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tv   National Governors Association Winter Meeting Health Care Panel  CSPAN  March 3, 2017 3:01pm-4:01pm EST

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the nation's governors gathered in washington, d.c. for their annual winter meeting. the event included former governors discussing role of state and health care. speakers talked about republican efforts to repeal and replace affordable care act and provide flexibility to the states. this is about an hour. hi, everyone. we are just about to get started. about 30 secretary. if you want to grab your seats. we will kick off. just a few more people coming in, get settled. my name is sarah cliff. i'm from i've been covering this health care debate for about seven years and it appears i will be covering it for many more years. and i'm a journalist with
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plentiful job security. so we are here today to talk to a few former governors about health care solutions, at a moment when there is a lot of potential for change. what they saw from their perch as governor and how they see the situations thousand with governors and the work they do will be quite affected. i will did a brief round of introductions then let them introduce themselves through a few opening remarks they prepared. i have jim doug as. jim hodges. ben nelson. and all the way on my left is haley barbour, former governor of mississippi. thank you so much for coming to join us here. [ inaudible ] >> that's good. just been waiting there with that one. so i will start right here next to me with governor douglas if you want to kick us off with a few opening remarks for the
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panel. >> happy to, sarah, thank you. and haley is on your right. well positioned for this panel. i have the privilege of serving from 2003 to 2011. about the midpoint in 200 of we passed health care in vermont. i can go into the details if you want but it extended coverage and focused on preventative care and within the next year or so reduced uninsured rate by about 25%. this is preaca. then in 2009 i was on national governor's association and i won't offer any qualitative adjectives of it, of chairing @chairing chairing @the aca during a debate. our message and my message was the same one that nba is offering today.our message and the same one that nba is offering today. i saw the letter that nga just
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sent to house leadership within the last month. first, listen to governors. secondly, don't impose any unfunded mandates on the states. thirdly, give them the flexibility to design health care programs that work tore their respective states. and in 2010 we were having pretty good discussions with the congress initially but as everyone knows in the end, it was ran through on party line vote and the rest as they say is history. i vetoed the first pibill they passed because of the taxes but then we designed something we are proud of a decade later. i hope they can find the purple ground and work together and respect the views of the states. >> all right. >> well i served from 19 the the to 2003.9 the the to 2003.9 the the to 2003.the the to 2003.he the to 2003.e the to 2003. the to 2003.the to 2003.he to 2003.e to 2003. to 2003. for the long time nga alums, you
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might remember the spending was under 10%. i'm guessing now it is third or maybe more than a third they spend on health care. i think that is emblem attic of the problem we have here. we need to fix the health care problem because it is crowding out investment. if we don't fix it in some way state won't have the sources necessary for education. we heard the discussion of early childhood development. whether they are spending for pension or medicaid, there isn't much left to address the other problems. that puts high stakes, that exist here, puts it in the order it need to be that that is a huge issue we face. one quick comment about health care, i really think and it is touching to what jim said, one is flexibility. to give states the flexibility
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they need to enact programs. there are lots of federal rules that existed a long time that i think need to be adjusted to enable states to better run programs like these, that suit the individual state. and second piece is stakeholder engagement. you mentioned governors, i think that's important, that governors do need to have a seat at the table. in addition, i would add health insurers and health care providers need to be part of this. final comment, we talk about the aca reform, 20 million or more people have health insurance coverage in some ways. medicaid skpaexpansion or throu the insurance exchanges. there are about 1 of 0 million more that have traditional medicaid, medicare and private insurance plans.6 of 0 million more that have traditional medicaid, medicare and private insurance plans.of 0 million more that have traditional medicaid, medicare and private insurance plans.f 0 million more that have traditional medicaid, medicare and private insurance plans. 0 million more that have traditional medicaid, medicare and private insurance plans.0 million more that have traditional medicaid, medicare and private insurance plans. of what is done at congressional
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level, whatever the president advises, they have to make sure not to screw it up for the 160 million. i'm worried the reform package will make it worse because they aren't thought through and they don't engage stake holders like they need to be to have the fix tha that will help us. >> thank you. i served from '91 to '99 in nebraska. that wasn't enough for me so i started serving in the senate and served from 2001 until 2013. so i have seen the affordable care act up close and personal. but have also seen as governor that the needs for having coverage available for people across the country. sometimes medicaid, sometimes medicare. sometimes private care. private pay. it is an issue that's been around for a long time.
