 Good afternoon and welcome. I'm Susan Collins the Joan and Sanford Wildein of the Gerald R. Ford School of Public Policy and it's really wonderful to see so many of you around the table to have so many distinguished friends with us today to as I Welcome you to what is really an important conversation That is hosted jointly by the Ford School and the University of Michigan's Institute for Healthcare Policy and Innovation As you know the the topic is the 50th anniversary of Medicare and also the 80th anniversary of Social Security We have a number of distinguished friends around the table and all of you have their bios Those of you who are joining us through the webcast the bios are available online So we won't do lengthy introductions, but I do want to particularly welcome our two guests of honor First congressman John Dingle served Southeast Michigan in the United States Congress for nearly 60 years He is the longest tenured congressman in US history and the lives of the people of the state of Michigan and indeed the lives of all Americans are Really better for his decades of principled service He is the recipient of the nation's highest civilian honor the Presidential Medal of Freedom Please join me in welcoming our good friend Mr. John Dingle And we're also extremely pleased to welcome our current congresswoman Deborah Dingle She was elected last fall to represent Michigan's 12th congressional district Debbie's work in DC builds on her own decades of service in Southeast Michigan and Alongside a very highly successful career with General Motors Debbie Dingle has served on the boards of over a dozen Extremely impactful nonprofits related in particular to women and to health policy and health care and that includes the Carmanos Cancer Center and the Detroit area March of Dimes Please also join me in a very special welcome for us representative Debbie Dingle So today we celebrate two major milestones anniversaries in US policy July 30th marked the 50th anniversary of the creation of Medicare and August 14th represents the 80th anniversary of the creation of the US Social Security Administration the past present and future of Social Security could very easily be an entire symposium on its own and then some There is much much of importance there But we have decided and planned to focus today's event Primarily on Medicare and so we have gathered some of the university's top experts in health care policy around the table Our co-host for this event is the director of the university's Institute for health care policy and innovation Dr. John Ayanian and he is certainly among those experts and so to set the stage for the Conversation that we will have today. It is my pleasure to turn things over to him John Thank You Dean Collins I'd like to add my welcome to representative Debbie Dingle and former representative John Dingle on this special occasion commemorating two of the most important milestones in our nation's history the signing of the law creating Medicare and Medicaid by President Lyndon Johnson 50 years ago on July 30th 1965 and the signing of the law creating the Social Security Act by President Franklin Roosevelt 80 years ago on August 14th 1935 On behalf of the Institute for health care policy and innovation at the University of Michigan We are very pleased to co-sponsor this round table discussion with the Ford School of Public Policy The mission of our Institute is to improve the quality safety equity and affordability of health care with over 470 members from 17 schools and colleges at the University of Michigan as well as five local partner organizations a Number of our leading experts on health policy and on Medicare in particular are participating in our round table discussion today To set the context for today's discussion Medicare and Social Security have enormous consequences for the health and financial well-being of elderly and disabled Americans Without Social Security one quarter of elderly Americans would fall below the poverty line But with Social Security this proportion has been reduced to 10% Similarly before Medicare was enacted about half of elderly Americans had no form of health insurance But now coverage is nearly universal for senior citizens who often have significant health needs In our population of 320 million Americans nearly 60 million received Social Security benefits and 55 million are enrolled in Medicare as the baby boom generation continues to turn 65 over the next decade Medicare enrollment is expected to grow to 74 million Americans These programs have major budget implications for the federal government with 14% of federal spending on Medicare and 24% devoted to Social Security Because Medicare represents 22% of all health care expenditures in the US It is also a major driver for how health care is delivered by hospitals doctors and other health care professionals So let's move forward with today's discussion We will hear first from representative Debbie Dingle who will share her perspective on the important milestones that we are commemorating today Next we will hear from former representative John Dingle Jr. Who was presiding over the US House of Representatives when it enacted Medicare in 1965 and whose father John Dingle senior Cosponsored the Social Security Act and was present when President Roosevelt signed this law 80 years ago this week After the Dingles remarks will have an open discussion led by Dr. Matt Davis Matt is the deputy director of the Institute for Health Care Policy and Innovation and a professor in the medical school School of Public Health and Ford School of Public Policy from March to 2013 through April 2015 He served as our state's chief medical executive in the Michigan Department of Community Health Please join me in welcoming representative Debbie Dingle Thank You John for those kind introduction and for Susan for the two of you Hosting this discussion, which I think is one of the most important discussions. We're gonna have for the next few years John will give you more of the historical Perspective surrounding the establishment of Social Security and Medicare and I know we've got a great group of panelists I'm very excited to hear from I've been fortunate enough to know some of you And even in the last week and spending time and finding more and more data out there that is reinforcing the need For updating policy that is we will celebrate the 50th anniversary of Medicare At the end of July and are celebrating the 80th anniversary of Social Security and there are two very strong pillars But they were written 80 years ago and 50 years ago And it's time to talk about them But I also think it's time to dispel some common myths about both Social Security and Medicare We often hear that Social Security will soon go bankrupt The fact of the matter is that if we make no changes to the program it's solving through 2033 and after that time it will not run dry. It will still be able to fund 75% of current benefits This gives us more than enough time to make tweaks to the program so current benefits can be preserved at the very least If not expanded We often hear that America can't afford Social Security given the national debt Well long term debt is an issue and I believe one that we have to deal with as a country Social Security is not the main contributor to the problem Costs for the program costs for the program are expected to grow only slightly As a share of the overall u.s economy and will remain quite manageable for the foreseeable future The reality is America cannot afford not to have Social Security Millions of seniors would be thrown into poverty millions are already in poverty that have Social Security And it would have a devastating impact on our economy as a whole Social Security is the bedrock of our nation's safety net In the first step in secure retirement that our seniors have earned and count on Just as Social Security has become a part of our nation's fabric Medicare is now woven into who we are as a country and how we care for our citizens We also hear that Medicare is going broke But when you look at the facts that claim doesn't hold up to scrutiny either The latest trustees report demonstrated that medicare's hospital insurance trust fund Will be able to pay 100 of all costs through 2030 Even in 2030 incoming payroll taxes and all other revenue will be sufficient to pay 86 of medicare hospital insurance costs Contrary to what opponents claim medicare will not cease to exist in 2030 as the term going broke suggests I strongly believe that long-term care is the missing pillar of our social safety net No program that exists today was designed