Thomas Miller, Health Analyst for American Enterprise Institute Discusses Market-Driven Approach to Health Reform

Thomas Miller – American Enterprise Institute

Mark Masselli: This is Conversation on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret, we just recently observed World No Tobacco
day. It’s a global event launched by the World Health Organi zation to examine
the impact tobacco is having on global health, as well as the global economy.
Well, it is certainly seen a decline in this country, smoking is on the rise in other
parts of the world.

Margaret Flinter: Well, the numbers do tell the sto ry on this important health
topic, Mark. Smoking is directly to some 7 million deaths per year globally and if
smoking and tobacco consumption continue at this rate, the number will be 8
million global deaths by 2030.

Mark Masselli: Well, smoking rates in this country have dropped significantly in
the past couple of decades, one - fifths of deaths are attributed to smoking or
exposure to secondhand smoke. An estimated 450 thousand deaths per year in
the United States; the World Health Organization is call ing for a collective global
action to curb the spread of tobacco, which is heavily marketed to vulnerable
populations.

Margaret Flinter: Well, there is an economic toll as well Mark, the World Health
Organization estimates 1.3 trillion dollars in product ivity loss from smoking
related health costs, as well as lost productivity due to sickness and
absenteeism. It is exacting a huge toll on developing economies and adding
100s of billions of dollars to healthcare costs, all the way around, terrible.

Mark Masselli: Terrible and there are some public interventions that seem to be
working, public smoking bans, higher taxes on tobacco products are helping to
curb the problem, but a much larger global effort is needed and speaking of
health costs, Margaret, it is all at the center of health policy discussions
underway in Washington.

Margaret Flinter: The Senate is now grappling with the GOP Health Reform
measure passed in the house to replace ObamaCare. The American Healthcare
Act has taken a lot heat from e ntities across the healthcare spectrum and that is
something our guest today has spent much of his career focused on.

Mark Masselli: Thomas Miller, Senior Fellow at the Conservative American
Heritage Institute has done much research on market - based alter natives to the
Affordable Care Act. He has some insights into what may happen with the
Senate iteration of the GOP Health Reform Bill. It’ll be interesting to hear what
he has to say about some of those market driven alternatives to the Affordable
Care A ct.

Thomas Miller – American Enterprise Institute

Margaret Flinter : And Lori Robertson also stops by, the Ma naging Editor of
FactCheck.org. She looks at misstatements spoken about health policy in the
public domain, but no matter what the topic, you can hear all of our shows by
going to www.chcradio.com .

Mark Masselli : A nd as always if you have comments, please email us at
[email protected] or find us on Facebook or Twitter , because we love
hearing from you.

Margaret Flinter: W e’ll get you our interview with Thomas Miller in just a
moment.

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

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines. July,
at the latest, that’s the timeline some Senate Republican insiders are putting on
producing a replacement to the House GOP’s American Healthcare Act on the
books. Back from Memorial Day recess, many including GOP leadership went
home over the holida y to some vociferous opposition to their plans to repeal and
replace ObamaCare. Growing contingents with the GOP majority say they will
not put their stamp on a Bill that kicks 10s of millions of Americans off their health
insurance as the Congressional B udget Office estimates might happen. With no
apparent healthcare deal in immediate sight, some in the Senate are looking at
ways they might be able to make short - term solutions and improvements to the
law to bolster the unstable insurance marketplaces. O pioid death rates appear to
have skyrocketed in 2016 with some early statistics revealing death rates above
the 50,000 mark last year as the epidemic continues to unfold, some State and
local governments are taking their own action. Ohio, a hotspot for op ioid
overdoses has become the largest State to sue Purdue Pharma, Johnson &
Johnson, Janssen Pharmaceuticals Unit, and the Teva Pharmaceutical, and
Allergan, the lawsuit seeks to recover money the State and residents spent on
unnecessary opioid prescriptio ns, as well as costs associated with addiction and
treatment. The five companies are denying allegations. The White House is
following through on a promise to rollback birth control coverage requirements in
the Affordable Care Act under certain circumsta nces. Federal officials drafting a
rule that would rollback the requirement that religious organizations must comply
with the mandatory birth control coverage. The proposed rule could take effect
immediately as an interim final rule. The typical process however is to open the
rule to public comments before a final decision is made. It’s being called the first
in clinical cancer trials, an experimental gene therapy for patients with advanced
multiple myeloma, a particular kind of blood cancer that is on the rise, shows all
participants in a study showed noted improvement after the experimental
treatment, though the sample was relatively small, just 35 patients; every single
one responded favorably to the treatment in all but two were in remission within

Thomas Miller – American Enterprise Institute

t wo months. Experts say it’s a first for multiple myeloma and rare for any cancer
treatment to such early success. I am Marianne O’Hare with these Healthcare
Headlines.