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but an issue that bedevils people trying to fix it. so having -- knowing i was coming here today, i went back and looked at all my votes in 2009 and 2010. to refresh my memory on the various things we were dealing with. it probably won't surprise you that it sound an awful lot today like it did back then. but no long he apparently according to my good friend john boehner, an easy decision to make about replacing or repairing or repealing. one of the things that governors i think have to pay attention to is the interest in block grants. when i was governor i loved block grant, as long as they were fully funded. that an oxy moron almost to say they will be. governors have to be quite careful they don't end up with a
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shift of the responsibility because if they get that shift of responsibility, without adequate fund, it'll be the shaft. they have to be alert. ask the right questions from either the people in the administration or congress. there is no easy solution it a problem of this magnitude. and it is not going to come easily. they will have to work hopefully in a bipartisan way. that's the hope. but whatever they do, they have to be sure that they don't make it worse in the process of trying to make it better. >> all right. govern governor barbour. >> thank you. i hope it doesn't discourage you that jim is from vermont and these two are republicans. i agree with almost everything
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you said. first of all, health care reform it is hard. took democrats a year and half to pass the affordable care act and idea to repair, replace, repeal, redundant or whatever, the idea we will particularly repla replace obamacare in a matter of weeks just ignores the difficulty of doing it. you can repeal obamacare fast. you can't replace it fast successfully. this is difficult stuff. i hope they understand it. i hope they understand 8 will 0% of the people who got health insurance who did not -- got health care coverage who did not previously have it got it from medicaid.
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16 million of the 20 million that jim mentioned. it wasn't just in states that expanded. my state didn't expand. our roles increased 12%. 72,000 more people because of what they call here in this town the wood work effect. so complicated, enormously expensive. patience is required. i'm one of those that believes we do need to repeal. and to replace this. but i think we need to set out a period of transition that does what a couple of of my colleagues mentioned. make sure we have stability, that insurance market does not collapse out of fearfulness. that the provider community believe in what's going to happen.
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and that patience believe in what is going to happen. we will see how long it takes. the last one i'm going to make, because 80% of the people who didn't have health care coverage and now have it got through medicaid, governors know about 50 times more about medicaid than most in congress. congress pro claims and governors actually run the business. and it is a complicated business. and the idea that if the same in nebraska as it is in mississippi is silly. even as much as we're like south carolina. we have different issues and different problems. and we have different solutions. and jim made the point in his state. there have been innovations done that paid off. that's the whole idea of the
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laboratories of democracy that we subscribe to as states. let the states have more flexibility but let's not believe that overnight that can produce gigantic savings. lastly, lastly for the second time, republicans should not force the people who did not expand medicaid to be punished for not expanding nor the people who expanded medicaid to be rewarded for expanding. whatever system they work out on the financial side has got to be equitable to those that expanded and those that did not. and to do that, while keeping the taxpayers from getting the shaft, is not easy. it takes a lot of work.
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>> great, thank you all. i will open a few questions to you all. then open questions to the audience. i wanted to say senator nelson -- but governor. you brought up these remarks that john boehner made recently that says he does not expect the republicans to repeal and replace the affordable care act. i wasn't there but i heard he laughed and said republicans can never agree on health care. where are you all at, just in a minute or two answers? are you expecting the law it be repealed and replaced? what are your expectations of what we are in for for the next year or two? >> well the frustration that they are already feeling and can you sense it is they want to keep the good things that are expensive and don't know what to get rid of to save any money and not have it be something that is
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one of the benefits that are so good as part of the repair. if you're going to add people, allow young kids to stay on their parents' plan until they are 26, that's expensive. because you will get adverse selection. ones that are out there working that have jobs and so forth that can qualify, if you change it, will take their own coverage elsewhere. but in many instances, the young people will stay on their parents' plan because they aren't working. but in many instaeninstances, i cheaper to stay on the plan rather than get substandard as they used to under a risk pool plan or something like that. th then to say we're going to knock down the preexisting condition exclusion, that means you take the sick. and you know, that is expensive as well.