with long-term care in mind Long-term care is unique and different from most health services We're talking about helping seniors with activities of daily living Like eating bathing getting dressed or making sure that they're taking their medicine on time Many seniors can do this in place. They can be contributing members of the community That can keep their zest for life and what we have now is designed for institutions It's not dealing with i've met the system. I've met it head on and it is broken not navigable I know that i'm lucky than 99 and 9 of the people in this country and It's broke We've all had loved ones who will face the possibility of needing long-term services and support In fact the demand for long-term care is expected to double in the next 40 years as our nation continues to age And just in 2012 our nation spent 320 billion dollars in on long-term care We spend a lot of time talking about medicare and medicaid But the reality is that neither one is designed to help seniors with those daily tasks medicates the largest payer of the long-term care costs covering about 42 of all long-term care expenditures But it's got strict income eligibility limits Medicare provides skilled nursing services and home health services Only for a very limited period of time as part of a patient's recovery for an acute Health care episode and even then i'll tell you navigating the system when you don't even when you know what you're doing has become almost impossible Private long-term care is not always affordable or available and when people have it they exhaust it way too soon Family caregivers are often called down to support people during a time of need However, the typical family caregiver spends about 20 hours per week Providing unpaid care to family member for nearly five years Totally in a massive amount of time and energy So it's clear that this problem needs to be addressed and not talking about it isn't going to make it go away So we need to listen to concerns today talk about these answers and Talk about what some of these solutions are and try to change the conversation a bit In washington when you talk about this issue you often hear it referred to as a crisis a catastrophe A democratic demographic ticking time bomb and it's true that 10 000 people are turning 65 each day But instead of instead of talking about it in the negative term I think we need to refocus it on seniors issues and craft a new paradigm Let's rededicate ourselves to promoting the well-being and the independence of seniors That's why one of the first bill it's the first bill that I introduced in the congress was a hearing aid bill Most people don't realize that Medicare doesn't cover hearing aids And we need to think about what that means for somebody that's cut off the social isolation What it does to a human life and now and this was one of the I had a great meeting with some of the doctors around this table Who are beginning to do some of the real work that we need? Anadotally speaking with people the first time I heard it the doctor told me that 50 of the people that she saw who needed a hearing aid Couldn't afford it and did get one We've had a study done now that came out in july that says 70 of the people Who need a hearing aid between the ages of 65 and 84 don't have one Now some of it we have men one I was married to that were too proud to get it But many of them is simply because they couldn't afford it And that's and you know and Things are data is showing and it's more anecdotal than the actual measurement Which some of the very doctors at this table are working on That not being able to hear leads to early dementia and to early Alzheimer's This is an example to me of an ounce of prevention saves money in the end So I want to thank everybody for being here. I look forward to this conversation And in talking about how both social security medicare and talking long-term care are critical in this country. Thank you And then do we turn it over to mr. Dingell You're on Well, first of all, thank you for having me Is a lovely Deborah here I see a room full of dear friends and I thank you all for being here present And I thank you for your friendship and your kindness over the years both to me And to the lovely Deborah I am delighted to join with you in celebrating the 80th anniversary of social security and the 50th anniversary of medicare programs which have changed the quality of life for our people Two percent of our people moved recently When they reached maturity in 65 the rest of them Did the best they could living off of the charity of the public or their kids or Government or something or that sort It was not a happy life My dad was one of those who was one of the authors of social security And he was particularly delighted With that and if you look you'll see him's right there behind president Roosevelt A little skinny pollock with a big broken nose and a mustache And a smile on his face That's an old picture was taken at the white house and those were the others who worked on social security with him So the right is me with my dear friend clad pepper When we had finished the enactment of medicare Medicare and Medicaid are two of the then 22 titles of social security which Of came into law Social security is of course many titles and it covers many many many things The number has grown. I believe significantly since the time we did that The most recent major addition to social security Is of course the affordable care act or what is called obama care or whatever you wish Simple fact of matter is each of these programs has had savage savage attacks upon them as they were going through But the interesting thing is if you follow those savage savage attacks you will find by the great horde spoon They attacked it but they never had a cure And if you will listen to gingrich or any of my other friends, they say we're going to get rid of it And we've said well fine. Tell us what you are going to replace this with The hard fact is the medical profession hospitals doctors nurses everybody Now supports obama care with the exception of one part of the medical profession The harsh fact of matter is that it has been proven that it works And if the system will collapse if we would take this out from underneath it I'm not going to go into The benefit of or the faults of it But the fact is it covers almost every american from the cradle to the grave now With some level of support Those of you who have kids know that your kids are going to receive benefits And know that they're going to be able to stay on your plan Until such time as they reach 26 You also know that no longer they're going to be able to say you can't have health care because you have a pre-existing condition Or other things of this sort We had a youngster in the office who was paying about 330 dollars for his health care and When we went through and looked at all the subsidies and everything else and he got what he got What do you think? His total cost of his health care went down to about 30 dollars a month Markable And you're going to find that that's going to impact you and there are other provisions in There into which I will not go today, but Understand that these are things which are important to all Americans and are important in terms of seeing to it that the economy the people The kids that we get the health care One of the things that Truman found when he ran the investigation of world war two was Americans didn't have adequate health care And he had health over time getting them up to the level of standards where they could get proper placement in the military service He did it and then he found he had a hell of a time educated them And so we began passing legislation on schools, but in addition to that he also But in addition to that he also found that he had Problems with nutrition and health care those took rather longer And the result was that ultimately we had finally addressed those things I'm not going to put you to sleep by giving you all of the Benefits for the costs or anything, but This is one of the things that my dad was most singularly proud of And that was that he Had fought it on ways and means so that he could begin to move this forward He was seven six months to die for to live in 1914 And he fooled him I've said John you're gonna die and dad had rather the selfish remark about how he was going to be there And he was And it was one of his great prides that he was able to see to it That he had fixed it so that all of our people Could have health care in both their young and their elderly years And he introduced the dingle marie wagner bill as you'll recall