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tv   Public Affairs Events  CSPAN  December 17, 2016 2:00am-4:01am EST

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provide more flexibility and regulations for the state to providers and participants. there are some of trade-offs although there is with think but third to implement the replacement will take a good deal of time. to move warps speed through the legislative process, and notwithstanding at present there really is no consensus
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with those agreed upon plans with the public but the of philosophy is easy to do end is much harder there will be complexities and controversies once a republican can modify to attract democratic support than the cbo has to score the of language and nine of the of philosophies i give one have been scored and. >> and what would they involve? maybe the drawing board but
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the legislative process is with several committees the beach chamber will do their drafting and those the resolve the differences? once the president has signed. >> the fact that we don't like regulations crisis throw a but then you will be tim for the various stakeholders improvisers for whatever the new system is.
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i would it be very surprised so we're talking about a deep breath and going about this in a very deliberate way and it is worth remembering as policymakers' we at infrastructure and entitlement programs increasing military spending and discretionary spending and with those controversial issues. but the affordable care marketplace in day need some
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shoring we were in a situation that reinforcement was needed. but then added usual period assistant canby point and i'm sure they have workable mechanisms for adverse selection and that was intended as the affordable care act leading to a uncertainty among providers
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and but the strange component of the affordable care action but immediately that was a component of the reconciliation bill will from january 2016 pour a decision was made that is currently on hold that occurs much faster that the voting public may not like be affordable care act they like the parts that they know about and of consequences but some of the
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parts they don't like a car thought to be necessary for the parts that they do like and it is explained the individual mandate to maintain adequate coverage with pre-existing conditions that underwriting would be limited and to explain that proposal that might encourage high participation on a voluntary basis for those to domain tain continuous insurance who don't know of these approaches will work it could be tremendously complex and intrusive if you keep record every month
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maybe the family splits and the kids get older to keep track of every petty so you don't like that to inclusiveness and now my final point with certain aspects that does not necessarily mean to be enthusiastic of the approach that has spent put forward nor does it mean they will be to avoid of complexity or limitations it is just the complexities of the affordable care act and just to illustrate this i will say a few words on those components but first
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opponents like the rail suggest and those tax deductibility of the employer paid premiums. but that is passed through the of workers who after all make the decision in what they are given a choice of with this is on the employer that is passed down in the invisible way. the employer makes a decision with the insurance company and then is a different mechanism. so that cap does not prove any more popular than of a
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cadillac tax whether that varies from the health status, a geography, and the risk of the occupation. >> and the myriad of implementations to allocate the proportion of thought premium meant now have different categories for individual families or adults with a child. day are not very by age. . .
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most would find the subsidy pretty skimpy, probably about enough to buy a bare-bones catastrophic policy and not much more. how is the public going to respond to that. and the comeplex advertise of the credit which includes determining how to calculate the average debt benefit of the average employer man and how one would handle the differences between the caps by internet and insurance filing unit, would easily be is a great and complicate as they are under the affordable care act. so, we're comparing sort of an image of the desirable to the
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reality of the affordable care act. when we talk about this. let me just conclude by noting that contrary to what one hears in political echo chamber, the public is not clamoring to have the affordable care act ripped up and replaced withsomething new and rat include dash radically different. the cares family foundation poll found 20% of the country wants to repeal the entire law. 17% would like to scale is back, but on the other hand 30% want to expand the law and 19% want to keep it where it is. split evenly. we are divided nation, which says that as hey move forward we other should try to tom together, and coming together might mean revising, reforming the reform, as opposed to crying trying to create something new and different because it has the label on it, obamacare.
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>> thank you for that very optimistic view, bob. but labels do matter. tom, you're up next. >> hi. thank you. joe, scott and bob have done an excellent job of depressing us in dealing with the -- so let's move on to the entertainment possession of this reality show. -- portion of this reality show. a v.i.p. strange group of political aliens lanked in the white house and health policy land, the previous incumbents and allies and supporters are having trouble understanding them. they didn't seem to speak the same language, and not e that's not freezing, they didn't come from the same political universe. and the main leader seems to have seven limits and eated in first class. so the translator is here in a
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different kind of landing party. still working on converting abstract symbols into something we can understand about what is ahead. let's start by contrasting the different approaches by aca supporters and opponents opponed constructing reformed health care system. president obama and allies trade to build a very complex, huge, and expensive vehicle never seen before. sort of like the fabled spruce goose by howard hughess that ron over budget and only got off the ground once. it was too wieldy to lan. the republicans claim to bill a much smaller air policy airship, stripped down so almost anyone can fly it, truly consumer driven. they just assumed there we be onway where it can land safely. just about any runway might do but they haven't built one yet.
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the feel out of the biplane was a member of the house freedom caucus was not fully informed. let's get to the basics. what's the game plan for republicans and thes a ca? the main goal. repeal as much as possible. and, damn it, we're going to have to replace and revise as much as is necessary in that order. some targets out there. most of them have discussed by scott and bob along the way. who gets the money and where it goes. regulation and mandates, individual mandates, hart nod too do politically and other regulations, budget reconciliation. the taxes. everybody wants to get rid of taxes. the problem is you have to replace the revenue and the kick backs industry, you change the leverage factors.
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medicaid passed 0 the states, both a budget donor, big deal. and it's also a place to say the problems are to be fixed by someone else and the blame will be assigned to those instead of washington. the federal role in reducing hack hillary clinton and this is healthcare and this is politics settling old scores. what might be better steps? this area where we all tune out so you can read them yourself nit real details are not what most washington observers are interested in so i'll get to the main political horse race action of the paramutual betting window. it's like flyover land. the real political bottom line here. from republicans if you blow all the smoke away, we won't reduce now subsidies very much. have to make the numbers balance
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but no one is opposed to getting money in their pockets from someone else. they're thinking it works that way. the most important point i bust want to interfere as much as how much you spend it. the one caveat your mileage may vary. now, there's some -- you can't goo that fast. that's the usual caution on this type of thing. a quick summary of the institution, bob hit those. all important ones but i underscore a couple of them. the past attendance, which is members of congress and their staff have a great deal of difficulty going in new directions so where they were in the recent past is where they'll go in the future youch can't you end up going in similar directions you did before. the transition is using -- think about the different cultures and temperment of the house and senate. in house they talk about regular orderren replace. in the senate they're going tight it up in a bow after we have thought about and it have no way to delay further.
