you have to understand that public opinion is squishy and malleable and people are not always rational actors in terms of how they respond. It depends upon how it's phrased, the orders of the questions and things, but a final ballot question, a final election result tells you something that has some permanence and significance. I guess the last question, before we turn it over to the audience. As we know, the deadline for the Senate pushing through a measure to replace and repeal the Affordable Care Act is coming up on September 30th. How do you see the rest of this month playing out in the Senate? Well, there's two efforts right now that are the most popular in the Senate. There's the Graham Cassidy. They put Heller in there to save his butt because he's in a tough election, so they added the Graham Cassidy Heller for political reasons. That would block grant everything, and I already mentioned the dangers of block granting healthcare and states having to make up that cost by cutting healthcare for millions of people. Then there's the Senator Alexander Murray negotiations on market stabilization factors, and they're running out of time and they have to draw support and popular support. President Trump is desperate for anything just so that he can sign and say face to his voters. You know that. He doesn't care what it is because most of the time, I don't think he knows the details and that's putting it nicely. And so I think that that's happening in the Senate. On the House side, you have different groups that are trying to negotiate things on a bipartisan manner. You have the New Dems and the moderate Republicans. You have a problem. Solver caucus that recently met with the president and our Republicans and Democrats. You have some of us who are trying to reach across and speak with individual Republicans who might want to put a package of bills together that will make it helpful. Both the chairman of Ways and Means and the chairman of Energy and Commerce have both publicly stated that funding, cost sharing, reduction subsidies are very important in keeping premiums from skyrocketing and that not paying them may result in more out of pocket costs for consumers, for the patients. So there is an awareness of what needs to be, what needs to happen. Now, the question is, what is the agreement that both parties will do? I know that Senator Alexander wants a one year funding. It puts us back to square one one year later. Murray wants two years. Again, my bill is a permanent funding bill that would increase support for patients and middle class families who are struggling with the higher premiums as a result of all these manipulations that Republicans have done to the exchanges that caused premiums just to increase more than medical inflation would have normally dictated. I just, I do believe that September 30th is really the closing of the window of opportunity for something to happen and no one should underestimate the possibility that Graham Cassidy could get legs and could move. I think the odds are against it and yet there is still some extraordinary energy on the Republican side to try to do this. And so I would not, I am not resting easy at this point and I don't think anyone else should. We need to be very vigilant. I mean, there was a recent poll from the Harvard School of Public Health. What is it now, the T-Chan School of Public Health? That partnered with the political group that shows that up to 89% of Republicans rank repealing the Affordable Care Act as a extremely important or very important issue. So, you know, we can't rest. We can't turn away our focus from defending healthcare and leave a window of opportunity for them to really push something through that would be detrimental. Congressman Ruiz, my questions for you. I liked your metaphor of pulling the carpet out from under the Affordable Care Act, but actually putting the carpet there so you could trip on it. What do you see is in the power of Congress and also in the power of all the healthcare institutions that did rally in the way that Professor McDonough described against the AHCA? What's in the power of those two entities to keep prominent the ways in which the Republican strategies like reducing cost sharing, for example, are going to be responsible for the increases in Obamacare dividends and it's so-called death spiral. What are your practical suggestions and who should do what? Yeah, so, you know, it's in policymaking, unfortunately it's not about in the real world, there's a problem, let's work together to find the solution and build upon our ideas to fix it. Oftentimes it's wait till there's a crisis of some form until it's on the news 24 seven, you have your ideological ideas and then you plug it in when the moment's right, okay? So how do we make it salient so that it is in the public discourse of what's happening? And I think that that's mostly media driven and it's whatever they're willing to cover to inform the American people, but at the same time, we as the American people could drive the media, right? That's the grassroots, you know, the million people marches that happen that bring attention, that's what the grassroots is about. And then every step of the way when there's a change or announcements in premiums or whether health insurance is gonna come in or out and for example, whenever I was invited to go on national news, I would always mention, you know, let's talk about why premiums are going up and we all know premiums are going up because healthcare costs are going up and we have to address that and none of these bills address that, but at the same time, premiums are going up because of the threat of not paying for a cost sharing reductions because the reinsurance programs ended and because Marco Rubio changed the way we funded the risk corridors and therefore you start to build the counter narrative that it wasn't an innate problem with the Affordable Care Act that caused these problems, but it was a mixture of a lot of different factors, one of which was intentional undermining by the Republican Party. And so I think that if you're gonna wanna bring that to people's attention, you have to be