Health Policy Challenges President-Elect Trump Must Face

Dr. Robert Blendon

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Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, what a wild ri de through this process that we call
American d emocracy. The voters have chose n Donald Trump , that decision
likely means some very major changes for the American health system .

Margaret Flinter: Well it does Mark , and the campaign was one of the most
contentious maybe that we have ever seen , b ut in the end Secretary Clinton was
ce rtainly gracious in her acknowledgment of her loss. The President welcome d
Mr. Trump to the White House for an important face - to - face meeting , and
certainly ma d e clear his commitment to a sm ooth transition of power. So you
know I think Mark we have seen many moments of grace in the afterm a th of this
election and that smooth transition of power is just so essential to our
democracy.

Mark Masselli: It really is, and you know many in the health care arena worked
very hard to transition their practices and care delivery systems to meet the
objectives of the Affordable Care Act , practices building around quality measures
and outcomes. The Affordable Care Act certainly has accelerated , much
progress in this quest for better health care but still there is much work that
remains to be done.

Margaret Flinter: When we look back , we began to show seven years ago really
the beginning of the health reform debate so that we could tap into the best
minds in the industry that were focused on creating meaningful health reform
really meaning just better health care for everybody . We hosted many thought
leaders from the Halls of Academia to policy leaders, legislative leaders, and I
honestly believe that that work is going to continue. And our guest today is one
of thos e many great thought leaders. Dr. Robert Blendon is the Director of the
Harvard Opinion Research Program . He has some very well - informed and
unique insights into what the American public is looking for.

Mark Masselli: Lori Robertson also checks in, M a n aging Editor of
FactCheck.org. But no matter what the topic, you can hear all of our shows by
going to www.chcradio.com .

Margaret Flinter: And as always , if you have comments, please e - mail us at
[email protected] , or find us on Facebook or Twitter because we love hear ing
from you. Now we will get to our interview with Dr. Robert Blendon in just a
moment.

Dr. Robert Blendon

Mark Masselli: But first, here is our producer Marianne O’Hare wi th this week’s
Headline News.

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Marianne O’Hare: I am Marianne O’Hare with these Health Care Headlines.
President - elect Trump has begun to assemble his transition team , addressing
one of his key campaign promises to repeal and replace Obamacare . Andrew
Bremberg has been tap ped to lead the team . He spent two years advising
Senate Majority Leader Mitch McConnell as well as Wisconsin Governor Scott
Walker ’s short - lived Presidential campaign . The nation ’s top insurance CEOs
gathered after the elect ion speculating on what lies ahead. Aetna CEO Bertolini
anticipate s several popular aspects of the health law will remain, young adults
being able to stay on their parent s ’ plan t ill age 26, but they expect there will be
more state - based approaches to Med icaid than was experienced under the
Affordable Care Act .

For the time being though Obamacare Open Enrollment is underway, the new
administration doesn’t take office till after enrollment is closed on the online
insurance marketplace s and insurance sign - u ps are a priority in the waning
months of the Obama Administration. Secretary of Health and Human Services
th
Sylvia Burwell recently tweeted that November 9 was www.healthcare.gov ’s
best day with 10 0 ,000 sign - ups since it began selling the 2017 Obamacare plans
st
November 1 .

A rare and deadly fungal disease has been reported in the US for the first time.
The C D C reports at least 13 cases of an infection called Candida auris have
been reported . The fungus is quit e dangerous in that it ’ s resistant to most
antifungal medications , comes with a high mortality rate and tends to affect those
with other underlying conditions. It's been found in several other countries
including the UK, Japan and South Korea.

I am Maria nne O’Hare with these Health Care Headlines .

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Mark Masselli: W e are speaking today with Dr. Robert Blendon , Professor of
Health Policy and Political Analysis at the Harvard T. H. Chan School of Public
Health . He is the Director of the Harvard Op inion Research Program . He
previously served as Chairman of the Department of Health Policy and
Management at the T. H. Chan School of Public Health , and currently co - directs
the Robert Wood Johnson Foundation, Harvard School of Public Health project
on u nderstanding Americans’ health agenda . He earned his MBA at the
University of Chicago and his doctorate at Johns Hopkins . Dr. Blendon, welcome
to Conversations on Health Care .