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they're going to operate differently and a mismatch on the timing. now, the danger in this, if you move too quick you might get exposed while thinking you're whether i on the grand stage now not really ready to appear. bit is some risky business. these are the different taxable moves. they're very good at this one. fire, aim, ready. we have had the various alternative scenarios in terms of playing chicken but the hard one is when you're trying diffuse what has already been out there. cutting the wires on the bombs sequentially. an example here is, is it the green one or the black one? what we have are two mutual hostage theories going on two different sets of bombs. the one on the right, i suppose, is -- just blow up the aca, full repeal no collateral damage no harm. there will be harm if you don't blew it up entirely. that's different type of political explosion.
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but the other one is from basically the defenders of the status quo, don't touch a thing. very carefully constructed and if you just cut the wrong wire at the wrong time in the wrong sequence, it re blow sky high and we'll have tens of millions of people without insurance coverage, tens of thousands of people will die win the next year, so that's the alternative hostage theory, if you don't cults the wires carefully and therefore you have very little maneuvering and end up in the same place. there's some timing factors for major changes. this what is driving the process. one point of view, if not now, whenever? you have to seats the moment, but sometimes it's not shock and awe, it's the shock and awful. you recall our history elsewhere. but there's a pentup political demand saying you have been talking about this stuff forever. put up or shut up and you won't
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get this thans jennings as president obama found out. he had a super majority for four years. the lesson is we have -- fled to have more bipartisan gestures. the other lesson is bipartisan gestures only go so far and you have to cut to the chase, did that's one tier theory about what happened seven or eight years ago, see what happens this time around. but there's on the other side of this reconciling rest rick -- rest -- rhetoric, i think there's go to be some real changes ahead. the direction and emphasis new e never as much as people fear or hope. what in that direction? more private and less public. matters of degree. regulations and mandates. a re-arrangement, reduction of the overall subsidies and readjusting the winners and the
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losers. the decisionmaking a little more back to the states, a little bit more in the handses of consumers and then what do we also get? new set's overpromises and developing new excuses and evasions and if trouble starts you resort to the three ds. more dollars are spent at the end of the day. just moved in other creative ways and then the other d is delay, which means, well, it's it's going to get there eventually, and the key one is definition. you are going to get things said to be different than hey were before. what you do it invent a new acronym and come up with another name. that usually works for a good day in washington. there some imperatives. you have to pass something because the alternative is that just not very good. what you do is whatever you pass you call repeal. it's just a matter of language even though it's the same way and you have to develop -- develop some creative work-arounds, all the type of
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institutional factors. they will be busted by a majority which has no other alternative. we have invented them before and will event them again in the future. recalibrate the incentive structure. the idea it's going 0 be a one size, what do you need, not how it's going to work. it's going be to changed around. the same way they were browbeaten in the last administration, that will help in terms of what keeps them onboard because the alternative isn't that attractive. the problem is kind of this separation in time between some version of repeal and some version of replace. the goal is to come compress the gap. the real goal is to measure nick its happen but a you can't do that. so you have to -- when your make your compromise, emphasize this is being done for the clear equipment commitment to higher goals. and don't look at the ugly details inside as we meander to trying to do that. i always come off as being so
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critical of the affordable care act and obamacare. like to give them credit. let's talk about what we actually accomplished and achievedded, some failures faild great discusses. able to change legislation without legislating. good accomplishment. the round of consulting and conferences such as this one. we appreciate that. that's something done for the future. set a new record for the longest opposition to major entitlement program. eight year -- stenyears after it's passed we're still fighting about it. pretty good. unable to shift all or most of the blame. that's a failure to -- an objective but didn't get there. substantially increase enrollment in high deduct able plans. we just put enemy in the exchanges -- put them in the exchanges and then reconstruct them, unlike general sherman,
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didn't have the same amount of fire power and urgency, nevertheless, there is no substitute for claiming victory as the majority which wants to remain a majority so as they idea to say in texas, there's no back door to the alamo so there's no sunner den. the problem is you need a lot more fire power to fire through the front door. some of my friends friends in te conservative community say we'll repeal it anyway. in the background playing is the theme song from "m*a s*h." i would just opinion out, though, it may turn out to be awe mutual murder-suicide pact. thank you. [applause] >> that was disturbingly upbeat. okay. well, let's see. so we have a few minutes for -- i'd actually anticipated a
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little argument across the panel but i see a certain common theme here. but start off with any of the panelists, want to make additional comments at this point. >> uh-oh. >> no commitment. >> revise and extend our remarks. >> i will make one comment, which is that -- i'll call it obamacare. obamacare had a huge advantage. it got there first. and so to some extent, by getting there first, it cut off many of the options that you might have rather done. in particular, although i agree with bob's point about the difficulties of moving from -- moving to a cap on the employer exclusion. nonetheless -- the cadillac tax
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not come, maybe the cap -- maybe every economist's dream of a cap on the employer exclusion for employer sponsored health insurance. might have actually been trade. lard to predict. but that's at least a pretty good example you can't go back and you can't go back because it's one thing to doo -- to take away a tax but for the republicans and democrats it's another thing to put a new tax on. that's a real problem. so the other aspect of this, always struck me, is that the democrats really took the easy job. because it's very easy to find ways to funnel money into an insurance market and expand coverage. that is the easy part. the hard part is that affordable part, which republicans have in essence said, we're going to do. and -- >> stole the name. >> well, that's true. so we'll have to have a new term
