The New Congress: What’s Next on Crucial Health and Education Issues?

to the forum live-streamed worldwide from the
Leadership Studio at the Harvard TH Chan
School of Public Health. I’m Dean Michelle Williams. The forum is a collaboration
between the Harvard Chan School and independent news media. Each program features
a panel of experts addressing some of today’s most
pressing public health issues. The forum is one way
the school advances the frontiers of
public health and makes scientific insights accessible
to policymakers and the public. I hope you find this program
engaging and informative. Thank you for joining us. [MUSIC PLAYING] MARTY KADY: Welcome
to the forum. I’m Marty Kady, and I’m
the editor of Politico Pro, and I’ll be serving
as today’s moderator. Our panelists, I’m going to
introduce them right now. To my immediate right
are Bob Blendon, professor of Health Policy
and Political Analysis at the Harvard TH Chan
School of Public Health and the Harvard Kennedy School,
Richard Frank, professor of Health Economics in the
Department of Health Care Policy at Harvard Medical
School, Martin West, Professor of Education
at the Harvard Graduate School of Education. Joining us remotely
is Sheila Burke, Adjunct Lecturer in Public
Policy at the Harvard Kennedy School. This event is presented
jointly with Politico LLC, and we are streaming
live on the website of the forum on
Politico, as well as on Facebook and YouTube. This program will also
include a brief Q&A, so you can email questions
to [email protected], and we’ll try to answer
some of those questions both from the live audience
and whatever you email in. There’s also a live chat
happening on the forum site right now. So as we open this forum
to discuss health care and education priorities
in the new Congress, we’re really doing
this at a fraught moment in American history. To put it bluntly,
our government appears to be in a crisis. We are on day 33 of the longest
government shutdown in history. It’s a shutdown long enough to
have cost billions of dollars and economic damage
and incalculable damage to our national
political dialogue. I live in the Washington
area, and many of my neighbors are furloughed, deciding
what bills to pay and what bills not to pay. I flew up here
yesterday to Boston. The TSA agents who screened
my bags are going on a month without pay. Everything from school
lunches to food inspections to national parks are threatened
by an intractable debate about a wall at the
US-Mexico border. So it’s with that
context, perhaps that cloud, that we will discuss
what our panel of experts thinks could happen on health
care and education policy. This could happen either in
Congress, through the courts, through the executive branch. Maybe, we’ll even
talk about what’s happening at the state
level, if and when Washington returns to
some level of normalcy. But first, we wanted to
examine, what do Americans say about the new
Congress’ top priorities? Politico and the
Harvard TH Chan School conducted polls of
Americans to find out. These polls will
serve as a background for today’s discussion,
but we’re also going to talk more broadly
about what actions could happen in this divided Congress. We’re going to set up
the conversation here with a brief video clip
about the top health issue that they came up for
Republicans and Democrats, drug prices. And this is a clip
from the US Department of Health and Services. Let’s see the clip. COARD SIMPLER: I was diagnosed
with chronic myelogenous leukemia. JANET FLYNN: With breast cancer. RICHARD KNIGHT: My kidneys
continue to deteriorate. PAMELA HOLT: I have
in this last year had to pay over $10,000 in
medical costs for my drug to keep me alive. RICHARD KNIGHT: My medications
are quite expensive. JANET FLYNN: The out-of-pocket
costs were staggering. SUSAN LEE: Over $5,000. COARD SIMPLER: So I just
ended up charging a lot of it on a credit card. RICHARD KNIGHT: I
probably won’t retire. SUSAN LEE: I am not going
to drain my savings account. I’m not going to sell my home. ALEX AZAR: For too long,
there’s been a lot of talk on drug prices and no action. It’s time for drug prices
to go down, not up. DONALD TRUMP: My
administration is launching the most
sweeping action in history to lower the price
of prescription drugs for the American people. SPEAKER 1: American
patients first. HHS.GOV/DrugPricing. Produced by the US Department
of Health and Human Services at taxpayer expense. MARTY KADY: Bob,
will you give us an overview of
these poll findings and what they tell us about
where the American public is on these policies? ROBERT BLENDON: Yeah. Marty, let me try to be helpful. So when this shutdown
is over, we’re going to have a country
in Congress that are unbelievably angry. They’re also going
to be very polarized. What we’re trying to
do in very few minutes is to use a poll we
did to find if there could be any common
agreement on issues that people would work on. And very briefly, the
research and the news coverage is not the same. It turns out when you
study a Democratic House, they actually follow what
Democrats think much more than the public. When you follow a
Republican Senate, they’re likely to follow
what Republicans say. So what I’m briefly
going to show is what people say are the top
priorities for this Congress, hoping something would get done. And then we’re going
to briefly look at do they agree on anything? And then my colleagues
are going to talk about what might happen in
areas where there’s even some agreement for this. So one thing about
our poll with Politico is most polls you see about
priorities give people five choices. We gave them 21, where anything
that appeared in the major news was on a list. So if we can have the first
PowerPoint just briefly. So these were out
of 21, the top six– lowering prescription drugs,
reducing the deficit, which I think the tax bill
got people nervous, spending on infrastructure–
and you actually have to describe the
people you’re talking about bridges and highways. They have no idea what that
“infrastructure” word means. Reducing the number
of hate crimes. Briefly, we’ve gone from worried
about international terrorism to actually hate crimes
in the United States. Addressing opioids, and
spending on kindergarten to 12 public education. The next PowerPoint briefly,
all you have to look at is the yellow. Given the top six, do the
Republicans and Democrats agree on anything? And it’s only on
prescription drugs, in terms of the hierarchy. But I want to take a quick look. Just take a look at Republicans’
one, two, and three, because you can explain
why there’s a shutdown. One is drugs. Two is unauthorized immigration. Three is the budget deficit. And on the Democratic side,
it’s drugs, climate change, which doesn’t show up on
the Republican list at all, and renewing DACA. So now you know exactly
what the negotiations are going on in Washington. And then we looked at just
health and education much more narrowly for that. So we go to the next slide,
and we looked at health first. So to no surprise
again, drug prices sits at the top of the list. But what showed up in
the election is here, an idea that was only an
insurance term protecting people with serious
illnesses is now so much in the core