it passed the house in bits and pieces but never in sufficient form to do Any appreciable large, you know good We finally got something close to it You know obama care and i'm pleased to say that it does do Most of what we want done And the interesting thing is the medical profession the health professionals They all recognize what this is going to do for the country They also recognize something else which is very important to all americans And that is a simple fact the matter is that health care has become Not just a commodity, but it's an absolute necessity for the country for the people and for the future And if we don't see to it that they have what they have to have in terms of health care We're going to find ourselves beginning to subside into a lower level of society throughout the world I Have found as have we all In the enactment of this legislation that it's not easy We've we have in each instance Sought to try to see to it that we have Health care bills which meet the immediate needs That has not been sufficient for our purposes What we need to do is to have something which does sufficiency of it This is going to take a long time to finally implement You will find that despite all of the threats and all of the All of the stargazing and all of the nasty comments that the simple fact the matter is That this bill is achieving success in terms of public support It also is achieving success in terms of improving the health care of our people and will continue to do so Your job today and that which I see being done around the country Is to see to it that we have intelligent honest criticism Which enables us to do the things that need doing To make it in fact work That I always tell my friends in washington when they start kicking up their heels about this legislation is not perfect It's got this defect. I said well the last perfect Legislation it was written In this world was the 10 commandments and I've heard a lot of people complaining about them so Your task now is to improve upon the 10 commandments To see to it that that when the next opportunity comes We're able to reform Medicare social security see to it that Obamacare does the things that we need and that we are able to continue to see to it that our economy grows not held down by Ethics or By problems that we confront with regard to health care of our people. Thank you for having me Well congresswoman dingle and congressman dingle. Thank you so much for your insights and your comments I know I speak for everyone here when I say we're delighted to have you here this afternoon and have a chance to share with you some thoughts about chiefly medicare And i'm sure we'll hear some thoughts about social security and medicare together You've both raised several Questions that folks here around the table Are addressing on a regular basis. So let me just say it's a privilege and a pleasure to serve as the moderator here I'm not a timekeeper. I'm not a gatekeeper, but i'm sure everyone will appreciate I'm going to try to make sure we hear from folks gathered here all around the table To hear about three particular aspects of medicare Number one is the people who are enrolled in the program Number two are the health care providers who both of you have touched upon in your remarks Who helped deliver the services that the beneficiaries are looking for and number three are the policies because after all medicare started as A policy in and of itself and has grown to become extremely influential and bid And subsequently been a hotbed for innovation in policy in the health care arena in the u.s We're fortunate today to have many of our colleagues here around the table who Have particular areas of focus and expertise in these three particular arenas And I also want to say that it's very exciting to have this opportunity to Have this conversation today and to work at a university where We do have this expertise and where there's also a dedication To asking and try to answer policy relevant questions That are relevant at the local level the state level and the federal level I know that we also appreciate Honest criticism of the program and we want to hear from both of you if you have questions Or follow-up ideas about the sort of things that we discuss here today Because it's not anything if it's not a dialogue about how we can try to improve the system And how the work that we do here at the university and in our communities and with our colleagues Can help improve that system and how it functions So we'll begin by reminding us all here that we are Living in the 21st century and therefore what we say and the questions we're considering today Are accessible through social media and we have set up a twitter account to receive questions from from the outside world about this Yes So for those of you following us on twitter right now the hashtag is hashtag medicare 50 um medicare 50 um And as we have our conversation today Our support team here will be giving me the questions that we'll put forward to our experts around the table All right, so dialogue aided by social media. This is really what it's all about in today's world So let's begin with the people We have some folks here around the table whose central work whether they are clinician researchers or Clinicians focusing on improving the care in the system itself chiefly within university michigan health system Our focus really on individuals who are today receiving those medicare benefits Trying to improve that system and how it functions for patients and those who Love them and care for them So i'd like a couple of my colleagues in particular ken langa here And rent williams to get us started with a little bit about what their work focuses on regarding medicare and the people it serves Let's start with ken Thanks matt and uh, yeah, thank you for inviting me here Really happy to be involved in this important conversation I was actually planning to focus on What congresswoman dingle has already described probably better than i can which is the the key issue of long-term care and sort of the hole in medicare if you will in terms of Funding long-term care services or or somehow increasing access to long-term care Again congresswoman dingle sort of highlighted these key issues. I'll just add a a few numbers to maybe try to amplify The importance of this issue that congresswoman dingle brought up So and many of you have heard these numbers before i'm sure about 46 million people now who are 65 Or older by 2050 that will be about 90 million people who are 65 plus in the united states um A 65 year old who was uh just entering the medicare program in 1965 could expect to live about 14 more years to uh age 79 Women a bit more than that men a bit less obviously today Someone who's turning 65 and entering the medicare program Can expect to live 20 more years or so to uh to age 85 so another six years of Of life expectancy for folks entering the program right now There's also this key issue of related to long-term care of Who's going to provide that care at home? Again the number of children per family has decreased significantly over the last 50 years since Since medicare was enacted and will continue to decrease because of the demographic the demographics going forward So there's about 24 Uh people 65 and older in the united states right now for every 100 People who are 20 to 64 the sort of classic working age Population that's going to increase to 37 older adults for for every 100 So to to add that up again so more older adults Living much longer once they get on medicare likely with more chronic diseases with fewer kids to take care of Of people as they become disabled so again to me that Long-term care issues around taking care of older disabled adults are Important now, but we'll just again as congresswoman dingle mentioned sort of exploded in importance over the next 30 to 50 years So I think we're going to have we're going to have to deal with this somehow Trying to deal with it in a a reasoned way that will hopefully use resources efficiently to address these key issues. I think is What I'd like to open up the the conversation about which I stopped there and then Go on and well, I think you've actually Created a great opening Ken. Thank you for Brent to talk about some innovations in care that can represent some opportunities to take care of the multiple needs of individuals receiving medicare benefits in the healthcare setting Great. I've been trying to follow this to know just what ball would be thrown to me At this point. It's a great pleasure to be here. Thank you for inviting me and a great honor to be In the presence of