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for that. how about less expensive. anyway, so it's not just an uphill fight for all the reasonses that people talk about but because there's already history. and it's not just the regulatory history. it's the political history that i think may be the biggest challenge of all. anyway, with that bit of commentary articulates go to -- let's go to the audience. i'm sure somebody must have a good, positive remark to make. please wait for the microphone. it's going to talk a little bit. when you do get the microphone, please say who you are and please make your statement in the form of a question. >> good morning. i'm an independent healthcare consultant and i work on both
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policy and new product technology that answers the question that i think is important, which is how do you improve the outcomes so you drive down the cost of care, and frankly, it's the best time i've seen in a long time, which i the good news, that a number of the programs that charge penalties and incentives are changing the direction of health care at the love level. -- at the local love and the accountable care organizations multihaltly bill we a great mod toll draw down costs, so i hope we don't move in shuffle of the national policy, very macthrow thing and will take more time, that many of these problems u-under the pack crow macro program are innocent viced and use the accountable care mod toll get appliance on our medicare patients at the highest risk of incident of episodes is
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which aren't good. the question is how don't we lose any national policy, let's repeal obamacare, which will take more time than anybody thinks enthe emphasis on the good stuff that's happening? >> well, the first answer is that they're not in great danger because most of the republican policymakers never read that part of the law so it's flyover land and not part of the political congress tension. however, would temper your optimism. we hey expanded the vocabulary of delivery system reform and coming up with all kinds of theories and terms and not yet proven. in order to feel good about that when you pour through the actual evidence on the ground, there's a lot less there, and part of the problem is, you can have all kinds of experiments which work very well for some experimenting. it's the scaling up. what i would hope policymakers would do is stand back, witness
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until someone else succeeds and claim it's there idea. that's innovation through policymaking. >> that makes sense to me. the other thing is, let's keep in mine that terms have to change. so, we're not going to call them accountable care organizations but a that is used up, right? and another factor is that people often forget, the -- what is called the innovation center isn't very innovative because most of the ideas have been kick around for decades and furthermore haven't worked out very well. not just -- partly because those ideas fall into the same category as philosophy. philosophically they make sense. the ground, how do you do it? and certainly having a system where you simply say, okay, this part of the country you detroit is in way, probably isn't a reliable test of whether
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something works or not. so, there's a real challenge there. i am a big believer in testing ideas but i believe in testing, not simply legislating without the use of congress. >> other questions? actually i saw you second and then after that. lost all track of who raised their hands. >> all republican plans talk about competition across state lines how rick is that to implement and what would be the political forced that would impede that. >> i'm partly responsible for that since i wrote about it about 14 years or so ago and hypothetically. a couple of problems. wrong moment, wrong time goods where conceptually, which is a better iteration you're trying to create a consumer-driven competition in how health insurance is regulated.
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we have done is in the other policy areas and you get some variation. federal regulations is one type of monopoly regulation which doesn't work very well. justoff you have a smaller boundary line, if people dome lining the regulationses which is part of the product they should be able to find something else. there's some speed limits on this. the standard one thrown up isow went get a new entry into the market pause you can't get the provider networks. that's trial and error, someone as to put capitol down and make it a successful business. sometimes you open the door and people come in, sometimes they're don't. the is we're in wrong moment in time. people point to a half dozen states with limited versions trying to make this possible. who is going to do anything when you just passed the aca? which is come -- compressing and making more uniform the regulatory parameters so you don't have the variation. now, they would, how do you
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become a millionaire? first earn a million dollars. so the same type of thing is -- steve martin joke. if you first repeal the aca or the fed regulation attached to it and then a phase-in time where states vary again, where there's a reason to some somewhere else, you might have a market opportunity which will save huge amounts of money but depending on the variation in mandates and rating rules, which some safeguards you my beth aim to save 10 to 15% of the premium if you get the other miracle chase state insurance real e reallyingor -- regulator, where it opens the door regardless of a regulator saying you can't come into any state. so over the horizon maybe. right now doesn't matter but it's something that people talk about thaws they heard about and it seem like good idea at the time. >> i would add that anyone who implies that moving in that
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direction is some sort of a game-changer. really doesn't understand how the insurance market works. >> it is rare complex because you have to decide are there going to be national minimal standards for what we consider insurance to be and can if you're going to leave that up to different states, some state is going to permit rather skimpy packages or insurance that doesn't cover certain expensive, mental health or whatever, and then go off and sell that, and it's going to undermine the risk pool in the other states, and everything begins to fall apart. so you get into a very -- >> works in two directions. the race can be to the top as well as the bottom. why you have a mismatch how you're regulating insurance in a state and what most of the
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people want to buy. that should tell you something about the regulation. so, if you put in some other provisions which say, you can't sell insurance in another state unless you sell the same dog food to the dog inside your state. begin to create those mutual incentives so say you get ath can't get away with fly by night stuff. >> you squeeze the outliers, to those with little and toe too much regulation have to move back to thmiddle. >> the proposal is devolving regulation back to the states under repeal and replacement but we don't trust the states to develop regulations to protect the own citizens and as good runs we want to federal government to tell thestates can do and i'm being a little satirical here. i have a problem with insurance over state lines and federalism.
