1 00:00:16,920 --> 00:00:20,879 We're back with another edition of the Federalist Radio Hour. I'm Emily Drshinsky, 2 00:00:20,960 --> 00:00:24,160 culture editor here at the Federalist. As always, you can email the show 3 00:00:24,199 --> 00:00:28,280 at radio at the Federalist dot com, follow us on Twitter at fdr LST. 4 00:00:28,519 --> 00:00:31,760 Make sure to subscribe wherever you download your podcasts, and if you want 5 00:00:31,760 --> 00:00:34,560 to support our work, you can head over to the Federalist dot com and 6 00:00:34,600 --> 00:00:38,880 subscribe to the premium version of our website as well. Today we are joined 7 00:00:38,880 --> 00:00:43,280 by Brian Blaze. Brian is the president of the Paragon Health Institute. You 8 00:00:43,320 --> 00:00:49,920 can find more information about Paragon at Paragoninstitute dot org. Brian is so intimately 9 00:00:49,960 --> 00:00:54,719 familiar with the topic of healthcare and conservative healthcare policy. He was a Special 10 00:00:54,759 --> 00:00:59,159 Assistant to the President for Economic Policy at the White Houses National Economic consul from 11 00:00:59,200 --> 00:01:04,040 twenty seventeen to twenty nineteen. He also worked on the House Oversight Committee their 12 00:01:04,079 --> 00:01:10,400 government healthcare reform efforts, their entitlement program oversight and investigations from twenty eleven to 13 00:01:10,439 --> 00:01:12,359 twenty fourteen. Then he went over to the Senate side, where he was 14 00:01:12,400 --> 00:01:19,599 doing Republican the Republican Policy Committee's Health policy analyst work from twenty fourteen to twenty 15 00:01:19,680 --> 00:01:25,760 fifteen. So if you're following that timeline, Brian basically has been involved at 16 00:01:25,799 --> 00:01:30,159 the highest levels of the Republican Party and the conservative movements efforts on healthcare for 17 00:01:30,200 --> 00:01:34,879 the last decade plus. And we talk a lot on the show about healthcare. 18 00:01:36,000 --> 00:01:42,359 I can't pretend to ever approach healthcare expertise. I'm not that delusional, 19 00:01:42,400 --> 00:01:47,280 but I do know that it matters a whole lot more than we hear about 20 00:01:47,319 --> 00:01:51,239 it in the news and especially from people on the right. So Brian, 21 00:01:51,640 --> 00:01:55,319 with that all said, thank you so much for joining us. It is 22 00:01:55,359 --> 00:01:57,959 great to be with you. Thanks for having me, Emily. Yeah, 23 00:01:57,120 --> 00:02:00,439 So Brian is the again. He's a president of Paragon, which is out 24 00:02:00,480 --> 00:02:04,959 with a new paper actually on the failures of the Affordable Care Act. And 25 00:02:05,359 --> 00:02:08,639 Brian actually some of these critiques as I'm reading the paper are actually being echoed 26 00:02:08,680 --> 00:02:13,120 by folks on the left. They'll have a different solution, but when they 27 00:02:13,240 --> 00:02:16,159 look at some of the failures of the ACA, they look at the prices 28 00:02:16,199 --> 00:02:20,680 of coverage, quality of coverage. Even some people on the left that are 29 00:02:20,680 --> 00:02:23,479 willing to kind of buck the establishment are saying, hey, something went wrong 30 00:02:23,599 --> 00:02:28,800 here. Maybe a good place to start is just some of those big takeaways 31 00:02:28,840 --> 00:02:32,439 from when you and your colleagues looked into the last decade plus of the Affordable 32 00:02:32,479 --> 00:02:38,919 Care Act. Yeah, so one, it's misnamed, right the Affordable Care 33 00:02:38,960 --> 00:02:44,560 Act indicates that what they were concerned about was the cost of health care and 34 00:02:44,639 --> 00:02:49,960 the cost of coverage. But that's not what the overall aim of the law 35 00:02:50,280 --> 00:02:53,960 was. The overall aim was to expand the number of people that had health 36 00:02:53,960 --> 00:02:59,960 insurance, and there were two main ways that Obamacare or the Affordable Care Act 37 00:03:00,080 --> 00:03:05,879 did that. The first was to have states expand their Medicaid programs. So 38 00:03:05,960 --> 00:03:12,080 Medicaid is traditionally a program for the welfare program for certain categories of low income 39 00:03:12,120 --> 00:03:15,439 individuals, kids, pregnant women, people with disabilities. So they wanted states 40 00:03:15,479 --> 00:03:21,159 to expand their Medicaid programs, and the federal government offered a lot of money 41 00:03:21,199 --> 00:03:24,159 for states that expanded their Medicaid programs. But the heart of the law, 42 00:03:24,360 --> 00:03:30,360 what President Obama talked about at the time, was that they were going to 43 00:03:30,360 --> 00:03:35,560 reform the individual market for health insurance. So the individual market is where people 44 00:03:36,000 --> 00:03:39,560 who are working age, you know, have families that don't get insurance through 45 00:03:39,599 --> 00:03:44,840 their employer. Where they go to purchase coverage. And they said, we're 46 00:03:44,840 --> 00:03:49,919 going to create this robust, dynamic, awesome market where people are going to 47 00:03:50,000 --> 