 I'm Michael Barr. I'm the Dean of the Ford School of Public Policy. I want to give special thanks to two people who couldn't make it today but who are integral to this event. Gil Oman and Martha Darling have provided generous support through a health policy fund for today's event and other events we've held on health policy. I'm deeply grateful to both of them for their work together. Before we get started, let me say today commemorates the 50th anniversary of Martin Luther King's assassination, which is obviously a deeply troubling event in our nation's history. And before Dr. King was killed, he was organizing a march on Washington called the Poor People's Campaign. And we have an exhibit in our hallway on the second floor that I encourage you to co-visit on the way out, highlighting some of his work in this area. The Poor People's Campaign was designed to draw attention to poverty in America as a global human rights issue. And the campaign sought to demand better jobs, better homes, better education, and quite relevant for our discussion today, better health care to improve people's lives. With many at the Ford School dedicating their work to address the issues of poverty and inequality through policy, it is my deep pleasure to introduce you to today's moderator, Associate Dean for Academic Affairs and Professor of Public Policy, Apollo Lance. Earlier this year, Dr. Lance was one of 52 distinguished social insurance experts to be elected to the National Academy of Social Insurance. As a social demographer, Dr. Lance studies the role of public health and health care reform, clinical preventive services, and social inequality and health. Her current research explores the potential of social impact bonds to reduce Medicaid expenditures and improve health outcomes. And with that, let me leave you in her capable hands to tell you more about our esteemed panelists today. Please join me in welcoming Dr. Lance. Good afternoon, everyone. Thank you, Dean Barr, for your warm welcome and kind words. And I also do want to honor Dr. Martin Luther King today by reminding us of one of his many moving and compelling quotes, of all the forms of inequality and justice and health care is the most shocking and inhumane. So we've gathered here today to talk about health care and one really important aspect of health care and that is financial access to health care through health insurance. The Patient Protection and Affordable Care Act or the ACA was implemented in 2010 and by no means was a perfect piece of legislation. With 1,000 pages as a law and many times that in rules and regs, the ACA implemented some sweeping reforms in health insurance and health care costs and quality. With a well-worn motto in public policy of don't let perfect be the enemy of the good and a few quick trips to the Supreme Court, the Affordable Care Act was implemented by the Obama administration. This included new regulations for the health insurance industry, including a ban on preexisting conditions, medical loss ratio limits, and coverage for adult children up to age 26 with many of the students at the University of Michigan really appreciating that provision. The ACA also brought us the individual mandate with few exceptions everyone was required to have health insurance coverage. To assist with these goals, states were required to operate marketplaces for people who needed to purchase insurance in the individual health insurance market with significant technical support and subsidies from the federal government. In addition, the Affordable Care Act allowed states to expand their Medicaid programs to non-disabled low income individuals who traditionally would not qualify for Medicaid. And this, again, was with significant subsidies from the federal government. The rate of uninsurance among people under age 65 in the United States was 18.2 percent in 2010. By 2016, that had dropped to a historic low of 10.3 percent. Even so, the Affordable Care Act has always had a loud, dramatic, and primarily partisan chorus of critics. With the new Congress and new administration in 2017, the Affordable Care Act has been threatened with full repeal, with repeal and replace, repeal and reform, and administrative sabotage. While major repeal efforts thus far have failed, the Affordable Care Act has been dealt some significant blows. This includes that the new tax bill ended the individual mandate. In addition, the Trump administration has pulled a lot of resources away from supporting and promoting the exchanges and has openly criticized the Affordable Care Act during the open enrollment period. Other administrative moves have included discontinuation of cost-sharing reduction payments and more recently, guidance for states to use section 1115 waivers to implement work requirements for Medicaid beneficiaries. It's complicated, as they say. Very complicated, and who better to help us sort through all of this than our distinguished panel of guests today. So please come on up, and I will introduce all of them. Thank you. So we are lucky today to have with us Dr. Gail Walensky. She's an internationally respected health economist and senior fellow at Project Hope, which is an international health foundation. Among her many impressive prior positions, she directed the Medicare and Medicaid programs from 1990 to 1992 and served in the White House as a senior health and welfare advisor to President G.H.W. Bush. Dr. Walensky testifies frequently before congressional committees, serves as an advisor to a wide array of policymakers at the state, federal, and international levels. And she is a proud graduate of the University of Michigan for both her undergraduate degree and her Ph.D. in economics. And she's also a very dedicated and warm friend to the Ford School. So please join me in welcoming Dr. Gail Walensky. Also with us today is Jonathan Cohn in the center hotspot. He's a senior national correspondent at Huffington Post. He writes about politics and social welfare policy with great expertise in the area of health policy. He's the author of a book, Sick, The Untold Story of America's Healthcare Crisis and the People Who Pay the Price. He has won numerous awards and accolades for his journalism and we're very fortunate to have him here with us today as well. So welcome to Jonathan Cohn. And we also have with us Dr. John Ianian. So John is a physician, professor of internal medicine and also a professor here with us in the Ford School, professor of public policy. And he is the director of the University of Michigan's Institute for Healthcare Policy and Innovation. His research focuses on access to care, quality of care, and healthcare disparities. And he's currently leading an evaluation of the Medicaid expansion in the state of Michigan. Dr. Ianian has served in key health policy advisory roles to state and federal government and is an elected member of the National Academy of Medicine. Welcome to Dr. John Ianian. All right. So we're going to get to our discussion and here's what our format will be today. I am going to ask our panelists some questions. We'll have a bit of moderated discussion. But then we'll turn to all of you and we will have time for Q&A with the audience. I hope you all have little white note cards at your disposal. You can write your questions on them and some terrific Ford School staff will be collecting them and bringing them down to our, who I'll introduce later, our team who will be presenting audience questions to our panelists here. For the people who are participating with us online, welcome to them and you are also encouraged to participate in the Q&A portion. You can send in your questions via Twitter using the hashtag policy talks. All right. Panelists. All right. We're going to start out asking you to think about the sort of where are we today? What are your thoughts on how the Affordable Care Act had been working through its first years in the Obama administration and the changes and reforms that the current Congress and administration have made to date? We'll start with Gail on that and then go in order through as you're seated there. So Gail. I think the hands down most important effect that we have seen to date is the expansion and coverage which you mentioned early on. This has been a challenge the United States has had, continues to some degree to have and was only going to be ameliorated if there were proactive changes to expand Medicaid coverage to some of the poor and low-income people not otherwise covered by Medicaid and to some of the people who were not in a position to get employer-sponsored insurance either because their employer didn't offer it. They were self-employed or entrepreneurial or they chose not to accept it. As you've indicated we have seen a substantial reduction. 