Your Vote & Health Care: Why It Matters

Your Vote and Healthcare

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Marianne O’Hare : Welcome to Conversations on Health Care. This week , we look at
Healthcare on the Ballot from two sides of the coin , with Emily G ee
from the progressive Center for American Progress , and Joseph A ntos
from the c onservative American E nterp rise Institute.

Emily Gee: Most people in America s upport -- you know , women in America
support a right to choose , but that doesn't mean that legislatures
won't go the other way. We've already seen some rea lly draconian
bans on abortion.

Marianne O’Ha re: Lori Robertson checks in from F act Check.org, and we end with a
bright idea improving health and wellbeing in everyday lives. Now,
here are your hosts , Mark Masselli and Margaret Flinter.

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Mark Masselli: Early voting has already started in some p arts of t he United States as
Americans make important decisions about who they want to
represent them. The polls show that health - related issues are some of
the most important ones to voters this year. Joining us to discuss
Healthcare on the Ballot are pol icy exper ts from two prominent
Washington D . C . think tanks.

Margaret Flinter: Emily G ee, PhD, is the Vice President and Coordinator for Health
Policy at the Center for American Progress. G ee has worked on the
implementation of the Affordable Care Act. And she was a n
economist on the staff of the Council of Economic Advisers in the
Obama White H ouse . And Joseph Antos , PhD, is a senior fellow at the
American Enterprise Institute. He served in high level positions at the
White House , for Con gress , and at the a gency level .

Mark Masselli: Well, welcome to both of you to Conversations on Health Care .

Joseph Antos: Thank you.

Emily Gee: Thank you.

Mark Masselli: Well, let's start with Jo e . The Republicans have released their policy
agenda called Commitment to Ameri ca . And it includes wording about
personalized care and lowering prices through transparency, choice
and competition. But it's a bit vague on details . But it does -- I'm
wondering if it aligns wit h your thinking , and tell us why.

Joseph Antos: It's not sur prising that R epublicans for the midterm are not being very
specific about health policy . Health policy, really I think for
Republicans , is really not high on their agenda right now. But the
other factor, which I think is often overlooked, is that they don 't want
to get ahead of whoever their candidate is going to be in 2024. That
said, yeah, the idea of promoting an efficient health care system,

Your Vote and Healthcare

working off of the current system that we have today which is a mixed
public - private system with regulation , tha t makes a lot o f sense . And
to try to create those efficiencies, I think there are several key
components . One clearly is that consumers, patients, and their
doctors need to have a better idea about not only what things cost,
but also how effective the tre atments are lik ely to be a nd whether
there are alternatives. I think that's really critically important. But
what really matters is health care. And what people care about is, am
I going to get the care I want a t the time I need it , w ill it be good care ,
a nd will I be ab le to afford it . I think those are the big issues.

Margaret Flinter: Well, thank you for those comments , Jo e . And Emily, let me turn to
you . Your think tank has the word ‘ progress ’ right in its name, and
CAP is known for its progressive stan ce. As you say on your w ebsite,
your mission is focused on improving the lives of all Americans with
bold and progressive ideas , as well as strong leadership and action.
So , maybe tell us where does CAP stand on health policy and any
points of difference f rom what we heard from Jo e .

Emily Gee: So , I think when I think about health policy, and in particular health
equity, there it's more than just the health care system. And there are
a variety of ways in which we try to approach this issue. One piece of
hea lth equity is of course health care system itself. The Inflation
Reduction Act which passed back in August , is a big step toward those
goals, helping decrease the cost of coverage for millions of Americans,
giving seniors protection they didn't previously have against out - of -
pocket cost s for drugs in Medicare. But also , that together with a
couple of the other big pieces of legislation that passed in the last
couple of years, the Infrastructure Investment and Jobs Act , the CHIPS
Bill , aren't necessarily hea lth care bills per se, but they do advance
health because they take care of what we call social determinants of
health , or the factors that influence what goes into health.

Part of achieving health is getting the health care that we need having
health cov erage, but a large part of it is about the environment that
we live in . Do you have access to clean water and clean food ? D o you
live in a safe neighborhood ? And so , in particular the Inflation
Reduction Act and the Infrastructure Investment and Jobs Act , do
affect our environment an d help address climate change , making
historic investments, not just addressing climate change , but making
sure that money goes to underserved communities. And so, you
know, our hope is with equitable distribution of the funding available
in those bills , w e can prevent situations like we just had in Jackson,
Mississippi, where a predominantly Black community with very
outdated water infrastructure didn't have access to clean water for
two weeks . That has knock - on effects to the a bility of businesses to
oper ate , the ability for kids to go to school . And so taking care of both
our built and natural environment , is really a key component for

Your Vote and Healthcare

health.

