Hear From a Progressive and Conservative – Can We Find Common Ground in Health Care?

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

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Marianne O’Hare : Welcome to Conversations on Health Care. This week we continue our
health care on the ballot series , opposing views on the outcome of
the midterm election and the impact on health policy moving forward
with former Obama CMS Adminis trator Don Berwick .

Dr. Donald Berwick : We can find a way to move money where health can be preserved, we
may see some progress .

Marianne O’Hare : And Jim Capretta of the Conservative American Enterprise Institute .

J im Capretta : Medicare's H I Trust Fund is expected to be depleted in five years or
so .

Marianne O’Hare : FactCheck.org’s Managing Editor Lori Robertson checks in, and we
end with a bright idea . Now, here are your host s Mark Masselli and
Margaret Flinter .

Mark Masselli : Roughly 112 million Americans voted in the recent midterm elections
and the candidates and issues they voted on will have profound
implications for health care policy in the states at the national level
a nd ultimately in all of our lives. We're following up on our series
called Health Care on the Ballot with the discussion focus ing in on the
results and what they mean.

Margaret Flinter: O ur guests today are Dr. Donald Berwick, who helped shape the
Affordable Care Act during the Obama administration, and the co -
founder and president eme ritus of the Institute for Health Care
Improvement. Also joining us today is Jim Capretta , a senior fellow
with the American Enterprise Institute. He is also the author of a new
book US Health Policy and Market Reforms ” .

Mark Masselli: Well, welcome to bot h of you in Conversations on Health Care . L et's
start with a question to each of you , it was widely predicted that the
midterms would really trim the sails on the Biden administration's
plan for Democrats in the States a nd yet the Democrats hold the
majori ty in the Senate are barely in the minority in the house and saw
many wins for their governors and state lawmakers. What is your
view of how these surprising results will influence health policy in the
next few years? L et's ask Dr. Berwick to respond first and then go to
James .

Dr. Donald Berwick: I sure have no crystal ball . W e still have a problem passing legislation
given that the house is going to be in Republican hands. I suspect the
elections signal that there's some public will for some moderation in
this highly polarized climate that we're in . I think people want action.
They know there are problems. T hey appeared relatively intolerant of
people taking very, very extreme positions.

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

I hope against hope, perhaps that this means that there'll be some
op portunity for some progress kind of in the center for things that
everyone cares about. Everyone's very worried about drug prices .
E veryone knows that the Medicare Trust Fund is threatened.
Everyone knows that there are people left out of the system now wh o
need to be included . I'm hopeful there'll be some progress .

The Biden ad ministration did pass some very, very important
legislation during the past couple of years. I also suspect that the
positive benefits of some of that legislation will become more
ap parent to people as the Affordable Care Act has been. T here'll be
some more wind in the sails of some of the reforms that we need.

Mark Masselli: Yeah, some of those policies come into effect in January , s o we'll see
if they come to fruition as they planne d. James, your thoughts?

J im Capretta: Well, I think the secret of the 2021 / 2022 term, there was a pretty big
group of senators, bipartisan group of senators in the Senate that got
a fair amount of legislation through to President Biden . T hey wanted
to mak e clear to the country that they thought a working Senate was
very important , a workin g Congress was very important. T hey're not
going to pass legislation that is highly partisan from an even a
democratic point of view, I think. Something like the Inflatio n
Reduction Act, which passed only with Democratic votes wouldn't
happen this time around , b ut things in the middle still could pass .
T hings that are bite size that can get some bipartisan support could
still pass . Things like mental health improvements, s ubstance abuse
questions, improvements even to the FDA and CDC. Those are
possibilities even in this new Congress it's coming in.

I think the big action might be in some of the states, actually, as you
sort of hinted that with your question. A lot of state s are still with lots
of so many initiatives like the public option plans, trying to do price
limitations on certain providers and drugs. Some of that action could
shift to the states.

