Can Health Care Policy Take a Page from Recent Bipartisan Efforts?

240415_Conversations_Parekh_01.mp3

Speaker 1 [00:00:04] Americans say they desperately want a bipartisan Congress and a
centrist president, according to a recent poll. But how do we get to that point, especially on
the hot button issues of our health care?

Speaker 2 [00:00:16] There are some issues, and an abortion is one where very, very
difficult terrain for us to navigate. And there has to be sort of a desire on both sides. Also,
is that the way we identify the issues that we focus on? Bargoed one is it has to be a
critical health policy. Issue number two. It's got to be an issue where both sides need to be
educated on what to be educated on. And then third, there has to be some sort of policy
window from a political science perspective.

Speaker 3 [00:00:45] Our guest and his colleagues are trying to find a path. Doctor Anand
Parekh is chief medical advisor at the Bipartisan Policy Center. He previously served in the
US Department of Health and Human Services as the deputy assistant secretary for
health.

Speaker 2 [00:01:00] We were instrumental, for example, in in ensuring that Medicare
Advantage plans re supplemental benefits are able to provide non-medical benefits like
housing, nutrition, transportation. We were critical in the passage of the 21st Century
Cures Act that really accelerated medical research.

Speaker 3 [00:01:21] This is conversations on health care.

Speaker 1 [00:01:31] Well, doctor, welcome to Conversations on Health Care.

Speaker 2 [00:01:35] Thank you so much, Mark. Great to be with you and Margaret.

Speaker 1 [00:01:38] Yeah that's great. You know, we certainly know the Bipartisan Policy
Center have had many, folks on over the years. But I'm wondering if our audience knows,
as well. And I want to really pick up on something you say on your website. We never ask
anyone to surrender their partizan beliefs, but the best solutions emerge from the give and
take between political opponents. What if you could just share more with our listeners
about how you see that play out?

Speaker 2 [00:02:09] Sure and happy to do so. You know, there's a difference between
being nonpartizan. There are a lot of nonpartizan organizations and being bipartisan. And
it's a it's a pragmatic difference. So we believe that that individuals shouldn't have to check
their ideology at the door. So we certainly want partizans we just want them to come to the
table, be able to have a discussion and be able to work together to solve our nation's
challenges. We are the only entity, I will say now in Washington, D.C., still with the word
bipartisan in our title. And that is, I guess, a sign of our times. But we think that, we think
this work is really important. We think the American public, believes bipartisanship is
important. And so we've been around that we're pretty young for about 15 years now to
provide a space for both Democrats and Republicans. And we take the best ideas from
both sides, to promote health security and opportunity.

Speaker 3 [00:03:04] Well, that's, saying something when you, note that there's only one
organization with the word bipartisan and it's title and Doctor Park, I think you, reasonably
take credit for helping a number of bills get across the finish line. The Policy Center takes
credit for getting a number of bills across the finish line. Share with our listeners. Where

would we find. Or where can you direct us to where the impact has been felt in health care
legislation of the work that your organization does?

Speaker 2 [00:03:33] Sure, sure. So we are a 500 1C3 organization, nonprofit
organization. We have a sister five and one C for arm BPC action. And they are able to to
really provide leadership in the advocacy. So we have a mantra here at BPC when we
press print on our reports and recommendations, we're only 50% of the way there. And so
it's really impact, what we're after. But if you look at, over the last ten years, BPC has
played an important role. I would say in the health care discussion and debate here. We
were instrumental, for example, in in ensuring that Medicare Advantage plans through
supplemental benefits are able to provide non-medical benefits like housing, nutrition and
transportation. We were critical in the passage of the 21st Century Cures Act that really
accelerated medical research. We played a critical role in reauthorization of the Patient
Centered Outcomes Research Institute to really propel comparative effectiveness
research. We've been tracking opioid spending at the federal level for the last several
years. Given the overdose epidemic in both Congress and the administration have done a
better job tracking those dollars to assess effectiveness. So those are just sort of a number
of areas where, we've tried to provide, we think some critical leadership. And then of
course, the pandemic, which we've just come out of, we were really on the forefront there,
trying to advocate for a new white House office on pandemic preparedness policy, which
which now Congress, has, has helped create, to really ensure that that coordination, that
whole of government response. That we need, when it comes to pandemics, are there so
in, in a number of different areas, we've tried to help, move the ball forward. I would say.