the dingles and a particularly enjoyable for me to kind of take a pause about medicare because I'm as I was thinking about this this gathering My clinicians had came on first So I've been a practicing primary care physician and geriatrician for about 25 to 30 years depending on when you start the clock And through that time as I thought about the patients that I've seen And their struggles through life and their work in and out of the medical system and the healthcare system The first analogy that came to my mind was the old saw about the two fish Swimming side by side and the one fish turns to the other and says how's the water? And the other fish says what's water? There is much about medicare that is underappreciated in the patients that I see and the students that I teach And I think at this 50 year mark it's if there's no other time to do this now is the time To say the transparency of medicare certainly around the acute medical issues So I encounter I work a lot in health disparities and I work a lot in teaching students about health disparities And I'm struck by the fact that every article virtually every article many articles start About health disparities say among persons under 65 in the United States the following Racial ethnic disparities and that one sentence goes largely unheralded in the conversation with our learners and with our patients I've seen bankruptcy after bankruptcy and people under 65 around acute care costs But have never seen one though. They have not happened I'm sure but it's extraordinarily rare to have a medical bankruptcy for acute care In people above 65 who receive medicare and that is phenomenal And but patients rarely appreciate it including my own parents And worth a pause It does take me though to the issue around long-term care, which I see in my patients, of course on a regular basis I first came to the University of Michigan Nearly 25 years ago with a mission to gather the database to create a home health long-term benefit I thought we could do that because the money existed and then a lot of things dried up right back in the early 90s And I decided that I wasn't going to solve that problem And it does persist the cost of long-term care Um Perhaps getting a little more to uh matt's point. I have had the privilege Recently the last five to eight years of being a participant in some of the medicare experiments and here's another Really key facet of what medicare has evolved into it has evolved into a self-examining Experiment generating Body which is moving in as in many of the right directions as fast as an organization like that probably can be Expected to as political and costly as it is So we here were one of the first Sites at the physician group practice demonstration project the pgp demonstration or medicare demo project back in 2006 ish And that allowed us to recast the way medicare dollars were flowing in move away from the fee for service shackles and Start to create Care models that would benefit medicare patients in ways that made most clinical sense Rather than generated the most visits and the most activity and under that The shop that I serve as medical director for called the complex care management program was allowed to be born We suddenly could afford to pay as a cost center a group of Social workers and physician assistants to reach out to patients and without being able to generate a bill Nonetheless find a business model that worked for us to provide them care We've since gone on to new demonstrations here under medicare One of which is called grace where we are putting it was a model created by steve counsel and his colleagues at Indiana university where we are able to put nurse practitioners and social workers into people's homes The frail elders who are discharged from the hospital or not And do an assessment in the home because we can afford to do it now because of the way That payment is being reconstructed and reward and risk are being reshifted under the medicare prospective payment or global payment options, which are continuing to grow it's been a great privilege To be a part of those I think i'll stop One of the things you mentioned was disparities And i'll turn now to john to say a few words about what we know Through research and what we know about how policies and medicare may have shaped the picture of racial ethnic disparities and other disparities In the medicare population. Thanks matt and thanks brent and ten for your comments I think one of the least appreciated facts of what medicare accomplished was within five years after the medicare program being signed into law in 1965 Hospitals that have been segregated for decades in large parts of the country particularly in the south That were not accessible to african americans They were desegregated within just a few years and we saw evidence Almost immediately of better health outcomes for conditions where hospital care matters for african americans in this country such as pneumonia And I think that's you know from a civil rights perspective This medicare was enacted one year after the civil rights act in 1964 And it really changed the face of health care in large parts of the country and and and started us on the path Towards greater equality, which is you know after 50 years. We're still striving for you know We certainly have evidence that for certain chronic conditions like diabetes and hypertension compared to Folks under age 65 those who have medicare coverage If they're african american or latino, they're much less likely To experience disparities in how well their conditions are controlled that the quality improves for everyone with medicare coverage And the disparities that we see before age 65 are significantly narrowed We certainly still have challenges though in that We also see in terms of the care of certain acute hospital conditions like heart attacks or strokes That minority patients are often concentrated in communities that don't have as many health care resources as other parts of the Country is more affluent communities. And so The health outcomes in hospitals With those fewer resources are worse for everyone, but those hospitals tend to disproportionately care for minority patients So I think one of the challenges is we see the greater degree of experimentation and innovation in medicare is How do we use medicare dollars to promote greater equity to create incentives for reducing disparities For improving quality of care in hospitals that may be historically deprived of resources But with more support can provide better care as well as raising the standard for everyone in the program So that we see you know some of the benefits that can describe in terms of improving life expectancy And and certainly in the last 40 years we've seen the gap in life expectancy between african americans and whites Narrow from about eight years of shorter life expectancy for african americans to less than four years That's still a big gap, but we we're making progress and I think we really need to emphasize this issue going forward Can I add a quick anecdote to that go ahead peter? I worked in the office for civil rights of HEW and NHHS from 77 to 86 when I started in 77 We still dealt with vestigial race claims we would get complaints about the vestiges of segregated weighting rooms and and Health hospital floor assignments By the early 80s. We had very few Racial discrimination racial disparity claims and the shift had been to the americans with disability act Actually the pre the predecessor to the americans with disability act. So the shift had been from race to Disabilities in a very short time period Thanks, peter so we've heard now as part of the start to our discussion About the people receiving benefits through medicare We're now going to turn to some of the work We have done here at the table around providers And i'm going to turn to maryan yuda phillips and to eve kerr whose work has focused on The organization of care in primary care practices chiefly and also efforts to measure and improve quality of care Very in yeah, so i actually want to pick up on something that brent said which is you know the exciting part of medicare And you know i can say this from having spent so many years on the private payer side Is when medicare decides to experiment everybody else pays attention And one of the great things about the affordable care act is it built in experiments under medicare under the centers for medicare and medicare innovation And it's allowed many of us to do things that we wanted to try Particularly on the all payer side of payment strategies to improve quality and outcomes for