00:03:55,080 want to go and buy health insurance coverage. And they put a whole bunch 48 00:03:55,080 --> 00:04:02,360 of sort of new requirements on health insurance, significant subsidies for the purchase of 49 00:04:02,400 --> 00:04:10,479 health insurance requirements, the so called individual mandate that people had to purchase coverage 50 00:04:10,680 --> 00:04:15,120 or face a penalty. And what the Paragon Report really looked at was these 51 00:04:15,160 --> 00:04:20,519 individual market changes. The authors, which are two actuaries that have studied the 52 00:04:20,600 --> 00:04:27,079 law very carefully went back to what was promised and projected when the law passed 53 00:04:27,480 --> 00:04:32,399 and compared it with actual results. And it turns out that the individual market 54 00:04:32,600 --> 00:04:40,519 is only about half the size of what was expected before the laws key provisions 55 00:04:40,560 --> 00:04:46,560 took effect, and that the average cost per new individual market and rollly is 56 00:04:46,839 --> 00:04:53,959 more than three times what was expected. So half enrollment at triple the cost. 57 00:04:54,839 --> 00:04:59,360 Giving sort of the law, the key provisions of it get a failing 58 00:04:59,399 --> 00:05:04,040 grade relative to what was told would happen at the time. And how much 59 00:05:04,040 --> 00:05:09,839 of this has been realized with the more time passes. I mean, I 60 00:05:09,839 --> 00:05:12,839 actually remember at the time a lot of this was fairly clear. Some of 61 00:05:12,879 --> 00:05:16,319 these predictions were pretty easy to make. But as more time has passed, 62 00:05:16,439 --> 00:05:21,160 how has that, I guess, sort of exacerbated or shown the problems that 63 00:05:21,199 --> 00:05:26,839 were always at the heart of the law. Yeah, so if you go 64 00:05:26,959 --> 00:05:30,879 back, if you take the time machine, I guess back when the exchanges 65 00:05:30,959 --> 00:05:33,079 launched at twenty thirteen, you know, a lot of the criticism at the 66 00:05:33,120 --> 00:05:36,000 time was, well, it's just a bad website, Like the government can 67 00:05:36,040 --> 00:05:41,439 figure out how to get a functional website. So it's sort of these mechanical 68 00:05:41,519 --> 00:05:46,839 problems that are at the root. But you know, the overall construction would 69 00:05:46,879 --> 00:05:51,279 have been great if we could have gotten the website off the ground. So 70 00:05:51,360 --> 00:05:57,680 in twenty fourteen, you know, enrollment was about where it was expected to 71 00:05:57,720 --> 00:06:02,000 be. In twenty fourteen, were about eight million people signed up for these 72 00:06:02,040 --> 00:06:09,720 exchanges, and that was pretty much on par. But it turns out that 73 00:06:10,000 --> 00:06:15,920 the exchange plans tended to be very narrow network, meaning they didn't cover a 74 00:06:15,920 --> 00:06:21,079 lot of doctors and hospitals, and just weren't that appealing to people who didn't 75 00:06:21,120 --> 00:06:30,160 get large subsidies to purchase the plans. So enrollment increased in twenty fifteen to 76 00:06:30,199 --> 00:06:34,879 about ten million people and has stayed at that level through twenty twenty. So 77 00:06:34,920 --> 00:06:40,600 the individual market was really and that is along the way I mentioned in my 78 00:06:40,639 --> 00:06:46,639 intro the individual mandate packs penalty that was eliminated by Congress in twenty seventeen, 79 00:06:46,680 --> 00:06:53,040 and President Trump signed that into law. So the individual mandate repealing that penalty 80 00:06:53,040 --> 00:06:56,800 didn't really have any effect either. It just turns out that what we learned 81 00:06:57,040 --> 00:07:03,160 was the only people who really purchased products in this market were either those that 82 00:07:03,279 --> 00:07:09,279 had really expensive medical conditions and they expected to use lots of medical care, 83 00:07:10,120 --> 00:07:15,199 or low income households that got very big subsidies to purchase these plans. 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And these costs, as you mentioned, 109 00:09:20,120 --> 00:09:24,840 are astounding just looking at this. The cost to taxpayers Paragon rights has 110 00:09:24,879 --> 00:09:28,840 been thirty six thousand, seven hundred and ninety eight dollars per additional private insurance 111 00:09:28,919 --> 00:09:33,120 enroly and twenty thousand, seven hundred and thirty nine dollars per additional non group 112 00:09:33,240 --> 00:09:39,279 enrollly, which is more than triple the CBO's original projections of around ten thousand, 113 00:09:39,519 --> 00:09:43,039 well actually around eleven thousand and around seven thousand, respectively. These numbers 114 00:09:43,039 --> 00:09:46,799 are astounding, and I guess I wonder why it does from your perspective that 115 00:09:48,399 --> 00:09:52,480 this isn't being treated like a five alarm fire by people on the right. 