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so the whole system of taking all comers who are universal, is problematic to try to control the costs. remember when this whole process started and bipartisan until summer of 2009, and they were working in the finance committee. working in the committee together bipartisan way, passing amendment and accepting amendments to the bills. as they work their way through in the senate. i don't know about the house. but they were doing that. then something changed. they went home and had what they are experiencing today maybe a reverse, they had, what are they called, town halls. and ruckus town halls. well, with that, what you had
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was no longer emphasis on trying to find a way to bend the cost kufb to try to make it less expensive to have care. so they had qualitative care, less quantity of care, left costly care wherever possible. that got shoved at the side. and it became universal access. and when you have universal access and don't have a way to control the cost, don't be surprised if the numbers go through the roof because you have people that will bring a very expensive conditions to the table. now they are going to be covered. and that's going to be shared by efb else. i do believe that the governors should have a strong say in dealing with this. because at the very least maybe they can't handle the universal access issue and the preexisting condition, but maybe they can work internally within their own states to try to find ways to
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reduce the excessive costs that are there. i trust them to do that. that's what happened when i was is governor and welfare reform. we were going to get people from welfare to the work force. from welfare to work. we gave them medicaid plans until they took a job and were qualified under their employer's plan. so i trust the governors and states to do an awful lot of the bending the cost curve by finding better ways to control the costs locally. >> when i heard speaker boehner's comments, i thought, he's right in the sense that it is so difficult to retreat from an entitlement that's been granted by government in any level. but at some point folks in congress have to remember where we are fiscally. our federal debt inching up
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toward $20 trillion, a lot of states, not all but state struggling to balance their budgets. these are supposed to be the good times. after the recession we are in recovery but states are struggling so we have to find wayes it ratchet down the costs. i think there are lots of options between the status quo and block grants. for example, in 2005 we add very high percentage of our population on medicaid. i went to four former colleagues, mike levin, secretary of health and human services and said, have i got a deal for you, mike. i'm going to accept less medicaid money than vermont would otherwise be entitled to over a five-year period in exchange for more flexibility. after all his lawyers looked at it he agreed and we saved a little over a quarter after billion dollars in that five-year demonstration period. than we would have otherwise. so my point is, states can find creative ways to run their
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programs. if they get flexibility necessary from washington and we should as ben said, let governors be created. >> you're expecting repeal and replace? you think republicans will get it done? >> i firmly believe that after this year we will repeal oba obamacare. and i think later in the year we ought to replace it. i think that's going to happen. it isn't easy. my own opinion is -- [ inaudible ] replacement is much, much more complicated. and ultimately, i hope what congress will do is pass federal guidelines, federal framework and give the states in 2018 to design within that context. and to allow --
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>> sorry, seems we are having trouble with our mikes. i think we are are all quite loud though. >> i think it is foolish to say everything has to be done in a few weeks. this is going to take more time than that. i hope by the end of next year we will have federal -- [ inaudible ] repeal and replace and have state implementation framework. and it will be implemented by 2020. i think that a -- in all years past, six years ago, and a lot of this has gone into effect. so the idea if we ka gcan get i done in six weeks is a joke.can done in six weeks is a joke. >> let me just comment. this sound like a project for a good long study committee. we are are really good that in state governments. feds can do that when you want to dump a problem on somebody,
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set a study committee up. but there are things that need to be fixed. we need functioning insurance markets. if we talk about the aca before we get into med dadicaid, there issues to be addressed. there are a handful of things that need to occur that can't occur because republicans wanted to repeal it and democrats are scared to reopen the process. let's look at quick fixes and take care of those that we think create effective competition in insurance markets. we need to deal with the mandate. i think everybody agrees we need, i think we need a more meaningful mandate. we've got to do something about subsidies to get people into the health insurance markets. the handful of things i think we can agree on is moving forward and looking at the problem. but they may name it something else but they're not making dramatic changes from the affordable care act now. >> i will give you one example. couple of states say there is this mandate in federal law that