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think you have to pay attention. if new york -- new jersey wants to have mandate is want to know how that affects me in pennsylvania. otherwise i income there has to be a certain amount of defer residence to state authority, and clearly repeal and replacement proposals emphasize that states can get this right and come up with their own systems to provide affordable coverage. so there's a little inconsistency in the dialogue. >> certainly it's really annoying that healths service markets don't align perfectly with state lines. but i think we can fix that. okay. well, let's see now. >> paul heldman we hell moan simpson partners. heard this addressed in dribs and drabs but looking for a cohesive answer. what needs to be done to keep
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the individual insurance marketplace from eroding or imploding during the transition? i ask that in the context of when you think about it you have a president who expended a lot of energy trying to implement this law and getted signed up. you're moving from that from a president who doesn't believe in this law and regime is saying get rid of this law. wonder, that's going to have an impact in the marketplace in and of itself. how do you address that? >> all right. >> i can clean up. >> you might try -- this is a new concept -- selling cheaper, more attractive policies to people that are willing to buy them. that's the starting point and sometimes taking the regulatory lid can help. you can stange-manage transitions. you flush dollars out the door
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to keep people at the table or threaten them with higher taxes for exiting the markets when they don't do and it use both tools depending on what is necessary. you can call the risk corridors and rear insure -- reinsurance something else to pay off people to stay there for the short term but on the long run you're going to spread the subsidies for individual markets to other groups of buyers who got left behind at the table in the outside market and they're going to be happy about it, and you're going to have less attractive, less expensive coverage for the other people who aren't going to get as much and less income related. it's not going to blow up. the last refuge of anyone who doesn't want to play health policy, adverse selection, one for your lives. people are really isic we don't go to the explosion point you self-correct, sell dill disproducts. we saw this with the bad lives
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1990s women move on to another set off dispinting, frustrating policies and that's what call success. >> you need the microphone. >> could -- >> i'm just ask before the legislative fix -- i understand the direction that the republicans want to take the system but before the legislative fix you can't -- you still operating under the mechanisms of the current law. right? >> but you are already stuck for the next plan year in reality you. can't exit the next month, just to bleed out hipaa. you're looking for better days ahead. youer 0 lore comply milessed alive that was pleading you drew and then you hung in, another year and another year. the same thing will happen in this case. >> the you that tom is referring
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to is republicans. run'sed have to deal with this problem. democrats can sit there and laugh. another point that tom made in my office, if you work here you learn a lot of things that are pretty useful to know so i'm going to give tom credit for this but i'll take the blame for getting it wrong. part of the aspect here is how much -- who has something to lose now? in other words, it's a bargaining situation. leaving aside whether donald trump is really a great bargainer or not, this a bargaining situation, the same bargaining situation that barack obama had six years ago. the question is who is going to say uncle? it's not obvious to me that insurance companies are all going to immediately exit every market. >> six years ago insurers were concerned, where is our growth
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going to come from? we're stuck with flat moyer market. we are have to get into medicaid, which they did. we have to get into other areas, and if you give us some subsidies we can sell this stuff and they put some stuff on the table, thinking that would make up their losses on volume. didn't happen that way under the aca but hope springs eternal. >> time for one more quick question, and actually this -- could you -- the next person. >> shannon from the -- i just want to ask about winners and losers if the subsidies are changed to tax credit system, that is age based and -- if we had the problem of getting young invisibles into the market before how will that change with changes to spending and the sub diz. whoer the winners and losers in the replacements land. >> winners, lower middle income
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white males, slight he older, poorlied of indicated. go with the folks who vote for you. >> that's a definition as opposed to real. >> under any sense able rating system, younger people who might not qualify for subsidies under the affordable care act should be winners under the system because they will now gate tax credit to help them pay for coverage, and in addition, they won't have to pay substantially higher premiums to help subsidize older and less healthy people. so less of that compression of premiums that does harm younger people unless they quarterfinal for major subsidy under thes affordable care act. look loser depend's then detail. the rue fundable tracks credit practice -- it's not clear how that will work in terms of
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providing the same amount of subsidy or comparable amount of subsidy under the affordable health care act for people, 150, 200 hsn of poverty but that it very politically sensitive if with see significant reductions in the net subsidy are in some replacements plan for that group of the population that, will be politically controversial to say the least. >> well, let's see. we really have run out of time. anybody who has questions for this panel, ask the next panel. you're tribal get better answers. now, if we can, let's try to change panels very quickly. so thank you very minute, and please join me in thanking the current panel. [applause]
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>> good morning, everyone. let's try that. get those right. good morning. this is the second panel of our event today and i'm very pleased to moderate it. i am jim capretta, a fellow here at the american enterprise ininstitute and i have a distinguished panel. just a word about what we're going try toy too do. the first panel covered a wide range of subjects associated with the status of the ac and the potential repeal and replacement. these folks are going to be able to touch on those same topics but we want to focus a little bit in part on the how. how would you go about doing this in a legislative sense, because i think in -- lots of times, particularly in this
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case, the procedure and process for moving forward with something could very materially affect what is done, and so maybe thinking through the implications of the various potential paths can help folks see where they might end up if they go down that particular road. so, a little bit this morning on the how of doing this because it's quite complex, as you'll hear as we move forward. let me introduce our panelists. the first speaker is james wellner. james this heritage foundation's group vice president for research. served on the nil various capacities for a decade, for senator jeff sessions and others. he received his doctorate and masters degree in politics with distinction and has written two books relevant to our conversation here this morning, especially the one that will be
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coming out next year from the university of michigan press, entitled "or parliamentary war, procedure change in the united states senate. "our next speaker will be doug badger. we have known each other for ang long time. has an incredibly distinguished career work neglective and executive branches. we both sender in the administration of president george w. bush, he worked in the white house as the top health care policymaker for the president and then later as a key person in the office of legtive affairs and worked on the hill in various capacities, including a long stint with senator don nichols from oklahoma in this capacity in republican leadership. the third speaker will be john mcdonough -- doug is now current lay fellow with the galen institute. john mcdonough is the professor of public health practices in the department over
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health policy and manage. at the harvard th chan school of public health, between 2008 and 2010 he served as a senior advicer on national health care policy reform nor the u.s. senate committee on health, education, labor and pensions. he worked on them and helped pass the affordable care act. for five years, prior to that, he served as executive director of healthcare for all in massachusetts, where he was an instrument principal player in helping lead the push for massachusetts' reform under governor rim mitt romney and implementations. he has written sever books, including "inside national health reform" she is story about what went on behind the scenes. so, with that, i will turn it over to each of you to speak.
