about this morning asfounding fe constitution. the judge in the hush money case gave the jury very specific instructions. these are some of the instructions. your verdict on each count you consider whether guilty or not ilty must unanimous in order to find the defendant guilty however, you need not be unanimous on whether the defendant committed the crime or by acting in concert with another or both. on those instructions the former president took issue. untrue social he wrote it is ridiculous, unconstitutional and the highly conflicted radical left judge is not requiring unanimous decision on the charges against me brought by soros backed d.a.. a third world election for interference hoax is what he has to say. the washington post writing about the former president

comments on truth social. the judge said the jury must be unanimous whether trump is guilty or not guilty of each specific falsifying business records counts and whether he did so in an effort to unlawfully impact an election. that's what the judge said. he added however the panel did not have to be unanimous about which of those three types of crimes c >> he can watch the rest online at anye. we are taking you to a discussion on u.s. health care medicaid hosted live on c-span. >> i've been talking about the country beijing's and benefits for years. so much since i started. when we go back to the first major report i ever wrote, i

basically explained in the report. the report was titled a primer on how employment based distort the health care market. they generally offer one health limits competition and undermines the ability to know product want and need. i have been pursuing policies that give more control. i think that is a better way to organize the market. to drive more competition within the provider space. i also have a lot of alignment with david's view.

i was in the previous administration. i started in late 2017 and ed with the administrator. he outlined all the states that came after 2018. those were all states that had a lot of pressure to expand medicaid. one of the reason they had pressure was a referendum where they knew that they were going to expand medicaid. they wanted to have some control. medicaid has a huge impact on the budget. they did not want to leave it to the ballot box. in particular, one state had an issue because they knew it was coming. we wanted to come up with some sort of idea that was some

alternative to expanding medicaid. not stirred up quite a debate. in july 2018, this was the headline for the new york times. the medicaid proposal after a furious debate. i was not in the room dung that to be, so i cannot confirm or deny how serious that debate was, however, i can confirm that the headlines usually exaggerate a little bit. it was usually a civil and productive debate. when it comes to making a deal, we went partial expansions. we would just go up to 100%.

there were certain positions that were more conservative and encouraged people to get back to work. that was our v the problem with that is that it still leaves this with keeping costs under control. basically, the white house was very concerned about that. they did not do that much in that regard. we did not get into a deal. at the time there was no good policy solution. since 2018, most states that couldedicaid have expanded. very few conversations about medicaid expansion recently, but that is not mean that the issue

is done. we still have the system that expanded medicaid and we still have other issues. with that lack of coverage, there are some conversations expanding medicaid like georgia and mississippi. without the deals in these holdout states, they are ultimately going to expand medicaid. we really do need to come up with a better a■nroach. we need to come up with a deal. i think the answer is yes. time was a big obstacle. developing alternative expansion needed more time. these are waivers that are

allowed to let states get out from under certain provisions of the affordable care act. we published new guidance that allowed far more flexibility on this. however, we knew that we were still a little bit late to the game. by fall 2018, legislative sessions at the state level had already been organized. agendas had been set. all of a sudden, it is 2020 and another election year. states are not going to take that on. even if they get something done, it would still be about when to finalize approaches. butng wecaid s have a change in administration,

there is far more experience from the first time around to allow the administration to actually get a deal. what should a deal look like? i could see the defined contribution fitting in with the waiver above 100%. that would be coordinated with another waiver, possibly. what would that look like? could it be a defined plan? i do not have experience like with other weavers, but i assume they would have difficulty getting approved. maybe congressman stepped in and say it is ok.