Mark Masselli: We are speaking today with Thomas P. Miller , Resident Fellow at
the A merican Enterprise Institute, where he studies health policy and market
based alternatives to the Affordable Care Act. Mr. Miller is a former senior health
economist for the Joint Economic Committee in Congress, where his focus was
private health markets, health information transparency, and market driven
healthcare. Also, served in the National Advisory Council at the Agency for
Healthcare Research and Quality, he earned his B.A. in Political Science from
NYU, his JD from Duke University School of Law; T om, welcome to
Conversations on Healthcare.

Thomas Miller : Pleasure to be with you.

Mark Masselli: You know, you’ve been a vocal critic of the Affordable Care Act,
but you also warned opponents of the ACA to get to work on replacement and
here we are, four years later, watching the GOP replacement for ObamaCare,
the American Healthcare Act take shape and I am wondering if you could share
with our listeners what you think that current version of the law and what’s really
going to happen, and is going on behind the scenes?

Thomas Miller : The Affordable Care Act put in place a set of benefits to people
and they don’t want to let go off them. The AACA is a reaction to that overreach.
Now, the problem with moving from criticizing what’s in place to replac ing it has
now begun to confront difficulties of the Republicans. They may be a little
th
surprised that the majorities they got after the November 26 elections including
the White House and you know, like the ultimate thing in professional sports is ,
you play like you practice. They didn’t practice enough and so they want it ready
on day one to have a fully fledged out legislative vehicle. So it has been a
turnaround in attitudes where people are reacting more to what they are
concerned about and disrup ting what they already know and the unknowns
ahead of this various types of replacement legislation. Moving over to the
Senate after some of the difficulties in the House involves changing what was
done in the House to some degree, mostly reactions of Sen ators to make the
rollbacks in the Medicaid expansion coverage was on risk. There is also reaction
that moving to the type of subsidies, the Republicans have advocated for health
insurance, moving into being so income sensitive to being a little bit flatt er with
some age adjustments may be too much of a stretch too quickly. And then the
just the normal problems of what you do, what’s called Budget Reconciliation
tried to do some things, but not everything and it is difficult for the Senate to
figure out w here they are going to get 50 Republican votes plus the Vice
President, but that’s what they are committed to as they stare into the deep dark
abyss of the alternative being a total failure.

Thomas Miller – American Enterprise Institute

Margaret Flinter: Tom, we’ve had a number of guests on the show recently,
who’ve shared their thoughts about how best to retool American healthcare and
American health reforms, specifically with a more market - based and consumer
driven focus. We’d really love you to share with us what you see as the essential
hallmark s of this approach, the market - based consumer driver focus.

Thomas Miller : Sure, we need to readjust our rhetoric and what we promised on
consumer driven care to what we can actually put in place in the speed at which
it goes about. We need a better way of usable and actionable information and
we’ve fallen short on that and we made some progress on that front. Yet, we
changed the incentive structure, so that people are rewarded for making better
decisions and have a few negatives inside just to make the m involve the
networks on both the provider’s side, the payer’s side, and the patient’s side and
that leads to a type of bilateral accountability. It’s not a one - way directional, but
you are responsible for the decisions and choices you make. We found ou t that
there are people who actually are more involved in decision making, ultimately,
better patients would end up with better health. You need to also un - bundle a lot
of complex integrated benefits that is possibly one side fits all and serves
everyone, but don’t actually match the leads in the coverage and the uniqueness
is you learn more about how well patients are very different. Safety net has been
matter though if you are going to train people used to make more decisions, not
everyone is going to w ant to do that, but also lot of people will fall through and
need special help and if you don’t invest there, you don’t have the political
support or the credibility to offer wider choices and more responsibilities to
everyone else in a freer environment. So the language here gets a little
overstated. You know, saying everybody is going to have the most wonderful
care possible at the lowest cost overstates it. What we can try to credibly
promise is that people can improve their situation if they are will ing to make the
decisions and tricky choices on their own. You can’t promise the best to
everyone at all times with no cost whatsoever. That’s simply a critical exercise
which defies the reality of what actually happens. You want to try to have people
f or however much they want to spend their own money, as well as what they can
get from other people, to maximize their value. That’s not the same thing as
saying just go away and we hopefully will request more.

