GOP Health Economist Dr. Gail Wilensky Explores the Future of Health Reform under the Trump Administration

Gail Wilensky

[ Music ]

Mark Masselli: This is Conversations on Health Care, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margret , open enrolment for this year’s health insurance market
place has come to an end. While billions of Americans enrolled for health coverage
in the coming year it ended with more of a whimper than a bang , the close of the
year ’ s open enrolment number s down by a couple of hundred thousand enrollees
from the year before.

Margaret Flinter: Well you know Mark I have to think that that’s an example of just
how disruptive uncertainty can be in the health marketplace . Early in the enrolment
season enrolment was running ahead of 2016’s numbers but then in the final two
weeks the numbers really dropped of f, so mething to think about.

Mark Masselli: Absolutely yes, that uncertainty of course has come with strong
redirect from the White House and the leadership in congress . As they plan to
repeal the health care law consumers aren’t certain they’ll be panelized with a tax
penalty now for not having coverage as stipulated in the Affordable Care Act . The
bad news is those who didn’t sign up for coverage remain uninsured.

Margaret Flinter: And I think also important to note Mark that enrollment did remain
robust in the states that had formed their own individual marketplace exchanges and
there is some evidence that in those states , with their individual marketplace
exchange , consumers were empowered to seek affordable coverage and they learn t
to navigate the port als early on , so for them the reenrollment process was a lot
easier . It looks like people actually got used to it and figure d out how to do it.

Mark Masselli: We’re in uncharted waters at the moment Margaret and to get some
clarity we thought we ’d bring back a guest to the show who has been on the
frontline s of health policy for several decades . Dr. Gail Wilensky is a renowned
health economist and senior fellow at the Centre for Health Affairs at Project HOPE .

Margaret Flinter: Dr. Wilensky served as the administrator of CMS under Bush 41
and has significant experience promoting national health policies. She has some
strong ideas about how reform should work moving forward and we really look
forward to hearing her expert perspective.

Mark Masselli: And speaking of strong ideas , Lori Robertson , Managing Editor of
FactCheck.org also stops by always on the hunt for misstatements spoken about
health policy in the public domain.

Margaret Flinter: And to no matter what the topic, you can hear all of our shows by
going to chcradio.com and as always no matter what the topic you can email us at
[email protected] or find us on Facebook or Twitter, w e love to hear from you.
We’ll g et to our interview with Dr. Gail Wilensky in just a moment.

Gail Wilensky

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

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.
President Trump has shi fted redirect on his plans for full repeal and replacement of
the healthcare law . He is now saying the full repeal and replacement plan for the
Affordable Care Act may not even be formulated until early next year saying it’s a
complex thing to accomplish. The President did vow that he would eventually come
up with something “ better than the ACA .”

Meanwhile, House Speaker Paul Ryan continuing to point to a March deadline for his
plan to come up with a replacement to the health care law, his plans have be en more
transparent stripping Medicaid expansion in favor of Medicaid block grants
incentivizing health consumers to build up health savings accounts , high risk pools
for those with preexisting conditions and even those living at the lower end of the
econo mic spectrum will have to pay more making consumers more accountable for
their own health choices.

However at the recent GOP leadership meeting in Philadelphia concerns were raised
about potential political backlash if the law is replaced too soon jeopard izing
coverage for millions of constituents or consumers learning that the GOP
replacement will not reall y help them realize significant savings on their health costs .

Tennessee Senator Lamar Alexander says a more prudent course of action would
be to re pair parts of the Law that aren’t working. Meanwhile the request from Vice
President Mike Pence’s home state of Indiana to please not touch the Medicaid
expansion there, the Medicaid expansion provided federal dollars to s tates who
expand ed their Medicaid eligibility that expansion covered by the Federal
Government for the first three years . All democratic led states expanded Medicaid
and were able to expand coverage to millions of Americans and a number of
republican led states followed suit , but some li ke Indiana put forth their own Medicaid
expansion that provided funds for those living close r to the poverty line . Indiana’s
experiment proved quite successful leading to coverage for some 350 ,000 residents .
Indiana’s new Governor Holcomb has issued a re quest to leave the Medicaid
expanded funding in place for 2018 for that state which would mean billions of
dollars to continue the program .

If only you could read their thoughts – well scientists have unwilled a system that
may actually allow completely p aralyzed people to communicate their thoughts. It’s
a brain computer interface that measures blood oxygen levels in different parts of the
brain when the person is being questioned . In a trial of the system in 4 patients with
complete locked - in syndrome , that is incapable of moving even their eyes to
communicate , i t helped them use their though t waves to respond yes or no to
spoken questions. All 4 original participants of the study reported being happy
despite their complete paralysis. Scientists worki ng on the project at Switzerland’s
WYSS center say the technology holds promise for those suffering from ALS or Lou
Gehrig's disease and other classes of locked - in syndrome

I am Marianne O’Hare with these Healthcare Headlines.