of American life. And to the surprise
of everybody, it wasn’t an election
issue, but both, you’ll see it in a minute,
Republican and Democrats do not want Medicare touched. Lowering overall health care
costs and biomedical research. So is there any agreement
between the parties? Next slide. And so it turns out
in the health areas, there is more agreement. What don’t they agree on? Republicans are high on reducing
health care costs and veterans, and they don’t show up
on the Democratic lists. And Democrats are high
on fixing the ACA, but not on the Republican list. And biomedical research is
still higher with Democrats. So you see some
possibilities here. Two of them are just sustaining
what the existing programs are, but prescription drugs
shows at the top. The last, we take a look
at two in education. And there’s a smaller list
because education has not had the same national focus. And so you can’t give
them 24 items when people aren’t proposing for this. So let’s go to the next slide. And so the top education
are student debt. For those of you who
don’t follow this, 10 years ago, there
was no such thing as a polling issue
called student debt. It just would never show up. Now, it’s the top. The spending issue, spending
for local community colleges, investing in school
buildings, and the last is expanding charter
and private schools. But watch when you look
at the partisan split in this last slide. So what you see is in the
narrow area of education, Democrats and Republicans
agree on everything but two. Republicans are
interested in expanding charter and private schools. Democrats are not. Democrats are interested in
regulating for-profit colleges and technical institutes. Republicans are not. So this is the agenda. And the question for
my colleagues are, given the animosity between
the parties and where we are, is it possible that
these could happen? And if is, what would happen
that would be helpful? But that’s the background. You have some
background of where people believe that Congress
should go in the next year. MARTY KADY: Thanks, Bob. That’s a great foundation
for this discussion today. There’s a fascinating
consensus between the parties on certain issues. But then when you
get down to tactics, when you go back
inside Congress, what we’re likely
to see is gridlock. What the American people are
telling us through this poll is one thing, and you do start
to see the ideological breaks. But moving back to Washington,
the likeliest scenario for this Congress broadly is
that this new invigorated House Democratic majority
run by Nancy Pelosi and a young, diverse
group of Democrats will pass a lot of bills that
reflect the progressive agenda, and a lot of people with
an eye toward what the 2020 agenda should be,
and almost everything will die in the
Republican Senate. So if we restrict
our conversation just to what will Congress do, it’s
going to be a very short forum. [LAUGHTER] So we’re also going to
include the potential for executive action,
what can happen in the courts on these
policies, and what’s happening in the states. At the state level,
you’re possibly going to see a lot of action
on health care, and education, on Medicaid. States have really become
laboratories of innovation on policy, chiming in where the
federal government has failed. So let’s go to drug pricing. Richard, you’ve
studied the forces that drive prescription drug
pricing in the United States. This is the number
one thing in the poll. Republicans, Democrats,
Independents all believe they pay too
much for drug prices. That clip was really compelling,
and you hear those stories over and over. We had that clip of
President Trump and Secretary Azar saying, we’re doing
something about drug prices. But let’s get realistic. Give us a roadmap on
legislation, regulation, and executive action. What do you see ahead? RICHARD FRANK: Yeah. Well, I think prescription
drug policy is a bright spot. And at the risk of
being Pollyanna, I think that there’s
progress to be made here in a bipartisan way. I think there have been
actions taken by the FDA. There are proposals
right now in the Congress and being made by the Trump
administration that offer, I think, reasons for optimism. For example, the FDA has
taken a number of actions to promote more
competition by easing the way for generic
drugs to come to market. So this includes putting
more money into getting drugs onto the market faster. It involves curbing some
of the practices that have been used to keep
generic drugs off the market and limiting the ability
to exploit consumer protections and safety. And so I think that they’ve
taken some good first steps. And there are now
bipartisan proposals working their way
through the Congress that will build on that. One example is a thing
called the Creates Act, which is really aimed at taking a
bipartisan approach to curbing anti-competitive actions
that make it harder for generic drugs to show
that they’re bioequivalent, that they’re equally effective. And that bill, I think,
is going to come up, and I’m very optimistic
that it’ll pass, and it will make a difference. It will save
billions of dollars. A related policy domain is
in the area of competition for biologic drugs,
where we have the possibility of a new
class, a new set of drugs called biosimilars,
which are like generics, but for biological drugs. And the FDA has been slow
in getting the regulations to bring those to market. But there’s impatience on
both the Democratic and the Republican side. And you see us trying to
learn lessons from Europe here to get those drugs
to market quicker, and again, save
billions of dollars because all the
really expensive drugs that you’ve read about in
the newspaper every day, for the most part,
are biologics, and so that’s a
great place to save. A couple of other areas where
I think, in a sense, there’s low-hanging fruit, one is
anti-gouging legislation. There are several bills
in Congress right now. I think it’s an easy one. Here we are in the middle
of an opioid crisis, and we have some of the most
effective drugs being jacked up about 600% a year. And I think that people
on both sides of the aisle are outraged by that. And so I think that
offers a possibility. And then finally, I think
one of the things that came through loud and
clear in the election is that wholesalers,
manufacturers, pharmacy benefit managers all
make money from the way that prices are set. The people that get hurt by
the price setting arrangements are consumers because
they pay list prices and don’t share in the actual
transaction prices post-rebate. And I think, again,
both sides of the aisle say, we’ve got to do something
to fix this and allow the consumers to share in
the cost-effective gains that we’ve made. MARTY KADY: Well,
thanks for your optimism in this moment of gridlock. It’s unusual when the
president, the Republican Senate and the House Democrats might
actually agree on something, so maybe you’ve got a
more optimistic outlook than a lot of folks here. Two other health issues we want
to touch on here that came up in the polls, Americans
are overwhelmingly concerned with protecting
Medicare and keeping coverage for pre-existing conditions. This is across the
board rhetorically. But as Sheila
knows, when you dig into the actual