116 00:09:54,240 --> 00:09:58,120 So that's a great question. I say. First, the way that we 117 00:09:58,200 --> 00:10:03,480 measured the efficiency was in this and with the actuallys in this paper, they 118 00:10:03,519 --> 00:10:09,159 looked at what's the new government spending divided by the number of new people that 119 00:10:09,240 --> 00:10:11,919 got coverage, and that sort of gives you a measure of efficiency for these 120 00:10:13,000 --> 00:10:18,639 changes. How much are taxpayers bearing for each additional enrollly, you know, 121 00:10:18,799 --> 00:10:24,840 I do think that Republicans viewed it as a real serious problem and a good 122 00:10:24,840 --> 00:10:31,879 political issue for them through twenty sixteen. So when people started losing coverage and 123 00:10:31,960 --> 00:10:37,759 it was clear that President Obama assurance that people wouldn't lose plans that they liked. 124 00:10:39,559 --> 00:10:43,120 Back in the fall of twenty thirteen, when millions of people started realizing, 125 00:10:43,159 --> 00:10:46,080 oh, I am losing coverage that I like. Right, that was 126 00:10:46,080 --> 00:10:52,360 a real major problem, and there were some band aids put in place by 127 00:10:52,399 --> 00:10:58,120 the Obama administration to sort of paper over that problem. But Republicans got unified 128 00:10:58,200 --> 00:11:03,879 control of government in twenty seventeen, and one of the reasons is because of 129 00:11:03,960 --> 00:11:09,159 how unpopular Obamacare was at the time. And I think it is an issue 130 00:11:09,320 --> 00:11:15,120 of the dog that caught the car, and they just weren't prepared with a 131 00:11:15,159 --> 00:11:20,759 plan for what to do to replace the aspects of the ACA, and they 132 00:11:20,799 --> 00:11:26,480 had gotten into sort of this repeal and replace slogan. This sounded good but 133 00:11:26,600 --> 00:11:31,320 didn't have any substance behind it. It shouldn't have been the slogan. I 134 00:11:31,559 --> 00:11:39,519 would have liked to repeal most of the ACA, but that the political exercise 135 00:11:39,559 --> 00:11:43,759 in twenty seventeen was really what can we do to repair and reform the ACA 136 00:11:46,120 --> 00:11:50,240 and get rid of the worst aspects of it. And I think the failure 137 00:11:50,279 --> 00:11:56,919 of the party in twenty seventeen to really coalesce around something, to figure out 138 00:11:56,960 --> 00:12:03,000 what could pass both Houses of Congress and be in improvement left the really bitter 139 00:12:03,120 --> 00:12:07,000 taste in the mouths of Republicans. So I get asked now by reporters like 140 00:12:07,279 --> 00:12:11,840 they wanted to know why aren't Republican presidential candidates talking about healthcare? And my 141 00:12:11,919 --> 00:12:16,480 answer is because there's so much else they can be talking about right now, 142 00:12:16,799 --> 00:12:20,120 Like people are concerned about lots of things with President Biden and his competency, 143 00:12:20,240 --> 00:12:28,440 They're concerned about the general economy, They're concerned about rising energy prices. Like 144 00:12:28,639 --> 00:12:33,320 healthcare is a complicated issue. There's serious problems with our healthcare sector, but 145 00:12:35,000 --> 00:12:39,159 it's not where Republicans have a bad experience in twenty seventeen. And I think 146 00:12:39,200 --> 00:12:43,960 there's just so much else in the political landscape right now. So some of 147 00:12:43,960 --> 00:12:50,320 the serious policy issues on healthcare are being neglected. I think for those reasons. 148 00:12:52,080 --> 00:12:54,240 Yeah, that all makes sense. And if we peel that sort of 149 00:12:54,360 --> 00:12:58,720 layer of the onion back even further and then get to the next layer, 150 00:12:58,759 --> 00:13:07,039 the question of why there hasn't been a real rallying consensus point about what to 151 00:13:07,080 --> 00:13:11,279 replace the ACA with. I'm fascinated by your perspective on that brand because you're 152 00:13:11,320 --> 00:13:16,799 sort of behind the scenes as the Trump administration and Republicans in Congress for a 153 00:13:16,799 --> 00:13:20,200 really long time, we're trying to land on something and almost it got very 154 00:13:20,240 --> 00:13:24,600 close with you know, basically at the very last minute, the late John 155 00:13:24,679 --> 00:13:30,919 McCain, you know, was one vote away became that one vote of separation. 156 00:13:31,440 --> 00:13:35,919 But it still stands out that even with a unified government, Republicans, 157 00:13:35,960 --> 00:13:39,120 after you know, ten years of replaced, didn't have something to kind of 158 00:13:39,200 --> 00:13:43,600 rally around, and that was, you know, an easy thing to do. 159 00:13:43,159 --> 00:13:54,679 Why is that so? I think hardly. It was a process that 160 00:13:54,879 --> 00:13:58,720 was in place. So Republicans have fifty two seats in the Senate in twenty 161 00:13:58,720 --> 00:14:07,039 seven team and had to use the reconciliation process, and the reconciliation process allows 162 00:14:07,080 --> 00:14:13,639 you to pass legislation in the Senate with just fifty votes. But the primary 163 00:14:13,799 --> 00:14:18,440 the provisions that you affect through that process have to be primarily