Gail Wilensky

Mark Masselli: We’re speak ing with Gail Wilensky , P h .D. , economist and senior
fellow at the Center for Health Affairs at Project HOPE , an d the international
foundation focused in on improving health care worldwide. She served as the
administrator of the Health Care Financing Admin istration precursor to the Center for
Medicare and Medicaid Services under President George H.W. Bush. Dr. Wilensky
recently served as president of the Defense Health Board , an advisory board of the
secretary of defense , was a commissioner on the World He alth Organization’s
Commission on Social Determinants o f Health and co - chaired the Department of
Defense Task Force on the Future of Military Health . Dr. Wilensky is an elected
member of the Institute of Medicine; she received a bachelor’s degree in psych ology,
a Ph. D. in economics at the University of Michigan.

Dr. Wilensky , welcome back to Conversations on Health Care .

Dr. Gail Wilensky : Delighted to be with you again.

Mark Masselli: You joined us back in 2011 when the Affordable Care Act was
gettin g underway, the landscape seems to be shifting rapidly again and you served
under President George Bush 41 as administrator to the precursor to CMS so you
understand the im portance of clear policy directives in health care . I wonder if you
could share wit h our listeners your advice that you might have for the Trump
administration.

Dr. Gail Wilensky : People are feeling uneasy now. They have not as a country like d
the Affordable Care Act, more had an unfavorable opinion than had a favorable
opinion but th ey are getting very uneasy because they understand what the
Affordable Care Act does and they don’t know what’s coming next to people who
have received coverage, people who have preexisting conditions. So the best thing
that can happen is to have a clear indication as soon as possible about what is going
to succeed the Affordable Care Act . Up un til now the focus has been on repeal and
replace , t hat has been the mantra of the Republican Party . We’re beginning to hear
the notion of repair and reform , p eopl e seem to be much more responsive to the
notion of repairing it and there is a lot of agreement that part s of it didn’t work as
intended but it makes people uneasy to not know what comes next.

Margaret Flinter: But Dr. Wilensky in a recent op - ed piece yo u noted that the
Republicans and Congress heads spent the last 6 years attempting to repeal the
Affordable Care Act but they knew the efforts would be vetoed. As you know there is
a reality shift as leadership learns it’s not going to be so easy to delive r on that
promise without disruption to the health care industry and without threatening the
status quo for all the people who gained coverage help our listeners understand how
the political imperatives may collide with policy as you r opt ed title suggests and what
you think is most likely to happen in the coming months?

Dr. Gail Wilensky : Because Republicans have focused so much on the language of
repealing the Affordable Care Act they would miss the opportunity to do something
that might be much easier a nd where they possibly could gain democratic support
which is not just good policy and politics in general but maybe absolutely key to
being successful . Well, Republicans control both Houses of Congress and the White

Gail Wilensky

House , the control on the Senate is by a very small margin 52 to 48 , t hey will need
Democrats to get to 60 votes.

There’s a process budget reconciliation which allows the Senate to vote on budget
related measures with only a simple majority but anything else , and many of the
insurance refor ms are believe d to probably fall into the anything else bucket , would
require 60 votes . That means that they are going to require some support from the
Democrats which means how they do this could become very important. In order to
repeal that whole mamm oth, 2 , 000 plus page piece of legislation , you would
definitely need your 60 votes. What they can affectively do is remove the funding for
almost all of the subsidies and other aspects that are funded by the various excise
taxes with simple majority but t he replacement may require a vote of 60 supporters .
It’s something that the Parliamentarian of the Senate decides whether or not a bill
needs only a simple majority or requires the normal vote that the center requires to
get around filibuster and of cours e you can count on some d emocrats wanting to
filibuster any removal of the Affordable Care Act .

Mark Masselli: You know Dr. Wilensky a number of well known GOP strategists
have been analyzing the kind of policies that are most likely to be part of whatev er
comes next and as Dr. Mark McClone, who was recently on our show , said that the
reforms are going to have a distinct ive Republican flavor have savings accounts, tax
credits instead of tax penalties, what other types of things you might see e merge
with t he new Congress and new President all aligned?