bills, especially some of the Republican
bills, there are some cheaper sort of
off-brand insurance plans that might not cover
pre-existing conditions. Sheila, can you talk a little
about those two priorities and what you expect to see here? And feel free to cover Congress,
executive action, wherever you see the roadmap ahead on this. SHEILA BURKE: Thanks
so much, Marty, and thanks for
including me today. Medicare, as Bob knows and
Richard certainly knows, remains enormously popular
among the American public. And it is approached
with great caution by both sides of the
aisle and both bodies. While the House leadership,
the new leadership is inevitably going to raise
a number of the suggestions about Medicare buy-ins
and Medicare for all, and will no doubt try and
respond to those issues that arose during the
course of the election, I think it is unlikely
that any major moves will be made with respect
to the Medicare program on either side of the aisle. Unfortunately or fortunately,
we are already in the ’20 cycle, so people are already looking
towards the ’20 elections. And I think they approach
Medicare and the suggestion of doing anything
to Medicare that will alter it any dramatic way
essentially will fall flat. But I think there is going to
be real focus on strengthening the program, and
I think there’ll be discussions that take
place about what might one do with respect to the current
structure of the program, which has remained largely
intact since 1965? Certainly incremental changes
may well be discussed. Drugs, as Richard has suggested. There is a big piece
of the Medicare program and a lot of the discussion
around drug reform, which has to do with the cost of
drugs to Medicare beneficiaries. So we already know the
administration and the Congress has begun to look at
some of those questions around negotiation,
around the price point, around rebate strategies. But there are also
other elements of the Medicare program
that people have talked about strengthening. There are a bucket of things
that Medicare does not currently cover that people
have suggested really need to be added to the program,
issues around dental coverage, interestingly enough, vision
coverage, hearing coverage. And really, the
out-of-pocket costs, because there’s no real
catastrophic protection for folks that are in the
traditional Medicare program. So I think there’ll
be attention given to some of those issues by
Democrats and Republicans. I also think there’ll be
efforts to try and simplify the program. The Medicare Advantage Program,
which is the managed care piece of the program,
now has about 30% of the population enrolled
in those programs, and there are questions about
simplifying that program, about access issues, issues
like telehealth, and other opportunities to
essentially make services more readily available. One of the other interesting
questions that may arise are over the historic Stark
rules about, essentially, the protections under
HIPAA and Stark, and whether they are inhibiting
the development of organized programs. Both the administration
and many others are interested in getting
Medicare beneficiaries into organized systems
of care, believing that coordinated
care, in fact, will improve the health of our
elderly and disabled citizens, so there’ll be attention to
those kinds of questions. Senator Grassley, the incoming
chairman of the Senate Finance Committee who had been
chairman previously, has a long-standing
interest in oversight, and has indicated
already his interest in looking at the
Medicare program, looking at fraud
and abuse, looking at the cost of the program. I fully expect he will do that. Incoming chairman
of Ways and Means Mr. Neil has also
indicated interest in looking at
oversight, but also interest in looking at what
the administration is doing in terms of demonstrations,
with respect to the Medicare and Medicaid programs, for
particularly the Medicare program, and wanting
greater transparency over what, in fact, might occur. With respect to, essentially,
preexisting conditions in sort of my short comments, a
couple of things come to mind. One is people are increasingly
sensitive to the increasing number of the uninsured. We’re upwards of 13.7% or
almost 14% now uninsured, so those numbers are going up. So the question
about preexisting, the question about
coverage availability is one that, in
fact, is of concern on both sides of the aisle. As Bob has suggested, deep
divisions over the fundamentals of the ACA. Of course, we have
the Texas court case, which has called into question
the fundamentals of the ACA, although it is on pause,
as a result, frankly, of the shutdown. But on January the 29th,
the Ways and Means Committee has scheduled a
hearing on oversight, essentially looking at the
preexisting condition issue, looking at what those
solutions might be. And it is the one piece
where, in fact, both Democrats and Republicans seem to
have an interest in finding a resolution as to what
one might do with that. The president has sent
sort of mixed signals. He wants to be sure
they’re covered. But then, of course, they put
forward the short-term plans, which will be
permitted to avoid any of the requirements in the ACA. So those questions,
the questions of what the administration is
doing on a regulatory basis, as well as legislative attempts
to try and fix that issue, I think, will be on
the agenda for both the House and the Senate. MARTY KADY: Thanks, Sheila. And we’ll be coming back to a
lot of the politics of the ACA in the future as
this panel goes on. But we’re going to
shift to education here. Another perhaps a bright
spot in the poll in a country so bitterly divided
over politics, there was some unity on
increasing spending on K through 12 education, on
funding for community college, and overwhelming concern
about student debt. That’s where there’s unity. The tactics on
what to do about it is where it sort of falls apart. Martin, thanks for
coming on here. You’re an education expert. What’s the outlook for Congress
and the executive branch on education policy on
these various topics? MARTIN WEST: Well,
thanks for having me. Let me start with the issue
of increasing spending on K12 education where despite
the very interesting poll results, I think you’re
very unlikely to see much in the way of
substantive change. Major changes to
federal spending on discretionary
programs like education tend to happen in the context of
major reauthorizations of laws, like the Every Student
Succeeds Act, which governs federal involvement
in K12 education. And while that
law is technically up for reauthorization
this year, there is absolutely zero
appetite in Congress to revisit what was a very
hard-won bipartisan compromise in 2015. And I think the overall
budget picture, which includes the threat
of sequestration cuts if there there’s no
new budget agreement, means that those who are
pushing for increases in any discretionary
spending category have very, very little leverage. Now, in making that prediction,
I should note two caveats. One is that I do think
the poll results help us understand why despite calls
from Republicans to reduce the federal footprint in
education, to even eliminate the Department of Education,
after two years of unified Republican control,