budgetary, so 164 00:14:18,519 --> 00:14:24,159 you couldn't get at all the harmful aspects of the ACA or all the reforms 165 00:14:24,159 --> 00:14:28,840 that you would want to do through the reconciliation process. So initially there was 166 00:14:28,879 --> 00:14:31,559 a thought, well, we'll do it in two steps. We'll repeal the 167 00:14:31,600 --> 00:14:35,440 parts of the law that we can repeal through reconciliation first, and then we'll 168 00:14:35,480 --> 00:14:39,639 come and we'll do replace and replace. Mate, you need to have bipartisan 169 00:14:39,720 --> 00:14:46,559 support to figure out what the replace was. In retrospect, that's the play 170 00:14:48,039 --> 00:14:52,519 call that should have been run. But the decision was made not to run 171 00:14:52,519 --> 00:14:56,080 that play. It was to do repeal and replace simultaneously, and it was 172 00:14:56,200 --> 00:15:03,200 just too complicated for Republicans to figure around what the replace mechanism was going to 173 00:15:03,200 --> 00:15:07,519 be. I can say so the congressional effort failed in twenty seventeen, but 174 00:15:07,600 --> 00:15:11,279 the Trump administration, and this is a large part of what I did when 175 00:15:11,279 --> 00:15:13,600 I was in the White House at the time, was figure out what we 176 00:15:13,600 --> 00:15:18,320 could do administratively to help people that had been most harmed by Obamacare. And 177 00:15:18,360 --> 00:15:22,960 there's really there were two sets of people that were most harmed. One it's 178 00:15:22,960 --> 00:15:30,600 sort of middle class families without employer sponsored insurance that faced doubling tripling of premiums 179 00:15:30,600 --> 00:15:35,320 and deductibles because of Obamacare. And the second was small businesses in their workers, 180 00:15:35,399 --> 00:15:39,240 which were increasingly not able to offer coverage because of how Obamacare had increased 181 00:15:39,240 --> 00:15:43,799 the price of coverage. So the Trump administration did rules that allowed small businesses 182 00:15:43,840 --> 00:15:48,039 to band the gather to offer coverage, something called association health plans. We 183 00:15:48,080 --> 00:15:52,399 opened up alternatives that weren't subject to any Obamacare rules and regulations called short term, 184 00:15:52,440 --> 00:15:58,480 limited duration insurance, and we allowed employers another way to offer health insurance 185 00:15:58,679 --> 00:16:02,960 where instead of the employer having to select the health plan for all the workers, 186 00:16:03,399 --> 00:16:08,919 the employer provides a contribution that the worker takes which is not taxed, 187 00:16:10,039 --> 00:16:12,879 and the worker can then take that contribution and buy a plan in the individual 188 00:16:12,879 --> 00:16:17,799 market that works best for them. So there were some actions that the administration 189 00:16:17,960 --> 00:16:22,200 did on its own that I think relieved some of the pain that people faced 190 00:16:22,440 --> 00:16:29,799 from Obamacare. But you still have all of this inefficient, wasteful spending, 191 00:16:29,879 --> 00:16:33,840 these subsidies that go directly to health insurance companies, and that are linked to 192 00:16:33,879 --> 00:16:38,559 the premiums. So this is one of the problems with the Obamacare financing is 193 00:16:38,600 --> 00:16:44,480 that you have subsidies, and the subsidies go up dollar for dollar as premiums 194 00:16:44,519 --> 00:16:48,679 go up, So all of the premium increases over time have been borne by 195 00:16:48,720 --> 00:16:53,639 the federal taxpayer. The enrollees are pretty insensitive because they don't pay the rising 196 00:16:53,679 --> 00:17:00,720 premiums over time, and insurers can price knowing that they're enrolled. Lease are 197 00:17:00,720 --> 00:17:03,599 not price sensitive that it is the taxpayer that's picking up the full cost. 198 00:17:04,240 --> 00:17:07,920 So you've got a very inflationary sort of pricing dynamic there that leads to a 199 00:17:07,960 --> 00:17:14,920 lot of waste we'll spending. So if you listen to this podcast by now, 200 00:17:14,960 --> 00:17:19,000 you've definitely heard about this crazy digital dollar idea that's being talked about everywhere. 201 00:17:19,000 --> 00:17:23,240 It's the one where the government monitors and could control your money. I 202 00:17:23,240 --> 00:17:27,319 mean, central banks and countries like China, Andy and Australia have already begun 203 00:17:27,640 --> 00:17:33,559 transitioning to a digital currency, and the Federal Reserve has been contemplating the same 204 00:17:33,599 --> 00:17:37,039 thing here in the United States. 