Dr. Gail Wilensky : Well people have been taking about the need to protect
individuals who’ve preexisting conditions and Republicans understand that but the
mechanism they use is likely to be different . In t he Affordable Care Act there is a law
that says that insurers cannot make any distinction according to the health status of
an individual , t hose of us who have employer sponsored insurance through the
HIPAA law that was pass ed in 1996 and it basically says if you maintain , continue
this coverage th e n you won ’ t the placing any exclusions when you change jobs or
get new insurance.

In the 1990’s people would be stuck in a job because if they changed jobs and g o t a
new insurance and they or somebody in their f amily had a preexisting medical
condition they would face a 6 - month exclusion from coverage for that preexisting
medical condition , t he HIPAA Legislation would not have to be subject to a
preexisting condition exclusion . Republicans have talked about this as a way to
provide a strong incentive to be continuously covered. There is a lot to talk about
removing the mandate on individuals. I and others have talked about whether the
Congress shouldn’t take a page from Medicare to do what Medicare does which i s to
say that for the voluntary part , part B the physician coverage and part D , if sometime
later you decide you want that insurance you will pay a penalty for every month you
delayed after that first year because they want to avoid a t their selection havi ng
people wait.

I was disappointed in 2009 that they didn’t give this strategy a try , so that’s another
kind of thing. In general, Republicans try to use less regulation and try to put in
strong incentives to encourage you to do something that they think is appropriate
and the Affordable Care Act – the amount that a premium was allowed to vary

Gail Wilensky

because of age was 3 : 1 and the youngest adult males were being as ked to pay more
than would have been actuarially calculated so that the pre - Medicare population
cou ld pay less . Except that we know that the youngest adult s are the hardest to
convince to go b u y insurance so unless you had almost all of the insurance paid for it
made it even less likely that we could get this young healthy population to buy i n and
of c ourse you want them in because they help your risk pool a nd what you require to
buy is probably going to be determined by the states . So those are the kinds of
changes that I would expect to see with the Republican package , 6 years after its
passage the m ajority to people in the country had an unfavorable opinion of the
Affordable Care Act . It ’ s only right now when they’re being threatened with losing it
and they don’t know what’s coming in its place that people are starting to be more
favorable in their attitude.

Margaret Flinter: I’d like to thither a bit to another area where there is lots of
concern , interest and de bat e right now and that of course is Medicaid . Lot of
concern among the states ’ Medicaid directors who’ve adopted their policies and
b ud gets to accept the Medicaid expansion in their states , but the talk coming from
GOP leaders like Speaker Ryan and Senator McConnell seem to indicate elimination
of the Medicaid expansion is on their agenda but also a fundamental change to the
Medicaid prog ram and moving it to block grant status. Could you talk about how that
might impact some of the recent coverage gains under Medicaid expansion and how
you think state Medicaid directors will prepare for what’s coming next?

Dr. Gail Wilensky : There are t wo kinds of block grants , one is just a fixed amount of
money which would put the state at great jeopardy and the other is called the per
capita block grant. They would be eligible to receive an amount of money for every
person if you get more people unde r the poverty line for example because you have
a recession. The state would automatically receive more money than if time s were
good and so my advice to governors is only consider a per capita Medicaid block
grant.

The second issue is how the governors feel about this change. They want more
flexibility and block grants provide a lot of flexibility of the Hyde Amendment which
prevents having federal money go for – abortions would probably be attached to that
language. Medicaid can provide a lot of flexi bility but frequently they have to ask
permission in order to get a waiver to do it their way. If the majority of at least
Republican governors don’t want to go on this direction, the Republican congress
would think wrong and hard about whether they do it anyway.

Mark Masselli: We are speaking today with Gail Wilensky , P h .D. , e conomist , and
senior fellow at the Center for Health Affairs at Project HOPE . She served as
administrator of the Health Care Financing Administration and co - chair ed the
Department of Defense Task Force on the Future of Military Health Care . I want to
get back at this issue of trying to find common ground , one area that we know where
there’s been bipartisan support has been the support for community health centers
maybe you could a ddress both of those.

Dr. Gail Wilensky : Fortunately, for the country the very close division in the Senate
requires cooperation to do at least some of the changes that you would like to have
associated with the next round of health care reform and that is going to pressure

Gail Wilensky

Congress to find ways to work together . It’s always better to get bipartisan support,
you are much more likely to get abeyant and stability over time. Republicans aren’t
going to have much choice , for some things they can go alone bu t for many pieces of
legislation they are going to need to have some bipartisan support. The question is
whether the Democrats and the Senate will want to provide that, some may not but
there are a lot of Democrats who are up for election in 2018 and ther e are people
particularly who are middle of the road politically that i f the Legislation is something
they can me ma de comfortable with might well support it. This will be much better
for the country.