you actually haven’t seen a decrease in federal
spending on education. Education’s actually fared quite
well over the past two years, from a budget perspective. And I think that’s because
cutting education spending at any level of government is
just not a political winner right now. And that’s what I
think you’re seeing reflected in the poll results. And the second caveat is
that it’s very important to keep in mind that the
federal government is just a 10% investor or
less in K12 education. And so that means even any
very substantial increase or reduction in federal
spending on K12 education doesn’t really translate
into a major change in the level of resources
available in a given school. As in most aspects of
our education system, the real action is at the
state and local level, and you have seen
increased activism around issues of school
funding and teacher salaries in the past year that
we can return to later. Now, on student loans,
I think it’s important here to distinguish between
efforts to reduce the debt load of former students
who are currently repaying loans and efforts to fix the
student loan system going forward. The former may be
a desirable goal, particularly as concerns
mount that debt loads may be holding back the economy. And I suspect you’ll hear
Democratic presidential candidates talking about that
a lot on the campaign trail. But it does nothing to
increase access for students to higher education
going forward. On the latter, this question
of actually increasing access, I think the big question
is whether Congress is going to be able
to reach agreement on a reauthorization of
the Higher Education Act. And there, the major player
is Senator Lamar Alexander from Tennessee. He’s a former Secretary of
Education, former university president. He’s recently announced
that he’s not running for re-election in 2020. He wants to go out
with a legacy bill, and this would be the
opportunity to do that. He’s made, I think,
good progress in creating some
bipartisan consensus around the goal of simplifying
the federal financial aid system and creating some
accountability for colleges by putting them on the hook
if their students don’t repay their loans. I think the big question then is
whether the areas where there’s not bipartisan consensus,
questions like campus safety, and sexual assault,
federal regulation, all that under Title
IX, whether they will get in the
way of the ability to reach a deal going forward. The other prediction
that I think it’s very safe to make with
respect to the new Congress is just that you’ll see
a ramped up oversight function in the House
of Representatives with respect to the
Department of Education. So incoming chair of the
Education and Labor Committee, Bobby Scott from Virginia,
has indicated that he’s going to be holding hearings. He’s going to be
requesting information from the department,
particularly with respect to issues of civil rights
protections in schools, and the regulation of
for-profit colleges. These are areas where the
Trump administration has made some significant changes
through executive action to Obama-era
policies, and I think you’ll see a lot of examination
of those areas over the months to come. MARTY KADY: Well,
as you’ve heard– thank you, Martin–
the student loan debt is a big burden
for many Americans. We’ve got another clip here. This clip is from the
nonprofit Student Debt Crisis. Let’s roll that clip
and then discuss. SPEAKER 2: I am 30 years
old, and I am currently $38,500 in student loan debt. SPEAKER 3: I am in
student loan debt. SPEAKER 4: $23,522.01
of student loan debt. SPEAKER 5: I’m 29
years old, and I have $60,000 in student loan debt. SPEAKER 6: $70,026
of student loan debt. SPEAKER 7: $44,000
of student loan money to get my master’s degree. SPEAKER 8: Today, I owe $89,000. ERIC SWALWELL: Hi. I’m Congressman Eric Swalwell. I represent the 15th
district in California. I have about $100,000
in student loan debt. SPEAKER 7: I’ve worked
at times four jobs. SPEAKER 4: I’ve been
making thousands of dollars’ worth of payments,
and I’m barely keeping up with the interest rate. SPEAKER 8: Rent was 250 a
month, and my car payment was 180 a month. SPEAKER 3: I do not want to
be paying off my student loan when I’m 80, when
I’m 70, when I’m 60. MARTY KADY: That’s a
pretty sobering clip, and really a wide range
of people talking, and wide range of ages, too. So this is clearly
a national problem. It’s a crisis for
a lot of Americans, a crisis for parents
trying to save, adults trying to pay it off. Can you talk a little
bit more about some of the options for this? You mentioned Lamar Alexander’s
higher education bill. And would that
impact this at all, or are there other innovative
ideas around student debt? I think that’s an important
topic, especially in a higher education setting here. MARTIN WEST: Yeah. I think it’s important as we
start talking about the student debt issue to make
sure that we have a good understanding of where
the problem is most severe. And it turns out
that if you look at who’s struggling in terms
of repayment, who’s defaulting on their student
loans, it’s generally not those borrowers who
have significant debts, those who have borrowed to
go to a four-year school, especially those who borrow
to go to graduate school, who tend to have the
largest debt loads, and ultimately tend to be
very successful economically, and to be able to manage
that repayment burden. Where the problem is
most severe is people who have very modest
loan amounts, generally under $20,000, who have borrowed
to attend a career training program, maybe in the
for-profit sector, have failed to complete
it, failed to transition into the workforce. And they’re the
ones who are really defaulting on their loans. And so I think the reason it’s
important to keep that in mind is that any sort of across
the board debt relief proposal is likely to be quite regressive
in its impact ultimately. And so I think
that’s where there’s a need for some creative
thinking, as you say. The idea that’s really
emerged in higher education over the past
couple of decades is the idea of income-contingent
repayment plans. So basing the amount
that you repay to some degree on your income. And this would target assistance
where it’s most needed. The reason it makes sense
from an economic perspective is that college is generally
still a very good investment. Most people, as a
result, are able to repay that loan that they borrow, but
it’s also a risky investment. And so I think this is a
good way to manage that risk. If it doesn’t pay
off for you, then you end up paying back less, and are
less likely to go into default. You saw a big expansion
in the availability of income-based repayment plans
under the Obama administration. And interestingly,
this isn’t an area where you’ve seen the Trump
administration roll back those programs. I think in the context of
a potential congressional reauthorization of the
Higher Education Act, you would see an attempt to
really simplify and streamline the various options that
are available to borrowers. They’re ridiculously
confusing right now. They require you to recertify
your eligibility year to year, and so they’re not as widely
used as they should be already. And so I think