2010 is a somewhat artificially high start date. It was very much when we were still on the throes of the recession but it's close enough to indicate that we have seen a substantial reduction, the number of uninsured. That's a real positive. It looked as though we were seeing a slower growth in spending that some attributed to the affordable Care Act's introduction. I was never convinced and I think there's enough indication now that most of the slowdown which was very helpful to have experienced from 2010 to 2014 happened primarily because of the global recession and secondarily because of the adoption of high deductible plans not just in the exchanges but more importantly because it's much bigger by many employers in terms of having an impact on healthcare spending. You raised some other questions about potentially undesirable effects but it has a real effect on spending. This became clear when OECD put out information in the fall of 2015 that looked at spending worldwide from 2009 to 2014 and as significant a reduction as we in the United States experienced during that period it was actually slightly less than the average OECD country experienced during 2009 to 2014. Again, we were able to have a period of slow spending, good for us that knocks down the base from which the growth is now reoccurring. It's a reminder that we have not actually resolved many of those challenges. The most interesting part of what has happened to date despite the best efforts or at least efforts, I don't know, they sometimes didn't seem very well thought through of the Republican Congress to repeal or repeal and replace or repeal and modify the Affordable Care Act. There has been very little that's actually happened to date including either legislation that has been passed or more importantly coverage that has been reported. Despite taking away some of the promotion money, the number of people in the exchanges is very modestly less than it had been, about 400,000 out of 11.3 million. That is really not very surprising because the good news or the bad news is most of the people who went into the exchanges were those individuals who were very heavily subsidized or who really, really wanted insurance and had been medically uninsurable before they act. Those people are continuing to participate with heavy subsidies. They are mostly the under 250% of poverty line people or people who are on the expanded Medicaid program which is where the heavy lifting of insurance expansion has occurred. It is really in many ways the unsung hero of the Affordable Care Act with a lot less drama. It's picked up at the majority of newly insured. As best we can tell, it has done a good enough job that the rest of us haven't heard too much about it which is usually not a bad metric to follow. The bad news is the instability in the insurance exchanges that had been present almost from the get go continues. Before the election, a third or slightly more counties had only one insurer. That is not improving. There has been substantial increases in premiums. Some people thought they would be one time. It was hard to make that conclusion on the basis of a one point. One point does not align or trend make. For most of the people on the exchanges, it was relatively irrelevant because their subsidies are calculated in a way to pick up the premium exchange, the premium change. It's really the people who are outside of the exchanges that have been impacted negatively because of the increasing cost of the exchange. Now, it's not like the Republican Congress didn't try to destabilize them. I think for the most part, it has had surprisingly little effect and in my opinion, the relaxation of the mandate will also have minimal effect. I'm not in favor of that by the way. If you guarantee that people with free existing conditions should not be penalized if they don't insure or decide at some point they want to become insured, you have to have some heavy-duty arm-twisting incentive around to keep them in or you invite bad behavior and adverse selection. The reason I think it will have almost no effect is because the people who are in are being heavily subsidized and there is no real place for them to go that would make any sense for them to go to. So while in principle, it's dumb, bad policy. In practice, I think it has a very little effect. But it wasn't the only dumb policy that went on. Jonathan actually had quoted me early on before the Affordable Care Act was implemented about some of the worries that I had. Was the mandate tough enough? The notion of guaranteeing people who are under 26 that they can stay on their parents' policy made great sense until 2014 when at which point you could get subsidized insurance on your own. It was not such a bright policy idea after that because it artificially narrowed the favorable risk pool that you would otherwise like to come in. This is all part and parcel of an ongoing problem of how to try to get a broad risk pool so that you don't get only those who are the expected high users wanting to come in or who will almost bear no cost. A little time I know to talk about some of the things that I think need to happen in order to fix those. But my assessment is, despite the efforts of I guess not very effective Republican in Congress, there has been precious little change on the Affordable Care Act in terms of participation, both by individuals and insurance companies. And I think actually the President is correct. The cost-sharing reduction payments ought to be done by Congress, not administratively. That was always a hokey fix and at least the one judicial ruling that occurred indicated that this was correct. It needed to be in appropriation, not an administrative expenditure. So, you know, Gail and I have done panels and interviews like this before and I'm a little disappointed because usually we have a more contrasting points of view and actually our 30,000-foot view of the Affordable Care Act is remarkably similar until we get to the effects maybe of some of what has happened since the Trump presidency has begun. But my overview is going to sound a lot like hers, so, you know, apologies for that. But I, you know, to me, what is the biggest accomplishment of the Affordable Care Act? I actually think there are two. Number one is the coverage expansion and I think it's important to remember that when we say, you know, so many millions of people got insurance that's not just numbers, that's not just statistics. These are real people getting healthcare. We actually are getting data now that shows pretty conclusively that overall we are seeing improved access to care. Overall we are seeing more financial security as a result of the, these things are hard to measure. The effects are not always as dramatic as you would like. But I think it's very clear that we have increased human welfare. We have protected people who need it protecting and that's a really big deal on this scale. We don't do that a lot in this country. The second big accomplishment I think is I think the Affordable Care Act has changed the political conversation. It has moved the bar. It has changed expectations. It has changed public expectations of what the government, what our society should provide to people in terms of health insurance. And that was actually not clear until the effort at repeal happened. It was only when the Republican Congress tried to repeal the Affordable Care Act which had never really been that popular. And yet when they tried to take away protections for pre-existing conditions, when they tried to take insurance away from millions of people who had on Medicaid, there was an outcry and they failed. Barely. It's not that hard to imagine that debate having gone a different way. But I do think that's an indication of how expectations have changed. At the same time, it said expectations that the law itself has not met. We still have tens of millions of people who don't have health insurance. Lots of people who have health insurance cannot afford their medical bills even now. There are a lot of people who feel like they are worse off because of the changes of the Affordable Care Act. These were all failures, shortcomings. And these were all true at the end of the Obama presidency. I want to drill down carefully onto the marketplace, the non-group issues. Because I think that's not, as Gail says, it's not the most important part of the Affordable Care Act. It's a portion of the Affordable Care Act. It's a tiny portion of the population with insurance. But it's where the most activity, where the most controversy is to reminder this was where you couldn't get insurance if you had a pre-existing condition. This is where if you bought a policy and you got sick, you suddenly discovered it had these huge gaps. And the idea of the Affordable Care Act was to upgrade coverage, make it available to everyone, make it more comprehensive. Of course, that made it more expensive. So then you had to subsidize it. You had to have a mandate to make sure healthy people bought in. It was not a crazy theory. It worked in Massachusetts mostly pretty well as well as these things ever work. And the idea was to replicate that. And at the end of 2016, early 2017, you