i still see policy issues that need to be addressed, if we are going down this road. the main problem with the is just an issue that needs to be addressed. that is the fact that the population of people are -- they have a higher rate of dependency, a higher rate of mental health issues. this presents two problems. the first relates to the risk pool. the risk of the individual health insurance market. they probably would be used by individual coverage. this moves into the individual market and it will increase premiums. it will increase the risk profile. the second issue relates to the fact they are also likely

need to have less ability to manage their care. it will result in worse care for them and it will increase cost to the state, depending on how things move forward and de. when you look at the risk pool, we have some examplesé. both new hampshire and arkansas have done this. the new hampshire approach however did not last too long. they started in 2016 and ended 2018. when they ended 2018, governor

sununu sent a letter to azide, explaining why they stopped. they said by stopping it, the program will bring greater stability to the marketplace, which experienced upward pressure due to the inclusion of those receiving medicaid services. the next slide gives you a picture of what was going on in new hampshire. the line that you are looking at is enrollment. there is a huge number that jumped into the market. in 2019, it was off. they are the ranking of the plan for the state. that is basically a measure of the experience in the market. we can see on the front that they were in the top 10

healthiest states in the country. i 2018, they were in the bottom 10, the least healthy states in the country. that is a problem for the individual market. the people paying higher premiums -- this next slide is a similar way to say the same story. it uses a different measure. the hierarchical conditions category. helping policy experts define the conditions.when you look atw hampshire market -- i also included the arkansas market. there is a much higher percent of people with one or more conditions in the market. in both markets. a higher percentage in new hampshire.

then he moved to 2019. basically dropping medicaid people from their market. they are below the national average. there is a very clear impact when you start introducing them to the market. it is not a goodwhen anything ad to do, you definitely need to account for that. i want to conclude with just a discussion on people that are higher risk people. this issue, back in 2009. this was a program for low income people in the population before expansion happened. not to get mid of it but to inform it. what happened was we convened

them. it was not serving the patients very well. what we ended up with was a much better approach that created some incentives for the local hospitals to take a more managed approach on the fron waiting for people. that worked immediately but then medicaid expansion happened. it■ is basically the evolution f thater an hmo. they are very coordinated with leone ma hospitals. also just social services department. they are very coordinated. i think they have had a lot of

success in what they have been doing. there is a small portion of people who really need something like this within this approach. but that is not the entire population of people. what new hampshire and arkansas were moved into individual market coverage, they had much better outcomes. when you are paying private rates, you get to see a specialist way quicker. evaluation reports for those programs were actually very good but the trouble is that in new hampshire, it had a negative impact on the market. those are the two things that we need to pay close attention to when this approach. with that, i believe it. the next --

>> the next discussion, he has extensive experience focusing on medicaid. congressional staffer, executive branch, outside scholar working on it. inc. of henry waxman with his hands all over the medicaid program. a lot of that legislation is working with him. working on care organizations with research on that. a different perspective. andy schneider. >> good morning. thank you for inviting me. i'm going to be brief. i will take a minute to explain to you that where i work is

nonpartisan center. we are at georgetown university. i'm sorry. yes. you are talking to somebody who is colorblind. you do it. >> there we go. all the information anybody needs. >> that's good. there is a research center there. our mission is to make sure that families have health care coverage. that means mostly to ensure that

low income families are eligible for medicaid if they are work. you can see where this is going. i am kind of the benefit died. we have an issue here. but i do like that we are now only going to talk to the medicaue. it is that it recognizes that there is a problem that we have these holdout states and they are leaving a lot of people dangling in the wind. we do need to file for that. i appreciate figuring out ways to improve situations.

i do not think -- i will use tom's metaphor. let's talk about that for a second. first of all, the here, the low income adults. talking about $21,000 a year. many of them particularly with the caretaker relatives below the poverty level. that is for an individual. as peter mentioned, there are

higher rates of mental health problems and conditions among this population. of course, a lot of them have higher need for health care d r. so, i think i'd start with the table that you saw of the decline in the holdout states from 2015 to 2023. we are moving down from 21 states. the -- one of the drivers there is alluded to here. it is an ocean of the initiative where people decide whether they want health care or not.