Mark Masselli: Well, let's make sure we're clear on where each of you are in relation
to the candidates in the ball ot. So , a question to both of you,
generally would you agree , Republican candidates are linked to A E I
support for what it calls pro - market solutions to our nation's health
care issues, and that the Democrats are aligned with t he Center for
American Progress vi e w of a shared prosperity model?

Joseph Antos: So , probably t hat's true. I think there i s a general understanding about
market - oriented principles and the need to create incentives that lead
to a more efficient health care system. But , also as Emily sai d, we
need to make sure that it is a fair system . We need to make sure that
people who need the help , get the help.

Emily Gee: So , for CAP , I would say we are open to working with people, any and
all political parties . But , o ur vision for what health care sys tem would
look like is universal coverage. It's a place where everybody has access
to health care , a nd everybody has the ability to achieve their full
health potential, both because they have good health care, but also a
g ood environment and good nutrition and good access to education.
All the other things are so impo rtant for a good start in life. And I
think, you know, the re a re probably also areas where maybe Jo e and I
would agree . If I could go out on that limb , I do th ink there are places
in health care where we do need better competition . One of them is
among providers in health care , where because of consolidation in the
market for health care providers and insurers, consumers are often
not getting a good deal on the price of health care .

Margaret Flinter: A ques tion for both of you on a little bit different thing . Th e Biden
Administration has extended the COVID Public Health Emergency
order for another 90 days. Emily , maybe let me ask you . You've
supported this move . Why ? What doe s it provide for? And , is it
po ssible for this to continue w hen the President has said that COVID is
over? How do we go forward with that?

Emily Gee: So , we are still dealing with the effects of the pandemic . I think we are
entering a new phas e in which, you know, fortunately, even as ca ses
are up and may rise into the winter , we're not seeing that same spike
in hospitalizations. And that is because vaccines work. We have the
new b ivalent vaccines that give us pro te ction not only against the
or iginal strains of the virus, but against th e Omicron variants. The
government has ordered more than 100 million doses of that , s o
there's plenty to go around. And I think getting that vaccination will
be important for maintaining our nation's health going into the
winter. But continued prepared ness and keeping up with new
variants , will require sustained funding for public health. My hope is
that Congress will provide funding for continued COVID readiness , as
well as shoring up the public health system that has been so badly

Your Vote and Healthcare

battered by the pandem ic.

Mark Masselli: The Supreme Court ’ s Dobbs decision overturned Roe v. Wade earlier
this year, and Senator Lindsey Graham has introduced a proposed
national ban that would prohibit abortion after 15 weeks nationwid e
with only a few narrow exc eptions. I'm wondering if you both agree
that more limits to abortion will occur if Republicans take control of
Congress and gain more power in state legislatures . Jo e .

Joseph Antos: No, no. This is a very personal kind of an is sue. I think both sides on
t his issue have tried to blow it up into public policy. I think this is not a
topic that needs to be legislated on. It may well be the case that in
some states, they will clamp down a bit more in terms of the period of
time over which abortion is permitted. That is apparently their right
under the Constitution. I'm not a lawyer ; I couldn't tell you. But I think
this is a very sensitive issue that is not going to be something that , at
least Republicans will be talking about at the national level. The fact
tha t Lindsey Graham introduced this proposal , doesn't mean that
Republicans will go for it. In fact, there's been largely silence from the
Republican p arty on this , and I think they are not willing to touch it at
the national level .

Mark Masselli: Well, before Emily responds though , Jo e , if the Republicans take
control of Senate , is it that you don't believe whether it will be up or
down , that Graham won't be able to get it on the floor for a vote?

Joseph Antos: That's right. This i s something that you can onl y -- people will not view
any action in this area as uniformly favorable .And every politician
wants to do things that are favored by the constituents , rather than
are controversial among their constituents. And this is a contro versy
that is true in ever y state and in every Congressional district.

Mark Masselli: Emily?