looked across the country. You found states where you had that. Not coincidentally, it looked a little bit like a blue-red political map, California, Rhode Island, tended to have fairly well-functioning markets. Michigan actually had a fairly well-functioning markets for reasons that had to do with the idiosyncrasies of the state. And that's one thing you find if you study states. There's a lot of factors at play here. Michigan happens to have relatively cheap health insurance, which helps. But you had states like Tennessee or Iowa or Nebraska where really things were already getting out of control, where if you didn't qualify for those subsidies, the coverage was really expensive. And that was, you know, again, I would call that a failure or a shortcoming of the Affordable Care Act, a product both of the way it was designed, policy decisions made by the Obama administration. Also, decisions made by state Republican officials who were hostile to it, decisions to not fund something called the risk corridors, which was supposed to be to help insurance companies weather early losses. That was something that was done demanded by the Republican Congress. So that's where we were 2016, 2017. The Trump administration comes in. The Republicans have Congress. Obviously, they tried. They failed to repeal the law. They have taken a series of steps to weaken it. They've cut outreach money for enrollment. They cut off these cost-sharing subsidies. The individual mandate is now about to come off the books. I always say, I don't think any one of these was all that devastating. I think with most of them, you can find a small effect. For example, I mean, a lot of people look to the numbers. They cut off the funding just before the end of open enrollment for this past year. And a lot of people look to the numbers and notice that usually there's a last-minute surge and that last-minute surge in enrollment didn't happen. And at the margins, that probably contributed to these problems. When you add them all up, though, I think what you do have is a situation where in those states where officials are committed to making the program work, it's going to continue to work. They're going to take the steps to shore up their markets. Even in those states, it's not perfect. Even in those states, they have problems. But where you have states where officials are not committed and not now being aggressive to really implement the law and really promote it to regulate the market in the way the designers imagined, I think you're going to continue to see this problem where for people who don't qualify for subsidies, coverage is just going to, it's become, frankly, truly unaffordable. Not just, this is more expensive than I want, but I just couldn't pay for this. And that's a real problem. And I feel like that's where we are headed. Dr. Ainean. So thank you, Professor Lance and Dean Barr, for the opportunity to join the discussion today. As a physician on the panel, I have to say every week in our primary care clinic here at the University of Michigan, I'm seeing patients who are benefiting from the Affordable Care Act, either through new Medicaid coverage or qualifying for a marketplace plan that they can now afford and sort of all the ways that Gail and Jonathan have described. And I think that's very important. We can look at the overall numbers. Over 20 million people now are covered, that weren't covered back in 2010. That's a real advance. The biggest drop in the rate of uninsurance in the last 50 years in the United States after sort of steadily increasing rates of uninsurance. I think it's also important to point out the equity effects of the Affordable Care Act, which have really been concentrated among low-income, non-elderly adults, so primarily those between 19 and 64, earning less than 200% of the poverty level. For them, before the Affordable Care Act, the rates of uninsurance were up around 40%, and they've been cut in half. And also from a standpoint of racial and ethnic equity, as we think about Martin Luther King's anniversary of his death today and this week, we've seen for Hispanic Americans who had rates of uninsurance over 40%, they've been cut in half. For African Americans who had uninsured rates of 20 to 25%, they've been cut in half. And for white and Asian Americans, they've been cut in half as well, just starting with a lower rate of uninsurance. So that means many more people are accessing care. And we're seeing, for example, here in Michigan, when we look at the Healthy Michigan Plan, where coverage has been expanded, people who've gone without care for five, 10 years or longer, including dental care, which is an important benefit that we've seen here in Michigan with the expansion of Medicaid, they're getting in for care, they're getting their chronic conditions treated, high blood pressure, diabetes, heart disease, lung disease, conditions where we know people are going to be in worse health, they're going to function more poorly, be less able to work if their chronic health conditions are not cared for. So that's, in my mind, the greatest accomplishment of the Affordable Care Act. There's some other points that I would add to what Gail and Jonathan have said. We've seen it's, particularly for safety net hospitals and community health centers, it's really stabilized their financial status. They were providing, many of these organizations were providing high levels of uncompensated care, what we call charity care. When we look here in Michigan, the rates of uncompensated care for Michigan hospitals have gone down by about half from 2013 to 2015 as coverage was expanded. And we've seen in areas like Detroit and Flint and other low-income communities that hospitals are able to increase their staffing, they're able to provide more services and actually reach out to the community to bring people in who are newly covered. And so I think that's an important benefit. The benefit's not just those who gain coverage, but it stabilizes those organizations for people who either already had coverage through an employer or were covered by Medicare. Another important point, it doesn't get a lot of attention with the Affordable Care Act. Although it hasn't really slowed the rate of cost growth overall in the health system, as Gail pointed out, that was more a function of the recession. Within the Medicare program where there was a lot of concern about whether we could sustain, particularly as the baby boomers aged into the Medicare program, we've actually seen from 2009 when the Medicare trust fund was scheduled to run out of funds in 2017 with the Affordable Care Act, both from a combination of raising some taxes on higher-income Americans as well as taking some money out of the system, some excess payments that Medicare HMO plans were getting or some of the cost growth for hospitals and nursing homes. We've extended the life of the Medicare trust fund by an additional 12 years out to 2029. So that has real benefits for the whole population that relies on Medicare either as we get older, turn 65, or become disabled. Two other points I'd point out as strengths that I think have benefited people with private insurance coverage is the elimination of exclusions for preexisting conditions, which was a big barrier for many people to get affordable coverage. And then the elimination of cost sharing for effective preventive services, so mammograms or colonoscopies or PAP tests when indicated for the right age group. People can now get those through either private or public insurance without out-of-pocket expenses that might have prohibited some people from affording them. So those are some of the big pros that I see with the Expansion to the Affordable Care Act. Some of the issues that still remain unresolved, it's not clearly a slow, the overall growth in costs within our system and particularly one where I think a lot of Americans feel the pressure of rising costs is for prescription drug costs. You know, it really, although it was called the Affordable Care Act, it didn't sort of do a lot to really move the underlying trends in terms of cost growth in the United States. Some of that's for innovations in new drugs and devices, things that we want to provide here in the United States. And because we fund much of that research and development, the rest of the world benefits as well. But I think we have to come up with some better mechanism, particularly for paying for new breakthrough drugs that may benefit a small part of the population but really can sort of grow out of control for private and public insurers. Another issue that doesn't get a lot of attention is that while we've reduced the rate of uninsurance by about 20 million Americans, there's still large groups, particularly undocumented immigrants or people who live in the United States as legal immigrants for five years or less don't benefit from the coverage expansion of the Affordable Care Act. So that probably represents about 10 to 15 million people who remain uninsured under the current system. And then lastly, I would say, you know, we've seen this law, the Affordable Care Act, it's, I think of it as a law with nine lives. It's survived a couple Supreme Court challenges, many attempts in Congress to repeal or replace it, you know, which failed by about the margin of John McCain's thumb on one of the most recent attempts last summer. But we now have 18 states that have not expanded Medicaid. And it's really, I think, a state-by-state struggle. 