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requires all eligibility for medicaid to be handled by classified state employee. well state have said we can save millions, literally, if we can outsource that simple process. a lot of things like that embedded in the affordable care act that i think could get us toward a better fiscal position than we are at now. >> one of the thing that i might add is that unless you find a way, to get everybody into the program, it is going to be less than whole. that's obvious. when it is less than whole, you're going to have more sick people and less sick people and more well people perhaps outside. the penalty was i guess was a heritage foundation idea. years ago. but the penalty on because if people have to pay a penalty would rather pay insurance. couldn't get the penalty high enough politically to really
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create a defense. have you a number of the young invincibles who most of them i'm sure were macho, i'm not going to take this government program. i will pay the penalty. well penalty is so small, a fraction of what insurance would be but i think it is a foolish trade-off. but that what people did. so governors have to find aa way internally, to get over the program and get everybody insured one way or the other or you will continue to have glitches on pricing. on rating. and what have you. >> governors douglas and barbour, we wrougbrought up the capita cap, that you would allow a certain amount per person and have that grow on some kind of predetermined formula. i know that's an idea a lot of your republican colleagues on
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the hill really like. what do you think it means as a governor? should governors support block grant? what do you think it would mean in your state if you add block grant for funding where you get flexibility but your grant is at a level? >> the commerce committee, the committee with jurisdiction over medicaid, said give me a block grant for medicaid and i will take 2% less. and in fairness, you get a plus up every year. i said take 2% off what i would otherwise get and we will come out ahead. jim douglas did that. he got a waiver to do that. i think that's very important. there is a lot of difference in some people's mind between a block grant and per capita cap. per capita cap seem to be getting a lot better reception
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than block grant. i can't speak for anybody but that seems to be the case pch a critically important development for governors in whatever it is, you have four big silos of spending, aged poor, blind and disabled, children, and it increasingly healthy adults. the last year for which we have figures which not last year, but the year or two ago, 16% of medicaid was healthy adults. that's $61 billion. for healthy adults. and governors want to not be put in position where they have to continue to spend 16% of medicaid on healthy adults on some per capita cap. so let them be able to take care
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of the people who need it worse first. the aged and blind and disabled. about 50% of spending in most states with medicaid goes into those two categories. don't hold them to 50% if they need because of the growth of the senior population to have more money than that. let them cut down the amount of money for healthy adults. make them work. like ben, when you did welfare reform. there are several ways to do that fairly. most of the healthy adults go back to what i mentioned earlier. 80% of the people who got heal mg care coverage under obamacare got it by being put on medicaid. now they are 1/6 of medicaid spending and our older population goes up and up and let's face it, the blind and
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disabled because of drug problems, because of things that weren't as big a problem 25 years ago, are more of them. children, god bless them, are not very expensive. and we got to take care of them. we got to take care of them. but i do think it's very important that we do capitation, we allow adjustments between groups. >> you said previously, just take 2% off the top and i would be happy. what if we move toward 3 p, 4, 5, 10%. how much would you give up for a lot more flexibility?, 4, 5, 10%. how much would you give up for a lot more flexibility? >> you know, these things change over time. your programs change. state by state. in state, when i said that, we could have done 2% really pretty comfortably. pretty easily. but today we have 72,000 more
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people that have come on because of obamacare. we've got a much bigger problem size wise. there are some in congress that want to do away with provider taxes. which for me is just a fool's game. if you do provider tax, that is providers of heal mg care who get medicaid payment, if you do away with those, then you either got to raise somebody else's taxes or you've got to cut spending. by that much. to me, we've built our highway system all my life on user fees. that what the gasoline tax is. a user fee. i say provider taxes the same way. it is a suser fee. those are people that are big paid mostly by medicaid. i think it is totally appropriate they ought to pay in some. otherwise you do get, where do you get the money or how do you cut the program?