Dr. Robert Blendon

Dr. Robert Blendon: Thank you for having me.

Mark Masselli: The American p eople have elected Donald Trump to become the
next President of the United States which is certainly going to have a major
impact on the Affordable Care Act , and you have been targeting this divide of
views that Americans have about health policy for some time a nd I am wonder ing
if you could tell us what role did health policy play in the election and what do you
think is going to happen .

Dr. Robert Blendon: So elections created an environ ment where political leaders
can move in one direction and not in o ther . So the health care issue was a n
important but a second level issue in this election. The issues of the economy , of
terrorism, of immigration appear ed to be more dominant than health care. What
has happened since this law was enacted is that the co unt r y , particularly people
who identify either as Democrats or Republican s have become almost an ocean
apart o n what should happen. Democrats believe as a whole this bill is working
well , when asked what should happen and not only should be implemented bu t
now the majority of Democratic voters would want it expand ed . Republicans
continue to believe that this bill is really working very poorly, it was the mistake
for the country in the first time . When you offer Republican voters what do they
want done , m ost actually choose scaling it back or repealing it. This is an issue
which is the equivalent of an ocean between two groups.

So it didn’t decide the election but the fact that you have a Republican President,
a Republican Congress is going to lead them to follow through in some part to
the agenda they have expressed for six years. It didn’t look as if they were going
to have a chance to dramatically change it, in fact had Hilary Clinton won the
discussion s would be about expanding this law. So you are going to see very
serious proposals by Republican s to really scale this back, change its name,
make it more limited and change the Federal role, and this could have a powerful
impact on the 20 million people who are directly being aided by this law. On th e
other side, a substantial number of Republican voters believe that this law is
driving their health care cost s . So for many of them if this bill is scaled back they
see this as a relief for them and it's really for people from other countries sort of
sh ocking how far a part people who live in the same communities can be.

Margaret Flinter: Well Dr. Robert Blen don, you are so well - versed in the science
of polling , a nd in fact I learned you have been nominated for the Pultizer Price for
a seri es of polls t hat you conducted. So based on your expertise and experience
with polling how was it that the polls seem ed to have been so off this time
around?

Dr. Robert Blendon: So in a national election only 55% of adult s who live in the
United States end up actual ly voting. So they interview people and try to figure
out who will be the 55 and who will be the 45% that don’t vote and what
happened here is that they were wrong. They under - reported many people ,

Dr. Robert Blendon

particularly white American voters who are mostly older , who had not voted in
either 2012 or the 2014 election , we re very highly motivate d in this election and
they came out and voted at much larger numbers than the poll s identified, and it
had to do with the polls missing people who hadn’t voted before . And o ne of the
ways that happens is you are thinking about how do I figure out if you are going
to vote s o I ask you did you vote in the last election, you say no, did you vote in
the election before, no , then I just s ort of check even if you say you are going to
vote well you are probably not going to vote , and so those people , a very
substantial share of them in the Middle West that hadn’t voted before voted in
this election. It really is a mistake and they are going to have to go back to the
drawing boards t o figure out how to interview people and get a better sense if
you hadn’t voted before are you are going to vote this time , but essentially at
least the media polling group were really taken by surprise.

Mark Masselli: You know I want to get back to your comment earlier that we are
oceans apart in terms of our perspective on the Affordable Care Act , and I know
you do some collaborative work with the Kaiser Family Foundation ; we had Drew
Altman the CEO on who shared the same perspective . But when you star t to drill
down on the Affordable Care Act and look at elements of it where do you see the
se a m of opportunity for elements of the Affordable Care Act to continue?