that’s an area where you’d see a lot of thought. MARTY KADY: Well,
thank you, Martin. Great review on student debt. Let’s go back to Sheila. To pick up on something you
mentioned, the ACA lawsuit. Basically, the entire ACA was
thrown out by a Texas judge back in mid-December. It’s caught up in
the courts now, and I think a lot of people
were caught off-guard with that. It was thrown on a
technicality, but that was an ideological
decision, but one that still reveals the ongoing
legal fragility of Obamacare. We’re almost 10 years into this
law, and it’s extraordinary, I think, to people
who don’t follow this that a lower court judge can
try to toss the entire law out. And it’ll go through
the courts, but what is your outlook on that and
any other legal challenges to Obamacare? I know one of the
questions pending from our online audience is
whether Obamacare is here to stay. I don’t know the
answer, but maybe you can jump in there a little bit. SHEILA BURKE: I’m not sure any
of us really know the answer. I mean, I guess I would posit
that it is, in fact, here to stay. But, in fact, the court case
did catch us by surprise. It, of course, is
being appealed. The appeal is obviously
on hold while we’re in this break period. But I think there is an
ongoing set of challenges. Certainly, there are
the court challenges which are being appealed. But there’s also
the ongoing efforts on the part of the
administration, with respect to the
program that occur in a regulatory or
an administrative way that we continue to see,
whether it’s shortening the period of enrollment,
whether it is basically ceasing the funding for much
of the outreach activities. So there’s no question that
there are efforts going on and will continue to take place. At the same time, I think
there is an acknowledgment that there are
elements of the ACA, have they been given the
opportunity to repair or to fix the original legislation,
that folks would have liked to have go forward. There is an obvious question
as to the benefit structure in the ACA, and the
fullness of the benefits, and whether, in fact, that
ought to be revisited. But I think we will continue
to see this tension. Obviously, with the House
now under Democratic control, you won’t see the
same kind of pressure that you saw from
the House Republicans essentially pursuing
legislation and moving it. The Senate has chosen not
to pursue much of that work. But I think you have to assume
that there will continue to be issues that arise. There are also
issues taking place at the state level with
a number of states not only in the case of this court
case, but a number of states that are seeking ways and
waivers to essentially do a number of things, whether it’s
with their Medicaid program, or whether it’s restructuring
their benefit structure, or restructuring their
insurance market. So I think we have to assume
those conversations will continue to take place. MARTY KADY: Thanks, Sheila. Richard, I want
to go back to you. On the question of
drug pricing, I’m curious about what the
industry’s approach is going to be. They’re going to get
hauled up to the Hill, and Democrats certainly love to
have pharmaceutical executives up there taking the
oath and being asked why insulin costs so much. So can you talk a little
bit about industry strategy when it comes to dealing with
the politics of drug prices? RICHARD FRANK: Well, yeah. We just saw a
report that came out that well I guess this past year
has been the biggest lobbying expenditure year
in quite a while. I think it was
around $26 million was spent by big
pharma lobbying. So clearly, they’re not
standing still for this. And I do think the
actual picture has gotten more complicated. I mentioned earlier that there
is this concern about why is it that everybody
is making money on the backs of consumers? And I think the entire way
that we’ve organized our supply chain and the way we
put prices and discounts through the system has
created enormous complexity and opportunities for our
firms with market power all the way down
through the supply chain to make lots of money while
the consumers are paying prices that are way out of line with
what any of the other players are paying. And so I think that’s
going to be a concern. And I think actually, efforts to
fix that will probably receive some support from the industry. And so that’s,
again, a common point where you can triangulate all
the players mostly falling on the side of fixing that. MARTY KADY: Trump is very
unpredictable, as we all know. Do you see him doing something
unilaterally on drug prices to make substantive
and political point? RICHARD FRANK: Well, there’s
this issue around his desire to introduce European
prices into the Medicare program for
physician-administered drugs. And I think that is
an important signal because much like the
Obama administration, it represents an effort to
separate how you pay doctors from how you buy drugs. And so that’s an
important debate to have. The actual specifics of the
use of international prices to set prices here is, I
think, less clear and much more controversial. And so whether we will
actually land there, I think probably we won’t. But I think having
a conversation about rearranging the way we
pay for physician-administered drugs is important and
will probably happen. MARTY KADY: Thanks. Let me go back to Bob here,
back to the poll, the foundation of this discussion,
and how it showed where American priorities are. There tends to be a mismatch
between what people polled say are their top priorities
and how they expect things to be carried out. That’s where the ideological
debate really happens, and that’s where the
breakdown happens in Congress. What does the polling show? This poll, the first
two polls of the year, or previous polls
that you’ve done show where the
breakdown happens. ROBERT BLENDON: This is
important generically for people to recognize. When people often
answer polls, they expect preferences
about principles. I want something done
about drug prices. When they learn about what
it is, they come apart. And so there’s a real
division about whether or not we should encourage just more
market competition on the drug side. People just believe for this. At the other side are people,
let’s get the government across from the
pharmaceutical industry. And basically, a
negotiation is a nice word for somewhat more
price controls. And so one side,
you split exactly on what you do about that. So a lot of these policies,
and the answer is taxes. When asked about, should public
school teachers be paid more, 73% of people said absolutely. Those teachers are right. And then just the
simple question, would you pay more taxes to do
that, half said no for that. So these divisions about
how the policies are– and it wouldn’t be as
difficult if people didn’t separate by party. That is, if you didn’t go to
a different clubhouse, you– but now, if I don’t
want to pay those taxes, I’m in the party of
no taxes for that. So a lot of these
issues come apart not only because of the
lobbying that goes on, but because how to solve them
is not a uniform agreement. That doesn’t mean it
can’t be done for it, but it’s harder because people
have philosophical views. Take the issue of the ACA. There are people who agree there