Speaker 1 [00:05:24] You know, speaking and moving the ball forward and the need for
critical leadership. You may know that many of those, in our audience are in the primary
care arena. Some say primary care is dead. Maybe it's on life support. Only 5% of the
dollars spent are on primary care. There are fewer providers coming into the primary care
area. I wonder if you could just shape up for us where you think there may be
bipartisanship in terms of promoting primary care? Is this a, an important issue to the
bipartisan center and to your, supporters?

Speaker 2 [00:06:03] Well, I'll start with myself. First, as a primary care physician. And
although I'm not seeing patients, at the current time, this is absolutely, I think, the most
important health care, related issue, in America, primary care, a strong primary care
system needs to be the foundation of our health care system. So many of what is ailing us
is because we haven't, as you said, put in the resources, the investment into our primary
care infrastructure. And in terms of the Bipartisan Policy Center, I can say, you know,
every report, it doesn't matter what the topic. And we always try to ensure that we are
recommending, the support of the primary care system, whether it's, behavioral health and
trying to tackle mental health and, and substance use, whether it's strengthening the
Medicaid program, in all of these areas. Primary care is so important. I'll just give you sort
of two, examples that we are tracking, over the last several months. And this came to
fruition on March 12th. The Bipartisan Policy Center helped, relaunch that that
congressional House primary care caucus. So this is a caucus that was, dormant for a
number of years. And, we ended up, identifying four members, two Democrats, two
Republicans, to really co-chair this caucus. We had a relaunch event in March 12th. In
fact, the board chair of the National Association of Community Health Centers, as well as
the CEO and president of the Primary Care Collaborative, were speakers. We heard from
all four of the members who had a number of offices there, represented the primary care
community as well. So at least there's now a flag back in the house about the important,
really educating members on primary care. And I see this group and they have about four

dozen members really providing that education, a lot of new staff, a lot of new members.
Before we even get into policy, it's really, really important that people understand the state
of primary care in the United States and why we need to strengthen it. So I'm really
pleased about that. And we're also now working on the Senate side, where there's some
momentum with respect to payment reform. As they think through, how do we better
support primary care physicians, primary care providers more broadly, in this country? And
those are conversations happening. We're involved in those conversation.

Speaker 3 [00:08:31] Well, that is really, good to hear. I had not heard about the relaunch
of the congressional, caucus. And, I think the timing with the primary care scorecard that
the Milbank Fund released recently saying things are getting worse, not better, despite the
Nasim report. Is, certainly a compelling, stimulus for that kind of work. But I wonder, and
thank you for that focus on primary care. To get within some of the other issues in health
care. You wrote in Jama, about what you called the four defining health issues of the
presidential election. So the biggest one is reproductive rights, which, transcends primary
care, really, all domains of health and health care in the country. But at, Kaiser Family
Foundation. Which I think is more commonly now called KFF. So KFF health tracking poll
found that nearly half of Democratic voters say they're going to vote only for a candidate
who shares their view on abortion, more than twice the share of Republican voters who
say the same on an issue such as abortion. How do you and your colleagues navigate a
bipartisan approach? I have to imagine this is one of the more challenging issues that you
face.

Speaker 2 [00:09:41] Yeah. You know, there are some issues. And, and, and abortion is
one where very, very difficult terrain for us to navigate. And there has to be sort of a desire
on both sides also, so that the way we identify issues that we focus on, Margaret, one is it
has to be a critical health policy, issue number two, it's got to be an issue where both sides
need to be educated on what to be educated on. And then third, there has to be some sort
of policy window from a political science perspective. Either Congress is is yeah, it is
looking at this issue. The administration is. So, yes, abortion and there are some, some
issues like that very, very difficult to, for us to navigate. And, and it has not been one of
the, one of the core, issues of focus for us, unfortunately.

Speaker 1 [00:10:31] You know, I want to stay on the legal challenges that are face and
also on the primary care area. I did not realize there were about 2000 cases challenging
the ACA, but there's one in Texas, the Braidwood management case, which is really going
at the heart of providing preventative services by private insurance groups, at no cost. And
this is under challenge. It again, gets back to the issue of, the assault that's going on,
essentially preventative primary care services, making them available. What are your
thoughts about that? Is this a serious challenge? This judge seems to be a plaintiffs judge.
But what's your what's your view on this? And what should our listeners be keeping an eye
on?