Mark Masselli: You know, its not a muscle t hat Americans have exercised much
in this sort of very complex disjointed American health system. It’s not like it
doesn’t seem to operate like the auto industry and where consumers are really
price sensitive and aware of that, you know, when you go into the emergency
room, there is real lack of transparency about what the price is and not sure if
you are thinking about it at that moment, but and I wonder what you are getting
to a market - driven health system is going to work through the issues of this
ins titutional resistance to get information about pricing out there, so consumers
can make some choice and what’s your sense of how that’s going to work in your
ideal vision?

Thomas Miller – American Enterprise Institute

Thomas Miller : Well, we all resist accountability and transparency if we are on
th e other end of it and certainly all those a bit little apprehensive in trying to have
you know the equivalent of menu boards of the itemized prices and sometimes it
doesn’t mean much to people in terms of the decisions they need to make. You
want to know, you know, what are my all - in costs going to be when I go to start
over here, but what’s my diagnosis and what’s it going to produce when
everybody throws the bills down and everybody gets involved in the multiple
stages of care. Now, certainly there are extreme circumstances where you are
totally unconscious, lifesaving reason, you are not about to be an active decision
maker, but you can plan in through a whole lot more, I mean you know right away
in sense of the insurance that you choose if you pay more attention to it, who is
in your provider directory and what you know about what that plan offers in as a
general rule and if you invest a little bit more, you might know that some doctors
are better at some things than other things. Now, we can include t hose tools, but
those are your decisions. Also, people are not usually you know, in life we get
instantaneous situations. Even people with chronic illnesses become much more
knowledgeable about their health condition and their care, so we need to deepen
the accounts to which people can find out more about what matters to them and
be able to make better more meaningful choices along the way. It’s not an only
nothing situation, you just really need to think about ways to reach caregivers
and other type of intermediary resources, where other people can take care of
those, who can manage things for themselves. We need to invest more in that
than sometimes the benefits themselves, so the more as we get people having
more interested in their health, would impr ove what would be a true market -
driven approach.

Margaret Flinter: Tom, you’ve wrote recently that in addition to the rollback of
government regulations, getting rid of the individual mandate requiring the
purchase of insurance, whatever version of the n ew healthcare or TrumpCare if
you want to call that, we end up with needs to significantly slow the growth of
Medicaid moving forward and certainly that advice would seem to have been
heeded in the ACHA, which makes dramatic cuts to Medicaid as does the
Pr esident’s Budget. You know, we certainly think as a Safety net in terms of
community health centers, which is the system of care that we are so familiar
with. So what does that Safety net look like if Medicaid is significantly reduced
and if the patient’ s with preexisting conditions choose to go uninsured?

Thomas Miller : On the Safety net, there is very little kind of too tight to populate,
we sometimes board them together. There are individuals who have short - term
financial emergencies, who are lower income in general and they may need
some ways to get out of that, low income problem. On the other hand, when we
are willing to best to invest side of the Safety net, such as the Medicaid
expansion, we tend to give a shorter shift to the people who have m uch more
serious and longer term illnesses or disabilities and then treat them as well. So,
we need to invest more in the people who truly can’t help themselves on a longer
term basis while trying to mainstream the other low income population into better

Thomas Miller – American Enterprise Institute

jobs as opposed to making their status on a longer term basis. You mentioned
community health centers, who tend to do a much better job worth the dollars
because they tend to be more accessible, less complex, less expensive as a
general rule, that can actu ally deliver the care that people need in many of those
circumstances. In addition though there are just many other ways in which we
can improve the health of the vulnerable popula tion, the low income population
and that may involve ways in which by inves ting earlier in their lives giving them
the tools, the business skills they need, the educational factors that they wouldn’t
have those type of problems that knowing the patients can been better mange
the rise in the healthcare and economic system. So if we could invest earlier in
delaying the onset of these chronic conditions. There’s plenty of research on that
front, we sometimes wrapped up in the idea of social determinacy, how we can
actually get better help over a longer period of time and they got e xpensive
system as fewer customers coming into it at least in the earlier stage.