32 states have opted to expand Medicaid since 2014, but 18 states, predominantly in the south and some in the west, has still not made that choice to expand Medicaid. We're starting to see some states put this on their ballot for a public's engagement in Maine last November. They approved Medicaid expansion through a public referendum. Three or four other states are considering putting it on the ballot in 2018. And then we have states like Virginia that have very closely divided legislatures where they may be on the verge of expanding Medicaid. And so I think that's an important question going forward. And I think another thing we saw last summer with the congressional attempts to repeal Medicaid, and I know Gail has written about this, that there was a sort of an outpouring of support from governors across the country, particularly Republican governors and states that expanded Medicaid, saying this program and the expansion has filled an important gap in our coverage for things like the opioid epidemic, where a lot of states were using the new Medicaid money to fund expanded treatment for people with opioid addiction. And so a number of Republican governors worked closely with their legislators in Congress and in the Senate to try and preserve the Affordable Care Act, at least the Medicaid expansion for that exact reason. Great. Thank you. So you've all alluded a bit to concerns you have about what the state of affairs right now, but I want to ask you all a bit more explicitly about what you think are the biggest, most pressing problems given the current state of affairs. There's really no one who thinks the way that the United States does healthcare and healthcare policy and our current status quo is a very good system, thinking about healthcare costs, again, coverage, access, disparities. So again, what do you think are just the biggest pressing problems for the people of this country and their health and their healthcare? We're going to start with Jonathan on this one and then go to Gail and then John. So I mean, I think the big problem in the background that drives all of this that I think probably all of us would agree is this, you know, it's somehow we have to get the cost of care down. And that's a long-term problem and a big project. So I'm not going to talk about that. We can talk about in the Q and A. I do actually have a nightmare. It's called Nebraska. Anybody from Nebraska here? Have I offended anybody? There's probably someone watching from Nebraska. I actually, lovely state, great people. I've spent a lot of time there this past year, but the Nebraska insurance market is my nightmare. Nebraska is one of those states I was talking about before for a combination of reasons. Some of it having to do with the demographics. It's a rural state. Some of it having to do with the policy decisions made by the people who run Nebraska. Some having to do with the way policy decisions made in Washington, both during the Obama administration and Trump administration and the design of the Affordable Care Act. It is one of those states where the market for the non-group market has basically split into two. If you talk to people there, I remember, you know, I've spoken to people there, if you are subsidized, you don't have a lot of choice in insurance. There's really only one provider in most places, but they do offer a couple. Dirt cheap, dirt cheap coverage, particularly after the CSRs which kind of backfired in a weird way. You can get really cheap coverage, really good insurance and you're golden. If you are above that subsidy line, so if you are above four times the poverty line, which for a family of four these days is about $100,000 a year, you're really in trouble. I was going to say something else, but this is a lecture. I won't use that word. The cost is just prohibitive. And what is happening now is you think, well, what are people going to do? They're not going to buy that insurance unless they can really script together the dollars and they have a very serious chronic disease which of course makes the problem, the overall risk pool worse. Everybody else is fleeing and what most of them are doing, and this has been going on for a while, is they are going into alternate plans that are out there and still legal and kind of work through the loopholes of the law, there's two in particular. One are the short term insurance plans which were originally created as this sort of niche product to get you between jobs or whatever. They were originally good for three months or a couple months. The others are what are called Christian sharing ministries which are run by religious organizations and have a long history going back to groups of small groups of people of like faith getting together to kind of share their medical expenses. What these have in common is they look almost exactly like the plans that were sold before the Affordable Care Act became law. They don't cover, you can't get them with preexisting conditions or they won't cover your preexisting conditions. They will have limits on benefits. They'll have big gaps. They may not cover full prescriptions. They certainly won't cover maternity. They frequently don't cover mental health. They are cheap. They are very cheap because they don't have to cover the sick people and they don't have to cover all these bills. So if you're healthy and you manage to stay healthy they're a pretty good deal. The problem is what if you're, you know, what if you're healthy and you buy one of these and suddenly, you know, you get sick, then what happens? Well, this is not a hypothetical. I actually met a couple. I wrote a story about them who had enrolled in one of these sharing ministries. Didn't really, you know, they read all literature. They were conscientious concerns but the stuff is confusing. Didn't realize that if they got sick there would be a look back to see if they had a preexisting condition. They end up in this big dispute where the insurance company found something from three years earlier and said, oh wait, this cancer you have was actually you had it the whole time and we're not going to pay the bill and they had to go through all the thing. Now they did in the end get the bill paid but, you know, that kind of thing used to happen all the time. The affordable character was supposed to wipe that out but it's happening again and we're seeing this world kind of come back this sort of substandard market and it's going to grow for two reasons. One is that states are discovering this and starting to kind of make it easier. Nebraska's neighbor Iowa just passed a law which under which the Farm Bureau is going to be able to offer insurance plans that are not insurance plans. So they're not calling it insurance. It's just a health benefit plan and because of that it's not subject to the Affordable Care Act's insurance regulations and the insurance department can't regulate it but it covers your medical expenses except it doesn't if you have, you know, a pre-existing condition or whatever. And then secondly, and this is where I think the mandate becomes an issue which is that these plans have been out there for a while kind of what was sort of holding back the dam on them was the mandate because you pay a mandate penalty at least for the short-term plans. The ministry plans were always exempt from the mandate. Now without the mandate there's more incentive to go into them. To be clear, Nebraska has a big problem. Coverage was already unaffordable for a lot of people but this is moving in a direction to make that problem worse and basically to recreate a market that for lease for the unsubsidized it looks like it did before the ACA and I think that's where we're headed in those states. Thank you. Right assessment of where we are, wrong assessment of what's driving it. And let me explain why I think that. Jonathan talked about subsidies up to four times the poverty line. Technically that's true. In fact, it's absolutely not true. If you look at who's been in the insurance exchanges since 2014 it has been 85% people who are below 225 to 250% of the poverty line. The reason you've got all of these offerings coming out is that you've had people who are above this including 275, 300% of the poverty line, 350 who were being expected to have the full broad coverage that the Affordable Care Act required except they were getting almost no subsidy. Well, of course they weren't doing that. The people who have been getting the heavily subsidized plans are going