should be many more benefit choices that are
available, and others who are very afraid
of what that would be. And so fixing the ACA could
be a very high priority. But the second
line is, OK, we’re going to have a thousand
different policies. No, we’re going to have
two, and that’ll do it. So the inability
to agree on the it. And I just want to
alert people, this is the most poorly
understood about polling. People like Medicare forward. They like this. And then they tell you they
won’t pay a dollar in taxes. And so unless you confront
people with the actual choice, a lot of these polls
are not that suggestive. At the same time– I’ll go back to
this at the end– I think the political process
will be unbelievably frustrated if two years from now
after people were told this election is one the
most pivotal elections in American history and
nothing gets passed. So I don’t want to
have a new cynicism scale about everybody’s
going to be running in 2020. Well really, nothing
could be done. We ran and we couldn’t. I think something on this
list will have to be done. I think there’ll be a
great deal of cynicism. But then again, I
didn’t predict who the president was going to be. [LAUGHTER] MARTY KADY: Well,
let’s leave Washington for a moment on that
note and discuss, I know this panel is supposed to
be about the role of Congress. We’ve established the
divisiveness and the gridlock. So I want to talk a little bit
with each of the panelists, if you have just a
moment to weigh in, about the role of states. States have become real
innovators on policy. If you watched Governor
Gavin Newsom’s inaugural in California, he’s proposing
free community college. If you look at the
state-by-state actions in K through 12 education
and in higher ed, there’s a lot of innovation. There’s things that are
working in both Republican-run and Democratic-run states. On health care, I was telling
our panelists beforehand, our Politico Pro
policy reporters, we have a lot of people
in Washington, but we’re finding more
interesting stories in California, and in New
York, and Florida, and Indiana, places that are experimenting
with different ways to handle the ACA. California wants to expand it
but other conservative states are trying to have work
requirements around Medicaid. Indiana has passed one of the
most restrictive abortion laws in the country because
they want to be the state that makes the
challenge against Roe v. Wade. So maybe we can do
a quick round robin with a few minutes
left here before we go to our audience about
what states you’re watching and should our audience
watch for, like, hey, Washington is gridlocked. Here’s what can actually
happen that could prove to be a productive policy move. I’ll start with you, Martin. MARTIN WEST: Sure I’ll
start with one of the issues that you just mentioned, which
is the notion of free community college. That proposal has been
made in California and some other states
by incoming governors. What’s interesting about it is
that it’s a bipartisan issue. Leading the charge, Tennessee,
a traditionally conservative state. And one of the reasons
it’s attractive to states is because it’s relatively
inexpensive to do. Community college is
already quite affordable, and a Pell grant from
the federal government covers much of it
for most students. So I think you’ll see
continued interest in that. One concern there is
whether that availability of a free option might
do some students who could have attended a
four-year school to attend a two-year school, where
completion rates tend to be quite low, and they
might have been better off in a four-year option. So I think that’s
something for policymakers to pay attention to. More broadly, I think
at the K12 level, you have seen some
divergence among states. There are several states
that have taken various steps over the past decade to expand
access to private schools. That really is a question
addressed by state policymakers rather than the
federal government, despite Secretary DeVos’
obvious interest in that. And so states like Indiana
Florida, Ohio, Louisiana have gone quite aggressively
in that direction. More blue states have
avoided that altogether. And so there’s an interesting
divergence going on that we can learn from a
lot going forward, I think. Bob, I don’t think many
in the charter community would have appreciated
your linking the notion of charter
schools to private school choice in the poll question. Charters have tried to
avoid that debate yet. ROBERT BLENDON: Yes. MARTIN WEST: And I
think you’re going to see ramped up conflict over
the role of charter schools. There has been a bit of
partisan polarization on that topic in recent
years, and so that’s going to be something to
watch going forward as well. MARTY KADY: I’d like to just
jump over to Sheila real quick. We’ve got about a minute here. Are there particular state
moves on Medicaid or ACA that we should be watching
that will tell us something about where things are headed? SHEILA BURKE: I think,
Marty, as you suggested, there are a host of
things taking place. Certainly, Wisconsin is an
interesting state to watch. It’s looking to expand
its Medicaid program. Colorado and New
Mexico are both states that are looking to increase
opportunities for coverage and are looking at public
options and expansion I think we also need
to watch what the state insurance commissioners you’re
doing in a variety of states, some of whom are trying to
prevent the kind of changes that a short-term plan
might result in in terms of their risk pools and
essentially drawing people out of the ACA plans. Obviously, California, as usual,
leading a series of efforts, including wanting
to provide coverage for undocumented immigrants. And that is
similarly, you’ve got that taking place in New
York, both in the city as well as in the state. So I think there are really
a host of activities. Arkansas, of course,
has led the effort on the work requirements. We’re now looking at
data that’s suggesting close to 18,000 people
will have lost coverage. So I think they’re really,
each of the states, either in Medicaid, either to expand,
or the work requirement issues, other waiver requests
that are coming forward from a number of states
in terms of flexibility under the 1115 waivers. And I think we also have
to keep an eye on what the Feds are willing to do. That is, what the
administration is willing to allow to go forward. And there’s another court case
before the Supreme Court, which is quite interesting,
which is looking at CMS’ authority with
respect to its regulations, and its pronouncements,
and what has to go through a
public comment period. So again, I think there is
a great deal taking place at the state level. MARTY KADY: Well, thank you. The Arkansas case is
an interesting example of what sounds good on paper. Let’s have work requirements, if
you’re especially conservative, for Medicaid, and
then 18,000 people end up getting kicked off. I don’t know if
they intended that, but that’s been the consequence. We’re going to jump
to some questions from both our online
audience. and if we have time, folks in our live audience
can ask a question or two. There is one question
about the poll, and I’m glad this is
in here, because it’s an interesting one. It said the majority