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Yeah, and 218 00:18:41,279 --> 00:18:44,000 again, as somebody who's worked really closely on these issues for a while, 219 00:18:44,920 --> 00:18:48,480 people tend to see the healthcare industry almost as a monolith, but of course, 220 00:18:49,079 --> 00:18:55,680 special interests are different, whether you're talking about hospitals or pharma or any 221 00:18:55,720 --> 00:19:00,680 of these other kind of blocks of the industry. That individual they might have 222 00:19:00,519 --> 00:19:04,359 interests that are competing with other interests and it creates, you know, sort 223 00:19:04,359 --> 00:19:08,880 of a spider's web to untangle. Can you tell us more about that and 224 00:19:10,279 --> 00:19:14,160 more about how that affects the system that we have, maybe about how that 225 00:19:14,200 --> 00:19:23,039 affected Obamacare, because that's something people don't talk about a lot actually, So 226 00:19:23,039 --> 00:19:30,680 so many of the decisions on how to allocate resources in healthcare are made by 227 00:19:30,680 --> 00:19:37,119 the government. And when the government has that much power over what prices are 228 00:19:37,160 --> 00:19:42,160 paid, whether things get reimbursed, right, you've got allocation through the political 229 00:19:42,240 --> 00:19:49,799 process rather than through the market process. And the political process often advantages the 230 00:19:49,880 --> 00:19:56,920 incumbent providers and firms and protects them from competition. So at both the federal 231 00:19:56,920 --> 00:20:02,200 and state level, we have enormous amounts of regulation that are really just to 232 00:20:02,279 --> 00:20:08,200 protect incumbents from competitive forces. So we've got things that protect doctors from competition 233 00:20:08,519 --> 00:20:15,759 from nurse practitioners and from physician assistants. We've got policies like certificate of need 234 00:20:17,200 --> 00:20:22,680 to protect hospitals, so certificate of need are the least competitive policy that I 235 00:20:22,720 --> 00:20:30,000 have ever heard of. In order to expand supply to bring on say you 236 00:20:30,039 --> 00:20:36,000 want to bring on X ray machines or MRIs in many states, you have 237 00:20:36,079 --> 00:20:41,279 to get approval from a government board to do that. And the government board 238 00:20:41,839 --> 00:20:48,119 is often controlled by the incumbent providers. So what incumbent providers are going to 239 00:20:48,160 --> 00:20:52,640 want to open up more competition to them, so they get these certificate of 240 00:20:52,720 --> 00:21:00,480 needs, and then you've got sort of provisions that advantage big insurers at the 241 00:21:00,519 --> 00:21:07,559 expense of smaller insures. So you you know, in healthcare, it's why 242 00:21:07,599 --> 00:21:11,519 one of my main sort of principles is we just need to deregulate just about 243 00:21:11,640 --> 00:21:21,119 everything to uh, to lessen the political allocation and sort of the regulatory capture 244 00:21:21,160 --> 00:21:26,480 that occurs in healthcare. And yeah, I mean, this is going to 245 00:21:26,559 --> 00:21:30,880 sound like such a simplistic, like crude understanding of all of that, but 246 00:21:32,480 --> 00:21:37,440 it's one of the areas where it's so grossly overregulated and then at the same 247 00:21:37,480 --> 00:21:41,960 time does need some I guess, basic guardrails, and that's you know how 248 00:21:41,960 --> 00:21:45,720 we ended up with like the individual mandate, which was determined to be constitutional. 249 00:21:45,759 --> 00:21:48,400 I guess in a way, but uh, you know that was a 250 00:21:48,519 --> 00:21:52,640 they had to really try to make that case. And so what is it, 251 00:21:52,799 --> 00:21:55,720 you know, as somebody who's looking at these issues from the right, 252 00:21:56,440 --> 00:22:00,720 you know, how do you make the case that regulating an industry so many 253 00:22:00,759 --> 00:22:06,839 Americans feel like is taking advantage of them? You know? How how do 254 00:22:06,920 --> 00:22:11,400 you think Republicans or conservatives can make that case just from a messaging standpoint, 255 00:22:11,400 --> 00:22:17,480 because obviously it's it's difficult given you know, there were some real problems before 256 00:22:17,519 --> 00:22:23,240 Obamacare came in, and a lot of people probably remember that good question, 257 00:22:25,960 --> 00:22:33,920 you know. I think, uh, part of it is to say we 258 00:22:34,000 --> 00:22:45,960 trust people rather than third parties, whether they be government bureaucracies or insurance companies, 259 00:22:47,279 --> 00:22:55,240 to figure out what the appropriate care is at the appropriate time. And 260 00:22:55,480 --> 00:23:02,559 I think we just like there needs to be more discussed of how government has 261 00:23:02,680 --> 00:23:07,799 caused so many of the problems in our healthcare sector. And in some ways 262 00:23:07,839 --> 00:23:12,000 they're hard conversations. Like one of the problems that we have in our healthcare 263 00:23:12,079 --> 00:23:19,000 sector is that most people get their insurance through their employer. What other major 264 00:23:19,319 --> 00:23:26,279 financial decision or product do people have if they don't make the decision over it, 265 00:23:26,359 --> 00:23:30,079 they give it to their employer. There's no other there's no other product 266 00:23:30,160 --> 00:23:36,920 like that. But people's health insurance is tied to their place of work. 267 00:23:36,960 --> 00:23:41,599 So then