it turns out that a number of states have gone into medicaid expansion. missouri, nebraska, oklahoma -- although states go before others and voted for more coverage. a defined-benefit variety. it is not entirely surprising that they feel that way because the deal in the table is not a bad deal. if you are not nt defining benefits, yes, it is not a great deal, but if you are a defined benefits person, the notion that the federal government will pay 90% on an open-ended basis, you have flexibility in your defined-benefit package. but when you take the deal now

and have not expanded yet to get the percentage point increase for your entire population, for your, it is a very good deal. north carolina is a state where i think most people would agree that certain incentives made a difference. that is in place. there are questions being raised about the matches underway and nothing is going away. none of the states that adopted expansion have adopted it. and i know in the paper, if it is a reasonable concern, you would think, you do not take

this off. 90% of the cost, there is still some residual liability for you as a state policymaker. so, if you look at the states with the lowest tax burden, which i have to think the paper for this particularating. this is the total tax burden. six of them are all expansion space. some of them are ballot initiative and some of them are out in front like new hampshire and delaware. neither of those states has walked away. so, how bad exactly is this deal

? does it put us in a position to protect the status and still reduce a number? iaare they federally qualified? it is just a question. so, as you can guess, i am an incrementalist and very generally, i do think it is worth taking a closer look at what is on the table. there is a reference to an expanding. i did not know how to read that. if we are talking about an attack on federal contributions

in the match state spending on this population, i think what truly concerns some of us, understanding that it can be approved. there are a lot of things wrong with it. so, what is that overall spending and do the states who we are looking to market this proposal to understand that there will be a cap on federal spending? ultimately, we are talking about the risk of inflation. they had a great deal of respece

market to contain health care inflation as long as consumers can make their own choices. i don't know. i don't know about that. i was wondering, someone with sickle-cell with hna needs the 3.2 million treatments available. how does that work, exactly? we can work through different examples of services, treatments. it is not clear to me that, at least for the national markets, putting dollars into the hands of individuals in these 10 states, assuming these states take it up, is going to result in better prices from a lot of

these institutions, providers, or manufacturers. the other thing that is unclear -- well, there are a number of things. the thing that i will leave you with is going back to the question of how do we get this proposal anywhere? congress seems unlikely. you can understand that now. if the state is going to pursue this and getwered about how this works it would be through the waiver process. there we have a statutory standard. his demonstration likely to assist in promoting the objectives of the medicaid program? the medicaid program is a defined benefit program.

at least for the foreseeable future it will be. there is a serious question as to if adopting a defined contribution model advances most of the objectives of a defined benefit program. particularly given the risk of shifting the cost of health care inflation to the states, to the beneficiaries, and without any clear indication it will change in pricing behavior for strong moi do appreciate the interest n solving the problem of what we will call thco gap or the remaining uninsured. thank you. ■ >> thank you very much, andy.

i will go at warp speed. feeling like matt damon is the last guest on my own show of jimmy,. this is kind of continuing on. david try to lower expectations. i can lower them even further. inc. of this as stress testing for the way -- think of this as stress testing for fortuitous marketing and complications of administration. there frequently at war in these areas. we can see the health policy deal, but i don't mean the usual way of doing the art of the deal. we will move beyond that, although there's probably some parallel in how you can do that. a few years ago i was great advice on how you want to sell this topic. an article about 20 years.

to succeed politically and reeducate wants to get political success. we will use those standards and see how well this one will hold up on it. battlefield shellsu met some o, though, on that front. we will go through these. the anecdotes, not statistics, i think overcharge handles that in spades. you have plenty of examples of the man is shafting you in the health care marketplace. i think the price is right on this one and can be brought down from what it originally was. i will have to check on amazon today. even the regional markets are working well on having demand match supply. how about the slogans?

i could use help on this front. i offered a few here. they need to go back to the focus group, perhaps. you're talking to the customer, not someone else. that doesn't really flow off of the tongue as well. get more for less doesn't really market well. tomorrow is your problem, not mine. you need to find allies. that is the other component. the lessons from other areas of the economy is that you have to do a bypass, a workaround. usually some kind of new technology, a new face on the product. you are buying something different than before. this is telecommunications, information technology. anted stuff they didn't know they wanted before that was available to them. less so in transportation where

we have the opportunity for deregulation. of course, unfortunately, you have to pay more to do this. more frontload gain, promises of backend savings and backend that is the marketing deal. ■david emphasized, you have to have the right enemies. this condition that i've noticed in government, i don't know if it is a birth defect or acquired on the job, it's very painful and i don't think they have a treatment for it yet but the pharmaceutical companies are working on that. maybe cash-based cosmetic surgery would do that. this centuries old standby, fraudulent providers. it can be your enemy or your ally, it is mix and match depending on what side you're going for.