Emily Gee: So , my colleagues and I certainly believe, you know, this is a deeply
personal issue for women and should be something that they choose ,
and something t hey are allowed to c onsult with their physicians on.
It's also, you know, most people in America support -- women in
America support a right to choose . But that doesn't mean that
legislatures won’t go the other way . We've already seen some rea lly
draconian bans on abortion , preventing it at the very early stages
where women may not even know they're pregnant , a nd, you know,
laws that don't have exceptions for cases like rape or incest or life of
the mother.

So , I'm very fearful of what could happen if Cons ervatives take
stronger control of state legislatures. Right after the Dobbs case, the
Dobbs decision was handed down, we saw a handful of states enact
so - called trigger bans or pre - existing bans on abortion, and they were

Your Vote and Healthcare

very eager to put those into effe ct as soon as the court decision came
out .

Mark Masselli: But Emily, we also saw Kansas, which I believe is a pretty Conservative
state , actually turn it down . What's your sense of that didn't seem to
break on party lines there?

Emily Gee : So , I think that that is hopefully part of a trend , of voters either
rejecting bans , or hopefully adopting constitutional amendments that
would prote ct a woman's right to abortion at the state level .

Margaret Flinter: Well, I think we are all in for an interesting time wa tching the returns
as the election arrives on our doorstep . But , certainly a group of very
engaged voters, usually our senior populati on, and certainly a
population that we're all concerned about , a nd Joseph, I wonder if
you can comment, Bloomberg is repor ting that House Republicans will
enact Social Security and Medicare eligibility changes , may be
spending caps , and Safety Net work requiremen ts if they win the
majority . Kind of h ad thought of those a s classic third rail that people
wouldn't touch , such pop ular programs . Do you think that's likely ?
Should seniors be worried?

Joseph Antos: Well, let's distinguish between the programs . I t hink you've mixed a
couple of programs up . No politician in his right mind , or her right
mind , would announce that they're going to cut Social Security
benefits . There may be a need to address Social Security funding ;
that's not the same thing as cutting the benefits. On Medicare, I think
the same is absolutely true. And there's obviously a need, given that
the Part A Trust Fu nd , Medicare Trust Fund that covers the cost of
hospital services and other inpatient services , the Part A Trust Fund
will become insolv ent in the next few years, probably sooner, sooner
than later , b ecause the assumptions that went into that estimate are
we're overly optimistic about how the economy is going.

We're clearly in a recession. We're c learly in a high inflation time .
These were not taken fully into account in the latest trustees ’ report.
So , things are going to happen , are going to have to happ en. But ,
touching benefits is really very difficult for a politician. It's much
easier to do what they've always done traditionally, which is to cut
payments to providers and hope that that doesn't restrict access in
any serious way. I think that's probabl y where it's going to be going.
Now, what you did refer to , which I think is an issue for Republicans ,
has to do with the expansion of Medicai d eligibility, and whether
there is a social compact with people on Medicaid , or on welfare
programs in general . D o they have some obligation if they are able to ,
and if the opportunit y is given to them , to give back to the
community? I think that's the quest ion. That was certainly an issue
during the last administration. I think it will be an issue in the future
as w ell.

Your Vote and Healthcare

The Biden Administration has made it perfectly clear by reversing all
the approvals for states that wanted to try something different wit h
their Medicaid programs o ver the past few years . They've reversed all
of those waivers. So , I'm sure that our R epublicans will be talking
about this over the next two years , b ut that won't change the Biden
Administration's position on it. I think the re is a legitimate question,
given that we have similar requirements for social responsibility for
welfare programs, that where a beneficiary in Medicaid program is
able , and where the opportunity is available , t he idea that there
should be some social resp onsibility requirement, I think resonates
very well with a lot of people, and certainly resonates very much with
Rep ublicans.

Mark Masselli: You know, Emily, I think --

Margaret Flinter: Thank you. And I should have clarified -- sorry Mark, go ahead.

Mark Ma sselli: No . Emily, I wanted to sort of pick up on Jo e 's comments about
benefits . Because you've written about , a lo t about the Inflation
Reduction Act, how it will save families thousands of dollars including
health care costs. But I'm wondering if it impacts the election ,
because getting to the insulin a t $35 goes into January , past the
election . Is this something tha t's really resonating right now? Are
people connecting that t hese are on their way? And is it translating ,
d o you think , into opportunities for Democra ts? Or , is it show me, I'm
from Missouri, show me it in my paycheck or in my Social Security
benefits b ut until then I don't believe you ?