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think we recall have ten minutes are so so and then we'll have the some discussion amongst us and some questions. james. >> thank you. good morning. and thank you, jim, and thank you to ai for hosting this debate -- not debate -- a discussion, should i say. it's wonderful, great to be in this bull building. a little chilly sounds but the climate system here is modern and ready to go. not chilly in here at all, but always good to appear alongside such knowledge inable and distinguished panelists and i'll do what i've tried to do in my life and associate myself with people smarter than myself so you will think i know what i'm talking about. we'll talk about the how of healthcare reform and how we can expect it to play out, and this instance, as we have all been read neglect newspapers the how is just as important, i think, as what. what can happen. 'll emphasize very briefly three
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points to help frame how you think about the how of healthcare reform. the first one, which i think is more apparent now than it has been in the past, is if the republican party is not as unified on repeal also it has appeared to be over the paster seven years. the unity around the repeal effort is striking if you think about it. other than the idea of repeal and replace, there's been no qualification whatsoever in repeal. the early messaging was the tax is too much, its spends to much, leaders say they're going to tear it out root and branch, completely and this has been a consistent message ol' from every single candidate for offers running on the republican party, for the past seven years. this is a implications. that unity one could suspect could be a function of the expectation we would ever be in a position to actually follow
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this through and repeal the law. could have led members to be a little more aggressive than privately they might have wanted to but it is a reality. it has created a new political reality for the party. another point here i would like to emphasize is the 2015 reconciliation bill. as you recall last year the house and senate both passed reconciliation bills, they've been reconciled and the president ultimately vetoed the last bill 40. 15, the house passed a bill that didn't repeal much of obamacare. it certainly didn't repeal everything you're allowed to do under the rules, under the budget rules governing reconciliation, basically repealed the individual employer mandate, medical device tax. it came over to the senate, and the senate was -- reddy to go to pass the same bill. a couple of senators said we are going to demand we repeal everything we can and that's led
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to the 2015 reconcilingation bill that the president veto-door zero toed. then that was a struggle, with the house passing a bill that wasn't as agreessive as it could have been in senate there was an aggressive debate whether that bill should expand it salt even at a time when the bill was glowing to be vetoed, it one can go to become law atlanta would a private debate playing out as to how hard the republicans ought to push to repeal. this is important because time is important here. a look lack of unity backs more apparent and the repeal effort become. begins to compete with a legislative priorities and in the new congress there's only 52 republican senators. and if you expect all democrats to vote against any repeal effort, you can only lose two of those and still pass with a simple majority using the vice president on -- in his tie-breaking vote. their second point i want to
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make here is there's been a lot of talk -- i'm sure we'll discuss it today -- about the sequencing here, repeal and replace at the same time? and as a practical matter, as someone who has experience the senate and congress and seeing how things play out, the only thing i see that can be possible here is to repeal first and replace later. this is just a practical matter of, no democratic senator is going to vote for a bill to replace obamacare. as long as that bill is coupled to a repeal of obamacare. that's just a fundamental point. so, therefore, it seems to me that you have to first repeal. now, we did pass the 2015 bill and that seems to be the floor. we can potentially get more and i'll mention that bit definitely is the floor. some talk about, well maybe we can figure out a way to keep the taxes or figure out a way to bank the savings to use them later on but that talk runs head into the messaging, going back
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to the unity on the bill that has been propoundses by every single republican since the beginning of this fight, which is that tax is too much. it spend too much. we have to reel peitz all, root and branch. if you cincinnati seven years and then turn around and say maybe we should keep the tax increases other, than make sense to the people who are supporting you. there is -- the argument that the bill -- the 2015 reconciliation bill could be expanded to include a lot of the insurance mandates, that were included in the original legislation, i think there's a good argument you can make that case but we don't know yet. that is a debate that's going on right now behind closed doors with the senate parliamentarians and the leaders in both partieses. what not -- i'm a bit of an opt mist when its comes to insurance regulations.
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eventive the 2015 bill is the floor -- is the ceiling and that's all you expect can't come back to insurance regulations and as we heard from the prior panel those will drive up costs and if you remover subsidies it creating problems for certainty in the major and consumers but in an environment where repeal has already occurred you can have a debate as what -- a to what regulations you need, and what insurance regulations you need. a lot of democrats are going to make the republicans own it. as someone who has advocated that kind of think are for many members i've worked for, i can telling you that is is no going to happen. voting for the most part is a dichotomous choice. members are confront private posesel and they're asked to cast a vote and if the insurance regulation are causing havoc in the marketplace there will be a
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demand to vote one way or the other. regular order here is critical. you allow member answers opportunities to have a stiever amendmentses to debate alternatives and try to boat vote down thing is they don't agree with it's going to be very difficult for them to sustain an obstructionissist positioned a infinned a infinite tim. when you -- if you don't produce outcomes is when you have gridlock and don't allow members to offer amendmentses and don't allow them to debate. so i'm an opt mist here when it comes to getting read of regulations they're not allowed to be debt with in regulation. that's the key first point in the -- the first step in replace effort. repeal everything you can now, and then immediately turn to the insurance regulations and then start to work through the very difficult debates we have to have in the country about what kind of healthcare system we want. the third point i would say here
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is that when we do get to the -- after the repeal point on the debate to replace, that needs to be a step by step approach and done in regular order unlike the original legislation here. it doesn't need -- the first panel mentioned this but we have -- when you write something in secret and jam it. >> don't allow people to have any say in it, then you get the kind of situation we're here talking about today. so, again, i think that you have -- you break this thing into more manageable pieces go threw process and allow for an open debate where the members and staff and the american people can weigh in on what they think is and is not appropriate and i think you'll get some good outcomes. not going to be great. not everybody is going to be happy. aisle i'm not. but we have seen over the past eight years that's the way the system ought to work and when its doesn't work that way,
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everyone is unhappy. just in conclusion, i would say three very short to go things. one we put too much emphasis in this discussion on this idea of what is the silver bullet plan? where are all the members going into a room and talk it out and come out with a big idea at that time that ill with ann associatety and will love it and we recall all be happy. that doesn't work. just doesn't. no one should have an idea that kind of thing works. we have a legislative process for a reason. we have rules in the house and senate for a reason. guess what? they actually driver to us outcomes. and when you follow them you will get to an outcome one way or the other. and it allows for a debate to play out and allows for their american people to take stock of the debate and then way weigh in on what kind of system they want. so, the idea that we can't start this process until we all come up with some silver bullet that
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all the republicans or all the democrat and or all the republicans and democrats can agree means we never get started in the first place. this next point is that the republican party has raised expectations on this issue. i think that's the understatement of the century. and going back to the idea of false unity, if that actually becomes apparent and they're unable to do this, or if they say, well, we're going to repeal everything but the tax increases because we want to use that money that we have been attacking for the past seven years as being bad for the economy, or immoral or whatever you want to say, we are'll use that for our healthcare plan. that is a very difficult proposition for the people who have been voting for them. then lastly, with the election results of the paster november, there are no more excuses. we have heard from the republican party, time and time again, give us the house, everything will be okay. then we need the senate and everything will be okay, and then it's like we can't do