time consistent choices are real enemy to with, because our human nature is we like something today and want to change it tomorrow. personal responsibility over gratification is uphill. those are your enemies if you're talking about managing your own system. and the system is doing it as well. very simple solutions. i usually caution on this front, words ofery complex problem there is an answer that is clear, simple, and wrong. which can happen on occasion in public policy. first party consumers may be can solve some. we can argue about the degree to which that occurs. the last rule is to never give up and never surrender. ■tthe offset ithe proble is

there are repeat players in the marketplace who know how to do it better. the problem of concentrated benefits. i am running quickly but i can always go faster. there are problems in terms of the nitty-gritty in terms of why, why not, and how. how is the big proble but let's talk about why you would want to do this. you have to get published. that is number one. there are other ones, but let's move down from that. desperation, no other way out. getting in the way of higher objectives. you moved my cheese and i wanted it to be used for something else. that is the cramping item in terms of why health care spending we want to use it for something else. you will have some difficulty. identifiable winners that you can come up with getting in the way of higher objectives. a temporary suspension of disbelief would work well. we like newly appealing beneficiaries. that is how we have done

incremental expansions. if you dress up the people and make them charming you will get that moving forward. it is always in health policy, disruption. it works very well in health policy also appeared more visible losers are usually the case when you make any types of changes. the windows of harmonic convergence for legislating or major policy undertakings are fairly rare, because our system is biased to oppose delay. it is the way that things are wired and they won't change. you kind of disturbed long-term mental resting places we have. we like to think that we gave at the fice to take care of the poor. we don't have to look under the hood. we feel like we did that well enough and that took care of it. that is a little bit of that letting beneficiaries have their own money to handle when we aren't sure what will be done.

we like to pretend that we've taken care of the problem, even if we haven't. how. these are the problems of unresolved matters that come home to linger. i will cut through my usual pop culture at slug, spontaneous combustion, which only happens with spinal tap drummers. another one, how to be a millionaire and not pay taxes as steve martin educated. first get a million dollars, second tell the irs that you forgot. how really matters. the difference between what we think of as private versus market. we already got medicare advantage, medicaid managed care, that is close enough in terms of private. we don't think we need to get this vigorous marketplace. the problem has been pointed out doling the money out as opposed

to matching risk and rewards you will come up short. if you really give it to those in need everyone will say, why didn't i get mine. trust is a big problem. who do you trust to handle your health care? you don't trust the insurers, you don't trust the government -- actually you do trust employers in the latest polling, the problem is we don't trust ourselves. until people trust themselves to make more of these decisions, that is e problem of where the default decision is on who will handle it. problems and infrastructure is not a long-standing issue. go. some other issues in terms of how to start. which is -- and he talked about that incrementally -- you want to start small, but if you start real small it is too small. there is this sweet spot where it is big enough to have

critical mass so you can't rid of it, like hsa's from the start, but not so small that it goes away. you can open doors, but you can't push people through them. that is where yorun into complications. the slide that david had in terms of transitions between social security and medicare is true of almost any major health policy change. the early going until the transition hits you. if you get a conflict between other goods versus subsidized ay comes that we say we want something else as opposed to the next increment of medicine, we will be there. i will give david a few minutes to rebut the entire panel. i thin that is the easiest way to do it and then we will take questions from the audience. either way. >> first, i want to thank tom,

peter, and andy for their helpful comments and calm for going first and last with two bites of the apple. reminding one of the perils of writing things is sometimes people find your earlier papers and say how do you square what you said here with what you said before? the title of the paper that he isixing the distributive injustices in health care." i think a guide for the perplexed, or something like that. getting the haves to come out behind was the[;■jther part of e title. these are issues that i have been puzzling about in various ways for a good long while. that was actually a response to a paper by others, one who is at gw for those of you who want to learn more about that. for peter's comments, i take your point about both the promise and peril of doing this