Dr. Robert Blendon: So what is it that Republican voters don’t like? They do not
like tha t people are required to buy insurance whose design has been set by the
Federal government. There is also a requirement that businesses have to
contribute , and many small business people feel that that is a real threat to their
business . So you say to Rep ublican voters what bothers you, they don’t say
having kids on the plan till age 26 and they don’t say to you that they are against
preexisting conditions , what they say to you is the government shouldn’t be
requir ing every person whether or not they want insurance or not to have it, and
the government has all types of regulations about what has to g o on health care
and how people are going to be paid. So I am sure that protecting people under
age 26 will remain. There will be some sort of protection s for people with
preexisting condition s , there will be some subsidies for low income people and
that is what bothers conservative s . They believe those requirement s are driving
up the insurance cost s of other people , where on the Democratic side people
really think more people have to be covered. So there is again this huge divide.

Margaret Flinter : Well Dr. Blendon we look and we say well 20 million Americans
have gained coverage but for sure those in the middle and upper incomes who
don’t quali f y for tax s ubsidies are certainly feeling besieged by big out - of - pocket
cost s a nd it seems as though everybody blames the Affordable Care Act , but
when you look at this what is your answer to these higher out - of - pocket costs?

Dr. Robert Blendon: Health care costs h ave been a rising issue for 2 0 some
years in the United States , and a lot of people blame the Affordable Care Act . If
you are not receiving a subsid y from the government you are looking at risin g

Dr. Robert Blendon

premiums, higher deductibles and co - pays, and at the moment for a lot of people
the Affordable Care Act has been what they blame , a nd then you sa y to yourself
wow it’s a lot of people who aren’t getting help from the law what do they worry
about, and they worry about their own affordability to their employer polic y .
Probably 10% of Americans are getting insurance from these ex changes , b ut
Republican voters who are not mostly benefiting from this law think it's been
harmful . Democratic voters , many of them don’t benefit either , but they believe
that it’s been help ful. So it’s a debate about what you believe the government
should be doing here in the future and how government action helps people who
aren’t directly getting subsidies. And so when you listen to the Republican
leadership talk , they believe middle inc ome people are worse off , and when you
listen to the Democratic leadership talk they feel that people are really a lot better
off, and the truth is probably in between .

Mark Masselli: We are speaking today with Dr. Robert Blendon, Professor of
Health Pol icy and Political Analysis at the Harvard School of Public Health . He is
the Director of the Harvard Opinion Research Program . Dr. Blendon, you
conduct hundreds of studies on a variety of topics from health care to economic s
and social policy, and you wr ote earlier this year about what makes Americans
dissatisfied with their health system and how it compares internationally s o how
do American view s stack up around the globe?

Dr. Robert Blendon: People who are in high income European countries or even
Ca nada , the people who live in those countries rate their systems better. We
have more people suffering economic insecurity about health care costs than
other countries. More Americans worry about how they are going to pay their
health care bills than in o ther countries. People in other countries generally trust
their governments more than United States , and the United States at the moment
has an extraordinary high level of cynicism towards how the Federal government
goes about its work and business and de cision making. And if you are a
politician visiting the United States from other countries what strikes you is the
parties don’t have battles over health care the way that they do in this country.
So we have less satisfaction but we have this very high l evel of [inaudible 14:04]
government , and I wrote a years ago when it comes to healthy policy Americans
aren’t British and so it's hard just transfer systems over because we don’t know
how to transfer feelings about government.

Margaret Flinter: Dr. Blen don you are right. It ’s brought me back to the memory
of the town halls in the summer of 200 9 people would say “Down with
Obamacare and get your hands off my Medicare. ” But you know in all truth
Medicare and I think surprisingly Medicaid recipients are p retty satisfied with the
coverage and the care that they get under those two big public plans , but House
Speaker Ryan for one has spoken of not only eliminating Medicaid expansion
under the Affordable Care Act but also moving towards privatizing Medicare a nd
maybe even delaying Medicare eligibility until age 67. What do you see as the
possibility of that happening?