Speaker 2 [00:11:17] Yeah. Unfortunately, this is a serious challenge. It's such an
important issue. Hundreds of millions of Americans right now are getting evidence based
clinical preventive services through their commercial insurer, without any cost sharing.
That's the way it should be. These are high value, evidence based services. And
essentially, this lawsuit would, would declare this provision of the Affordable Care Act
unconstitutional, under the Appointments Clause of the US Constitution. Essentially the
body, the US Preventive Services Task Force, the lawsuit contends, hasn't been
presidentially appointed, confirmed by the Senate. So they don't have the standing. They
also cite the Religious Freedom Restoration Act, saying that, for example, HIV preventive

services, ought not to be covered. And so this is a serious challenge. The appeals court is
looking at this. This will probably go to the Supreme Court. Eventually I hope there some
sort of resolution perhaps maybe that, those businesses, just narrowly to them. But it
would be a big blow. If, if in fact, this was ruled null and void, because you could be then in
a scenario where we were created, where many people wouldn't be able to access these
preventive services. Now, fortunately, we're seeing insurers and employers right now say
the right things, that these are important irrespective of what happens in the court of law,
they're going to keep these and and not, not our cost sharing, but we don't know whether
that's going to be true for all insurers. And so I think it is something for, for, for listeners
and viewers to track. I think we all realize how important it is to get immunizations, to get
cancer screenings, to get mental health and substance use counseling services. And, and
cost is not the only barrier, but it is an important barrier. The ACA tries to take it off the
table. Hopefully it'll remain that way.

Speaker 3 [00:13:16] Well, I would say from the front lines, you're right, it's not the only
one, but it's about 90% of the the reasons that people used to give in the, what I like to
think of as the olden days and hope they'll, stay that way. But I want to talk about another,
area that's contentious, maybe in the public eye that you've written about. And that is, a
link that, Republicans sometimes make between the immigration issue and public health
and not a positive of link. You point out that unauthorized immigration has corresponded
with an increase in customs making fentanyl seizures. Democrats see these two issues as
unrelated. But I think there's probably larger issues there about how, our legislators
perceived immigration and public health. How do you think about this dilemma when you're
trying to get people to consensus?

Speaker 2 [00:14:09] Well, this is traditionally been, a bipartisan issue, at least for the last
few years. And, you know, our overdose epidemic in this country continues to claim over
100,000 lives, every year. You know, we need both the supply and demand, strategy here,
supply in terms of curbing the flow of illicit fentanyl coming into the United States. But that
can't be the only strategy. We also need to pair that with continued efforts in prevention
and treatment. Looking at the health care side, naloxone is critical. Medication assisted
treatment or medications, for opioid use disorder? Absolutely critical as well. So, you
know, all of these things are going to be important. There's no magic bullet here. The
illegal immigration issue is one that could be linked. Even though it's a pretty tenuous link,
because most of the illicit fentanyl that is coming, from Mexico is coming actually through
legal border checkpoints. It's not coming through illegal migrants, sort of illegally coming
into the United States. That being said that these two issues are often linked. I think the
more important issue, is that, you know, whichever administration, you know, is there in
2025 have both an important demand prevention treatment as well, a supply side strategy
to to reduce, overdose deaths in this country.

Speaker 1 [00:15:36] You know, you talked just now about a magic bullet. And I know
you've written about the looming insolvency of the Medicare, hospital trust fund. Doesn't
seem like we have many folks who want to take this issue on. I think there's bipartisan,
assessment that the trust fund is in trouble. But there doesn't seem to be any collective
action. What should we think about this particular problem? How how large it looms, for
the country. And is there any seam of opportunity during an election year in which there
should be robust debate, that there will be debate on this issue?

Speaker 2 [00:16:16] You know, not surprisingly, in an election year, this is an issue. I
would say that that's not going to get, the attention that it deserves. I think both candidates
have already been on the record, you know, and and this can be politicized very quickly.

And I think they realize that it. And so other than saying that, that no, no benefits will be cut
with respect to Medicare and Social Security, neither candidate really wants but wants to
get into it. But I do think that come 2025, regardless of the makeup of Congress and the
administration, you know, our report really indicated that that these are issues that we
ought to be talking about. Insolvency is looming, you know, 20, 31, 20, 33, you know,
around that time frame, which is not too far, from now and so understanding. Exactly. You
know, the program, where, where it's going, understanding where we can reduce, waste in
the program, whether it's, it's essentially, resources that are not going to improve
outcomes. Where is it that that, we can do a better job in terms of, of working, whether it's
with Medicare Advantage, whether it's it's working with the hospital sector, whether it's
working with the pharmaceutical sector. How do you simplify from the beneficiary
perspective, them making the best choices they can? It's often difficult trying to compare
traditional, Medicare and Medicare Advantage. How do we make sure that we align the
incentives at best in primary care? So there's so many issues when it comes to Medicare
solvency. And and I think at some point we're going to really need a bipartisan discussion.
That's really what I report. A couple of months ago, was about we knew that it probably
wouldn't get a lot of attention this year, but hopefully it'll get some more attention next year.