if you lose your job, you lose your health insurance coverage, 268 00:23:41,680 --> 00:23:45,000 which is a real problem. Right, So how can we get at the 269 00:23:45,079 --> 00:23:52,359 government distortions that lead to sort of so many of those problems that we see? 270 00:23:53,480 --> 00:24:00,799 And I do think like tying big government to big industry is a message 271 00:24:00,839 --> 00:24:08,079 that conservatives should really hammer in healthcare like Obamacare, the main beneficiary of Obamacare 272 00:24:08,640 --> 00:24:15,559 has been big health insurance companies. They've gotten hundreds of billions of dollars of 273 00:24:15,720 --> 00:24:21,319 government payments in Medicaid expansion and in these subsidies. Right, if we want 274 00:24:21,359 --> 00:24:26,599 to help lower income people get healthcare, the best way to do that is 275 00:24:26,640 --> 00:24:32,319 to subsidize those people directly, maybe in health savings accounts, where they then 276 00:24:32,400 --> 00:24:36,359 have control over how to spend the money on what works best for them, 277 00:24:36,839 --> 00:24:45,279 rather than funneling all the money directly to health insurance companies or hospitals. Hey, 278 00:24:45,359 --> 00:24:48,680 y'all, this is Sarah from the Sarah Carter Show. Thanks for listening 279 00:24:48,720 --> 00:24:52,480 to the Federalists or radio hour. We all have a heartfelt reason to support 280 00:24:52,480 --> 00:24:56,759 our blood pressure. In fact, more than half the US population would benefit 281 00:24:56,799 --> 00:25:00,599 from blood pressure support. 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So supporting healthy blood pressure comes with a bonus Superbeats 289 00:25:36,279 --> 00:25:41,279 Heart Chose support healthy circulation, So you not only get blood pressure support, 290 00:25:41,319 --> 00:25:45,279 you also get a productive heart, healthy energy without the crash. Double your 291 00:25:45,279 --> 00:25:48,799 potential with Superbeat heart Choose. Get a free thirty day supply of Superbeat Heart 292 00:25:48,880 --> 00:25:55,799 Chose and fifteen percent off your first order by going to get superbeats dot com 293 00:25:55,839 --> 00:26:00,759 and using promo code Sarah. That's Saar. Get super Bee dot Com code 294 00:26:00,799 --> 00:26:07,359 Sarah to get fifteen percent off your first order get Superbeats dot Com promo code. 295 00:26:07,599 --> 00:26:14,119 Sarah, And you've mentioned this just a couple of times, naturally in 296 00:26:14,119 --> 00:26:17,160 the course of the conversation. But the report does talk so much about the 297 00:26:17,200 --> 00:26:19,279 expansion of Medicaid in particular, and I wanted to ask Brain if you could 298 00:26:19,319 --> 00:26:25,119 flesh some of that out for everyone, just understanding what the ACA did to 299 00:26:25,200 --> 00:26:30,960 Medicare and then understanding how that is sort of further distorting or interfering with the 300 00:26:30,000 --> 00:26:41,279 market. Yeah, So Medicaid is the federal government reimburses, so states decide 301 00:26:41,319 --> 00:26:47,359 sort of how to manage their Medicaid program and they'll contract with insurers to deliver 302 00:26:47,480 --> 00:26:52,000 benefits to people that are enrolled in Medicaid. And then what the federal government 303 00:26:52,079 --> 00:26:56,720 does is it reimburses state expenditures, and on average, it reimburses about sixty 304 00:26:56,720 --> 00:27:03,880 percent of state expenditures. What Obamacare did is create this new population, able 305 00:27:03,880 --> 00:27:10,880 bodied, working age adults and reimbursed the full cost of states spending on them 306 00:27:11,160 --> 00:27:15,440 for the first three years of the expansion. Then the funding phase down. 307 00:27:15,519 --> 00:27:21,000 But right now Washington is set to reimburse states ninety percent of the costs of 308 00:27:21,039 --> 00:27:30,519 their Medicaid expansion in perpetuity. So two main problems. One, states now 309 00:27:30,640 --> 00:27:37,680 have an incentive to over provide for this new able bodied, working age population 310 00:27:37,880 --> 00:27:42,680 at the expensive traditional enroll lease. And we've seen states that have expanded taking 311 00:27:42,759 --> 00:27:51,720 resources away from disabled individuals and away from kids and spending more on the expansion 312 00:27:51,759 --> 00:27:56,720 population, so that traditional Medicaid recipients now have a harder time getting doctor appointments 313 00:27:57,319 --> 00:28:03,559 because of Medicaid expansion. The second is it just creates really bad incentives. 