Emily Gee : I think these reforms will make a big difference . You know, there are
multiple components of the drug reforms that run Inflation Reduction
Act . One is allowing Medicare to negotiate lower prices for drugs,
which is a wildly popular proposal [inaudibl e 00:17:09] across not just
Democrats, but Republicans , and in voters of all affiliations. And it
also stopped our companies from hiking prices. The law will force the
companies to pay rebates back to the Medicare prog ram if they raise
the prices above the rate of inflation. But even less abstract, you
know, are these parts that will protect seniors from high out - of -
po cket costs. And I do think many people are eager to see those go
into place, and they are very tangible , very understandable benefits
for people who have high drug costs. That $35 cap on o ut - of - pocket
costs for insulin goes into place just two and a half months from now .
The $2,000 cap on drug spending in both Medicare Advantage and
Part D standalone drug p lans , will take a couple more years to
implement , b ut that too is something that seniors will see . I think it
will be very real to [inaudible 00:18:03] families.

Margaret Flinter: Well Emily , CAP recently published a report th at stated that the
Federal pub lic option would improve health equity across the United
States. But Joseph, I think you've written that Federal public option is

Your Vote and Healthcare

unlikely to deliver the market transformation that some advocates
predict . I wonder if Jo e , could you explain your perspective , a nd then
Emily, if we have time , we would like you to comment as well .

Joseph Antos: Well, first of all, I don't believe that anybody 's really talking about a
Federal public option . A number of states have attempted to create a
so - called public option, C olorado being the first one that comes to
mind. And the states that have tried to do this , actually have been
highly unsuccessful. I mean i n ma ny people's minds, a public option is
something -- is a health plan that's run by a government, state or
Federal possibly. In the case of the states that have attempted this,
none of them have taken on the task of having the state government
run a health plan . They're not good at it for one thing. Instead, their
strategy has been to try to impose requirements on exis ting private
health plans, and more importantly, a requirement on providers,
especially hospitals, to participate in what are essentially discount
plans , where the provider is required in some states to accept much
lower payment rates than they typically g et from commercial insur ers .

That hasn't worked out well for Colorado , that hasn't worked out for
other states as well. The fact is that there is a public option already
since in the Federal government . The ACA created it . It's called the
Ex change Plans . And if you're eligible for it, then there's your public
option , and the fact is that only about six million people in this
country, six million citizens of this country are not insured . Maybe it's
about eight million now . I'm not sure what the exact number is. But
it's a relatively low number , compared to the 350 million peop le we
have in this country . And most of those people who aren't covered,
have options that they could pursue, and for some reason they
haven't pursued them. So , I think we ’ re largely co vered on this. I
would argue that the ACA has largely solve d the cove rage problem. It
did not solve the cost problem, but it solved the coverage problem ,
and y ou know, three cheers for that.

M ark Masselli: Emily, response?

Margaret Flinter: Emily, anything -- sorry, Emily, did you want to comment or respond
to that?

Emily Ge e: Yes. So I will say that the exchanges are working. I mean, they were
not designed to substitute for employer - sponsored insurance or
existing public programs. They ’ re designed to fill a gap for people who
didn't have either an employer or a publi c program option like
Medicare and Medicaid. Prior to the ACA, people faced higher
premiums if they had a pre - existing condition , or for being a woman ,
or for being older, with no limit . And so what these changes were
designed to do , with the ACA plans or O bamacare, whatever we like
to call them, is fill that gap . And they've been very successful. It's
actually 14 .5 million people , a record high , who are enrolled in

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marketplace coverage this year . And the ACA marketplaces, in
addition to Medicaid policy , have hel ped the U.S. weather the
pandemic . Even though there was a lot of job loss , income loss during
the pandemic, the uninsurance rate in the country held steady
because those affordable option s were available out there for
coverage.

Joseph Antos: Can I make one other comment about the public option? If Democrats
were to try to push through a Federal public option, the first plans
that would be hit by it would of course be the ACA Exchange Plans ,
unless of course, the public option wasn't a better deal. So , this is not
a shrewd political idea , and it's not very good policy.

Mark Masselli: Emily G ee with CAP , and Jo e Antos with AEI , thank you both for your
insights. We look forward to your future writings and ideas. Thank you
to our audience for being here . And you can learn more about
Conversations on Health Care and sign up for our emails , updates at
www.chcradio.com . Thank you both again.

Emily Gee: Thank you.