Mark Masselli: We are speaking today with Thomas P. Miller, Resident Fellow at
the American Enterprise Institute, where he studies health policy and market -
based alternative s to the Affordable Care Act and Tom, you know, I would like to
take a look at the national discussion that is going around health reform now and
what we are seeing now is a deeply divided public perception about the Bill that
came out of the House. I am wondering how the Senate sort of builds public
trust or what’s your view of the polling data right now, which did show in the
Affordable Care Act was not liked that they were pretty accurate in that. Again, it
is showing that they’ve got off to a bad star t and so what’s your thought about
how do you think they’ll be able to close that divide in terms of public perception?

Thomas Miller : Well, it’s a serious case of risk conversion. There were some
over - promises as well or contradictory promises, which c ame out more from
President Trump. I think it’s hard to regenerate some type of these non - extreme
bipartisan committee. We’ve just got a long history as to where we’ve been on
healthcare and you are not going to put that egg back together at least in the
short term. That’s why the Republicans are going it alone, the same way did the
democrats and that’s just the underlying political reality. With the narrow margins
they have it oncoming, they got in toward to exercise to use the tools they have
to deliv er something although they didn’t know what that was going to be.
Looking ahead, we are likely to see some desperate moves later on as we enter
the end of this year, early next year to move more toward a broader short - term
set of intermediate fixes and th en rescue efforts, particularly as some of these
markets begin melting down ; t hat’s is bailing water out of the boat, but we will
eventually go through that exercise if necessary. I would like to be more
optimistic on this front that I tend to adopt the p erspective of the Miracle Max in
the Princess Bride, I’ve seen worse than is most here.

Margaret Flinter: Well, I am going to give you a chance to be a little bit optimistic
perhaps, because one of the tenets we live by is we should always be looking
aro und the country to see who is doing innovative work, who is not just had a

Thomas Miller – American Enterprise Institute

good idea, but is implementing it, innovating, and has some results to show for,
so when you look around the country, what States do you see that have really
made some positive stri des in health reform; we’d love to hear your take on that.

Thomas Miller : States have been, newer things happens a small degree, you
can pull out particular reference on whether there would be no managed care in
Medicaid or small pockets of individual pr ovider groups trying to do things
differently and having some, we tend to know about the excellent examples, the
problem is how the broad - base them and still them up and they tend to have a
certain organic nature to it. The same people who had been before yet again
they definitely try to give you an answer to it. With the Affordable Care Act, we
increasingly treated the States as the equivalent like a large employer, salary
plan that are for administrative services only, but we also stunted what might
hav e been the more evolutionary bottom up development of things working and
other people saying, hey that works and you think what if you do it, so lets do
more of it, because we put things into a little bit more of a cookie cutter
arrangement and so to be ab le to use the word innovation, I don’t want
innovation, I want something that works and if something that works well, it
should work on kind of a larger scale and people should do it, so it needs to be
tested by what results are actually produced. If we g et into a more results
oriented approach, which doesn’t measure whether you’ve hit the check marks in
the various set of potential healthcare inputs, by that measurement, that actually
produces better life expectancy or less upsetting consequences to your injuries
and improves your health, that’s what I want to know, but I also want to know
how much it costs and that’s a balancing act between the cost and the outcome
side as to which side you would prefer and they call that value.

Mark Masselli: We have b een speaking today with Thomas P. Miller, Resident
Fellow at the American Enterprise Institute, where he studies health policy and
market - based alternatives to the Affordable Care Act. You can learn more about
his work by going to aei.org. Tom, thank you so much for joining us on
Conversations on Healthcare today.

Thomas Miller : You are very welcome.