Dr. Robert Blendon

Dr. Robert Blendon: President - elect Trump ran all the way along saying I am not
going to touch Social Security or Medicare. Speaker Ryan has been saying for
many years that Medicare is too expensive and we have to move to limited future
expenditures that h as financial problems and he ’ s proposed fixed limits on
contribution s , moving the retirement age . This is going to be a real battle. So in
the politics from the voter point of view , Medicare and Social Security are the two
most popular domestic program s in the United States so people across the aisles
feel good about those program s . That from his point of view was going to be a
huge battle. Medicaid is in the middle. Medicaid is an established program but it
doesn’t have the same wide public popularity as Medicare and Social Security,
and so trying to cut people off Medicaid will not be easy. So he is going to have
a battle in reducing th e Medicaid coverage , he is going to have a huge battle
over changing Medicare, and the surveys we are involved in most Republican
voters don’t support a number of his proposals. They are arguing give the states
more authority which may or may not move for ward. So the ACA turns out to be
the most political ly vulnerable of the big health care laws because it doesn’t have
a Republican constituency.

Mark Masselli: Well let me pick up on that thought too because you referenced
bipartisan support and that the re was not a constituency , any support from the
Republicans on the Affordable Care Act , and we had David Gergen on the show
sort of a w ise man who opine d that having bipartisan support is very important
and sort of walk ed through the history of the Medicar e legislation, Medicaid , civil
rights legislation . These are settled matters because they ha d this bipartisan
support. Aren’t we going end up in the same position on the Affordable Care Act
if it gets repeal ed because it will not have bipartisan support and we will be back
at another election at another time even in the repeal side unless there is sort of
a bipartisan support? Aren’t we just on the other side of the coin looking
backwards with the same sort of oceans a part end game?

Dr. Robert Blendon: So let’s record your line and play it over and over all day
again because I 100% agree. What we are going to have let ’s assume they cut
back part s of this and repeal parts of it. When the Democrats come back in there
is going to be another piece of majo r legislation. A large share of Americans feel
very vulnerable for health insurance coverage and cost and the Democrats i t‘ s
part of their generic code a nd the only way that we can ultimately move forward
is we have to find some compromise that can have b ipartisan support. This will
be in the next Democratic agenda with another plan and if it's enacted by only
Democrats you will have the same cycle , a nd so the y need to find some way to
have an agreement of a plan that can satisfy some of the concerns of
R epublicans and Democrats , you just can't go o n this way. So we are going to
have to find a way through American politics to reach a compromise with a law
that Republicans may not love but can live with, and Democrats in order to have
some stability go alo ng with it, and we are not there now . If the election hadn’t
gone so much to the Republican side there might have been a compromise

Dr. Robert Blendon

between a Democratic President and a more Republican compromise , b ut at the
moment the party suddenly found out , one party , that they have the ability to
shape that agenda.

Margaret Flinter: We have been speaking today with Dr. Robert Blendon,
Director of the Harvard Opinion Research Program at the Harvard T. H. Chan
School of Public Health. You can learn more about their w ork by going to
www.harvard.hsph.edu/horp . Dr. Blendon , thank you so much for joining us o n
Conversations o n Health Care today, very fascinating insights and we really
appreciate your wisdom.

Dr. Robert B lendon: Good. I will t alk to everybody again and thank you.

Mark Masselli: Alright . Thank you.

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Mark Masselli: At Conversations on Health Care we want our audience to be
truly in the know when it comes to the facts about health care reform a nd policy.
Lori Robertson is an award - winning journalist and managing editor of
FactCheck.org, a nonpartisan, nonprofit consumer advocate for voters that aim to
reduce the level of deception in US politics. Lori, what have you got for us this
week?

Lori Robertson: Now that Donald Trump has been elected President what may
happen to the Affordable Care Act ? Trump vowed on the campaign trail to
repeal and replace it , though it could be some time before that happen s or
consumers see any impact. Vice Presi dent elect Mike Pence said in early
November that there would be a transition period for those receiving government
subsidies and Congress would need to pass replacement legislation. Let’s look
at some of the statistics under the law. Million s have gaine d health insurance .
The Obama Administration puts the number at 20 million and figures from the
National Health Interview Survey conducted by the Centers for Disease Control
and Prevention support that. Those figures show a drop in the number of
uninsure d since 2010 , the year the law was passed , of 21.3 million . Not all of
that decline in the uninsured would be due to the law of course .