sort of thing. i'm not ■esure, because we are t calling for either premium support or dumping -- that sounds pejorative -- adding people to the individual market. the lessons from that carryover directly to this. the proposal here is to give people money and let them spend it rather than giving them insurance. the political economy of giving insurance -- partly, there is good research indicating medicaid beneficiaries don't value the coverage they receive anywhere near 100 cents on the dollar. it is more like $.40 on the dollar. that creates obvious possibilities for making people better off by giving them something they value, money rather than something that they don't value, ie medicaid. andy started off by saying i am

a defined-benefit guy so my prospects of persuading were low to begin with. i sell short that possibility. it is clear he doesn't think it will work. that's fine. the laboratories of democracy ideas is that individual st[rats get to experiment with these things. that is true of the states who opted into the current program and the states who opted out of the expansion. what we are trying to do is to meet them on their own terms rather than lecture them that this is a good deal and you should take it. we are trying to identify the factors that we think are important. we don't know for sure what they will think is important. i don't think they're going to go for the current deal, which is why we are trying to come up with ways of offering a different deal. if we can get four or five to sign on we will have covered half of the number of states and if they are big states we will punch above our weight. i don't take the view that we

used to be at 20 and now we are at 10 and the trend will continue indefinitely. i think that the hold out states are holding out because there is something about them that@: maks them not think that this is a good deal. it's not spite. there might be spite, but it is politics, finances, the i didn't know that i was going to be the one to pay for other people's health care that may vary among states as to how much that is an impediment to moving forward. i certainly agree that these are low income adults we are talking about. they don't currently fare well in those 10 states and i'm looking to improve their lives. this isn't a let's stick it to the poor proposal. as to the 1332 versus 1115 waivers, and whether the courts will accept that or not, i don't know.

i think we will see. i think that the goal of medicaid was to provide access to health care for poor people. i don't think it was to run a defined-benefit program. i think that that is a means rather than an end. i have only taugh it was a very unpleasant experience for my students. any time that you teach something for the first time -- i mentioned the trauma episode earlier. it happened three weeks before the end of the semester. one of my students at an email saying, professor, i know that you hate chevron but this seems a tad excessive as a way of getting out of teaching it. i didn't have the teach the last three weeksr, which was chevron. we won't know until we try it. that is true of all sorts of things. i think that the imperfections of our current system,

particularly for medicaid beneficiaries, who even in the states where they have expanded coverage have an insurance card that only works at hospital emergency departments. it didn't really get them access to the general health care system which was a big part of the goal of the great society program. it was to open the doors to the health care system for people. i could go on, but i won't. thank you to all of the commentators. i look forward to comments from the audience. thank you for coming to hear about medicare, medicaid, and defined contribution approaches. davidp suffered for his art and now it is your turn. >> do we have questions from the audience? please identify yourself. i know that you've had an hour to prepare your op-ed. i assume that it has already

been published so just a question will suffice. >> i have a two-part question about medicaid expansion. the first part is, with the existing system, compare the existing system of what medicaid recipients get to the health care they could get. how much are they getting compared to what they should get? the second part of the question is, at the defined level right now, is it an adequate level, should it be higher? how do you decide what level that is? >> there have been multiple studies about access of medicaid beneficiaries. i think we do very well with pregnant moms. we do owe -- we do ok but not great with kids. i think if you need ape challen. we heard discussion of that already.

tions and diseases. certainly, if you offered people the choice between being covered by medicare and medicaid and -- it would be irrational to pick medicaid for regular health caobviously, nursing homes are t covered by medicare, so that would be the one area where you might prefer medicaid. amount, i don't know and neither does anybody else. i would view what we are spending now as a starting point and see what the state's willingness to fund these things are and if the federal government is willing to continue its open-ended commitment when there are lots of other things. we have deficit funding of half of the medicare budgemedicaidi s that involve not just, sort of, u know, positive issues of

u:fact, but also values and whether i am any good at the former, i know i am no good at the latter. >> a question brewing? >> quickly on that, we have a lot of disagreements here, but i don't think anyone will disagree that if you are a low income adults and are not eligible for traditional etiquette and are in an expansion state you are better off. you might not be as well off as others might want, but you are better off than if you are uninsured. you are more likely to have access. that is .1. just a general preposition. .2, you have to look before making a categorical statement about this.