314 00:28:03,799 --> 00:28:08,720 So if the federal government is going to reimburse almost the entire cost of state 315 00:28:08,799 --> 00:28:14,680 spending on anything, states are not going to get a lot of value from 316 00:28:14,680 --> 00:28:18,000 whatever the spending in that area is. So we've seen just a surge of 317 00:28:18,559 --> 00:28:27,119 enrollment and expenditures on the Medicaid expansion population without good results, like actually mortality 318 00:28:27,240 --> 00:28:33,319 worsened in Medicaid expansion states relative to non Medicaid expansion states in the years after 319 00:28:33,559 --> 00:28:38,599 Alabamacare took effect. And now I mean with some of the the COVID policies 320 00:28:38,599 --> 00:28:44,880 that have kept people on Medicaid for the duration of public health emergency, I 321 00:28:44,880 --> 00:28:48,920 mean, we have almost ninety million people this spring who are enrolled in Medicaid, 322 00:28:49,039 --> 00:28:56,079 so more than one in four Americans getting their health coverage through a welfare 323 00:28:56,119 --> 00:29:00,279 program. I was just going to ask you to talk a little bit about 324 00:29:00,279 --> 00:29:06,519 how COVID, the Public Health Emergency affected all of this. You know, 325 00:29:06,640 --> 00:29:10,799 things were going in a particular direction twenty nineteen, early twenty twenty. What 326 00:29:11,000 --> 00:29:18,599 happened when COVID came in. So Congress in early twenty twenty was afraid of 327 00:29:18,680 --> 00:29:26,920 people losing their jobs, understandably and losing their health insurance, so they required 328 00:29:27,240 --> 00:29:34,200 they provided states additional money through Medicaid on the condition that states not remove anybody 329 00:29:34,200 --> 00:29:40,279 from the Medicaid program, even people who were no longer eligible for the duration 330 00:29:40,400 --> 00:29:45,279 of the public health emergency. Now why that might have made sense in the 331 00:29:45,279 --> 00:29:52,279 short term, It turned out that the public health emergency lasted forever, like 332 00:29:52,319 --> 00:29:56,160 the Biden administration just kept the public health emergency going. So people went back 333 00:29:56,200 --> 00:30:00,279 to work like people weren't. Most people weren't unemployed that long because of the 334 00:30:00,279 --> 00:30:07,799 pandemic. There was a real drastic decline in employment. But then people went 335 00:30:07,839 --> 00:30:12,400 back to work pretty quickly. So people lost work, got went on to 336 00:30:12,480 --> 00:30:18,319 Medicaid, went back to work, got employer sponsor insurance but remained on the 337 00:30:18,319 --> 00:30:22,920 Medicaid program to the extent that we had eighteen million people, according to estimates, 338 00:30:23,400 --> 00:30:27,640 enrolled in Medicaid who were not eligible for the program aus of this spring. 339 00:30:27,839 --> 00:30:33,200 So, just to think about the loss of taxpayer dollars there where taxpayers 340 00:30:33,240 --> 00:30:41,359 are sending money to health insurance companies for people enrolled in Medicaid who have been 341 00:30:41,400 --> 00:30:47,079 on other coverage, mostly like employer sponsor coverage four years, but whose states 342 00:30:47,079 --> 00:30:52,640 have been prohibited from removing people because of these these sort of outdated pandemic policies. 343 00:30:53,200 --> 00:30:56,440 And then here's, of course, the much more than a million dollar 344 00:30:56,519 --> 00:31:03,119 question you're probably very used to fielding. Say, there's another unified Republican government, 345 00:31:03,279 --> 00:31:08,720 what does you know the right healthcare policy look like? What what should 346 00:31:08,920 --> 00:31:17,039 Republicans be pushing for? What can fix what feels like an overwhelmingly dauntingly broken 347 00:31:17,119 --> 00:31:21,519 system. Yeah, so, I mean that's one of the reasons we have 348 00:31:21,640 --> 00:31:26,279 Paragon is to think through what the policy ideas would be. And I would 349 00:31:26,319 --> 00:31:30,720 encourage you know, the listeners to go to Paragon's website because on our home 350 00:31:30,799 --> 00:31:36,039 page we actually have a set of one page briefing documents that lay out what 351 00:31:36,079 --> 00:31:42,039 we think is a practical free market health policy agenda, and I'd say, 352 00:31:42,279 --> 00:31:49,920 you know, on issues related to Obamacare, we need to allow people to 353 00:31:49,960 --> 00:31:55,880 purchase the coverage that works best for them. So these one size fits all 354 00:31:56,720 --> 00:32:00,480 health insurance plans like don't work for a lot of people. We should let 355 00:32:00,519 --> 00:32:07,920 people purchase the plans that work best for them. And we obviously we need 356 00:32:07,960 --> 00:32:15,799 fundamental medicaid reform. We need fundamental medicaid reform. One of the major policy 357 00:32:15,880 --> 00:32:22,559 problems facing the country is the unsustainable levels of federal deficits. I mean, 358 00:32:22,640 --> 00:32:27,559 our debt is now I think thirty three trillion dollars and the fiscal trajectory that 359 00:32:27,599 --> 00:32:31,839 we're on. The main problem and paragons that work on this is federal health 360 00:32:31,880 --> 00:32:36,599 programs. It's federal health programs, and it's the interest payments on the debt. 361 00:32:36,839 --> 00:32:39,599 And the interest payments on the debt with the rising interest rates are a 362 00:32:39,599 --> 00:32:44,279 real problem. But we've got to get The main thing we have to get 363 00:32:44,279 --> 00:32:50,240 