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>> i've been careful not to use the term bg, because it is a hot button phrase. but as haley suggested, as i indicated earlier, there are opportunity to find more efficient ways of providing this care to people if state are allowed the flexibility to do so. we mentioned what we've done some state want to impose a work requirement. someone who impose a co-pays that are beyond what is permitted now. my successor once removed, governor scott, just entered into an agreement with cms on pilot basis for one year it put 30,000 medicaid participants in aco for flat amount of money which is lower than they would otherwise drawn down from the federal government. i think there are lot of opportunities. governors are on the hook. they are running for reelection. they are responsible. they have to deliver for their constituent.
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i think we have to persuade congress to allow that flexibility. this is a federal system and states aught to be able to do their way. >> governor hodges, let me ask you a more political question. you were a democratic governor in what i think is fair to describe as a pretty conservative state, south carolina. >> yes. >> you all signed a significant number of people up for aca. you didn't expand medicaid but still robust enrollment. looking at about 200,000 people through the marketplace. has the law gotten any more popular? and if not, why not? why do people in south carolina like the thing called obamacare? >> it's the obama part of obamacare. you know, it is very republican state. i think if you took individual pieces of the aca and asked south carolynians, if they had been asked about it, that they would be in favor of those pieces. i think it became so politicized that it was connected to the
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president that people could not see past that and their partisan instincts took over and didn't give it a chance. but if you ask people if they believe that we should do more, find a way to put more people or medicaid because we have too much care at hospitals, they would say yes. if you ask them if they like the pieces about children staying on their parent' health care plan or making sure that people that had preexisting conditions get covered, if you went through all these things, i think they would say yes. i think we now, you know, i like president obama. but i think now we have a chance to try it recalibrate this perhaps and come up with something. a comment about this and what troubles me and panelists here is that comprise has become a dirty word. we need to make the changes we need to and there has to be compromise. it won't be the republicans win or democrats win, it is going to
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be compromise. and it troubles me that we sort of gotten to this position where we have this inability, whether it is in washington or some of our state capitals, to bring stake holders together and fix things that need to be fixed. >> that is my billingest complain about the aca. not the spefbs but the process. here congress was reforming a sixth of our economy and ran it through on party line vote and now nearly seven years later half the country doesn't like it. so we have to find that common ground. jim is absolutely right. we have to have buy-in. that what we did in vermont and that is a mirror image of south carolina. >> yeah. >> but we found a way to work together and it is a law a decade later we all feel good about. >> it is one of the things that makes it more remarkable. ben mentioned that the heritage
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found dag foundation generated some of these ideas. when i was governor, our biggest group of uninsured that we thought we could deal with were employees of small businesses. so we decided based on heritage foundation work, created ex change, interesting word, created exchange for small, interestin created exchange for small businesses. believe it or not, democrat majority by one vote state passed it four years in a row. democrat-controlled house never let out of committee. so a heritage foundation idea back then. then of course, the exchange idea got greatly expanded. for us it was neither mandatory nor subsidized. but we think it would have helped a lot. but that just part of the product the two jims are talking about. >> you worked on a law that
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ended up being on party line vote. do you think republicans in congress will have better luck this time in bipartisan effort or were they in the same vote you were looking at before. >> then by start zipartisan is operative word. i think the answer is we all hope so. it actually, at end of the day, didn't pass on a party line vote. it passed 56-42 -- 43. so it wasn't ---i wasn't the 60th vote. want to make sha clear. but the key here, istsha clear. but the key here, ishasha clear. but the key here, istsha clear. but the key here, is clear. but the key here, is if the members will talk to one another and start sharing ideas, as opposed to doing it formally, informally talk to one another, it seems to be safer on the hill