The ACA has expanded coverage in two main ways , by expanding eligibility for
Medicaid coverage in the 31 states , plus Washington DC that have implemented
that expansion and by offering subsidies and new insurance protection s for those
buying their own coverage . For instance, insurers now can't deny coverage or
charge higher premiums for preexisting conditions. In the Me dicaid program ,
15.7 million people have been enrolled since October 2013 when the ACA
marketplace s first started operating. Individual s were required to have insurance
or pay a fee effective January 1, 2014. As for the ACA marketplaces , 10.4
million peo ple had marketplace coverage in the first half of 2016 and 84% of

Dr. Robert Blendon

them , that’s 8.8 million people , received tax credits that lowered their out - of -
pocket cost for premium. The Nonpartisan Congressional Budget Office and
Joint Committee on Taxation have per iodically estimated the impact on the
Federal budget of repealing the ACA. The latest report from last year estimated
that repealing the law would increase Federal deficits by $137 billion over a
decade including macroeconomic effects. A s for the impact on health insurance
coverage the groups estimated that the number of uninsured would increase by
19 million in 2016 ; that’s for a full repeal of the law. And that’s my fact check for
this week. I'm Lori Robertson, managing editor of FactCheck.org.

Marga ret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, e - mail us at www.chcradio.com . We will have FactCheck.org's Lori
Robertson check it out for you here on Conversations on Health Care.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to
ma ke wellness a part of our communities and everyday lives. “ You have cancer, ”
these are words nobody wants to hear . Not only does the diagnos is conjure fear
of the ravages of a potentially life - threatening illness, but it implies months of
sickness associ ated with chemotherapy and other treatments. But a device
that’s already been approve d for use in Europe and has just been approved by
the FDA in this country can mitigate one of the more unpleasant side effects of
hair loss. The Dignicap is a skull cap placed on the heads of chemo patients that
cools th e scalp and limits chemotherapy’s toxic impact on the rapidly dividing
cells in hair fall .

Dr. Hope Rugo : Scalp cooling does in no way diminish the effectiveness of
chemotherapy , no r does it increase the risk of recurrence.

Margaret Flinter: That was dr. Hope Rugo speaking to NBC News recently . She
had led the clinical trials at five different hospitals testing the efficacy of the
Dignicap which cools the scalp to 37 degrees and that’s col d enough to i nhibit
cell death and hair loss go al s.

Dr. Hope Rugo : You didn’t choose to get your cancer, you can affect the
chemotherapy . This gives you something that you can do for yourself.

Margaret Flinter: 70% of the women in the trial kept more than 50% of t heir hair
and some like Donna Tooke s of Connecticut kept all of it. She was selected for
the trial after her husband musician Darryl Tookes wrote a letter asking that his
wife be considered for the US trial.

Darryl Tookes: I wrote a letter to several of the doctors conducting them and --

Dr. Robert Blendon

Donna Tookes: A wonderful letter.

Darryl Tookes: Donna has a head f u ll of beautiful thick hair, a unique feature that
is a shock of whiteness creating a halo for her young face.

Margaret Flinter: Not only did his wi fe keep her hair, her doctor s say her early
diagnosis and treatment have yielded an excellent outcome, cancer - free .
Dignicap , a scalp chilling device for patients undergoing chemotherapy , helping
to preserve a sense of identity and dignity while enduring the rigors of cancer
treatment and mitigating one of the most emotionally challenging side effects of
that treatment , hair loss, now that’s a bright idea.

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Margaret Flinter: This is Conversations on Health Care. I a m Margaret Flinter.

Mark Mass elli: And I'm Mark Masselli, peace and h ealth.

Conversations on Health Care, broadcast from the campus of WESU at
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