Margaret Flinter: Well, Jim, you're well aware, and we appreciate your pointing out
some of those areas where there does actually seemed to be some
agreement . T he country h e ard not to have it on the crisis, mental
health, substance abuse and where we might see some agreement.
But Dr. Berwick, you are a veteran of many Washing ton battles, and I
know we still have Congress's lame duck session to tackle.

The thing that always surprises me is when I see that we're set for
something like a decrease in Medicare payments. All providers looking
at a 4% cut unless Congress acts . W e hea r Medicare so often talked
about a s the third rail something that you can't touch. What do you
think is going to happen in that arena this year?

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

Dr. Donald Berwick: I’m not sure the lame duck hasn't got many breaths left. But I think
some of the problems y ou cited the payment cuts will have to be I
think the y 'll be moderated . I don't think that anything dramatic is
going to happen at lame duck to cut back on payments . I think that
there is some work that needs to be done to make sure that people
ha ve the co verage that they need, a nd perhaps we're going to see
some of that. But as Jim said, I think a lot is going to shift to the states
in terms of innovations.

For example, I would watch, not necessarily during the lame duck, but
over the next year or two Medi caid waivers as an area of very
interesting variation and novelty amongst states, there are some real
will to get that done , a nd perhaps the administration then will be able
through its administrative authorities to allow more variation
amongst states in t rying to do some creative things with financing.

Mark Masselli: Jim, let's stick with Medicare. Your book makes the case for what you
call a vigorous and properly structured competition in health care that
could deliver the same benefits seen elsewhere in the economy. In an
ideal world, what do you think Congress should do about this
Medicare payment reduction issue? Let it stand or make some
modifications?

J im Capretta: Well, I think the payment reductions that are scheduled to happen
here in the next few weeks, if something isn't done, I th ink those need
to be addressed a nd probably less e n . I don't know if they need to be
gotten rid of all together. But some moderation of what's expected
probably is an order, especially with inflation running a t 7%. Y ou ha ve
physician practices paying out a lot of expenses. I f their fees also get
cut, I mean, you're going to have a real pressure point building there
that I think probably w on’t just be sustainable. J ust to get through the
next few months they probably should do something there.

Having said that, I think over the long run is your question indicates
they need to kind of take a step back, Medicare's H I Trust Fund is
expected to be depleted in five years or so . They need to look at the
whole program, how to struc ture it better, simplify it, make the
benefits more uniform and standardize and improve how
beneficiaries interact with the program.

Margaret Flinter: Well Dr. B erwick , maybe I can pick up on what you were just
referencing as we talk about innovation and M edicare. Y ou were
commenting that the states might actually be looking to do some real
innovations in Medicaid through waivers. Would you like to highlight
one or two states where you see some really interesting proposals
th ere th at you think might move us forward around Medicaid reform?

Dr. Donald Berwick: Yeah, Maryland's always interesting to watch . T hey're making
continue to try to tweak and adjust their payer model . My home state

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

Massachusetts now is implementing a massive Medicaid waiver that I
think to be highly significant, very important to watch it as we try to
give an opportunity to move resources to social influences on health,
which really is the secret here . I f we can find a way to move money
where health can be preserved we may see some progre ss against our
deteriorating health status.

California is interesting, I think we're going to have it . Oregon would
be good. T here are some M idwestern states that I think to watch
here, this may not just move in Medicaid reform . I'd say the basic
reforms t o watch are ones that move us toward global budgets and
consolidated payment, allowing people to give care to use resources
to meet many more kinds of needs of patients in Medicaid instead of
just continuing to run a repair shop. That's what I've got my ey e on
right now. I hope all of that can happen.

At the federal level, there are some early steps . F or example, in the
ACO REACH program, there's a pretty dramatic change. It's small and
it may not have immediate impact. But the willingness of Medicare to
pa y plans just a little bit extra for entering areas of geographic area s
of deprivation . I t's probably not enough to influence behavior much,
but it's the first shank in payment that might allow us to move some
payment toward the social deprivation indices a s a way to allocate
resources.