Margaret Flinter: Well Dr. Wilensky I think there is one issue I’ve noted that’s
emerged from the administration that seems to have actually resonated with people
on both sides of the aisle and that’s getting a handle on reducing the exorbitant cost
of pharmaceuticals . You recently wrote that the high cost of prescription drugs is
much more than a political issue , President Trump has promised to incentivize the
pharmaceutical industry to reduce the cost of drugs to consumers but also to reduce
the role of the F D A and drug approvals to accelerate the pace of competitive drugs
entering the market place. What policies do you think might actually lead to making
pharmaceuticals more affordable for consumers?

Dr. Gail Wilensky : The pharmaceutical industry is different from other aspects of
health care when it c omes to regulating the prices or trying to control spending the
way we do in Medicare. Generally in Medicare the Centers for Medicare and
Medicaid Services set a price that they’ll reimburse hospitals , if you miss on pricing
for most services you get a pu shback right away hospitals will threat en not to
participate or will have trouble staying in business of getting participation in Medicaid
is a problem in many states because of low fee schedules.

In pharmaceuticals, it’s a little different, there is a very long lean time while drugs are
being developed in the laboratory and then go through clinical testing, go to the F D A
for approval for safety and efficacy, and finally get to market . But also a lot of drugs
that look promising at various stages don’t make it through that whole process or by
the time they make it through there may be a lot of other drugs that are already on
the market. Once you actually get through that process, the cost of producing the
drug is not usually that high. The high cost is in the whole development process and
the likelihood that a drug that starts to look promising and never makes it through
that whole process but it may not be worth it for the company to try to do that again
for the next product because they have to absorb all of those cost s. So the concern
is that unlike a physician where if you’re not paying enough you’ll know pretty quickly
because physicians will refuse to see certain patients as happens in Medicaid.

In the pharmaceutical world you won’t feel that imp act for many years to come
because of this long production process. I think the best thing we can do is try to
expedite the review of expensive specialty drugs because we’ve seen that some of
the large buyers can play one drug off another if there are com petitive drugs i n the
specialty area , we saw that with Hepatitis C drugs , there was a big drop i n price once
there was competition to Sovaldi and Harvoni the price dropped significantly . So,
there are other things you can do but one of the things we can d o is to try to help by
providing enough resources for the F D A , we don’t want them to skimp on their

Gail Wilensky

process , w e just want to give them the resources so they can do this as
expeditiously as possible.

Mark Masselli: You know you’ve dedicated a good portion of your carrier to
improving the plight and the health of American veterans . What are your
observations on the new administration’s call for more privatization of the VA ? Dr .
Shulkin is the nominee who faces enormous amount of challenges as Secretary fo r
Veterans ’ Affairs . What are your views at how best to make the necessary
improvements to fix the current system?

Dr. Gail Wilensky : There are a number of things that need to happen and we owe
this to our veterans to get it right . Having options outsi de of the VA for individuals
who either live in an area where there are not the kind of resources available within
the VA to see them in an appropriate and timely manner makes complete sense
particularly when it comes to providing regular health care that can be provided
easily through the private sector and that option is actually not new to the choice
program , it ’ s just been expanded and it makes a lot of sense.

We do ultimately need to decide what role we see in the future , 10 years down , for
the vetera ns ’ administration. Do we see them providing all of the health care needs?
Most veterans actually don’t receive their health care at the VA , there are some
22 - 23 million v eterans , t here are 6 million or so regular users , and 1 or 2 million
occasional user s of the VA . But another way to think about the VA would be to have
it focus on providing the health care that specializes in the needs of war and have
regular routine care be provided by the private sector . So you could imagine a VA
that focuses on PTS D , and prosthetics , and the multiple injury support that we have
seen following the wars that we’ve been in in Iraq and Afghanistan and of course
other wars as well a nd so ha ve this very specialized focus for the VA which it does
very well .

Historically it ’s done very good post - stroke work but we have special injuries , I E D in
particular and PTS D following these wars and have a take on a much more
specialized function that would help us structure where we go i n the future and it
makes a huge difference about whether we’re going to think about having
specialized support for the VA and using the regular health care system to provide
the routine support , or whether we’re going to continue trying to do what we’ve done.
We have a problem , there is clearly a lack of accountability and appropriate
incentives and structure , problems with the use of electronic scheduling and support
that has not yet been dealt with , it ’ s been noted as a problem by the G AO
repeatedly , we got to get this going.