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anything without the presidency, and now we have unified government, heading into the next congress. and right now, if the republican party doesn't deliver, it's going to be very interesting to see what happen because i don't think anyone interprets the election result as somehow a vote of confidence in the republican party? that's not what happened in november. people are frustratessed and fred up and tired of excuses from both parties and it's unincumbent on republicans to follow through on the repeal effort and the promises they've made over seven years and then take a step back and let the process reply out on hautbois replace the law. thank you. >> doug. >> thank you, guys. tom miller, have a slide show here. and my goal today is to add a thirds r to repeal and replace. and that is rescue, because i
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think that one of the first things that president-elect trump will encounter as white house -- the new president, and that the new congress will have to deal with is enact there is generally a failure in the individual markets and the aca. no talking about the small group markets, not talking about medicaid. i'm talking correctly about the individual markets, the 2015 data that cms released last month documents this to some extent. the corridors were eluded to in the earlier panel but the idea is to transfer excess gains from some insure 'er insurers to competitors who made execs losses. in 2015, the excess losses more double from 2.2 billion to
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5.2 billion, that losers outnumbered winners by five to one, and then even in california, which is taken as a state where the aca individual marks are working, excess losses outnumbered excess games by a ratio of 282 to one. that was 2015. since then, things have gotten bad. we have seen four of the five largest insurers withdraw from most of the exchange. the fifth, anthem, the ceo -- this is prior to the election -- said on an investor call that he may pull his plan also off the exchanges in 2018 and his stock price spiked upward in a matter of minutes. even the blues plans have pulled out of several states. it's a real quandary that this is now the new administration's problem because we have already got the narrative out there that president-elect trump is
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responsible for the crash in the aca individual markets. so it's a problem that's wait for him on the desk of the inaugural parade next month. and there's also a general political context to be aware of, which is that taxes are competing with each other how many people will lose coverage if republicans repeal and replace obamacare. the figure the administration uses is that 20 million people gained coverage under the aca. i think that's a inflated figure for a variety of reasons can but eni've we accept that the latest is that 30 million will lose coverage if a republican replacement is put into place. so that'sed the political context that's going to surround the house deliberations. so i'm going to lay out now three possible possibilityways for how that's plays out -- path ways for house this plays out as
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congress moves forever of repeal and replace. this first is the one we have heard the most about, two-stem process, first repeal bill and then later replace bill. the repeal starts with a budget resolution, doesn't have to be signed by the president. a simple majority vote in house and senate and will provide reconciliation instructs. the house says they're going to work on jap 3rd or 4th after being sworn. in they're hoping this moves quickly and then to a reconciliation bill that we'll talk about in more detail in a minute, and generally they're talking about competing that process -- completing that process of a budget resolution and reconcilingation on the president's desk by the first part of february. so we're talking bat very, very abbreviated five or six-week process at least that is where
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people are starting with their expectations. the second part is replay, and this is kind of lather, rinse repeat. do an fy2018 budget resolution with reconciliation instruction, and to james' point and also to the point that was made by the first panel, you are probably very, very limited in what you can do in a reconciliation bill so this is not necessarily the pathway they will follow but this is a pathway that has been discussed. and the -- that is something that will take a number of months to play out. so, the previous repeal bill -- there we go -- i had poor clicker skills -- the previous repeal bill didn't repeal everything. did repeal the subsidies and the medicaids expansion but there was a two-year delay.
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it immediately repealed, as james point us out. a whole variety of taxes. it did not repeal all of the thing inside obamacare -- there was a question after the first panel about what about acos and cmmi there were things they could have repealed they did not. in medicare and medicaid, and as james pointed out there may be things they could repeal that the parliamentarian that would be allowed. but again, last time out two republican senators voted against it, one, mark kirk, is not coming back, the other, susan collins is, so as james points out a very, very narrow knife edge to get the repeal bill through. i do believe that they're going to have to address some of the
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rescue things in this bill. we had a question about that. one in particular is the cost sharing reduction subsidieses. the subsidieses that were the subject of the house lawsuit that they succeeded in the district court level in saying that congress failed to appropriate these cost-sharing reduction subsidies and the administration was spending them anyway. the house prevailed on that's point. still up on appeal to the dc circuit but i say if the new congress wants the aca individual markets to continue for a couple of years, i would argue they need to appropriate this money. because you cannot take that money out of the system if you're objection is a constitutional one, it is something that you ought to address. now, the challenge is to the two-step approach, are many.
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first, is passing the budget resolution. the reason why there's no fy2017 budget resolution when we're already coming into the second quarter of 2017 is republicans in the house couldn't agree on spending levels. so the first thing that has to happen is that members have to understand that this is a shell budget resolution which is being passed only for the purpose of allowing consideration of a repeal bill. but i don't think that's a done deal. the second difference that we all are well aware of, the existential one, least year they were passing a bill they knew the president would veto. this year they're passing a bill they know the president will sign. so that changes the mentality a little bit and brings out potential concerns that james raised in his. thirdly, enacting repeal
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without replace does fuel the debate that republicans are just tearing everything down and they don't have anything to put in its place. and so all of those estimates about 30 million people losing coverage will become 40 million 50, million, and the stars will begin madly shooting from their spheres. this will escalate the criticism that republicans are not serious about replacing it, and the fourth point is the trump administration. all of this is happening at the time where shortly after the swearing in, when your hoping to get some cabinet members in place, you really don't have established routines in the affected departments and agencies, not to mention the fact, i don't know that the president-elect has signed off on this particular approach and set a priorities. so, those are the challenges. the one step approach talks about, again, a similar kind of
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procedure, but says, look, let's package the repeal and replace together. as james points out, that looks a lot less like repeal and replace than it does like amending or fixing the aca, and that may cause some angst among folks, and so it does face some challenges. the first being that for seven years republicans said they're going repeal and it the first thing they do is say, let's wait in not repeal it until can agree on what replaces it and that's something that could be difficult to sell some members. secondly, i think joe poinds out, it's not the republicans don't have replace bills. it's that they probably got a couple dozen of them. and the problem is there's no consensus around any one of
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them, and so the question is, will that consensus continue to prove elusive. the third thing is the longer congress waits, the more other things are going to crowd out the agenda. the administration has its own priorities. there's a senate ban division -- ban division, they have to deal with a supreme court nominee, resolution as disapproval against regulations, the continuing resolution expires on april 28th. ...