I must say the other thing that I've got my eye on but not much hope
as Jim knows, I am very critical of where Medicare Advantage has
gotten now . I think it's a tremendous problem. It's an enormous
subsidy going to private in surers now without equivalent benefit at
all. I don't think the administration will have the political chips to take
that on, if ever . B ut there's an awful lot of reform needed there. I just
wish it would happen.

Mark Masselli: I think you're right on that . That Mas s 1115 waiver is certainly one
we're keeping an eye on . Jim perhaps one of the s ilver l inings from
the pandemic has been really the loosening of regulations that have
resulted in the greater use of telehealth . Americans in rural parts of
the coun try have really embraced greater access to health care . It
w asn't necessarily on your list earlier , b ut it is certainly had been a
benefit for accessing specialist and yet the flexibility authorized during
COVID - 19 Public Health Emergency will expire soon. Do you see
telehealth as part of this push for market reform?

J im Capretta: I do I mean, I don't know people who are for it or -- or when I'll put on
the label of market reformers. I think they probably are just saying it's
a good potential supplement to existing ways of trying to help
patients , and there's bipartisan interest in it . Now honestly , I think if
there is a spending deal here , and the next before, the end of the year
before the holidays I wouldn't be at all surprised if telehealth some fix

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

in t elehealth is put in independently of the public health emergency
to allow it to continue for a couple more years, get a real evaluation
done of it . T here are some concerns about just sort of adding on
another service on top of other services without really making
substitution and cutting costs. T here's a little bit of question about
what it does over time and how it affects patient's health . I would bet
the Congress that will authorize it, if they get the opportunity. There'll
be bipartisan support for that . G ive it a couple of years and have an
independent evaluation to see what it's doing to patient outcomes.

Margaret Flinter: Certainly on the ground we're certainly seeing telehealth is something
that contributes to access , especially in that all important area of
behavioral health. No w maybe some better ways to make it more
available for substance abuse treatment as well. W e certainly are
keeping an eye on that . It may be a little bit outside of the policy
realm, but what will captivate the public's attent ion and has in many
ways is upcoming , we hear Republican leaders really want to
subpoena Dr. Anthony Fauci bring him forward for h earings in the
house and also talk of Hearings about federal waste in the COVID
relief programs.

Dr. Berwick, you certainly we nt before Congress many times when
you were running the Centers for Medicare and Medicaid Services . D o
you think these h earings actually serve a role and might be a way of
continuing to educate the country about what the entire COVID
pandemic and response was about? Are they needed or not so much?

Dr. Donald Berwick: We certainly need a period of national reflection on what we learned
from COVID about preparedness , about pandemic respons e, about
public health response to the strengthened the public health s ystem
of public communication, educating the public . T here's a tremendous
amount of learning that we need to gather and then map it into
policy. I just must say to take an American hero like Dr. Fauci who is
just as good as it gets both in science and in p ublic leadership and
subject him to gaming in testimony. It's a waste of time, and I wish
they would just give it a rest. But we do need to learn , a nd hopefully,
there'll be a period of reflection in Congress and the executive branch
about what this tells us about how to be a more prepared country.

We were clearly not prepared, our performance was probably about
third worst in the world, and we didn't have to lose a million
Americans to this disease. We got to be smarter than that. The other
preparedness -- I can't help mentioning this is the recent attacks on
the grid are not trivial matters. This is as dire a threat for this country
as the public health emergency was in COVID. We are definitely not
prepared there. I hope Congress is going to take this extr emely
seriously. I t would be not just a health issue, but certainly a health
issue if we can't secure our grid.

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

Margaret Flinter: Well, we've heard from so many guests that this isn't the last
pandemic that we're going to face s o we really need to be prepa red.
Jim , of course, Dr. Berwick was a key architect of what we know is
Obamacare. W e saw some interesting election results in South Dakota
where voters approved a ballot measure to expand the state's
Medicaid program under the Affordable Care Act, opening up
coverage to additional 40,000 residents. But we also saw that earlier,
Oklahoma and Arkansas, very conservative states, is the fight against
Obamacare really over , what does it mean for the future market
reforms that you advocate for?