the medicaid of each state. the way that states administer their programs and the way that things work in the trenches in the different state delivery systems, there is a huge variation. thetory in minnesota is different than the story in d.c. or the story in -- pick another. california. before you go and answer that question, you have to look at how things are going in any particular state for that population. >> that is absolutely correct. it is different by state. dy mentioned previously new hampshire and delaware doing better. even though they are lower tax states. they are doing better because they have a lower poverty rate. that is a big reason why. the poverty rate, i wanted to

see a scatterplot of poverty rate versus quality of the medicaid the medicaid program. i think the lower the poverty rate the better the medicaid program will be. the state has to devote less resources to it because it is lower poverty. the hold out states are high poverty areas in many cases. it is really hard for them to make the expansion decision because that will put enormous pressure on the rest of the medicaid program because they have a lot more poor people than minnesota, delaware, new hampshire. i think that's to recognize. it isn't racism it is resources. >> any further questions? seeing that -- >> let me follow briefly. when i started working in this field onofhe first things people said about medicaid is if

you have seen one medicaid program you have seen one medicaid program. there is obviously huge variation, and that will complicate any response to how is the medicaid program doing? it places huge pressure on getting good■$ data. the other point about the research of medicaid versus being uninsured is the randomized study done in oregon gives us materially different results than the observational studies done. i could talk at length about that, but i think that it's clear that medicaid reduces financial distress because it stops you worrying about the medical bills associated with seeing the health care system. the evidence on positive health effects has been much more limited. the positive results in the first year much less impressive in the second year. we unfortunately didn't follow it long enough to see if there are mortality effects.

i think the observational studies are more positive. huge beneficial impacts. i do causal inference stuff. you should trust randomized studies more than observational studies. >> part of the problem in health care politics is trying not necessarily for succeeding. as long as you throw some services at -- we did our best and the outcomes are different matter. one further question? >> i wanted to suggest, instead of each state having features you don't want, your assumpt wit people generally do a good job of evaluating cost and quality and ■making good decisions, and that they would, in this ?context, and thereby lower cost

and increase care. i have to wonder if you really believe that. the other, what happens if someone has a really serious medical condition has spent all of their money? >> on the former, you know -- rational choice model is people maken utility. sorry? >> that is what communists say. >> if you look in the real world you see that except there are a variety of impediments to doing that. that is an invitation impedimenn throw up our hands and assume there is an all-knowinpe in fairness, i have done work on online evaluations of doctors and it is pretty chilling. i took the absolute worst doctors in two states and

compared them with matt controls with clean records and patients were not doing a good job telling them apart in their online reviews. when there are problems we take steps to address itather than running the entire world on a defined-benefit model with all of the pathologies. he didn't like that word, but i think that it's an apt description of certain aspects of our health care, financing, and delivery system. in terms of how do we deal with the unfortunate cases, i only have two minutes? that would be tom's approach. my approach would be to figure out which one we want to fix and are willing to pay to fix. >> priorities. >> i think we set priorities.

because this is a multi-year thing we can recoup money that was not available in the first year. the papercular problem. this is not a let them eat cake, let them starve opposing, it is to try to move from where we are to somewhere that has features that will be better. >> we will wrap up. insurance, and somehow the money does run out. the question is if the doughnut hole will be hidden or made more transpart. you cannot pay for everything, everywhere, all the time. who gets to manage that along the way? i said at the start of the program that this is an ambitious, honest effort to try to work through issues.

we don't have all the answers because it's hard to do this kind of stuff, but there is the possibility that that one claiming thought may come through and turn out -- gleaming thought may come through and turn out. i have seen pigs fly at least once and they might do it again. it might be david's proposal. thank you for coming, and please thank our speakers. [

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