well i'm tom hartman in washington d.c. and welcome to a special holiday edition of the big picture whole team here hope you had a great thanksgiving and i we're going to bring you two very important in-depth discussions i had on the show recently about two of the most important issues facing our nation health care and climate change we begin with the bigger picture discussion from just last week what the recent election means for our nation's health care system now that obamacare is to quote speaker of the house john boehner the law of the land in this discussion i speak with three health care experts about what to expect as obamacare kicks into effect over the next few years and what the

prospects are for a single payer system to finally materialize in the united states so here it is a bigger picture discussion on health care in america. tonight we have a special bigger picture discussion on health care in america an increasing number of republicans in congress acknowledging that obamacare is here to stay and president obama winning reelection it certainly seems that obamacare as speaker boehner put it is the law of the land and with obamacare millions of americans will have unprecedented access to affordable health care many of them for the first time but while the up shots of obamacare seem clear the details and fine print of the law are hazy at best and it will get down to the nitty gritty of obamacare and answer the pressing questions that americans on both sides of the aisle are asking about president obama's signature legislation joining me for the discussions and i are ethan rome executive director of health care for america now karen davenport

director of national health policy with the national women's law center and ron pollack executive director of families u.s. . say thank you all for joining you tonight great to have you all with me. first of all just a general question i'd like to toss out to all three of you one of the big problems with health care in the united states seems to be affordability part of that is the health insurance companies have been skimming twenty thirty forty percent off the top for a long time for. is america going is health care in america going to get more affordable let me start with you ron what is going to be more affordable and for individuals and families one of the things that people are going to really value is that people are going to get tax credit subsidies to make coverage more affordable so when people go into these new marketplaces called exchanges and they purchase insurance through these exchanges a very substantial portion they're going to get significant tax credits subsidies and that will mean the premiums that they have to pay out of pocket will be

considerably lower and you mentioned before that insurers often take over a fair amount of money for marketing advertising agents c.e.o.'s making a billion dollars c.e.o. compensation and profits you know that's actually being significantly regulated now insurers have to spend at least eighty cents out of the dollar in the larger plans eighty five cents out of the dollar in actual health care for people so that's a big deal and by the way any plan that fails to do that has to pay rebates to those people who have enrolled and you're over a billion dollars in rebates that have been paid already this year so care and we're we spend about twice as much as any other country in the developed world the o.e.c.d. nations on health care on a per capita basis and our results are not that different from the more well developed countries are we going to see not just the individual affordability that

ron was talking about but affordability care costs under control system i think that well one of the really unheralded parts. my care is the investments that it makes in improving the value of what we get for our health care dollar a lot of that starts with the medicare program which is a place where the federal government does makes the payments to physicians and hospitals and is able to really experiment with that but i think we'll see that spread into private insurance and playing employment based insurance but not too long a time when they all want to add to what ron said about affordability also one of the real achievements of the affordable care act also is that women will no longer be paying more for the same health care that men purchased. is no longer a preexisting condition that's exactly right even a woman's no longer a preexisting condition and right now women pay twenty percent or more for the same policy that men can purchase in the individual market the spread is that water can be more than that too it depends on the state but right now women are paying about

a billion dollars more in premiums every year compared to men for the same coverage and that will no longer be allowed as the law comes into place good things. thoughts of the states and i think you know one of the things that this does is that eliminates discrimination against people with health care conditions one of the most outrageous things about health care in our country is if you purchase insurance and if you actually need it they drop you they won't sell you the policy they'll charge you more this involvement it's that it ends insurance discrimination ends abuses of insurance consumers and what it does do is put this on a path to focus more on health care outcomes instead of debate about health care financing we can go getting people healthier instead of people going through medical bankruptcy so that's what makes this so significant is that it does make health care affordable for businesses for families and it changes the completely unscathed for health care workers my sense of this law is that this is very much