J i m Capretta: I d o think that the question of Medicaid expansion is largely settled.
T he reason is that the Affordable Care Act sort of set up a structure
where it's easy now for a state to be presented with a yes or a no
question. We either expand Medicaid according to th e ACA 's
stipulations, or it's going to be very difficult for you to get coverage to
that population, but you can't undo the rest of the structure of the
ACA and go in a wholly different direction.

G iven that the ACA is in place has been for over a decade, and the
only way to get coverage to that very vulnerable population below the
poverty line is to provide Medicaid coverage at this point . T hen, yeah,
I think that states are wise to just take it because you're not going to
get coverage to that population i n any other way , so they should
adopt it. But remember, when President Obama passed the
Affordable Care Act he called it a market based reform. Remember,
it's competition on the exchange , i t's choice amongst private plans.
It's a Medicaid expansion to be s ure, but its central feature was
competition amongst insurance plans on the exchanges for the
individual market. In some ways it is a market reform . T he question
for America is how to make very complicated, fragmented,
uncoordinated and not so well designe d system of public and private
work a little bit better together ?

Margaret Flinter: A question that maybe both of you would like to respond to. But Dr.
Berwick, let me start with you, whether it's in the exam room or town
halls or legislative assemblies, f ew things get people talking like drug
prices . Y ou've noted that there are actions President Biden could take
now to lower drug prices including the Most Favored Nations drug
pricing for a number of drugs. Take us through your thinking on the
topic about w hat needs to be done in this area . Jim, we welcome your
comments after Dr. Berwick as well.

Dr. Donald Berwick: It's a very bad problem and continuing to worsen mostly . It's not one
problem, though , their drug prices depends on which tier of drugs
we're ta lking about . T he high end or the extremely expensive
biologics and biosimilars, we a re seeing very, very little discipline
exercised by the companies themselves and the market forces are not

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

working . I'd love to hear Jim's comments about it. I can't wait t o read
his book. I'm personally see ing no alternative, but some very
aggressive administrative pricing of drugs . I just don't see a way to get
that under control there. The prices are obscene, and they don't have
rationale in my book .

In the middle ground there I think competition can do a lot. I think
Part D, remember came in a lot cheaper than anyone thought it
would. T here is room for competition. To do that you have to be able
to open up competition, there are some patent laws that need to be
changed. T here are some awful stories around the defects in the drug
patent laws that allow capture of medications as old as a pyramid and
then on this high pricing.

I'm also a fan of some of the new stuff that's going on in competition
th e generic market . I was an advisor to Civica R x , which is a very, very
interesting move by healthcare providers to make their own drugs ,
and I suspect we might see some more of that. I t's not one size fits all.
I am a fan of Medicare negotiating prices , but we have yet to see
really whether that's going to work . I'm going to follow the changes in
recent legislation with great interest as kind of an early trial, whether
that using that market power can help. But, a gain, I say the lack of
discipline is shocking . In fact, the nearly fra udulent or nearly not quite
illegal activities around drug pricing ne ed to be brought under control.

There are some FDA reforms that would help . I hope there are some
bipartisan thought about that because we are a little slow in terms of
helping important drugs emerge , and I'd be ha ppy to see that happen
as well.

Margaret Flinter: Jim.

J im Capretta: Well, my perspective basically is that inevitably in the drug space, and
the drug pricing space, you're balancing two conflicting objectives
which is you want research and innovation to bring new products into
the market that are better therapeutics than what is currently
available. At the same time you want to make all of the therapeutics
priced at a level that they're affordable and accessible for the whole
co untry, everybody equally, and those are difficult to reconcile . I think
the big missing piece here is really a much more vigorous and publicly
run and publicly initiated effort to figure out which drugs coming
online are actually valuable, and which ones a ren't.