Margaret Flinter: We’ve been speaking today with Dr. Gail Wilensky , economist and
senior fellow at the Center for Health Affairs at Project HOPE. You can learn more
about her work by going to projecthope.org. Dr Wilensky I want to thank you so
much for joining us today on Conv ersations on Health Care .

Dr. Gail Wilensky : You’re very welcome , pleasure to be with you.

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. Lor i

Gail Wilensky

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 Robertson: I n an interview with ABP News , President Donald Trump questioned
the estimate that 18 million Americans could lose insurance if the Affordable Care
Act is repealed with no replacement. He said “ nobody ever deduct s all the people
that have already lost thei r health insurance that liked it .” In fact estimate s from
governmental organizations on how many have gained insurance under the ACA , or
stand to lose it if the law is repealed , are net estimate s . The Centers for Disease
Control and Prevention publishes data on health insurance status from the National
Health Interview Survey , the latest report shows an estimated 28.4 million Americans
of all ages were uninsured for January through June 2016.

The number of the uninsured in 2010 , the year the ACA was en acted , was 48.6
million – that’s a decrease of 20 million people . In percentage terms 8.9 % of all US
residents lacked insurance during the first half of 2016, the lowest uninsured rate on
record. The rate was 16 % in 2010 and has been declining every ye ar since. These
are the total numbers for the uninsured in the country. The claim that million s lost
their insurance is a longstanding talking point based on the fact that many with
individual market plans receive d cancelation notices in 2013 when their plans no
longer met minimum benefits standard s required under the ACA , when those specific
plans were discontinued policyholders weren’t denied coverage.

Another study from the Ryan Corporation suggested that most of those who had
their plans canceled fou nd coverage elsewhere and remained insured. To be clear
some who buy their own insurance on the individual market got a better deal before
the ACA , were relatively young and healthy who also earn ed too much to qualify for
subsidies under the health care l aw and there is evidence that some have lost or
dropped their insurance coverage even as many more have gained coverage in
recent years. As for the estimate that 18 million could lose their insurance if the ACA
is repealed that comes from the non - partisan congressional budget office which said
that the number of the uninsured would increase by that much in the first year
following repeal of the individual mandate penalties . The number would be higher
once tax subsidies and Medicaid expansion funding were eliminated , and that’s my
fact check for this week. I ’m Lori Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Publi c Policy Center at the
University of Pennsylvania. If you have a fact that you would like checked, email us
at chcradio.com , we’ll have FactCheck.org’s Lori Robertson check it out for you here
on Conversations on Heal th Care .

Each week conversations highlights a bright idea about how to make wellness a part
of our communities and e veryday lives. Stanford based b io engineer Manu Prakash
has a simple goal , h e wants to create a portable medical lab small enough to fit i n a
backpack and he has already developed a tool that fits the bill. While sitting under a
tree in Uganda he noticed that the local medical clinic ’ s door was prop ped open by
an expensive centrifuge machine , one that was reliant on electricity , now broken and
no longer in use . He wondered how could he create a portable centrifuge that will be

Gail Wilensky

inexpensive to make, easy to operate, and easy to replace . His inspiration came
from a simple ancient childhood toy – the whirli gig , a toy that functions by pulling two
ends of a string threaded through a round object like a button

Manu Prakash: Before us nobody had actually understood how this toy works, so
we spent a significant portion of this time truly understanding the m athematical
phase for how you can conver t linear motion into rotational motion and there is some
beautiful mathematics hidden inside this object

Margaret Flinter: So he took this simple toy idea to another level creating a human
power centrifuge made from simple components paper, twine and pla stic. All
together each paperfuge , as he calls it , can b e constructed in under two minutes and
costs only 20 cents and yet remarkably it works extremely efficiently.

Manu Prakash: With this set of principles we’re able to essentially make a centrifuge
t hat spins all the way to 120,000 rpm. In the lab we can separate and pull out
malaria parasites from blood, separate blood plasma – i t is an ultralow cost
centrifuge.

Margaret Flinter: It’s currently being tested for Malaria diagnosis but is being read i ed
for far more complex diagnostic challenges.

Manu Prakash: This is a tool that requires no electricity, no infrastructure , you can
carry them around in your pockets for a price point of 20 cents.

Margaret Flinter: The paperfuge , a cheap but highly ef fective feedthrough for
clinicians providing a portable solution to diagnostic challenges creating a quicker
pathway to diagnosis and treatment. Now that’s a bright idea.

[ Music ]

Margaret Flinter: This is Conversations on Health Care , I ’m Margaret Flint er.

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

Conversations on Health Care broadcast s from the campus of WESU at Wesleyan
University streaming live at wesufm.org and brought to you by the Community He alth
Center .