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to do things informally right now than normally because you go home for a town hall meeting and you get the wrath of the crowd that absolutely convinced it is going to get repealed. so being able to talk to one another and share ideas and getting groups whether the heritage foundation or another group, to come in with ideas, and take the best of the ideas sometimes it's, you're idea isn't always the best. turns out to be something else and then you can find a way to improve it. i really do have hope for governors on controlling the cost. maybe not figuring out what plan itself will look like but on what they can do. keeping a lot of flexibility on the plans is important. in trying to control costs. i know of a particular large operation that has their own health insurance plan. they decided that they would
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have a smoking cessation program to provide the money for to their employees. the point i think that they did that, 40-something percent of employees smoked. they played for the smoking cessation program. if people continued not to smoke, they reduced the employee's portion of the insurance premium. the group premium. so they goot beneft a benefit f. the number of smokers dropped from double digits to single digit in a very short period of time. in addition the accident rate dropped. they tied that together with smoking cessation. in addition to that, their sick leave dropped. people were healthier and worked more. that just reduced the cost of the insurance program
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dramatically to the employer and employee. if we put thinking caps on and deal with people at the local level, there's a better chance of doing it. when we work on it, we try to get it through so i put the insurance commissioners in the bill. i think something like 13 or 14 times. not because i knew it would be ceo of it. but i wanted to get the state commissioners who have a better idea of what is working this their state and what will work in their state and what will work within the state capital. that's why the governors will be critical to this. >> let me answer another question. i asked for short answers. we have about 15 minutes left. one governor wants to comment then we will open it up to questions. states are involve fed regulating insurance as you just mentioned. a lot of that work happened on the state level.
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what is your level, with the insurance regulator, and governor nelson was an insure regulator, what should states be doing to keep their individual markets stable? again, short answers, but curious to hear what you're expecting in the individual markets aep the states you worked for. >> short answer is politicians. we do our best. the administration came out with a new rule adjustment in the last week that seem to get some cautiously positive responses from some of the insure you'rers. but a state that has nobody offering policies on the exchange is unacceptable. i think the state is better off if there are multiple options so there is a choice for consumers. i hope that some changes will result in some of the companies that were threatening to withdraw reconsider.
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>> greater certainty. i think lack of certainty is hurting markets to bring healthier people in the market. i think dealing with the fulfillment of promises in the aca, some of which haven't been done. and i think the last piece is listening to them. i think the insurers, insurance companies, that i've been my observation has been that insurance companies want to make this thing work, and they want meaningful competition to exist in their markets and they need to be listened to. the concerns they express. >> there are fewer, more insurers, health insurers, getting out of the market than new ones coming into the market. that should tell you something. one things we got in the bill is a medical loss ratio of 80 or 85%. which means inshowerers have to give back in benefits 80 to 85% of the premiums that they
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collect to make sure that the -- that it wasn't rate control but close to it by controlling the overhead cost and the cost of boards, bureaus an acquisition cost and stuff like that to try to keep from having what people consider gouging by insurers. they have to give back either through more benefits or some actually giving back rebates when they hadn't given back 80 to 85% of the premium. so the cost factor is real. and if we don't find a way to reduce the cost to insurers and the state and federal government for the program is we's, we're o continue to see the cost and whole economy of health care go from 30%, 35%, just continue to
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spiral like that. so i'm hopeful that we'll deal with the cost control because the actual premium can, federal loss ratio, controlling, run away premiums based on profit eering. >> the benefits package has to be made different. that's one thing that it runs what you make, you make these young people buy benefits that they got no use for. it runs up the price. you need to take the benefits package and greatly reduce it. i'm not one that believes selling across state lines is necessarily a solution. who is going to regulate it? if the same state regulates it where you live, that doesn't really give you much. but i will say something that states did far better than the federal government. risk pools.