to continue in there. The problem has been this was an inherently unstable dynamic that was put in place because of the way the subsidies run and the requirements of the plans. Most of the people who are fleeing to get either the short term plans or the options available in the farm plan or its equivalent are people who were not on the Affordable Care Act exchange. Those people were and continue to get heavily subsidized. Now, that doesn't mean there isn't a real problem that's out there about what are we going to do for people who don't have employer-sponsored insurance and that has its own issues who don't get major subsidies and oh, by the way, we have some real problems that are brewing because if you're a low middle income person twice the poverty line, a little higher, the amount of subsidy you get when you go buy your insurance in the exchange is way more than the subsidy you get when you have employer-sponsored insurance and that is fundamentally unfair and likely to lead to its own instability. Us economists like to talk about horizontal equity. That is, people who are at roughly the same income ought to be treated roughly the same by the government but they're not in this case. If you're just at twice the poverty line, 225%, 250%, the fact that you don't have to count your employer contributions as income tax means basically nothing to you because you're not paying income tax at that level or a very little amount. You do get some savings I'm not having to pay Social Security and you get some averaging that occurs because the employer is offering the same healthcare plan but it's nothing like the subsidy that people who are at 150 and 200% of the poverty line are getting. We've got to make some decisions about what are we willing to subsidize? What kind of plans do we want to have offered to people? And this instability that was going on that Jonathan describes has basically been inherent in the Affordable Care Act since it was started. It is only playing out more dramatically. Now personally this notion that we were ever going to repeal the coverage expansion was ridiculous. It had already been in place for three and a half full years by the time this came up. There's absolutely no precedent in our history ever of having an entitlement and expansion of benefits in place for any sizable population for three and a half years and putting it away. And while we talk about and I don't want to in any way take away from the brave public stand that John McCain took I think there were several Republican senators if there hadn't been three the magic number needed torpedo the legislation in the Senate who would have done so in large part because you had so many Republican governors who were so staunchly in favor of the expansion and what it meant in the Medicaid program. The question we really have to deal with is what can we do to try to stabilize these markets that will not be inherently unfair to the people right above them right on the side of them and it's going to get to some of the discussion that we have with regard to the Medicaid expansion. To me again one of the questions is how can we make that transition between Medicaid and other kinds of insurance be more seamless where we don't disrupt the delivery systems the way we do now and what are we going to try to do in terms of a trade-off it is not going to be have the same extremely expansive benefit package that the Affordable Care Act is all the way up to four or five hundred percent of the poverty line. I just don't I think that the money is just going to cost too much. That doesn't mean we have to go back to the very narrow plans that we are seeing crop up in response to people who are unsubsidized who are being said this is the only thing you can get under current rules. We shouldn't have been surprised they were the very people who you heard on television in 2014 and in the fall of 2013 when they got noticed people especially in their fifties childless couple or a couple whose children had grown up and gone away that were not going to be receiving a big subsidy because they had forty thousand dollars of income hardly a wealth of money were going to be expected to buy a very broad based benefit plan including many benefits they would never use except they weren't going to get any help paying for that. It is really what we are seeing playing itself out in a different way same issues we have to come back and fix them. So Jonathan and Gail have I think covered you know the instability of the marketplaces I think very effectively I'll touch on a different issue and then so we can move forward and get to the audience questions as well but briefly to recognize that the Affordable Care Act was health insurance reform it was not health care reform and if there's sort of an unresolved issue in the US system of health care it's sort of how do we get greater value out of our health care system and the Affordable Care Act took some initial small steps it created a center for innovation within the Centers for Medicare Services what's known as CMMI that's testing out some new demonstrations of how we might try to integrate care more effectively we've started and always had a very fragmented health care system and that's a big part of what drives the rising health care costs that put us so far apart from the rest of the world in terms of what we spend and we have it's not just cost growth but we have value stagnation we're not getting the value for the dollars we spend on health care I think if our costs were growing at a modest pace and value was growing even faster we would potentially accept that as a good use of economic resources but oftentimes we see the cost growing and our life expectancy in the US has stagnated the last several years infant mortality is still much higher than it should be and we have large burden of chronic disease that we're not really tackling so one of the important issues is sort of how we think about integrating healthcare and social services to address social determinants of health I think that's something that the rest of the world does more effectively than we do here in the United States if oftentimes in the developed countries the OECD countries if you look at the combination of healthcare spending and social service spending it's a lot closer in the United States to other countries it's just we spend a disproportionate share of our resources on medical services and less on social services affordable housing and transportation and home care services so I think that's one of the big unresolved challenges that I would highlight is sort of where as a country we still have to go beyond the Affordable Care Act Great, thank you I'm going to ask the panelists one more question and then we'll turn it over to all of you who find people so those of you in the room who consider yourselves policy people you know that we often try to imagine ourselves with a magic wand so if you could wave your magic policy wand my friends what would be the one policy change you would like to magically make in regard and we'll come back to let's talk about health insurance reform right now in the U.S. if you could wave that magic wand and today make one policy change in health insurance in the United States what would you do and we'll do John, Jonathan and then Gail so my magic wand would be very simple expand Medicaid in the 18 states that have not yet expanded it and you know that would help millions of people low-income people with chronic illness who would benefit from the coverage like we've seen here in Michigan and 31 other states that was easy because it's magic so how powerful is my magic wand it's really really powerful can I go back and change the outcome of the basketball game? No so that would improve the mental health of Michigan elders I really would I mean if it was an all-powerful magic wand I mean you know I'd go back to 1932 and start a national health insurance system then we'd have something that looked like one of these while functioning I didn't see you had time travel powers okay lacking that power and since John already talked about the Medicaid expansion I would I would boost the subsidies plain and simple I think what Gail was describing the dynamic I think we were both describing the same dynamic we're basically if you're either unsubsidized or not subsidized well and that was an important distinction I should have made if you're basically above 250% of the poverty line particularly though if you're above 400% of the poverty line you're not getting much assistance that is a root cause of the instability both baked into the cake made worse by various decisions along the way I would argue you can deal with that in two different ways you can make the insurance package less generous you can so that it's cheaper that way or you can say that's actually what we want to provide people so we need to give them more money there's a trade-off here it's in my magic wand is not going to make the trade-offs go away it's