people And you know so brent's point about these experiments and you'll probably talk about the The demonstration project which was one of the first that michigan got involved in allowed laid the groundwork really for us to Apply with with our partners at the state when jim was running the department of Community health for the state and with the private payers in the state for the medicare advanced practice Demonstration project and we were one of eight states in michigan chosen to run that demonstration It was a three-year demonstration Michigan and five other states have just been extended for an additional two years Because we've showed enormous success in reducing cost For an improving quality for medicare patients as a result of this demonstration that brings all payers medicare medicare and the private sector together To expand the way primary care is delivered and really focus on treatment of particularly individuals with chronic disease So we are in many ways here in michigan because of what the affordable care act did in partnership under Uh medicare are really demonstrating that we can make significant different significant improvements in the cost of care So important for you to know we've talked a lot about We lead the way in so many ways in michigan, but that's not always known in washington Right, and so I think that all right the demonstration project here called the michigan primary care transformation project Mipct is a great example of that great example of how we can really change The practice of care in ways that improve quality and outcomes and cost Thanks, mariana. Eve. Maybe you can say a few words about the quality research you've been doing against your relationship to medicare beneficiaries also to the dangles and John mentioned that One of the kind of unheard of part of medicare is the differences it has made in disparities I think the other part that is probably little little known in kind of the general conversation is the difference it has made in The way we think about quality of care and the way we assess quality of care So, you know, it was really because of medicare and and medicaid both that We got the peer review organizations Back in the sixth season seventies that started to really look at quality of care It started to assess quality of care and what patients were receiving And that started a movement in many ways that continues today as marianne said in many different ways with some Experimentation about the best way we can we can measure quality and the best way we can improve quality of care Was under medicare that we got the prospective payment system where we started looking at the way we Deliver care differently and and we pay for it differently But also a lot of fundamental research that had been done then to see well, how does that affect quality of care? and that's always been Kind of put together when we make the changes and we want to evaluate them So I really welcome your invitation to kind of think critically about those issues and ways we can continue to improve Both medicare and the affordable care act And I think one of the things that is happening now In medicare is that kind of experimentation and the experimentation about the way we pay for quality as i'm sure others will comment But also about the ways we think about what quality is and what value is And that has great potential to improve Quality but it also has some dangers and I think we have to think carefully about What goes into that equation what goes into that value equation as we try to improve outcomes and decrease costs for patients And in the end it does come back to patients. So one of the things that We've been trying to look at here at michigan is ways to make those Quality measures better ways to put patients back into the equation of quality Because I think in some ways we've removed the patient and we've focused maybe too much on the organization So I think The the kind of the future of medicare and the future of the affordable care act Gives us an opportunity to think about ways to measure quality That takes into account patients individual characteristics patients needs patients risks and very importantly patients preferences preferences for the way they want to get care and that goes Directly not just into our acute care setting samples for care, but also in long-term care So that's the opportunity and I think that that is something that We need to continue to think about as we assess value and I'm sure mark will also comment on Ways to think about value and putting that back into or continuing that with the medicare Thanks, eve congressman This has been I think an excellent discussion Two things though have to be addressed First of all, you've got to get a change in the political climate And without that getting a Change that's going to do us good in terms of making significant changes In the way the society functions or matters this kind is going to be very difficult. That's firstly second thing is money You got to figure out how the hell you're going to pay for it now. There's always this wonderful crowd in washington that says Medicare is going broke so scared go broke medicare is going broke Always seems to going broke country is going broke And yet they won't look at the necessary things go with finances. You have to have A major change in Administrations and this has got to be if you observe like linda johnson medicare or like obama Medicaid Clinton tried it and he Stubbed his toe with mrs. Clinton because he was going too far too fast and and and so That is a component. We're not discussing today and I have no criticism for not having done so But I observed that is an essential component of what it is. We've got to deal with Go ahead marion. I really want to say we're particularly on your point about the money because you know There's this proposal in congress to eliminate the centers for medicare and medicaid innovation right to cut that funding and we've all been talking about how Great that part of the affordable care act is and we're demonstrating results from that But we're also demonstrating it saves money and so that's the that's the thing So I don't know And I want to hear from everybody else, but I want to go back to brand because I don't want you to abandon the idea You had in the 90s. I think we have to take what I mean I have gut feelings you all have metrics and we need to take the empirical evidence Back to washington to show we are cursed with people in washington who knew the cost of everything At the value of nothing. Yeah And the result is that we have these idiotic fights that we're always having with the t-values and others And we need to give you that data. We have great data for you. So we need to take the data and start to build a business case But keep going map. We don't want to Well, I I think these are I could see these comments just about to emerge. So i'm glad you Brought them up and I actually think we have some expertise around the table That can speak exactly these issues I'm going to turn to dais ballinger and to jim haven to speak a bit about From their leadership positions as part of major organizations that have to deal with Some very clear financial constraints. How does medicare fit into the the challenge, whether it's in innovation or Encouraging systems to evolve So I want to follow a little bit with that rent setting Not a criticism, but we actually didn't get a global payment But I But I but I wanted but but the important thing was That because medicare had a demonstration project It was the feeling of the university that this is where This is where to quote the You know famous hockey player. This is where the puck is going and And that we were willing to put our resources up to invest into the complex care management system And our resources into changing the way we deliver care to enter into the my pick project To be the coordinating center for the my pick project And at which is 600 practices across the state of michigan and continue this experiment I can say we've been in this experiment since 2006 and every year Even though we haven't always hit the two percent hurdle to get shared savings every year Since 2006, there's been we've had savings to medicare uh for nine straight years and so And we I can't tell you about this last year because it's embargoed, but it will be positive But and so I think that we we've shown that we can make investments in change And and and provide improvements in the way care is delivered And both in the cost and the quality outcomes for patients And so I think the experiments are critical. I think the cmmi is