I f we have things coming online with very high and elevated price,
that don't deliver therapeutic benefits, they shouldn't be priced high .
The big part is deciding what is the clinical value of a new product ? I
think we could do a much better job of identifying that . F rankly,
Germany does a better job than we do in that regard, and trying to
price according to value rather than just letting the drug companies

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

decide what the value is. T here should be a much more public effort.
My view is around ident ifying those things that are coming online that
really are beneficial and those things that are not . T he things that are
not , they should be priced at generic level.

Dr. Donald Berwick: I'm also wondering about another need that I'd love to hear Jim's
thou ght about at some point . T here actually is not an awful lot of
correlation between what might call the social need for a drug , that if
you could pick the top 10 drugs to create what would they be, and the
research investments and being induced by the curre nt market forces
or whatever forces are there . I'm wondering if there's a possible
policy initiative, which would change that which would sweeten
interest in producing the drugs which we need most for the health of
the public and decrease interest in the o thers . I've not explored that
to the extent , I want to , but I think that would be a very interesting
avenue of policy research.

Mark Masselli: Well, in that spirit of the season we want to end on a positive note.
Where do you see the opportunity for progre ssives and conservatives
that come together in 2023 on health c are issues? Not crickets.

Dr. Donald Berwick: No, I think we've already hit on some -- t here's no -- there should be
bipartisan interest in a strong public health infrastructure. It doesn't
mat ter how you vote you're going to pay the price if we don't have
one , and that's got to be government. You can't -- there's no private
sector public health defense . We did talk about drugs, I think we're all
worried about it, we have different solutions. My solutions are
certainly different from Jim’s, but we're concerned enough we ought
to find our way to some answers. The mental health and substance
misuse arena is desperate killing tens of thousands of Americans and
we have not yet formulated strong publi c policy on that and I think we
probably could find a bipartisan route there . O n markets and the ACA,
we will continue to disagree . I don't have much faith that market
solutions are going to be the ones that work , but then again I haven't
studied Jim's boo k yet. M aybe I'll change my mind.

J im Capretta: Well, I think on this question of mental health and substance abuse,
it's really bordering on really a crisis in United States at this point . I t
really needs to be attended to by both parties because it's aff ecting so
many aspects of our society . I think there is great interest in both
parties and being just much more aggressive and putting together a
national strategy to really get the problems that are out there a little
bit better under control and directed and treated . I'm hopeful that
that it could be one big area where there could be a lot of bipartisan
agreement and movement.

T hen on these other things some of them are by necessity . They’re
going to have to do Medicare probably on a bipartisan basis beca use
neither party probably has enough political capital to do it on its own.

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

Some Medicare solvency will probably be bipartisan. I wouldn't
anticipate that right away , but over time that'll probably happen.

Margaret Flinter: When all else fails, bipartisan ship possibly may win the day. Thank
you both, D o n and Jim for joining us today for sharing your insights for
your work. Thank you to our audience for joining us. You can learn
more about Conversations on Health Care, and sign up to keep
updated with heari ng from us at www.chcradio.com . Thank you so
much. Best wishes to both of you.

Dr. Donald Berwick: Thanks, Happy Holidays to you.

J im Capretta: Yeah, Happy Holidays. Thank you.

Mark Masselli: Take care.

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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
Editor of FactCheck.org, a nonpartisan, nonpr ofit 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: A randomized controlled trial and real world studies have found that
for certain patients , PAXLOVID, Pfize r's COVID - 19 antiviral pill reduces
the risk of severe COVID - 19 and death. The Food and Drug
Administration authorize the drug for outpatients at high risk for
progression to severe COVID - 19 based on a randomized controlled
trial that found the medication to be about 88% effective in
preventing hospitalization and death in unvaccinated high risk adults
with COVID - 19.