a starting point that we may be just a little behind the curve the scotch want to hear you know a general. two generations ago when they went with a single payer health care system and then the other states across the other provinces across canada so they wouldn't be too. is curious and should be your son so is this a beginning point or is this something that you know twenty years from now is still going to be in place pretty much as it is i think every national reform that we've had in this country of any kind whether a civil right or a program has had to be protected and is still being perfect but so this is a first step but it's an extraordinary first step and it puts the makes implementation such a priority in the next twenty four months all of these things come on line people get insurance people get subsidies and so that's why it's so important for governors to stand down from their politics and stop being partisan about this law is the law of the land and we all need to come together to make it

a reality for everyone look here and speaking of the governors being partisan you have we have a handful of republican governors who have some of it's great it's a growing handful maybe just two handfuls who are explicitly coming out and saying no we're not going to do the exchanges in our state and and there's a one body of thought that suggests that buys by saying that basically the federal government are going to end up with the federal exchanges and that actually may be a good thing there may be economies of scale there you know rather than having an exchange replicated eight or ten times there's just one federal exchange it could be run more efficiently might it actually be a good thing that that these republican governors are saying no we're not going to do in exchange for state to for the for the citizens of their state well i i think it's pretty ironic when and hire any they say we need to get our heads around right in some cases i think they exchange that they're fed the federal government will

facilitate in some states will have better consumer protections and probably better standards for health plans that you might see if the state were to. put it together itself so by those governors saying they don't want to play they may actually be doing a good deed for the citizens of their states and in some cases you know there are some states that are very small and run in exchange is going to be you know probably isn't that much of a doable concern for them and so having the ability to have that federal exchange that they can tap into whether they're in partnership with the federal government or have the federal government do it itself a state like delaware new hampshire or you know someplace with a small population that's probably going to be a good choice for them and you're right isn't there an incredible and almost a lucia's irony there about a republican governor of governors and i don't want i don't want a federal takeover of my health care is now it's all going to turn this over to the frets. that's right so you've got these conservative republican saying i'm not

going to do it so they say come on in federal government so there is this delicious irony you know i would say as ethan was indicating to your previous question the affordable care act provides a really important foundation but you know many very significant pieces of legislation created a foundation social security when social security act was passed in one nine hundred thirty five it didn't cover over half the women in the workforce it didn't cover over two thirds of the people of color in the workforce but we fix those things. civil rights legislation took a long time to be implemented i would say to you the biggest challenge that we have now with respect to the affordable care act with respect to implementation is we've got tens of millions of people who don't have health coverage and i just came back from a number of focus groups of people who are uninsured or recently were uninsured and

literally not a single person in the four focus groups that i saw in philadelphia. and then there were focus groups in columbus ohio then in miami and tomorrow in san antonio literally not a single person knew how the affordable care act was going to affect their lives so the big challenge for all of us and for the obama administration is to create a big public education so how is it going to affect their lives if there's somebody watching the program right now as it had insurance for the last x. years and hasn't gone to the doctor because of it or if they have a suspicion you know they paid one hundred bucks out of pocket to get severe drops or something but that was it how is this going to change their lives for it's it's a very significant so there are two different groups of folks. for those people who are middle class and moderate income they're going to now be able to go to this new marketplace they'll be lots of private insurance plans they'll select one of those

and if they have income say for a family of three of less than seventy five thousand dollars they will get a tax credit subsidy to help pay for a portion of the premium so they won't have as much of an out of pocket cost for those premium tax credit is an actual check from the government that's right so that's one group of people the other group are low income folks people with incomes below one hundred thirty three percent of poverty for a family of four we're talking about roughly thirty thousand dollars in annual income they will now be eligible to participate in the medicaid program will be the program will be expanded however but some states are saying some of these republican governors are saying we don't want your stink on that or medicaid everyone else yes you're right however in the first three years in twenty fourteen fifteen and sixteen the federal government will pick up one hundred percent of the costs of those newly eligible and thereafter it diminishes somewhat

but it never goes below ninety percent so there's an important lesson by the way with respect to the budget fight the. now taking place here in washington if the governors are going to opt into medicaid they're going to have to feel that the payment that the federal government is providing is reliable that it's stable and so there's a real important lesson for the folks who are going to be negotiating the budget don't cut the medicaid program if you want to make sure that obamacare truly reaches the people without legislation the republicans who want to blow it up be sure to cut medicaid because then we're going to you know it's going to be a very interesting one to keep track and do you expect that that battle is going to happen i do expect that that battle is going to happen i would say we're very confident the president is going to stand let's hope so more of tonight's bigger picture discussion health care in america right after this break.