critical part of The affordable care act and I think the affordable care act is a good it has its issues But it's a good platform for improvement. I mean, I think the challenge we have Is that that people think that you know, it's sort of this hl mink and Quote, you know for every complex problem. There's a simple solution that's usually wrong And we sort of we it seems like the mentality in washington is we have to we didn't get it right So we should abandon the whole thing and try again over I think it's a platform for which we can continue to improve and I think the cmmi is actually one of the One of the most important things and I think then the the Projects in the cmmi then have to be used in form policy going forward. So for example, you know, do we need to move Away from the three-day rule Yeah, yeah in uh, you know that you have to be hospitalized three days in order to get into The answer to that Should we um, that's one just one should we have a different benefit Related to you know, subacute nursing facility, you know and in and and how that's handled Going forward Can we do more home care and and what and should we talk about virtual care right now virtual care? Is not you know not reimbursed And we could provide much better Care in the home with virtual care we we have a program where we send We we send health care assistance to homes and then we virtually connect with both a A physician and a pharmacist to go through I mean the problem is we go into homes and we see the candy bowl effect right the The candy bowl full of different colored pills And they're going to have to try and they have to figure out how they're going to take they somehow supposedly take those in the right It's not going to happen. So, you know, I think that the cmmi is a critical part of the Affordable Care Act in and it's also And cms needs to also exert its its influence which it has in january this year announced Creating a network to try and influence other payers to move in this same direction Thanks, Dave. Jim. Can you show me of your perspectives on this? Well first? Let me thank you for what you've done for the state of michigan. There's 1.7 million people who are on Medicare in this state 2.2 million on medicaid in the state 500 600,000 on the healthy mission plan. So a total of almost 4 million people in this state Uh get some type of support for healthcare and that's a great step forward for the health and the economy of the state Uh, I agree with you carmswoman dingle that long-term care if you can address that and focus in on that I mean, I'm really proud of the innovation that michigan does and we can't do it alone I mean, we've worked hard with the universities and michigan's been a great player But but it's very complex and you know it and I know it because we've had friends who've gone through it I mean you've got waiver programs over here. You've got Area agency on agency. You've got the nursing home industry. You got the home health care industry none of it's coordinated So you have to pace programs for the frail or if we can start getting some coherent approach We would make a great step forward, especially with the number of people who are entering the industry michigan is part of the innovation and the whole dual program where you've got the We got 200,000 people in the state who get medicare and they get medicare Two different programs each spending four billion dollars each And if you can just put under one case manager and do more holistic approach to health care What a simple thing to do. Well, we're we're experimenting that in michigan And I think it's going to make a difference the other important piece Is of the 2.2 million people who get assistance through the department of health and human services now About 1.2 million our children our children michigan 94 percent of the kids either have private insurance or public insurance That is huge if we want to make a difference the last statistic I want to tell you under the healthy michigan plan, which you all were key in making happen Two million people two million primary health care visits already The number of preventive visits that people have gone through we are changing the behaviors of people And if that's what we can do we can start moving from a curative model to a more preventive model And that's our goal, but long-term care if you can focus in on that I think you'd find a willing partners to help you with policy Thank you jim For excuse me for our remaining partners around the table. We're going to focus on medicare policy And how innovations in medicare policy some of which have been alluded to here are helping shape the Medicare of the future if you will Because we know that 50 is still young right and heck And so what i'm going to do now is turn to a few of our experts around the table who Are taking particular looks at certain elements of medicare and its innovations And look to see how those innovations are helping inform our system today And how future innovations might help shape it into an even better program in the future. Excuse me So i'm going to ask Helen Levy and mark fendrick and andy ryan And peter jackison to wrap up our comments here And we'll ask Helen to start off with some comments perhaps about medicare part d and what we've Learned about that program and continuing tinkering with that under the affordable care act Sure, I think this follows up nicely on congresswoman dingles point about gaps in these programs because one of the biggest gaps in Medicare was the lack of a prescription drug benefit for most seniors And medicare part d reduced the fraction of seniors who don't have drug coverage from about a quarter of them to about seven percent So it it Has been a tremendous success in giving people access to this coverage and protecting them from the potentially high cost of prescription drugs It did come with its own gap Which was the doughnut hole which is being closed by the affordable care act So I think that sort of continued incremental progress in closing these gaps That that has been the name of the game and will continue to be as we think about Other issues like the coverage of hearing aids coverage for dental services The under insured people who have insurance with maybe not enough financial protection I think the lessons of a program like part d Are very encouraging And build on this idea that medicare is still, you know, 50 is young So picking up on Helen's theme mark of The importance of pharmacy coverage connects into the idea of value and what you've been working on around value based insurance design So thank you. I should tell you It's great to be here and congresswoman and mr. Chairman my 24 year old daughter Just sent me through twitter because I told him that you heard that you rolled your eyes when you said We're doing this through social media. She said she loves your tweets And I should also say for those of us around the room The chairman's background for his twitter account is the big house just like my daughter So I didn't know that you had that allegiance to our football stadium. So You got to be careful with everything you say these days So one of the most notable statements of the press conference from president johnson signing the medicare Statute was seniors no longer would be denied the miracle of modern medicine And you see from this day one issue that the cost of insurance was six dollars a month with the employee had to pay three and I think we know Certainly that it's the cost of health care that's being discussed much more so than the quality and I'm Very happy to have traveled to 49 states telling people that I did not go to medical school to learn how to save people money That I really do believe whether it be in state capitals or in boardrooms or In the hallowed halls of the u.s. Congress I think there's way way too much attention being spent to how much Is being spent as opposed to how well we're spending it and that's been kind of our Our pithy sound bite of what we've done in the center for value-based insurance design and And value-based insurance design emerged from the idea that even though americans are covered Have insurance cards whether it be in commercial plans or now in medicare With the cost of care and the issues of copayments co-insurance and deductibles There has been a rapid and real increase of what we call cost-related non-adherence And as someone who's just a gigantic fan of all things medicare including part d It's amazing in 2014. There were more beneficiaries who had to forego basic services to buy their medicines with part d Then they did Before part d suggesting that