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p 35 states had high risk pools before obamacare. nobody likes to tell you that. the idea you couldn't get insurance if you had preexisting condition. what at good word for bs? that not accurate. i see ronnie sitting there, my predecessor. high risk pool that we had in mississippi which predates either one of us. charged 50% premium extra if you joined it. but in six months you went down to standard preemus pu you were covered from day one tp it was a very superior risk pool to what obamacare did because you weren't covered for a while that way. some stuff like that probably helped savings accounts. will help carry the ball for some of these things. but those are things that were obviously saving money. >> great. a few comments from governor
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garinger, former governor of wyoming. we have these microphones here if folks wanted to step up and ask some questions. i think we would be happy to answer them. >> i expect the reason i'm not up there on the panel is because i'm also a jim. >> another jim. >> that's another partisan issue. too many jims on one panel. and we had two jims and haley before. that was a riot. where was i? okay. because this is entitled lessons on leadership, i thought i would focus on leadership and governor nelson you made reference to the government in 90s. i will dwell on the process of how that occurred. that is not a direct analogy of health care because health care has a different population in many regards because of
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long-term dependencies that welfare did not. but there are thaults i wanted to put forward about what happened back then. the president had said he wanted to reform welfare as we know it or replace it. so here we are talking about the same thing. we are talking about replacement. the governors decided they would take the initiative and as i recall, on the republican side, it was strong leadership of angler and levin, if i remember right. and on the democrat side, roller and i believe lauten chiels. and dean from vermont. a subdued quiet individual as i recall. but they worked out a plan among the governors so there wasn't just a block grant request. it is, here is how it is going to work. and it was have that sem platemn place, the initial put down we got was, well it'll be a race to
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the bottom. if you let the states lead it, it'll be a race to the bottom. but those block grants to the states wasn't just a concept, it was a plan to go with it. as we negotiated among ourselves and kind of came up with an agreement, we dispatched roam toeer to the white house to work a deal with the administration and to royce's credit, shall i say, he always knew what our fall back position was and i think he often times communicated that a little too early. but we still arrived at an agreement and it passed and we had cry tieiteria of how we wou evaluate it ourselves. tommy thompson and i had a race to see who could improve their situation best. i one-upped him. we reduced welfare rolls by 93%
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and five years later that entire population still add johad a jo. i wonder if we can take that model and as a lesson on leadership and said all right governors, tell our colleagues in their chairs now, whient to you work outwei a way among yourself ease people that were natural leaders, it could be one of the doctor's doctor, the alabama governor, and integrate these services as we heard this morning with early childhood education. not just about early childhood education. it is social economic and health activities that need to be combined into a package which a block grant represent. it is not just about health, but the whole community. let governors not only ask for a pl block grant but lead the initiative to say here is what we would do. you heard several ideas about how we could take various parts of it and make a sound and i was
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curious, among the four up here today, if you think there is something we could have gleaned or learned from the initiative the governors took then, ben i know you were right in the middle of it, but you others were involved or suffered from it, however it might be. i was anointed as governor douglas's mentor as he was leaving a i was leaving and he kass wwas co in. >> taught you everything i know. >> ben i know you didn't have the partisanship you had then. and it is a political debate, an health debate. you need to give them cover. what better way to give them cover than the staay the governs will take the initiative. can you complain all you want but silently you will go ahead and help it to happen. giving congress cover is probably the best thing the
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governors could do right now. so any response you might have. >> sir, i was chairman republican national committee when this happened. and beginni and newt gingrich and dole, said you tell us all about. now far beyond the economy than welfare. but governors know so much more about it than congress. jim came to meetings. tommy thompson was the third. andrew thompson and michael levit. they had meetings. they had staff in town all the time meeting with ways and means and energy commerce and senate finance. that's the one thing that, jim, i would say to the governors, look, take this seriously. be in it for months and don't let this get done without your
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em per modder. >> i think it is gubernatorial leadership, jim. i think you're absolutely right. as everyone recalls in '09 and '10 when the aca was debated, there was a great deal of division here. it became as partisan as the congress did, so it wasn't possible at that juncture, but now with changeovers and two branchs of government with turnover in the governor's ranks as well, with experience and continued unsettled opinions about the aca, i think it's a topic that would lend itself well to leadership. it's a great idea. >> i think the biggest challenge would be to deal with the promises made in the last election, timeliness, to repeal and replace.