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don't tell me. welcome back to our bigger picture a discussion of health care in america with me tonight ethan rome karen davenport

ron thank you all for being with us tonight ethan pain for the the whole world is the funding come from how do we make sure that the funding is there how do we make sure that we don't get to three four years down the road if ministration changes the republicans take control of the house pull the rug i mean it will what's the mechanism i mean the law paid for itself and in fact it created a budget it contributed to reducing the budget deficit the fight that's going on right now that relates to how we pay for health care is the fight to defend medicare and medicaid in the so-called fiscal cliff discussions the budget debate there is you know this week and next week in this week right here in washington that we are all happed up about the so-called fiscal cliff the fiscal curve the showdown whatever you want to call it it's a debate over priorities it's a debate about what we want our country to be and for those of us who support

medicare and medicaid who believe that health care is something everyone ought to have it starts with having the wealthiest people in this country contribute their fair share and to. unfortunately the republicans have been drawing a lot of the said and it makes no sense makes no sense at all and so it's just so critical not just for the affordable care act but for medicare and medicaid for health care for people disability for the elderly for all of us and that's why we're very very hard for them and the president has made it quite clear that he's going to stand for the. revenue and he's going to stand up for these programs cures the director of health policy with my shoulders was how does this affect women and families and what is how is it going to be different to yours you know that it is now what i was going to be different two years after well the immediate issues around the budget debate women have a lot of stake out in because not only are programs like medicaid and medicare that are so important to women's health care you know potentially open for forward

negotiation but programs that support child care and the able in women to get higher education and improve their family's financial security off those kind of programs that are at risk too and that's why you know like ethan we think that having the revenue the new revenues being part of the mix is such an important piece. but you know stepping back and looking at how does health care reform end up helping women it's going to i mean it already is women are able to to access preventive services like mammograms and contraception without co-payments when. the full flower of the law is implemented in two thousand and fourteen the kind of benefits the plans will need to offer include maternity benefits which are not very easy to find in the individual market these days and so that is something that everybody every woman will be able to have covered you know the kind of financial cost that families look at in terms of their health care is just going to really

change in terms of what's covered and what how much they have to pay out of pocket for the services they were. we need thank you ron we were talking about the politics of this before we started you know touched on this topic how do you see this playing out over the short term and over the long term political in the short term i think the real battle is going to be on revenues and the president campaigned. very clearly that he thought that the wealthy should contribute a portion of what is needed to get us better in balance i think the president's going to win that battle i think the president is not going to yield on that battle . so i think that'll be the short term battle with the cliff in effect the president is saying let me move forward and continue to provide tax

cuts for middle class families. but don't hold hostage the need that i have to do this for the wealthiest families and i think the president's going to win that by the way if the if if congress does nothing then all the tax cuts are. in and so it will hurt middle class families after that happens then there is going to be a real budget fight and what we have looming is that the debt ceiling is going to have to be raised and i think that's when you're going to have most of the bargaining and you know the republicans in the house last really tried to decimate the medicaid program and what congressman ryan the chairman of the budget committee tried to do is to cut the medicaid program by one and a half trillion dollars over ten years more than i think you can take any six programs in the country and combine them and the cuts that he proposed would not

equal the cuts that he proposed in the medicaid program and of course we want to restructure the medicare program the. president has bones for us you know he has you know he wanted to make it a voucher type program those things are not going to happen and the president was really clear about where he stands on those things and you know elections mean something and i think those things are not going to happen i think the president is going to stand firm and i think we're going to wind up having a deal that is going to protect these health care programs. what's hope so from your lips to god's ears will see karen vermont i lived among for ten years a. great affection for the state and they passed through their legislature a single payer health care system this was like a year and a half ago pastor governor peter shumlin actually campaigned for governor if this gets passed i will sign it one the governorship signed the bill is it twenty