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>> >> but i a thing that is a short to live discussion because by the time we get to the middle of next year will become apparent that no insurers will be coming into the exchange's it and they will be sitting out in a number of counties in numerous states and they will have to do something to address the yen near-term issue n naturally that will
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take one of these approaches. if you want to bet with me and i against it, but the two-step approach probably is still the highest priority as of today. but we are handicapping this the lesser is the up one step approach for others who called for that and that nine step approach has ben negligible probability but never bet against the louisiana legislative branch. but it may be urgency to rescue that hca but when i
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left this morning i left to come to a warmer climate. [laughter] this is beautiful in with the incoming trump administration. [laughter] and now from what i can understand sitting next to tom miller so the of movie i would call attention to it is ghostbusters want. remember there are four that capture the ghost to put them in a containment facility in a former new york city fire house there is an attorney for the epa and at one point he comes
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into the firehouse with utility workers with the container facility they said shut off. but they said you really don't want to do this you don't know what will happen. bad things will occur. he said shutdown. shutdown they shouted down and all hell breaks loose i offer that as a metaphor. [laughter] now people on my side of the fence face for having this that this opportunity and i do know that donald trump
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invited romney will to trump tower so let the healing begin. [laughter] but i will focus on and just a few police from our perspective that to feel comfort to have hardening words and promises ended is better coverage and will cost less. and if fact he and have been then we are good but what stands in the away is by a donald trump a. e. i.. in the levels of coverage
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and to repeal the of taxes into a flat one and those who do get a the subsidies today is not enough. and refund democratic think-tank. to all those people that will do coverage that the president would veto last december. and those business people are back in charge. was repealed financing and what comes next so that
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stance is a the way. another major concern that the president and the speaker yes we will continue but we have heard today from mothers there is the fine print after that. with continuous coverage. and care princess seven circle of hell of underwriting fee and is gone and based upon prior illnesses are chronic illnesses, engender the they have never been a victim of domestic violence it is gone . if you would get the letter last week they are not hungry for medical
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underwriting they did not want to go there. so how long is the gap if you 1/7 circle of medical underwriting hell how long tube live there? winona with 28 or 29 million others. there is some number of the of the 20 million and then the dexterous rush -- the next recession? watery talking about? then there needs to be more on the of level that we talk about to fall into that circle of hell.
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into have a tougher time. donald trump won with that chronic bill this. and then help the people. and i find it disingenuous to leave out that. and let's get that out there. for mental-health decisions the ac a is one of the most important to end vance medical care and treatment and access and then to have
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the substance abuse to eliminate lifetime benefits is incredibly important. so behavioral health is one of the benefits a.m. prescription drugs these are of few of the things that our critical. i don't know if there is any clear conversation how do you not make this work? and in terms of losing coverage. and dos substance abuse and mental health with the
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really deep systemic problem the fourth concern hospitals came out and we will give up $155 billion now is $350 billion. and they did that to make dec commitment and stuck to that. into repeal taxes for those high in comes and with uh
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drug companies and insurance companies you'll even repealed of taxes at the tanning salon is the most important public measure in bill whole law if you know anything among melanoma. all of those pet hospital of the front-line of the uninsured the will keep those cuts? they sent a letter last week that said if you repeal this to make the money back it is legitimate but it is partly paid disingenuous. eleven democrats were judged for cutting medicare by budget after budget paul
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ryan would appeal -- repealed and now also just leave it is opportunistic. to the unrolled these budget where is the fairness? everybody else is paying taxes. and then coming through. the last thing that i will say.
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and by the way from the heritage foundation, it was them hickey met to romney and one of my colleagues and bigger things. and up problems of the exchange's and as a former panel would say i wouldn't challenge that. in that individual warm market and you cannot let that happen.
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and the state reinsurance program and overnight to california doesn't have a broken market we have a good exchange structure. going haywire in 17. but these are fixable problems. i spent 13 years in the massachusetts legislature and i learn something. in the senate cochair and i
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the most difficult things to get done and when we did not like each other we could not even schedule a darn hearing. that is not a systemic failure. and then that would make those permanent. wide is reinsurance adjustment in the exchange's can somebody explain that to me please? of medicare part d at? [laughter] >> double-a-2 hope you.