savvy on knowing how to make it a salient issue with national media. Hi, thank you both so much for coming. My name is Sanjay, I'm here with one of my other medical school classmates, Margaret, and I think we just had a question for both of you, we were just chatting. You know, Dr. Rees, you were talking about when you have a patient in the ED, you gotta go back to the ABCs, right? You gotta stop the bleeding and I think in the next week, we have to make sure that Graham Cassie doesn't pass, we have to stop the bleeding, but if that doesn't happen, you know, I'm wondering about these conversations about single-payer that are happening right now and is there a world in which actually articulating values like single-payer, like a world where everyone has access to care and dignity, et cetera, et cetera? Is that actually a way of stopping the bleeding in the future? Is this an organizing principle that, you know, we as a liberal community should be thinking about seriously? And I haven't really seen that here at Harvard, I was really embracing that. So I think for both of you, that's my question. It seems like, you know, we on the left are looking for a little bit of a stronger articulation of values and, you know, a public option, Medicare negotiating prices, that seems like on a straight line to a world in which they're single-payer, so, where do we go from here? So let's talk about a stronger articulation of values and what are the values that are being communicated within the single-payer system? And I can tell you, I wholeheartedly support the value of universal care. I support the whole value that health is a human right and not a market commodity because there are market failures in healthcare. You need choice. And the fundamental principle of a market-driven system is that there is a cost based on supply demand and you're okay with people not getting the product if they choose or they can't afford it, right? In healthcare, we can't be okay. It's unethical. It's morally wrong. You have a heart attack and you go into the emergency department to say that this patient, because of their socioeconomic status, is not gonna get the care that they need to save their lives so we're not gonna take care of them. To us, it's morally wrong. So, but the mechanism in which we start to realize the universal care, the health as human right, the compassion that we have to take care of every human being because they suffer pain as everybody else are multiple mechanisms. And so, therefore, we have to figure out, as policy makers, is which ones will help get us there, not only in policy, because like I mentioned before, it's not just the policy and the evidence, but also the politics. And how do we garner enough support so that we don't lose the house for another 20 years? And we'll have no chance of getting closer to making sure everybody gets care when they need care. And so that's the issue. And if we use one bill as the emblem of that value, then we're short changing ourselves and our abilities and our talent and our skills to get to those values. You see what I'm saying? Right now, in these bills, there's a lot of questions unanswered. For example, how much is an individual willing to pay an increase in taxes in order to ensure that everybody gets coverage? What are we gonna do with two to four million people that may lose their jobs, who no longer work in the administration world? All of a sudden, they don't have a job. What are we gonna do with the physician workforce need when we know that there's gonna be a lot of doctors who are gonna retire and we already have a physician shortest crisis in our country, desperately in areas like my district where there's one doctor per 9,000 residents. And the norm is one to 2,000. So are there some questions that are left unanswered? But we believe in the value, but we want to have these conversations. And I think the most important conversation that we can get to help us figure out good sound policy so that nobody suffers needlessly because they're inability to pay or because there are no providers in their community is to ask that question. Is healthcare a human right or is healthcare a marketplace? Because fundamentally, if you believe it should be in the hands of a private market, then you fundamentally believe that you are only deserving of getting the care when you're sick or injured if you can afford it. And if you can't afford it, then you're not deserving of that because that's the whole market principle. If you believe health is a human right and wanna figure out a way that you can combine some market principles, combine some public safety nets, but at the same time ensure that nobody goes without care, then we can start looking at the multiple ways that we can get there. So I would just say there's a conundrum in public policy and Congressman Ruiz faces it a lot and I used to face it when I was in the public sector. And it's the duality between this. You have the opportunity for major enormous revolutionary systemic change. You have a window of opportunity that you could actually achieve that and you settle for half a loaf. Shame on you. On the other hand, you have an opportunity for real meaningful important progress that will help and improve many people's lives. And because you go for the whole thing, you end up with nothing. Shame on you again. And so how do you know the difference between those two and how do you know the moment that you're in? Well, I'll tell you one very simple rule of thumb. If there aren't 60 Democrats in the Senate, then you're wasting your time, okay? And you're gonna go down a track. Like Bill and Hillary Clinton in 1994 went down and we ended up with nothing and lost the House in the Senate. So there are real risks. And also frankly, as this week, our side, the Democratic side is dominated by talk about single payer. And meanwhile, Graham Cassidy is gathering steam. I'm wondering, is this really the best conversation to be have about single payer this week when the car's still on fire? All right. Well, thank you all very much. Thanks again once again to our experts and we'll see you all next month. Thank you very much.