more money but you know you make the subsidies a bigger more generous and you try to make it a better deal for those people who don't find it to be a good deal so that would be my three magic wand you have to to again use economists term focus on both horizontal and vertical equity that means you've got to be mindful about how you treat people at the same income level issue that I talked about for low middle income people who are treated dramatically different by the government depending on whether they get a subsidy from the exchange or their employer-sponsored insurance and you have to be more mindful about what happens as you go up the income scale so that you don't find people who are treated dramatically differently in unintended ways depending on either how they access insurance or where they're living and that we need to take this has been a long-term issue in the U.S. for people who are not poor low income who don't have employer-sponsored insurance with the incredible inefficiency of having this tax exclusion cost the government $270 billion a year and could be spent in a much more rational way so trying to sort out both having the slowdown and the tax subsidy as people have higher incomes having it be available for middle-income people who are working but not getting employer-sponsored insurance and therefore have to use after-tax income and having the rational transition between fully funded Medicaid and what happens when you cross whatever line so being much more mindful both of the movement of the income scale and treating people more comparably who are at a similar income level but who are either getting employer-sponsored or not in change it would take care a lot of the non-healthcare delivery issue challenges doesn't mean to be easy but I very much agree that the real problem was that we looked to the Affordable Care Act as being healthcare reform it never was it was insurance market reform for the individual market and an expansion of coverage by subsidizing some poor and low-income individuals important, not trivial but actually not the hard problem. Thank you. All right, so now we're turning to all of you seen a lot of the questions come down already on note cards and again for those who are with us online you can tweet in your questions using the hashtag policy talks. We have two terrific Ford School students who are going to be asking the audience questions and they're going to be assisted by my friend and colleague Professor Rick Hall here at the Ford School our students are Jeff Gam who is graduating in a few weeks yay with his BA his BA in public policy and a minor in business and Jeff's moving to Madison in a few weeks to work for EPIC work on healthcare information technology and we also have with us today Dr. Jen Villavincencio who is a master of public policy student with us here at the Ford School she's also a practicing obstetrician gynecologist in her spare time and so we're delighted to have both of you here today to help us with the Q&A portion. Thank you. Can y'all hear me? Great. Thank you for having us I'm Jen. It's different than Jeff here. Thank you for all of your questions from the audience as well as from Twitter. We've gotten some really great ones and we've had to make some hard choices. Our first one for the panel panelists are going to be about Medicaid work requirements. The question reads CMS or the Center for Medicare and Medicaid has issued guidance for Section 1115 waiver proposals to implement work requirements and community engagement requirements. CMS has approved work requirement waiver in Kentucky and many other states have put in their requests for that. What are your opinions about work requirements for Medicaid beneficiaries? Both traditional and expanded Medicaid. So I can start us off and we're actually going to be debating in the coming weeks and months of potential Medicaid work requirement here in Michigan. There are a couple bills in the state legislature now that are under consideration. As the question mentioned we've seen work requirements approved in three states, Kentucky, Indiana and Arkansas. And I think here's an example and if we turn the clock back to 2013 when Michigan was deciding whether to expand we had a Republican State Senate, Republican House and Republican Governor and made decisions in the legislature through bipartisan negotiation and agreement to expand Medicaid with certain stipulations that required approval from the federal government cost sharing and financial incentives for healthy behaviors among others. And this is another example where I think your work requirements at least on a trial basis I think could be something that is worth considering in Medicaid programs. I think if we do institute them we should start with the expansion population. The traditional Medicaid population that existed before the Affordable Care Act typically covered low income, elderly, disabled, children, pregnant women, groups where the likelihood that they're not working but easily could work is going to be relatively low. Whereas we have actually data now from our evaluation of the Healthy Michigan Plan here in Michigan that among the expansion population about half of the adults in that program are working. About a quarter of them probably can't work because they're either in school or they're caregiving for a disabled household member or they have a serious health condition themselves that prevents them from working. So all the discussion of work requirements may be sort of a lot of political angst for a relatively small part of the population. Maybe as we see in Michigan maybe only about a quarter of Medicaid enrollees would even be potentially subject to the Medicaid work requirements depending on how the exemptions were arranged. So I think if that was something that we need to consider in order to keep this coverage that we have for millions of Americans nationally and about 650,000 in Michigan it really will come down to how do you implement it because what we don't want is people to lose their coverage because they're not working and in fact they're not working because they have diabetes or they've had a prior stroke or they have chronic lung disease and you take away their coverage and now they're even worse off and they rely on emergency departments at that point and lose their access to primary care. So I think that will really be the question do we have sufficient exemptions and hardship considerations for people with severe functional limitations or chronic health conditions? Do we provide job training and job coaching to get people connected to work if we're expecting that as a condition of their Medicaid coverage? And do we evaluate how this plays out? Because I think one of the big concerns is it could be a very large administrative cost to track all the people who are subject to work requirements for relatively modest financial savings for the state if people are moving out of Medicaid and into jobs that offer health insurance. I don't think it will have much effect but I think it's a very important provision that may bring in some of the 18 states that have thus far not been willing to participate in the expansion. The reason I don't think it will have very much effect is because as John has indicated many of the traditional Medicaid populations they are not people who are likely to be able to work. They're dependent, they're old, they're disabled, they're pregnant women. It's more in the expansion population and the numbers he quoted are the ones that I've heard guest at in general which is about half the population works and of the population that doesn't work some number maybe half could potentially work and some number is not likely to. If you look at the actual Medicaid waiver requests they are not just work effort. They are either being employed, looking for work, doing community service, having job training or some other activity of that sort. That is not a particularly unreasonable set of requirements to have on the books for people who are not disabled, pregnant, unable to work for various reasons. You would not like to ever invoke taking away someone's Medicaid coverage. You would like to use this as a big stick to get them to act somewhat differently than they may be. My view, however, is much more practical. There are several states that have thus far not expanded their population that have indicated as a result of CMS being willing to consider this they will now reconsider. Virginia got within one vote of the Medicaid expansion. Kansas has talked about reasserting their ability to expand. For me, there is sometimes a fundamental failure to understand that in some states the notion of not expecting people to either be working or in training to be working or have some other clear reason that exempts them from an expectation of work is not tolerable with regard to an expanded public program. So I have encouraged some of my friends who are very much against this provision to take a deep