Speaker 3 [00:18:04] Well, Doctor Parikh, we will all have the indelible cry hands off my
Medicare from the, the run up, yours to the Affordable Care being passed. And I don't think
the Affordable Care Act, has generally stimulated that kind of hands off my Affordable
Care Act, insurance, in the general population. But you've said that you don't think we
need to worry too much about Republicans repealing the Affordable Care Act, despite
what former President Trump has said on the campaign trail. But from, from your senators,
positioned, are you concerned that there will be an attempt to, do death by a thousand
cuts of the Affordable Care Act with subsidies or, as we talked about, mandates for, 100%
upfront payment of preventable screenings. What what do you think is likely to happen
with the Affordable Care Act if there's a Republican administration?

Speaker 2 [00:18:57] I think the big debate will be in Congress actually next year, because
in December 2025, the advanced premium tax credits, will expire and Congress will have
to decide, whether or not to, to extend those, because of those tax credits this year. I think
the administration has said there have been over 21 million Americans who have signed
up to to the Obamacare or the ACA, exchanges, sort of a record number, right there.
They've been, you know, much more generous. And and so I actually do think that that
specific issue, I didn't write about this in my jam article, but I do think that that President
Biden Democrats will tout that the the success of the Affordable Care Act exchanges.
Now, some Republicans may counter and say, well, that may be so. But for so many
people, they are still facing high deductibles and narrow networks in those plans. So I think
you'll see a debate there. But then certainly next year for Congress, this extension would
require, resources. And, and taking into account, the federal deficit and debt and, and a
focus on fiscal issues, I think Congress is going to have to figure out, you know, how to
extend this, and there'll be an ideological debate. There'll be a fiscal debate. But I do think,
Margaret, that that that I think it's really going to be the extension of the advanced
premium tax credit, visa, the ACA. There are other issues. I think if a Republican
administration came in, they'll look at how do you create more flexibilities in the market,
short term plans and other things. During the first Trump administration that they focused
on, I could see them focusing on that once again as well.

Speaker 3 [00:20:33] So you would say that, these are things that might decrease people
signing up on the exchange for it, but wouldn't really, fundamentally alter the Affordable
Care Act's coverage and structure.

Speaker 2 [00:20:44] I think that structure is here to say. I think you've even heard from
from some, you know, Republicans, that, that that an Affordable Care Act, much of it is so
entrenched, particularly on the insurance side, into our health care system, that, you know,
and there no replacement as well. Back to your point. And so I do think that that is, is here
to stay. I think it's a matter of tweaking it based on ideology as well as, more importantly,
how do you strengthen it so it can be more impactful and effective, to support, the
American public.

Speaker 1 [00:21:19] Speaking more impactful and effective. We've seen the, the new rise
of these, obesity drugs. I know you wrote a book called Prevention First, in which The
advocate, you advocated for greater measures to reduce preventable diseases. The book
came out before the obesity drug hit the market. I'm wondering, what do you think about
the drug's the role the federal government should do in paying for these drugs as a way to
reduce the incredible skyrocketing of diabetes, rates tied to obesity. And other thoughts
that you might have in terms of this, the release of these GLP drugs.

Speaker 2 [00:22:03] I do think that obesity is, if not the most important. One of the most
important challenges. Health challenges that this country, is facing today and will face this
century. With 4 in 10 adults, with obesity, which is which is a medical condition, 2 in 10
children, with obesity as well. Again, also with obesity, there is no sort of magic or silver
bullet. It requires a focus on on everything from food policy, health care policy, education. I
do think that these medications are critically important, a scientific breakthrough, based on
the data, and the evidence that we've seen, of course, we're going to have to see sort of
long term studies, and see whether the effectiveness, continues and how long you might
have to be on these medications. Is there an off ramp? But certainly, these medications,
from an effectiveness perspective and a safety perspective are a far cry, much better than
they were, that the medications from two decades ago. I think the biggest policy issue right
now is if you go back 20 years to the Medicare Modernization Act, Congress put, in statute
there, that the Medicare program, cannot provide coverage for any medications related to
weight loss. Back then, 20 years ago, we knew much less about obesity. The medications
were not safe. So these were considered sort of cosmetic related conditions. Now, we
know that obesity is a medical condition. And so I think there is tremendous bipartisan
support for Congress to revisit that issue, to allow, the Medicare program, the ability, to at
least assess the evidence and decide on coverage of these medications. Of course, since
Congress gets involved, that means the Congressional Budget Office would need to get
involved as well. And, and they, they would need to score this legislation that it's, there
would be a price tag with it. And I think some of the reasons why we haven't seen
Congress move on that, is, is trying to figure out how to pay for that and what the offsets
would be. But I do think that that that Congress should provide Medicare the ability to
assess the evidence, as well as cover these medications. They are, they come with a high
price tag. And so hopefully with both competition as well as negotiation over the next
couple of years, those prices can come down.