Mark Masselli: At Conversations on Healthcare, we want our audience to be
truly in the know when it comes to the facts about healthcare reform and policy ,
Lori Robertson is an award - winning journalist and Managing Editor of
FactCheck.org, a non - partisan, nonprofit consumer advocate for voters that aim
to reduce the level of deception in U.S. politics. Lori, what have you got for us
this week?

Lori Robert son: Our readers have asked us whether have scientists have
confirmed that E - cigarettes cause an incurable respiratory disease called
popcorn lung. The answer is no. The vapor of some E - cigarettes contains a
chemical associated with popcorn lung, but th ere’s not enough evidence to

Thomas Miller – American Enterprise Institute

conclude they cause the disease. Electronic cigarettes or E - cigarettes were
introduced into the U.S. market in 2007. They deliver nicotine flavorings and
other chemicals to users in the form of a vapor and they are often prom oted as
safer than traditional cigarettes. Online articles on E - cigarettes and popcorn lung
have been circulating on social media. Popcorn lung or bronchiolitis obliterans is
an incurable disease characterized by the scarring of the smallest airways in t he
lung. That scarring limits the passage of air. If the disease becomes severe
enough, the only treatment option may be a lung transplant. Researchers have
associated the inhalation of popcorn flavoring chemicals with popcorn lung in
workers at microwa ve popcorn factories. A December 2015 study conducted by
scientists at the Harvard School of Public Health found at least one of three
chemicals associated with popcorn lung in 47 of these 51 E - cigarette vapors
studied, but the study didn’t confirm that E - cigarettes definitely cause popcorn
lung. Previous research on exposure to diacetyl suggests it might not be that
chemical alone that can cause respiratory issues. While it’s unclear whether E -
cigarettes can cause popcorn, what is certain is that they a ren’t harmless; they
contain nicotine, which poses health risks, especially to children in teens. And
that’s my Factcheck for this week. I am Lori Robertson, Managing Editor of
FactCheck.org.

Margaret Flinter: FactCheck .org is committed to factual accu racy 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, email us at www.chcradio.com , we will have FactCheck.org ’s , Lori
Robertson, check it out for you, here on Conversations on Healthcare.

Mark Masselli : Ea ch week conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. Fitness t rackers
have become all the rage, especially among upwardly mobile fitness conscious
people seeking to monitor their own health and fitness goals. But another trend
has emerged in the age of wearable devices; after a few months, about a third of
users sim ply stop using them, leaving a lot of costly devices sitting in the shelf
and not in use. The reality capture the imagination of Tufts University School of
Medicine, Professor Dr. Lisa Gualtieri.

Dr. Lisa Gualtieri : And I thought what if you could take all of these abandoned
trackers and give them to the people who could benefit most from them.

Mark Masselli : So in 2015, she launched her nonprofit enterprise, Recycle
Health, an online social media campaign which seeks donated wearable devices
to provid e these expensive devices for free to those in need.

Dr. Lisa Gualtieri : People are excited about the potential how these devices help
them leave healthcare alive. At the same time, there are many - many barriers.
So we found a lot of people, who never d ownloaded an App to their smartphone.
So how do you get the package, get the device working on your wrist.

Thomas Miller – American Enterprise Institute

Mark Masselli : She partnered with organizations working with adults in wellness
programs, seniors in fall prevention programs and veterans as well . Her goal is
to start collecting vital data on the deployment of these devices and the impact
they may be having on behavior change in vulnerable populations.

Dr. Lisa Gualtieri : One of our dreams would be to make it really easy for
organizations that have money, say for instance in short to say the money that
we spend on giving people trackers is going to save us so much more than that
in reduced healthcare costs. We are working with a number of senior centers in
the Greater Boston area. We really se e a lot of potential with populations who
are not the ones that the vendors are targeting.

Mark Masselli : She is hoping to expand their data collection on health outcomes
for vulnerable populations, who gain access to these wearables.

Dr. Lisa Gualtieri : These are devices that people weren’t using, people no longer
want and other people are being helped by it. It’s about a low - cost intervention
we could possibly have.

Mark Masselli: Recycle Health, a simple repurposing of personalized wearables,
prov iding these tools to vulnerable populations, empowering them to engage in
activities that can improve their own health, now that is a bright idea.

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mar k Masselli, peace and health.

Conversations on Healthcare broadcast from the campus of WESU at Wesleyan
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