costs of everything Are rising and we we do have to make some real issues about What we cover when and why and whether it's things that not covered Like hearing aids or it's the money issue that you say, you know, I think if we really focused on this how much to how well issue We may make some progress forward The great health policy researcher woody allen Said the best way to reduce expenditures is death And uh, we are not in that business and I think that as I have had the good fortune to visit Mr. Chairman your office several times and debbie your Mark we have a guy in congress who made that suggestion to the republicans and you can't imagine the outrage Let loose by so doing Right, so this idea that that both of you raised that um The attention about the budgets and how much as opposed to the issues of what we're spending and what we heard you know from even others that maybe We may go about this idea of spending our money better and spending our money better On the supply side has been discussed by Dave and Jim and others But we have focused on how to get consumers to spend their money better And this value based insurance design idea is one that that actually strengthens Medicare by creating a benefit design That makes it easy to get the services for which doctors like friend williams would say I beg you to do and You might remember that uh, we actually incorporated value based insurance design in section 27 13 of the affordable care act Uh with your health senator stabbin now I actually sat in senator kennedy's office one of my great moments of my professional life and actually typed myself Uh part of what became the affordable care act Which uh signed copies, you know hangs of your signature hangs in my office So the good news is for preventive care 137 million americans including everyone with medicare now has access to high value primary preventive service at no cost to them The issue of course being both of you focusing on the money is 98 of medicare dollars are not on preventive services They're on chronic diseases So I get sad emails from patients that say thank you for the free mammogram I now have to foreclose on my house to get my breast cancer surgery Thank you for the free access to colorectal cancer screening I can't get the drug that my oncologist tells me Will cure this cancer And we work very hard with both of your office to try to convince either congress of the obama administration to create a value based Insurance design demonstration medicare You helped us introduce a bill prior to the aca mr chairman and and we were very very pleased to see this summer I'm going to say this slowly with strong bipartisan support Strong by partisan support that's extraordinary The strengthening medicare advantage through innovation and transparency for seniors act of 2015 HR 2570 was passed this to you Greg Sundrom and both of your offices was a great help to us moving forward and I'll disclose with the You know, I see patients a day a week My mother thinks I worked for the cia because I travel around all the time and not a real doctor like many people around the room But I've learned firsthand that we need this interaction between policy and practice And both of your offices have just been absolutely instrumental to see these ideas that we generated the academic setting to move forward You might have heard In our word world we publish or perish Well, I published and still perished Until our government relations team brought me to washington the first time since my fifth grade field trip to introduce People like you to ideas like this and understanding completely that the political realities of what we do are absolutely essential And I understand the vitriol and rhetoric, but in some circumstances there might be that fine place To talk about ways to make our seniors healthier, particularly the most vulnerable ones Thank you mark and we've heard from mark and helen In large part about the benefits within medicare now. We're going to talk with andy about how Healthcare systems are being restructured with encouragement shall we say from the affordable care act and from medicare Well, thanks so much matt and so I just wanted to comment about some of the reforms and the aca that are designed to improve quality and value In the system and you know, they have gotten Not quite as much attention as the insurance expansions But I think they're really crucial to the future of medicare and its long-term sustainability And so I think the timing of these reforms in the aca has coincided with You know reduction a bending of the of the cost curve of reduction and the rate of medicare spending But it's really unclear how much of that Is can be attributable to what's in the aca versus other factors in the environment and as researchers We're trying to do this Provide this honest criticism to see what's actually working And to say this needs to be expanded This is something that can actually improve quality improve value and you know this this reform not so much I think what's interesting about payment reform is there's no silver bullet with Insurance expansion and we knew with the three-legged stool that a combination of you know guaranteed issue mandates and subsidies would Nice and solve the problem that we could get people covered and with stable insurance markets But we don't have that same set of policies for payment that we know we're going to work So we're experimenting with all kinds of things studying the effects and trying to Expand them gradually and I think that's just our task as researchers if you think about the history of medicare payment reform think You know prospective payment for hospitals in 1983 clearly worked to reduce Hospital spending but so many of the other things that happened in medicare You know it's kind of mixed bag worked in some ways. Maybe not so much in others And I think that just speaks to the prerogative of continuing our work to study these Interventions and see what works and how we can expand value in medicare Thank you, andy and now i'll turn to peter who has additional background besides public health in the world of law Yes, and has Offered to share some of his perspectives about how medicare has shaped Some of the world of judicial and regulatory doctrine Could I make a comment here that I think is important? Medicare, medicaid and social security are like taxi They weren't born they grew and the hard fact of matter is We're always trying to see That those do what is needed But we're always approaching it from the rear Not from the front. There's very little foresight goes into these things. This is all Stuff that we should have done Years ago Europeans did it England did it in 1870 with Good King Edward Bismarck did it in the 1880s in Germany in Prussia so We are just trying to get caught up living at the biggest idea quite frankly what the hell we're doing And very truthfully we need you and the other experts in gatherings like this and through your Communications with us of what is going on to tell us look dingle these are changes got to be made now Dingle this thing goes out with that dingles in and the fact of matter is that if If if if you will do that and the rest of the profession will do this We will we will we will make some Effort and some accomplishment in terms of catching up and doing the things that desperately have to be done so that When you talk to us, you won't be able to look at it and say well Dingle here again But give us a lot of sympathy. Well, we're we're we're trying to find out what's going to happen and and and hope that something will flow from this But you guys who have to know how and understand the science and the technology and all the other things and the You got to tell us what's got to be done so that we can respond Okay Well, I don't think I'll answer that question But and of course this mark had the kaiser and I'm not sure we want the kaiser back to solve our kaiser And we can talk about that later so I actually Your point is interesting in terms of how the law has developed Because it does evolve and if we were to look at when you when you signed or held your hand up With representative pepper at that time What would the law of medicare look like 50 years later? I doubt that you would have predicted what we have now What's interesting about that to me and and I teach health law to unsuspecting graduate students And so my appointments in the school of public health Law is pervasive now and medicare is one big reason but what's interesting about that gets back. I think representative dingle to your point about Medicare being woven into who we are If you