breath and recognize this may be the one way to get 18 states who didn't respond to 100% federal money into the fold. And if that's the case, it's okay because there are a multitude of outs as to why the negatives might not occur. As I've said, I would hate to see both at a practical level and a medical level it ever get invoked because the rules require that hospitals have to take care of medically unstable individuals. So nobody's going to be better off by actually yanking the Medicaid coverage since you can't keep, you don't want to keep people out of the emergency rooms but that would just be terrible for them and terrible for us as the payers if that happened. It's really a club to try to convince the people of your state that those receiving this expensive service are doing their share. Some states, that's not been necessary. Other states, apparently it's a much bigger deal. I'll just echo what something Gail was saying which is one of the interesting things about this I think she's absolutely right. I mean this may be the ticket to get a bunch of states that would not think about Medicaid expansion into Medicaid expansion. And if you're thinking in practical terms that's a big deal. You get old enough you start thinking in those terms. You're talking about states the size of, if you could imagine, look at the states that are out of the Medicaid expansion. You're talking Texas, Georgia, Florida. We're talking in the millions here. So that's a big deal. I also think what she said about the sort of moral argument here is something that kind of, I think people in rooms like this sometimes don't appreciate that is that the policy arguments against the sort of work requirement, there's a long list of them. I mean it doesn't work well. It's not a lot of people. It doesn't encourage people to get work. They're expensive to administer. But you know you talk to people and there's a lot of people who are like angry like why is someone getting free medical care and I'm not. And that work requirement means a lot to them. So that's there whether you like it or not. The flip side is that number one, in reality what is going to happen and I think what worries a lot of the progressive advocates is in this world of low income work, it's not even the work requirement. It's the paperwork requirement to satisfy the work requirement. It's the number of times you have to show that you're doing these things. These are complicated. And again in this world, you're dealing with a lot of people who have, maybe they have mental health issues. They have disability issues that are not qualifying them for disability payments but make it hard for them in transportation issues. It's going to be hard. And everybody kind of knows that when you impose these kind of requirements, one thing that happens is that you pair the roles down just by sort of introducing that hassle. And some of these people, a lot of these people are the ones who you really don't want to go without health insurance because they're really the ones who if you can get them in for the preventative care and you can get them into the mental health, really stand to benefit from it. So that is a sort of moral argument or a practical argument, whatever you want to call it on the other side. And so this is a complicated question if you're strategizing or whatever. But there's a lot going on here. Awesome. So my name is Jeff again. Nice to meet you all. I'm a senior here at the Ford School and actually in the next few years I plan on joining the University of Michigan School of Public Health Healthcare Management and Policy Program. So I'll have to see in classroom one day. So Gail, you mentioned in your discussion that there's never been a precedent for repealing an expansion of general social policy. And my immediate reaction, the reaction is some of the notes from our audience was that we weren't so certain because it seemed like a new precedent was very close in coming. And so the question that we have from the audience here is this reversal in the historic trend towards expansion? Is this a blip or is this something that we're going to see more long term in terms of rising uninsurance again? And do we see populations or groups more of them being covered in the next 10 to 20 years or do we expect the potential increase in uninsurance to increase instead? Again, as taking a longer view there has never been a take away of a benefit and I don't think you will see it here. My view had been if 2014 came and went that was when the Medicaid expansion and the subsidies took effect. It was going to be there more or less forever although changing something about the distribution or the shape which may well happen in Medicare that by the way the looming crisis is not the individual insurance market. It is a problem. It's unstable. It's not going to be easy to fix. The looming crisis is the doubling of the population on Medicare for a program that is not currently set up to fund all of the promises with regard to healthcare that have been made and you ought to be most worried because it is not the people who are close to retirement. It's not the people who are over the retirement age. It's the people who are coming along the line and that is going to be a very serious issue. I don't see us going back and having large numbers of poor people without insurance coverage. There is debates about should Medicaid stop at 100% or 135%. I'd actually like to let more people buy into Medicaid with their subsidy dollars. It's a very narrow network, but it's a broad package and it has gotten the job done because both the clinicians providing services and the people who are on it have different expectations than the people who have been typically in either individual or employer-sponsored insurance and it has worked in a much more stable way. I don't see us going back but we haven't resolved this issue about what it is we want to stabilize. What our vision is that people who are primarily being subsidized should get at whose expense. You don't hear the kind of angst or not very often about people who are on Medicaid who are getting a fully funded package of benefits but take narrow networks to new definitions. The question that we haven't resolved is how do we view the population that is somewhat above that and it's because we really haven't been willing to have that honest conversation with us. I don't think we're going to take it away but the question about what that insurance looks like and at what point do we try to rationalize the kind of subsidies that happen as people go up. The people who have really gotten the short end of the stick are unfortunately the people who typically get the short end of the stick. The middle, the slightly middle plus, middle to higher income but only not in what most people think about higher income in the statistical sense. The three to four hundred thousand dollar, three to four hundred percent of poverty line family, the people who are talking about between fifty thousand and a hundred thousand dollars a year for a family of four. We need to be more honest about the numbers of people that are there and what happens as you continue up. So we haven't had that discussion but we are not going backwards. It's just not going to happen. Thank you. We're going to take a question from Twitter and add a little bit from the audience. The question from Twitter, we've had quite a few different questions coming in about insurance provision structures and so the question from Twitter is, what will be the role of employer-based insurance in the future? And we'd also like, if you could comment on the single payer health system as well and which one of those you see being the most useful in this country. And if Dr. Ayanian, if you could answer this one. Sure. One of the reasons the Affordable Care Act was so complicated is that it was not a government takeover of healthcare. It was built on the foundation of employer-sponsored insurance and the understanding that many Americans who have employer-sponsored insurance may not be totally satisfied with it but they're satisfied enough that they don't want to give it up and are very uncertain about sort of moving to a single payer system. So I think the challenge is, even though as Jonathan was saying with his magic wand, if we were to start from scratch, we might build a single payer system or predominantly a government-funded system like most other countries have done. It's very hard to get there politically in the current environment where most voters, and it's actually been tested in a few states where there have been ballot referenda attempted to try and move to a statewide single payer system and there either hasn't been the support or in the case of Vermont, they tried and couldn't make the finances work. So really it may only be able to work at a federal level and right now the votes aren't there I think in the population or in Congress to move in that direction. So then we're left saying, how can we