Joseph Antos: 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 and policy. Lori Robertson is an award - winning journalist , and Managing
E ditor of FactCheck.org, a nonpar tisan, 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 Robertson: The Centers for Disease Control and Prevention hosted an onl ine
seminar about the treatment of blood clots, which is expected to grow as the U .S. population ages and the obesity rate increases. But
some vaccine opponents , misrepresented the webinar to falsely
suggest that the projected rise in blood clots is relate d to the COVID -
19 vaccines. It's not . Most of the people attending the webcast , were
health care providers. But anti - vaccine campaigners , posted videos
online about the CDC seminar highlighting a CDC synopsis of the event that said experts estimated the nu mber of patients needing
anticoagula nt care to prevent blood clots would double by the year 2050. The post baselessly suggested this was related to COVID - 19
vaccination . But the webinar explained that for several years before
the COVID - 19 pandemic, studies have said there will be an increase d
need for anticoagulant care. That's because two common medical conditions requiring blood thinners are expected to increase as the population gets older and obesity increases. The conditions are atrial fibrillation and venous thromboembolism or bl ood clo ts that start in a

Your Vote and Healthcare

vein.

The expert featured in the webinar, A l lison Burnett, President of the
Anticoagulation Forum , told us the expected increase in anticoagulant
care has nothing to do with COVID - 19 vaccination. In f act, she said a
person is much more l ikely to get a blood clot after being infected
with COVID - 19 than they are to get a clot after being vaccinated.

And that's my fact check for this week. I'm Lori Robertson, Managing
Editor of FactCheck.org.

Margaret Fl inter: 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’d
like check ed , email us at www.chc radio. com . We’ll 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 make
wellness a part of our communities and everyday lives. I t's estimated
that a majority of a person's lifelong health expenditures are often
spent in the final months of life. But death is one of those topics that
generates the least amount of conversation in the clinical setting in
American health care. For folks who end up critically ill , are facing a
terminal diagnosis , this can often lead to poorly communicated end of
life wishes being discussed with the clinician who then often resorts
to extreme interventions.

Dr. Man ali Patel: In oncology, you know, t here i s a d esire to want to provide patients
with truth. However, there's this unspoken misconception that by
having honest conversations about prognosis, that we are somehow
removing the hope. And actually most studies t hat have evaluated
this , have shown that when you provide honest prognostic
information to patients , and allow patients to be part of the decision
making about their goals of care, they are more appreciative of it .

Margaret Flinter: Dr. Manali Patel at Sta nford University School of Medicine , sought to
find interventions that might give clinicians and families a more useful
tool to address this gap in communication. Her earlier research at
Stanford , had yielded an interesting finding. Late stage cancer
patie nts felt more comfortable talking about end of life issues with a
lay person as opposed to a clinician . She and her fellow researchers
followed patients at the Veterans Administration Palo Alto Health
Care System after they were diagnosed with stage three o r four or
recurrent cancer. Half the people wer e randomly assigned to speak
with a lay worker about the goals of care over a six month period , and
the lay workers were given a rigorous 80 hour course and clinical

Your Vote and Healthcare

observations before being assigned to the s tudy .

Dr. Manali Patel: She learned as she went , and then at the end, she came to that
realization that these conversations really are not scary . We had hired
her specifically because of her service orientation , and that's really
the main crux of this inte rvention , was finding the right person who
ca n engage in these conversations.

Margaret Flinter: 92% of the participants who received the layperson intervention,
compared to only 18% of the control group , we re likely to have end of
life directives in their Electronic Health Record , often choosing
hospi ce over emergency room interventions as their conditions
deteriorated. The average cost of care for the intervention group in
the last month of life was about $1,000 versus $ 23,000 for the control
group.

Dr. Ma nali Patel: We found that the satisfaction scores w ent up for the patients in the
intervention arm, but they went down for patients in the control arm.

Margaret Flinter: A low resource , compassionate patient - centered intervention that
assists terminally ill patients, their families and their clinicians to have
a frank discussion about end of life wishes , improving patient
satisfaction at such a sensitive and challenging time , and saving
significant costs as well , t hat's a bright idea.

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Mark Masselli: I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and h ealth .

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Marianne O’Hare: Conversations on Health Care is recorded in the Knowledge and
Technology Center Studios in Middletown, Connecticut, and is
brought to you by the Community Health Center , now celebrating 50
years of providing quality care to the underserved where health care
is a right not a privilege , www.chc1.com and www.chcradio .com .

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