High risk people with mild to moderate COVID - 19 are eligible to take a
five day course of PAXLOVID as long as they start the pills within five
days o f symptom onset. PAXLOVID consists of two sets of tablets that
are taken together. One drug prevents replication of the Coronavirus
and the other boost levels of the first drug in the blood. Several
observational studies have subsequently found that PAXLOVID is
effective in the real world, particularly for older high risk people and
those who are unvaccinated. An online post being shared on social
media ; however, claims that the drug is a fraud and shouldn't be
used. The r eal w orld Studies however ha ve sho wn the medication is
effective.

One study published in October in The Lancet found that in Hong
Kong PAXLOVID was associated with a 66% lower risk of death and
24% lower risk of hospitalization among a mostly older 60 years and
above, or unvaccinate d population. An unpublished study of patients

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

50 years and older in Massachusetts in New Hampshire similarly
found the risk of hospitalization after COVID - 19 diagnosis during an
Omicron wave was 45% lower among those prescribed PAXLOVID
with greater reduc tions among those who are unvaccinated or obese.
There have been cases of rebound with and without taking PAXLOVID.
That's my f act c heck for this week. I'm Lori Robertson, Managing
Editor of Fact C heck .org.

Margaret Flinter: FactCheck.org is committed to fa ctual 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.radi o.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. When Indu
N avar’s husband was diagnosed with ALS, Amyotrophic Lateral
Sclerosis , their experience was worsened by the medical
establishment lack of s wift testing protocols for diagnosis . Of the
30,000 Americans who suffer from this debilitating disease di agnosis
is often the result of the process of elimination and it can take an
average of 18 months to confirm .

Indu Na var: It took us two and a half years to get diagnosed . I n that time, I saw
him deteriorate every day .

Margaret Flinter: As ALS slowly overt ook her husband , N a var founded a nonprofit to
help others that are dealing with this paralyzing disease. She launched
Everything ALS with a goal of developing artificial intelligence ’s
interventions that might help clinicians diagnose the illness sooner.
N oting the growing body of research looking at the voice as a new
biomarker for neurological disease, a decline in speaking patterns
often precedes more serious neurological symptoms. W orking with
engineers, she launched the Everything ALS Speech Research S tudy,
an online volunteer voice bank in the hopes of building an algorithm
that could detect subtle changes in voice expression .

Indu N avar : What people can do is they can actually donate their speech and also
get involved in our research by going to www.everythingals.org . W hat

we do is what that all that data, we actually apply machine learning and artificial intelligence to find patterns. For example, right now
we're finding patterns in speaking rate and also c hanges in the lip . W e
will start finding many such biomarkers that will be implicated in progression tracking of the disease and also for early diagnosis of the disease.

Progressive - Conservative Pundits on hope f or Bipartisan consensus on health policy

Margaret Flinter: Vocal volunteers merely download a dedicated app speak into it for a
few minutes once a week , and scientists continue to fine tune the
algorithm detecting which patients are experiencing further decline.
Their data is also Open Source so their findings can be shared broadly
with researchers and pharmaceutical companies tha t are developing
better diagnostics and treatments for this devastating disease.

Indu Nevarez: It’s really bringing in open innovation. A ll the data that we collect is
anonymized and then made available in an open innovation platform
for thousands of resea rchers who can actually take a look at the data
along with our own data science team. T hat's how we facilitate many
clinicians, researchers and pharma companies who work with us to
benefit from every second of the effort that you actually put in . T o
accele rate research we need to get involved in the research. T hat's
why we've created a platform with citizen driven research and open
innovation is a future of solving ALS and other neurodegenerative
disease. T his is really a force multiplier.

Margaret Flinter: A nonprofit hopes to expand their research and data offerings to
those working on other neurological disorders like Alzheimer's and
Parkinson's . The Everything A LS Speech Research Study , an open data
algorithm building platform using vocal volunteers in c ollaboration
with dedicated scientists, all motivated by seeking a swifter diagnosis,
and hopefully one day a treatment or a cure for ALS. Now, that'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 prov iding quality care to the underser ved where healthcare is
a right not a privilege , www.chc1.com and www.chcradio.com .

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