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that's going to be a big challenge because people are taking that seriously. i agree with you, it's better to do it right than it is to do it wrong and do it quickly missing the opportunity to make appropriate changes, but i think it's going to be very difficult for a lot of folks in d.c. to move very far away from the dates and predictability that they provided. i hope not, but i worry about that, including the white house. >> i would agree with everything i heard. given the poisonous climate that exists here, it seems to me that some external voices have to be the ones that forge a solution. i think the challenge for the governors is can they -- the climate is different now than in '94. we all acknowledge that here the
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commonality is different than it once was. i don't think that in washington that they've got the capability to do it. if they don't, then it's up to the governors to. if the governors don't, somebody else is going to have to, whether it's business leadership or business owners or stakeholde stakeholders. my challenge would be did you take this job for the title or the job? if you took it for repairing things, then you'll step into the void. as you mentioned for welfare reform there was a great dividend for governors to that i that courageous step and they can do that here. >> we have time for a few questions. who wants to be the first? do you want to tell us who you are and go ahead with your
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question. >> my name is vince surf. i'm vice president of google. i have a question for the four governors sitting up there and any other former governors that may be in the audience. it has to do with some insight into the reasons that the health care costs escalated so quickly. i'm guessing -- i'm just an engineer, but i'm guessing there must be incentives built into the sometime right now driving those outcomes. when you don't like outcomes, the best thing to do is figure out the incentives and change the incentives. i hope you can give us some incentives that are driving costs and how we might change them. >> i have one thought. when the cost of your medical care is driven by the quantity as opposed to the quality, the outcomes you have a tendency to get the result we're looking at.
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if you look at a hospital bill this thick for a week stay, for this amount, this amount, this amount and an infinite different kinds of categories for care, we don't have to go back too many decades when the bill was one or two pages as opposed to a stack like this. getting away from quantity to quality and outcomes is what really has to happen. a lot easier said than done, but there's no magic solution. that's the formula. >> i think your thesis is right and it is beginning to change. i often said medicaid isn't really a health care program, it's a sick care program. it takes care of folks after they have a problem and that's why we entered into this waver
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agreement 11 years ago now to get permission to deploy medicaid dollars for preventative care. we had programs for kids and for the elderly and workplace wellness and we created patient centered medical homes so physicians are rewarded financially for taking care of people. we used the criteria set up by the national committee on quality assurance that requires regular interaction with patients and we pay an increment of the primary care docs who follow those criteria. i mentioned the aco contract for a small number of medicaid patients in vermont, so i think we're moving in the direction that's been suggested we need to. >> i agree with everything that was said. i think we are making progress. we're doing preventative medicine and all the things that are important, but one thing we
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all need to be cognizant of this isn't purely a market based product. if it were we wouldn't have hospitals and health care in lots of poor areas around the country. for us to try to say that we need to look at market based solutions in health care is wrong because it just -- we have similar demographics in our states, but i'm watching what's happening to rural hospitals closing and the inability to provide health care in some of those spots. market based solutions aren't going to solve that and we need to recognize that while there are improvements that can occur to get better outcomes, there also are things about health care that are never going to be optimal for market based solutions. >> i would say mike levet put his fingers several years ago on one of the critical issues.
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for most citizens they have no access to data about quality, outcomes or about cost. newt gingrich used to say all the time what are the two health care procedures that have gone down in cost? breast augmentation and lasix surgery. why? because neither one is covered by insurance. you know what you pay. you don't have an idea what you pay at the hospital. you're paying for toilet paper by the square. i think that's one thing. the other thing that i don't think i'm the minority, but i may be, too much government makes health care more expensive, not less expensive.
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>> i think we are already over our time. thank you so much to the four of you for joining us. we really appreciate it. [ applause ]
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former president trump campaign manager offered insights into trump's white house, what it took to get there and how the presidential campaign operated. he was in his home state in new hampshire and he sat down at the new hampshire institute of politics. see his remarks on saturday 8:00 p.m. eastern. here's a preview. >> we looked at a couple of different factors coming into the


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