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>> i am supposed to be the moderator there's so many things that want to say and so many comments. >> the level gave you the short answer but what shed be repealed. in the eighth california you have the exhilarated pays congress provided for the appropriated shortfall
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according to uh can of the cbo and cns predicted they would make money so when you cannot legally spend the money on reinsurance one through september 29 of this your that was required by law and not distribute to the insurance company. >> if one is lawful one is not. but 16 years ago of markets of the health care system was a holy mess it was called medicare plus choice
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now known as medicare recanted. if people took the attitude we would toss whole program out. insurers word dropping out to there was a massive number of counties and a stupid idea off with the head out the door, mostly republicans in 2003 they fixed it. we think they fixed it too much to create medicare vantage but it was fixed now is healthy have they a good time sailing along. by the way the accusations
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and with sows problem issues to do all kinds of stuff in the problems in the market bearish it is a political will to get those exchanges going say don't have chaos to revalue the value of the mechanisms with this particular part of the conversation actually i everywhere if you that the concept of the exchange providing consumer information in a transparent and clear way i am for that
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but the individual mandate that i would not call exchanges house that is a forest with the tax penalty with that combination to be calibrated. i a agree that could be calibrated to be sustainable but i don't think they did because it had to go way at the because those voted to bring it down. there is nobody to blame. the. >> because you make of bloody shirt issue. maybe there is the question
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so how much can that go up in the away to stabilize the market? so what about the political process with that sustainability over time. and then to take some personal responsibility is to have a pathway and if you decide not to have that but under these plans. to say that insurance is too skimpy the first and foremost, is somebody decides not to have it was are the consequences? they don't get health care? it don't think they want them to do that so there is a huge question of
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calibration but that with the insurance market reforms , i am not sure that they found out the combination. i will let you respond although we are short on time to bring up the point the level of commitment to appeal is very high. and to move forward. in a with that point the view. and i do believe that then
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repeal and replace. on this they watch same candidates trump on the trail with obamacare why is this important? because it seems predicated to replace this big game intimacy and complicated and that is not what they promised. and that this the answer in the. and to with connective replace. with promising repeal without replace. and with that warning of''
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was replaced with politicians and that isn't what they promise. so what is the response to that? >> and the reason why it is repealed and replaces that it is good politics. said repeal of replace was the response that the status quo was good to hang up the cleats and go home and don't worry about it anymore. but the question is if repeal andrew plays was a rhetorical weapon vice there were plans and a number of
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different ideas to be considered in of first place. of the delivery negative process because they were organized to force through this piece of legislation. and there was a law more distasteful but the atf was we will jam this through to what we get otherwise. but my point of repeal and replace so just as a practical manner you tweak the and you save with a political cost to the political party but i don't
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think it was never at a level of new one sword detail -- nuance or detail as a possibility. because you can repeal the law law. so you will fix the law. in that is not open into do so far. >> a should have given you a chance right away. the penalties are too low i would counter that. i would hold out the simple of massachusetts. the mandate penalties with those formulation.
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and with that massachusetts forum to get the insurance down up to 4% in did stayed there through the evolution and what is different for people to buy insurance in massachusetts? in what that had bent for massachusetts reform. in that comes very low so the problem is not the penalties are not high enough but they are not supportive enough in that is the of place and that is
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politically salable in the way. in at market has been report -- repaired. that is with the state dollars. but the state had to put him place when the state takes it from one insurer and gives it to another and having said that what we start to hear all of these panels very softly is one pathway for word is the federal government to usurp the individuals with this small group insurance markets.
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mendez not working and alaska or montana that the government pulls back. and to use the extent of what the faa california has done. with those health insurance markets and with the life and now that hca and that might allow for the fact. and in ways that achieve the goals.
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and to increase the of insurers that maybe it is the state's. >> they could pull me off of the job because iran long. inez saw the hand up first. and those that are moderating very well but to ask a detailed question with over arching with the affordable care act that is
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about changing insurance but not health care. so what are those things that could be dead and? and with the replays process? and then to that point because that is a much later conversation. >> if you look at what congress passed bipartisan to address part d and did you ask yourselves of that model, does that continue and in france is that
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rejected and throw that out? it seems that it is pretty clear that the directions are set to to a change of transformation. there may be some playing around but a bipartisan victory. >> in that will be the last question. and something that doug said. and the change happens at the speed of trust.
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so given that congress has the approval rating. if you lock it up and then it was the other side you were h. sheets and allied air so if you are prognosticating. and it is o k. and through that process you get the outcomes that the people like. and that speaks to us core of the health care system now and the debates that have been.
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and that is to get rid of it to come back to the table and all i can think of is lbj and genius and a law of respects. also can he not then vice president and i submit to you the way he exercised power with l. hall host of liberals down mansfield comes along and could not control it so he takes a step back and focuses on facilitating the process and rich ride to work that out armed the back and according
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to those honorable sides of the ideal and to have and the futility that no one person in the senate can control that. chuck schumer cannot do that and to let the senate worked its way. and that is the way my system is set up. [applause].
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>> the bill of rights was ratified yesterday marking uh discussion of the role of america. this is 90 minutes. >> good evening. i am the archivist of the united states whether you are joining us for watching
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us with our friends from c-span2. since franklin roosevelt first proclaimed that this day has served as a reminder our partner for today's program 21st century is a constitutional sources project. before we begin tonight secession on to say january january 17 to talk about the new book of the of final mission as a farewell address then over the next two days we will shawl a selection of films from the
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vault the inauguration and with the monthly calendar of the events are all mine has assigned a sheets and these activities with their applications for membership in the claimers made and while those of 1789 met
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recall the bill of rights it was necessary to declare mankind with this constitution. with the 22010 anniversary year to put together a nationwide program of defense to examine the bill of rights with discussions like tonight of the constitutional rights of justice around uh country of educational resources. we have the opportunity of the outside of washington and d.c. area to minnesota the of bill of rights and will soon be in houston that parchment documented self of
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the of rotunda for the charges of freedom in nate teen 50 today all charter the institution of the first display together in the rotunda but harry truman declared in my opinion the only a document in the world against his government and then they become no better than money is so judging from what i have seen they do not consider those charters they ended distinguished panel edges have meaning for us everyday
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of the executive director of the constitutional sources project. [applause] >> good evening. we have the of privilege as serving as the executive director we are an organization devoted to the history of the '90s states constitution at his store called documents the ratification and the amendment. so thanks to the archivist of the united states for the introductory remarks and with the special bill of rights day in with the ratification of the bill of
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rights on december 151791. with those deluges and ideals move agenda and a the press to assemble the of speedy trial by jury and at unreasonable searches and seizures and the rights to bear arms. but the declaration of independence not for most in to know the history of of bill of rights one out of 10 think that includes the right to own a pet. so before i a invite our panel to the stage we thought it would it be useful with the very brief
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history from when the document was drafted to give you that history is some babies surprised to learn that it does not include of bill of rights george mason proposed be added prior to the end of the constitutional convention that it was unanimously rejected so that state declaration said the federal bill of rights was necessary or even dangerous. so with ratification of no bill of rights so the call for the anti-federalist there also interested in the amendments that will alter

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