fourteen or twenty sixteen that the waivers kick in and that allow the states to do this and is this the crack the door cracking open two to the first major expansion or transition of this program i think it is either twenty six hundred twenty eight different back up here from my colleagues that there's still waivers to do something rather very different come in a couple of years after the full implementation of the affordable care act you know i don't. i think it will be fascinating to see what vermont does and how a couple of other states move forward and share instead of about have to redesign the mare or their whole state programs and say and looking at single payer. my personal view is that we we've taken such a big step with the affordable care act we tend to sort of move more in a more evolutionary manner in our health care system then phantom make those kind

of big changes and they will show us if we can can take that kind of big step and then we'll see where it goes from you know having talked about this on previous occasions. it's not an easy thing in this country to move towards a single payer system in fact. in you know when the fordable care act was being debated and you had democrats in control of the house and the senate it was even difficult and it wound up not being included having a public plan arguably democrats were in control the sun at that point you know when this scott brown had been sworn in and so there was not a lot but even before even before that even even before scott brown was elected this passed the senate actually on three different occasions before scott brown was elected and and a public plan option could not pass the senate. i think our big challenge now is to

make sure that we fordable care act is implemented effectively just and i think you know make this thing let's build confidence about this and the most important thing is let's make sure that the tens of millions of people who don't have coverage today actually get enrolled and so that's going to require a huge public education campaign and it has to be run like a campaign so that the people who can benefit from it actually know about it and then get a role in there's you know the pushback is you're giving people. yes it's healthier it's a gift we can't have that and there's all these new taxes you know. six taxes eighteen taxes three hundred twelve all these different numbers. how do you respond to those well here's the thing i mean i think i mean obviously after the whole campaign what's really really clear is that there was two candidates one of whom campaign to rebuild the middle class and one of whom did it one of whom believed in

the middle class and the other of whom talked about a slacker class and so the middle class one and when it comes to all of the debate about this law has been totally political i've never met an uninsured person who says i don't like this law it's too complicated right i just doesn't have it right and so you know and small businesses that are struggling with health care costs that actually provide health care for their employees are excited about this so you know i'm of running care and we need to keep our eye on the prize right now implementing this law thirty five million people get health insurance medicare medicaid get stronger we improve care we get better outcomes that's what this is about and and the politicize it right it's there you know we were just a little few a few days after the election when our point with everybody is let's just stick with policy for a few minutes and talk about well speaking of there are. going to be enough doctors

and nurses this is another one of the things that was brought up in the er in the in the debates you know if you give everybody health care that everybody's going to show up at a doctor's office and the system will write down what we already have in particularly in certain areas particularly rural areas we have a shortage of physicians portable characterized to improve. it's going to be an incremental improvement they're going to be somewhat improved payments to primary care doctors those are the doctors we really have those are the folks that we have to do better. yeah we need more primary care doctors you know if you compare the united states to other countries one of the glaring differences is the ratio of specialists versus primary care doctors and we have a much higher ratio of specialists we need to have a whole lot more primary care doctors we're going to move in that direction it's going to happen overnight is it going to be quick enough for you know it's it's

going to be incremental but it is going to be an improvement over your career and you do expect to i've been watching this british t.v. series called doc martin that's about it a little country doctor you know and he does everything i mean he does everything he delivers babies he stitches people it does things that you know here in america people are always sent out to a specialist do you think that nature in the minute we have left here that the nature of medicine in the united states is going to change as a consequence of the affordable care. well i suppose in some ways what i think we'll see are not so much that that solo practitioner doing everything but you know continue to see more physicians working together and to see. you know people like physician assistants and nurse practitioners really providing a lot of frontline care to bet in the most important way i think we're going to be seeing people who today don't have health insurance but have chronic illnesses like diabetes and heart disease they're going to be able to get the care they need to

manage those diseases and to live better and for their lives and that's the kind of improvement we're really looking for critical stuff. and thank you all so much for the great conversation. to see this bigger picture discussion again or to see any of our conversations great minds go to our website conversations with great minds dot com.

and welcome back to the big picture i'm tom hartman of washington d.c. in this half hour we bring you another recent bigger picture discussion this one about climate change in just the last week we've seen major new developments one.