Speaker 1 [00:24:26] So I think that's important.

Speaker 2 [00:24:27] Part of the commentary.

Speaker 1 [00:24:28] Right. Speaking of the negotiations, do you think you'll see these
drugs move up to the ten that the government gets to choose, in terms of negotiating
rates?

Speaker 2 [00:24:38] Not immediately. It's it's going to take some time. You know, and I
have to go back. I think, that that particular, molecule was, was first approved by the FDA
in 2016 or 2017. So there is sort of a 8 or 10 year window of exclusivity. But but over the
next few years, you could imagine, that. Yes, that, that Medicare could consider, GLP one
agonist. But but first, Medicare would need to be able to cover that drug in the first place.

Speaker 3 [00:25:12] But, Doctor Parikh, I want to pivot to children, for a few moments
before we wrap up, you were involved in a report that, said that the United States should
ensure that all children, regardless of household income, have access to nutritious food to
allow them to learn and grow, including during the summer when schools are obviously
traditionally out of session. But I understand we have, Republican governors in 15 states
who are rejecting summer food money for kids, saying they don't believe in welfare, and
even saying, you know, we have a youth obesity problem. And that should be a
counteraction to that, I guess. Is this one of those points where, your organization can say,
no, the opponents are just wrong, or how do you how do you advance this one on a
bipartisan basis?

Speaker 2 [00:25:58] Yeah, I think on this one, what we're trying to to show that that the
evidence over the last ten years, demonstrates that that these programs, child nutrition
programs, in fact, do improve health and, and reduce obesity. And so this is really, you
know, a way of starting young, focusing on the evidence, focusing on schools, meeting
children and families where they are. And obviously this was really important during the
pandemic, but, but, but, but even, you know, now it's just really important that there, is an
opportunity for children and families to get, healthy meals. And I think, I think there are a
number of many Republican governors who who have accepted the dollar. So it's not
purely a Democrat or Republican thing, but but there are holdouts, as you as you stated, I
think this is a very sort of cost effective way to really invest in our young generation. And
again, nutrition, one of the most important issues, tackling childhood obesity. And we know
that from a health perspective. This ties in that to to educational readiness as well. So it's
just such an important issue.

Speaker 1 [00:27:08] You know, I want to one last question. Bipartisanship is is key. But
you you walk the walk, because you served in both the George W Bush and Barack
Obama administrations. I'm wondering, how did you manage to serve both administrations
and how is it informed your work? And do you see this as a exemplar of future
opportunities for people to serve in both Republican or Democratic administrations? Or do
you think we're too divided as a country for that to happen today?

Speaker 2 [00:27:42] Yeah, thanks for that question. I was actually a career civil servant
throughout, and that's the reason I was able to, you know, to be there for, for ten years.
But, you know, I just believe that that we're two divided of a country and sometimes
artificially, whatever we can do, to work with, with, with both sides, you know, no one side
has a monopoly on, on good issues. And so I think that was always part of my, my DNA
that, that, that, that most people have good intentions on both sides. We just need, people
to work together, and, and help the country come together. And I think that's why I spent
ten years at HHS and why I was drawn to an organization like the Bipartisan Policy Center
to try to take the best idea from, best ideas from everyone. So I hope to continue, to do
that.

Speaker 3 [00:28:34] Doctor Parekh, thank you so much for your time, for your work, and
for sharing your insights. And thanks to our audience for being here. Be sure to subscribe
to our videos on YouTube, find us on Facebook and X with our account name, CHC radio.

And as always, you can go online to CHC radio.com. Sign up for our updates. And also
please share your thoughts and your comments about this program with us. Doctor Parikh,
thank you again so much for being with us today.

Speaker 2 [00:29:01] Thank you for having me on. Thank you.

Speaker 3 [00:29:06] This copyrighted program is produced by Conversations on
Healthcare and cannot be reproduced or retransmitted in whole or in part, without the
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