make the employer-sponsored system more effective? Certainly we have generous tax subsidies, the fact that most of us who have employer-sponsored coverage get that coverage through pre-tax dollars and that goes back to World War II when there were wage and price controls and the only way that employers could give an extra benefit to employers' employees was by giving them tax-free health insurance and at that time it was a small number of people and it was inexpensive and it's grown beyond anybody's expectations. So, you know, most economists that have been interested in Gail and Jonathan's thoughts would say, you know, that tax subsidy doesn't make a lot of sense but how to take it away politically is a really thorny problem and you know, I think we, you know, it's really making people more educated and informed about their own health choices, both the personal choices they make and the societal options that we give people to live healthier lives as well as sort of what happens when they start using the health care system and do they have enough financial incentive to use it wisely? You know, oftentimes that's very uneven and you know, we see clinically that, you know, there are a lot of people that overuse health care and a lot of people who underuse it and it's that mismatch of resources and needs that is one of our biggest problems. I don't think we'll take it away per se. We could certainly target it better. We could have it be graduated and this notion of trying to be mindful, not so much that you have to have exactly the same subsidy for people who are inside or outside the employment world but to have such drastically different levels of subsidy for people at the same income level really is problematic. It leads to a bad dynamic as people try to go to where the higher money is and it's just unfair. To me, the question with regard to single payer is it's a political values issue. How much power are people willing to transfer to the federal government which at least to date has been not that much, not 17% of our GDP. I mean it has grown in a variety of ways in terms of the government role but people need to understand it's very different to say government funded as though this were all one monolithic system. It's not. It's a whole set of different kinds of programs with different levels of control. So to me the question has been what can we do that is stable in an environment that is as large and diverse as this country that will be politically acceptable to the country over some period of time? And ultimately if that's not where you're at then you're not in a stable position and unfortunately it's not where we were at with the Affordable Care Act. It was just astounding to me that Republicans who were so politically successful in beating up Democrats for having made this major change in social legislation with a single party vote got in power and turned around and tried to do exactly the same thing. It's like what part of this outcome did you think could possibly be different if you had been able to succeed? If you had driven this repeal and replace with a single party vote you would have just produced the reverse dynamic of what you've gone through for the last six years. I am still left shaking my head about what part of that perfectly obvious message are we having so much trouble getting across. So we will have to do something that works for us. It's not going to look like what looks somewhere else. I just don't think so. This next question is actually for Jonathan. So you had mentioned in your discussion as well if you could wave a magic wand. First you go back and change the outcome of the basketball game which we applaud you for. You also said that you go back to early 1900s and you would institute a national insurance market. And so the question from the audience that we have is in discussions about the Affordable Care Act we've mentioned a couple of times how ultimately this was health insurance reform. And so how far can health insurance form take us without accompanying increases or changes in social service? How far can health insurance without changes in social services? Social services are more underlying values within the health care system beyond just insurance markets. So I feel like you can answer that in a couple of ways. I mean health insurance reform. So I mean health insurance reform basically is giving people insurance and it doesn't change the way we deliver health care. I always thought to be fair to the Affordable Care Act and to be fair to the Affordable Care Act's architects. They said all along they were actually trying to do health care reform. They were actually trying to drive the system in a different direction. And I would say there was a lot in the Affordable Care Act that was supposed to do that. The reality is that by the time you've made all the compromises and you scaled back it was a lot of small, small steps. Now I am for what I'm not totally ready to give up on all those small steps and in fact you know you see little springs and signs that maybe this stuff is going to work but it was always going to be a very long-term project. I mean look this health care system looks like it does because it's evolved this way for almost 100 years now basically. It ain't going to change in a year. It's not going to change in 10 years. Driving that change is really, really hard. You can do it. I mean there are ways to do it more aggressively and I would hope that we would continue to move in that direction but there's a reason. I mean one of the things I was trying to remind people it's very easy and this is more sort of direct at the people who supported the Affordable Care Act and obviously the people never supported the Affordable Care Act. They never supported it and that's their position. A lot of people who did support it are very disappointed in the results and feel like we could have done X, we could have done Y and yes it's very easy to imagine a law that would have worked much better. I can imagine one, you can imagine one, you can imagine one but there's this thing called the United States Congress that had to get through and we remember the thumbs down from Senator McCain. Please take your time machine go a little further back to 2010 and 2009 and you want to talk about the nine lives. That thing seems so close to collapsing so many times it was barely, barely, barely they got it through Congress really pushing as hard as they could on, that you can argue and rest like well if you hadn't pushed so much here, you know if you hadn't pushed so hard to do X you could have gotten Y and Y would have been better. That's a totally reasonable argument. You could have been taking more chances but you know it's hard to do this. I mean politically any kind of change is hard to do so I hope we'll get to the point where we change health care more but you know it's kind of hard to do. I think the person asked actually the wrong question. I think what they should have asked or what they meant to ask was can you improve health by just expanding insurance and I think the answer is either insurance or access to health care is unnecessary but not a sufficient provision in order to improve health. There's a lot about health outcomes that is dominated by non-medical factor events public health, nutrition, education, employment, other opportunities and that was really going to the comment that John Anion had raised. We spend twice as much on medical care as we do on social services. Most of the rest of the developed world has reversed the ratio. Spends twice as much on social services as they do on medical care. I think we're going to find it hard to increase much in the way of social service spending until we can slow dramatically the growth on medical care. There are some hopeful signs. The Chronic Care Act was passed that will go into effect in 2020 which begins to allow a lot more flexibility in the Medicare Advantage Program in terms of what can be included under the health care budget relative to the traditional very narrow definitions. The Medicare rule that was released two days ago started moving in that direction and a number of private payers have moved out either in Medicaid or in their private insurance to try at least to make linkages with meals on wheels or housing assistance or other social services that they understand will be critical to improving the health and well-being that go beyond medical care. So I think there's increasing understanding that improving health is not just about healthcare and for many circumstances it's least about healthcare although at moments in time that's of course all about medical care. Thank you. I regret that we are out of time today. I want to thank you all so much for coming and participating. We have a reception out in our great hall and our panelists will be out there so there will be a little more time to engage with them. Again, thank you all for coming and please join me in thanking our distinguished guests.