of Democrats want to repeal and
replace the ACA. When you pause and say, wait
a second, that’s not right, it’s because they want
something bigger, Medicare for all, single-payer,
maybe a European-style plan. Bob, can you talk about what the
poll revealed on that question? That is a question
from our audience. ROBERT BLENDON: So
a terrific question. How can you have people
incredibly in favor of something for repealing it? So it turns out an
accident of the poll is if I want something bigger,
I have no way to say that. So we looked at the second poll
we did, and the results are. If a Democrat said, I want
repeal and replace, almost 80% wanted Medicare for all. They wanted universal coverage. What they were saying is the
ACA is too anemic as it is. I need something bigger. But we only gave
them one question. So Republicans were answering,
I want this thing shrunken. I want a lot of conservatives–
and the Democrats in it wanted to have a debate
over Medicare for all. So we really in the future
need to split that out. When you say that I want
an alternative to the ACA, do you really want
something larger and bigger that covers everybody,
or do you really want something much
more restricted? But our apologies to everybody. We’ve got numerous
emails about, my neighbor is furiously in love
with Medicare for all and said they wanted
to repeal the ACA. Could you clarify that? We have. MARTY KADY: There’s
a specific question from an online participant
here who didn’t provide their name for Richard. I don’t want to duplicate what
you’ve already talked about, but this person is asking,
since reducing drug prices is an area of consensus, what
is the first actionable steps we’ll see? I know you addressed some
of the legislative options, but if there’s something
specific that people out there should see as a signal
that there’s actually something happening on this. RICHARD FRANK: Yeah. I think you’re going to
see a lot more being done both in legislation, regulation,
to get generics on the market quicker, to get
biosimilars on the market, to just really amp
up competition. I think everybody agrees
that that’s a good thing. And we’ve seen that when you do
that, prices continue to fall. MARTY KADY: And one
for you, Martin. It’s from one of our
online participants. The question is, given
the student debt crisis, community colleges become
increasingly more attractive, but it’s still really expensive. What would have to be
done at the federal level to make a difference
in increasing access? This poll shows people
are in favor of it, but is there any
collaboration you see between the
Republican worldview and the Democratic worldview? And you mentioned a lot of
the folks on that video, I don’t know what their higher
education background was. But some of them didn’t
look like they had just graduated from a
four-year college, maybe had gone for master’s,
taken some community college, or for-profits. But can you try to
address this question? MARTIN WEST: Yeah. A community college
option is usually quite an affordable
one, contrary to what the question suggests. Now, there is the difficult
issue of living expenses. And it may be possible to
provide additional support for students as they are
going through the school beyond tuition. But I think that’s where
you’ll see states trying to innovate through the
free community-type programs that I was mentioning
a moment ago. I think, from a federal
policy perspective, the Pell Grant system is
relatively well-established. There is question about
who exactly is eligible and how you certify
your eligibility, how we can simplify that for
students and make sure that process is not a barrier. But I think the real question
is, how do we give schools some skin in the game when
it comes to student results, right? And I think finding
a way to hold them accountable
for their student success in repaying
their loans has to be part of that conversation. And I think members
of both parties have come around to that
view, sometimes reluctantly. The Obama administration
really tried to advance that cause
through something known as the gainful
employment rules, which said that career-focused
programs mostly in the for-profit
sector might lose their eligibility for
federal financial aid if their students weren’t
successful in repaying their loans. There’s been a
lot of controversy around that proposal,
questions about its legality, its feasibility. The Davos administration–
the Trump administration, Secretary Davos, has
repealed that approach, and I think that’s where the
action will be going forward. I think the key step
will be to make sure that it applies to all colleges,
including community colleges, rather than appearing to single
out the for-profit sector, which I think was one of the
challenges with the Obama approach. MARTY KADY: I want to put in
a plug for a Politico story. We mentioned that
Gavin Newsom, who is a governor of one of the more
liberal states in the country, is pushing free
community college. But we had a recent
story in Politico about a community college
in eastern Tennessee, which is a place that Trump
won by 40 or 50 points that has long had free
community college. The name of the college is
slipping, but look it up. It’s a really interesting
story on a policy that is working in a
different part of the country. I’m going to throw a
question to Sheila here. It’s from Joyce Friedan, who is
a news editor at MedPage Today. Hi, Joyce. Any thoughts on what might
happen with the Medicaid program? She’s specifically asking about
whether the administration or congressional
Republicans will push for block granting Medicaid. That’s a long-term
conservative priority block granting federal
money so that states can put their own ideological
imprint on it is something they love to do with Medicaid. Can you take that question? SHEILA BURKE: Sure, thank you. It’s a terrific question. There has been a very
recent story suggesting that the administration
was going to allow states to essentially
seek through a waiver process the ability to block
grant and give them full flexibility in terms of
the design of their Medicaid program. The other form of this
is a per capita cap. Both are resisted tremendously
by Democrats, a fear that the program, in
fact, will not only change its nature because
of the state’s flexibility around issues like
eligibility, but also that the funds over time will
be an adequate cover the folks that are currently
covered under the program. So I fully expect that there
will be continued pressure on the part of
Republicans to pursue that or to allow the states to do
it through a waiver process, but I think it will continue
to be fought tooth and nail by the constituencies over
the entitlement program nature of Medicaid, and also
those states, essentially, who are likely to lessen
the number of things that are provided and lessen
the coverage writ large. But I assume it will
come back up again. MARTY KADY: There is a
question on drug prices from our online audience. What can be done to
lower drug prices by reducing risk
and inefficiency in drug development? For example, this questioner
says that 90% of new drugs fail in phase 3 clinical trials. So what is the improvement
that could happen during the clinical process? I don’t know if that