look at the development of judicial doctrine In medicare from 65 until now It's very difficult to see any clear the triangle development or role But you can't understand health law without understanding how medicare helped shape the institutions the providers And patient response and how we developed law in in its role Second point Is that in the future? I suspect we will see much more of doctrinal development related to medicare particularly around governance quality of care And and possibly liability and and I trust As the institutions take more and more control the liability will change And for a lot of reasons and I trust also through the medicare shared savings program But when you really see the effect of law in this area is on the regulatory side so My so you raised earlier also suggestions. We need regulatory reform desperately It's out of control. You look at how we regulate and largely Through medicare medicare you see a couple of things first some real positives as a result of medicare The expansion coverage determinations technology assessment as regulatory Matters Marriott's point earlier about the incubator of ideas can be seen as a regulatory development quality of care that you've talked about the professional standards review quality of care conditions of participation arguably positive not necessarily definitive But then you start to see the fraud and abuse regulations Which are mammoth And I think crushing in the sense that they impede legitimate arrangements in the marketplace that are effective for physicians and patients So This is on the small bore side of ideas but I think What's happened is we now try to micromanage healthcare delivery through the code of federal regulations and it's not effective in fact it raises costs It potentially harms patients. So we need regulatory reform at least The the absent the policy missing one of the policies missing from the affordable care act That's all Very good, so That's all she's written for right now We we've had a pleasure we've had the pleasure of sharing with you from several different faculty members here are some of our current work and thoughts and also we appreciate The additional benefit of hearing from folks like Jim Haveman and Dave Spalinger who've kindly joined us today to share their perspectives as leaders in the world of health care and We have a few minutes for any follow-up questions or Suggestions you have for us Well, I have a ton of questions Which won't get answered in the short period of time And one of the things I I want to spend more time with Brent is why have you abandoned trying to Because I think that's the answer down the road I think we have to talk about that and how we make it affordable and that longer term it really Can reduce costs I want to I think that I'm going to make a very parochial comment in one way Which is I think that some of the top research in the country is being done at this institution on a subject that needs Real dialogue that most people don't understand the subject until There everybody suddenly finds themselves in it when they're taking care of somebody that they love or that they care about And You know, some people are lucky enough to realize how broken the system is and other people never figure out How to make the system work I think there's very real data and metrics being done here And we need to educate policymakers about what the different issues are and how we Really begin to have this conversation uh Mary Kay Henry was in my office and seiu is an aarp was in and everybody's talking about we have to do something And I say okay, when are we going to stop talking about it? And when are we going to start? Okay, how do we find those solutions? Obviously the data the metrics the Experimental programs that are being done here have some of the foundation work and I suspect you're aware of Where other work is being done around the country? I I hate to say this but I think that most members of congress have no idea what's really happening at cms Understand it understand the kind of research that's coming out of the affordable care act I I I look at jim and I it reminds me of a day I think one of the happiest days I've seen in the last decade was rick snider and john dingle standing together And they both had a sparkle in their eye, which you rarely see any either of them ever get When they not much reason But my point uh when they announced the And it was signed and they were both being Roundly denounced by both sides of the party before they ever walked out of that room But I I think there's so many so many questions And how do we take the findings here and really begin to translate it Into policy when he was moving out of his office. I found a bill that his May have been one of I've shared this with mary ann may have been one of the first medicare bills It was handwritten in the 1940s And as you all know medicare itself didn't pass until 1965 And I found a million things that he had tried to do in the 60s that I was unaware of which are now part of the library Here at the university of michigan, so I You know the question is how do you take this conversation broadening it? Include policymakers across the country and really start to talk about these ideas. So we translate them into Not ideas, but into reality for Americans that every single day are facing crises that they need help in I ever felt one time say that it would be very nice if some folks would get down off the wagon And would help to push And the guy who said that was a father them a program I'm gonna Site him as authority for everything in this particular room, but the simple fact matter is He was saying that we all ought to get together and push well The hard fact matter is if this thing is going to be successful In terms of saving money and doing the things that we wanted to do in terms of the time that we have in terms of all The other constraints and limitations that we confront It means that leadership is going to have to come from here And other people who know and understand and care That's why what you're doing today is so valuable And so if if if you will do what you do so well, then it's get out of the wagon and push And you've got to understand that Brother Graham's going to be pushing the other direction And there's a whole bunch of baskets like that that you're going to have to worry about But it's the question here is how soon can we generate the political forces that are necessary To generate the kind of support that we've got to have to make this darn thing work In the time that it is constrained upon us by events in history Well, I just want to take this opportunity to thank you The director the institute for health care policy and innovation at the university of michigan We really appreciate the opportunity to celebrate and commemorate the anniversary of social security and medicare with you I want to thank all of our colleagues here and including the director havenman Who's joined us from lansing And and really sort of taking the time to reflect on how our work and what we're learning can help you Create a better medicare program for the american people in in washington and and hopefully do that in a bipartisan way That you know improves value that you know gets us the best health outcomes that are Possible with the medicare program and and I hope we can invite you back to celebrate the 60th and 75th and 100th Anniversary of the medicare program here with us and an arbor and it's just been a great occasion And we actually have one very special thing that we wanted to do quickly, but I don't want to Not take just a moment to thank everybody for their comments and their thoughts a very helpful conversation Which clearly is ongoing and so it has been a pleasure to host this and to have our special guests But as our kind of wrap up perhaps I will turn things back over to My friend and colleague matt davis Thanks, susan and mr. Mrs. Dingell We heard that you may not have this On your mantle We don't And we thought actually in following up on today's conversation this this photo Which is the same of small version of that one there? The to victorious gentlemen of the congress celebrating medicare's passage is a photo of action And that sort of action is something that we can get behind and start pushing the wagon And hopefully this will be just a sweet memory of this conversation that we've had today I know speaking for everybody. We have greatly appreciated the chance to Hear your ideas about the future of medicare and contribute some of our own and may the best team win Absolutely. Thank you. That's right. Absolutely. Exactly