MICHELLE WILLIAMS: Welcome 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 theforum@hsph.harvad.edu,
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]
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