statistic is correct, but you can correct as you go. But that’s an
interesting question. A lot of the cost is
built into the process, not just at the retail end. RICHARD FRANK: Yeah. And this is not a
place to necessarily be super optimistic. Most of the cost of
the clinical trials comes from human testing. And as you get more and more
towards personalized medicine, as you get more granular
in your clinical targets, unless you have huge
impacts on the disease, you need very large samples. You need to do big tests,
and that’s expensive. And the combination of
having these targets and having these
dramatic testing needs does not leave me
optimistic on that front. I do think that artificial
intelligence, some of the big data things
that we’re seeing offer some opportunity to
shave some costs, but I don’t see a clear path
right now to dramatic changes there. MARTY KADY: We’re going
to do some wrap-up here. We have about four
minutes to go. And I’ll ask each panelist
to give a quick takeaway on our discussion. Feel free to make any
bold predictions that are sure to be wrong,
since we’re on tape. I’ll start with you, Sheila. SHEILA BURKE: So I think your
suggestion, bold predictions, I think the question is
really what’s unknown. I think we have to
anticipate that there will be either actions on the
part of the administration on a regulatory basis or
an administrative basis that we can’t predict
today that could have some enormous impacts
on either the Medicaid program or the Medicare program. I think it’s a two-year
period of time where there is deep division,
as Bob has suggested, with little where one sees
the opportunity for coming together. Drug prices may be
one of those areas. But I worry that, in fact,
we will make little progress on some of the other
broad health care issues about which we are
concerned because of that fundamental
disagreement as to what the role of the
government should be. But I’m expecting and
looking forward to the states testing out a lot of things,
positively, one hopes, in terms of providing
services and making things more affordable. MARTY KADY: Martin? MARTIN WEST: Sure. So I guess one prediction going
forward, as we’re sitting here, teachers in the nation’s
second largest school system, Los Angeles Unified,
have recently wrapped up a week-long strike. Teachers in Denver
have just voted to authorize a
strike of their own. This comes on the heels
of statewide walkouts in six states, including some
quite conservative states last spring. I think there’s
a lot of activism around the issue of school
spending and teacher salaries right now, and I expect
that to continue. Public sector unions,
including teachers unions recently lost the ability
to collect agency fees from nonmembers for their
representation services. They’re out there really trying
to demonstrate their value. And so I think you will
see continued activism on that front. One last observation, I
was wondering about my role on this panel and
why it made sense to have one education person
alongside multiple health care people. I do think there is a natural
connection between the two issues, however. And that’s because this question
of controlling health care costs, which came
up in the polling, is one that matters for health
care and also for education. If we look at why states
have reduced their investment in higher education
on a per-student basis in the past few
decades, the key driver seems to be that
they’re spending a lot more on Medicaid. So I’m not an expert on the
health care cost control front, but I hope you all
can do a good job, because it will matter
a lot for those of us who work in education. [LAUGHTER] SHEILA BURKE: And actually,
Marty, if I could just add one note to that point, and that
is the link between education and health care. And we know that the
social determinants of health care and the
contributors education is an enormously
important factor in terms of people’s access
to services and people’s understanding. So there is a real
linkage there in terms of how to make
services available and how people take
up those services MARTY KADY: Richard, any
quick wrap-ups or predictions for this year? RICHARD FRANK: Yeah, two things. I think that we
all are clamoring, and the public’s
clamoring for quick action on drugs and things. I think it’s important to
have a new conversation. This has been lying dormant
for about seven years since we had the last
serious conversation. I think that there are huge
problems in Medicare’s drug program that will be
important to address. And I think having a
conversation about how to do that, the
negotiation issue, putting down on the
table what the ideas are, and vetting them carefully,
I think it’s important. Just on one last point,
which is slightly different, I think one of the
areas that showed up in Bob’s poll that also shows
up in the state federal nexus is addressing the
opioid problem. And I think there is enormous
bipartisan opportunity there. And I think leveraging
all the tools we have at both the state
and the federal level is incredibly urgent
to do and really should be the major responsibility
of this Congress. MARTY KADY: Bob,
you’re the one who monitors trend lines in polls. Where do you see things going? ROBERT BLENDON: So
most practical takeaway is six months from now,
the leaders of the parties are going to go
off by themselves, and they’re going
to ask one question. Do we want to run in
2020 having done nothing? And President Trump’s going
to have to look in the mirror and say, what did
I actually enact? And so where there’s a big
difference about the future is I think you can’t be alone in
that room and say, do nothing. I think something
here has to happen, that you actually
go back to people and say, this just
wasn’t a sabbatical. We did something here. But others will
write tomorrow, no. The best advantage is to hold
hearings and investigations and go home. I just think some
of these issues, whether it’s education
or drug prices, they’re actually going
to have to act on, because the cynicism
of voters, that you ran on these
dramatic discussions and nothing happened, is
going to be very, very hard. But that’s a
prediction of someone who’s been wrong
quite frequently. [LAUGHTER] MARTY KADY: Well I’m a
Washington journalist, so I’m trying not to do
any predictions after 2016. So I don’t know what’s
in the Mueller report or what will be in it, I don’t
know when the shutdown will end or how it will end,
and I don’t know what the economy will
be like a year from now when Democratic voters are
going to the Iowa caucus and deciding among 30 to
40 Democratic candidates. But do know that
those three things will be the cloud over
these substantive issues as we roll through the
next six, 12, 18 months. We’re going to wrap up here. On behalf of the
Harvard TH Chan School of Public Health
and Politico, I’d like to thank
everyone for coming, and thank you to
our online audience. I’d like to put in a
plug for the next forum. It’s on February 1. The title is Rare Cancers– Charting a Faster
Route for Treatment. And with that, we’re
going to wrap up. Thank you everyone for joining
us in person and online. [APPLAUSE] [MUSIC PLAYING] [MUSIC PLAYING]

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