a hold of is the trajectory of Medicare, Medicaid and the ACA, So 364 00:32:51,279 --> 00:32:58,680 refocusing reforming subsidy structures so that they're not inflationary and that so the spending is 365 00:32:58,759 --> 00:33:05,359 under the control of the act visual person has like health savings accounts contributions instead 366 00:33:05,400 --> 00:33:10,079 of these subsidies that just go directly to health insurance companies. Is I think 367 00:33:10,920 --> 00:33:20,960 had to be a central focus of conservative reform. The Watch Doot on Wall 368 00:33:20,960 --> 00:33:24,519 Street podcast with Chris Markowski. Every day Chris helps unpack the connection between politics 369 00:33:24,519 --> 00:33:28,480 and the economy and how it affects your wallet. Have you been thinking about 370 00:33:28,519 --> 00:33:30,920 your home as an investment this whole time? If it's just another bill for 371 00:33:31,000 --> 00:33:35,000 you, do it the right way. If you've been stressed about paying back 372 00:33:35,039 --> 00:33:37,160 the massive loan you took out for it, it's not certain you'll sell it 373 00:33:37,200 --> 00:33:40,519 for more than what you paid for it. Don't become mortgage poor. Whether 374 00:33:40,519 --> 00:33:44,440 it's happening in DC or down on Wall Street, it's affecting you financially. 375 00:33:44,519 --> 00:33:46,680 Be informed. Check out the Watch dot on Wall Street podcast with Chris Markowski 376 00:33:46,720 --> 00:33:54,200 on Apple, Spotify, or wherever you get your podcasts. And I also 377 00:33:54,240 --> 00:33:58,200 just wanted to ask if you could take us behind the scenes of what it 378 00:33:58,279 --> 00:34:00,960 was like, you know, to go through the repeal and the place years 379 00:34:00,079 --> 00:34:05,759 on House oversight, then jumping over to Senate and then to the White House. 380 00:34:06,279 --> 00:34:10,360 There was so much zeal behind repeal and replace, and obviously everybody remembers 381 00:34:10,400 --> 00:34:15,639 this. It was, you know, basically the high point of the Tea 382 00:34:15,679 --> 00:34:19,280 Party years. Everything. You know, there was so much and also like 383 00:34:19,360 --> 00:34:22,360 so much populist anger that people kind of forget about. There were a lot 384 00:34:22,400 --> 00:34:28,719 of average people that were outraged about what Obamacare was doing, not just on 385 00:34:28,760 --> 00:34:35,440 the sort of practical pragmatic level, but also the philosophical underpinnings of Obama Obamacare 386 00:34:35,440 --> 00:34:37,159 and everything that they were trying to do to the market. Can you just 387 00:34:37,199 --> 00:34:39,599 take us behind the scenes and just talk a little bit about what it was 388 00:34:39,719 --> 00:34:45,320 like during those years fighting on these issues, and then you know the arc 389 00:34:45,360 --> 00:34:53,079 through the Trump years too. I love this question. It's thank you for 390 00:34:53,119 --> 00:34:59,320 asking it. I don't get asked this question that much. So. My 391 00:34:59,599 --> 00:35:05,079 career and health policy started in the spring of twenty ten when I was a 392 00:35:05,119 --> 00:35:09,880 graduate fellow at the Heritage Foundation, and Obamacare passed a month later. And 393 00:35:09,920 --> 00:35:15,440 the reason, one of the reasons I did my career in health policy is 394 00:35:15,440 --> 00:35:20,400 because of Obamacare and because I know I want to focus on reducing the size 395 00:35:20,400 --> 00:35:28,400 of government, maximizing sort of free enterprise and Obamacare was a real I mean 396 00:35:28,440 --> 00:35:31,039 it was. It was the biggest It's been the biggest expansion of government over 397 00:35:31,079 --> 00:35:37,199 the past several generations. So first going to the House Oversight Committee and really 398 00:35:37,320 --> 00:35:43,559 developing what the oversight agenda was going to be for trying to figure out how 399 00:35:43,679 --> 00:35:45,880 CMS was going to implement the law and point out all the problems with the 400 00:35:45,960 --> 00:35:50,880 law. And we were the key committee that did the investigation, I mean 401 00:35:50,960 --> 00:35:54,119 several of the investigations. But when Healthcare, the Obama administration launched the website 402 00:35:54,159 --> 00:36:00,320 healthcare dot gov in October of twenty thirteen, and they hadn't tested the website, 403 00:36:00,000 --> 00:36:07,639 so it was such a debacle. And we were I was leading the 404 00:36:07,679 --> 00:36:10,599 staff work for Congress. I'm getting all the information about how bad it was, 405 00:36:10,679 --> 00:36:14,639 and we were uncovering things that we would then send to you know, 406 00:36:14,679 --> 00:36:19,800 the CBS evening news that would lead the CBS eving news coverage those nights on 407 00:36:20,559 --> 00:36:25,320 just how few enrollees got covered under the law. I then went so I 408 00:36:25,360 --> 00:36:29,000 did that for about three and a half years, and I could spend a 409 00:36:29,039 --> 00:36:32,239 whole podcast talking about the investigations. I didn't Obama here then, but I 410 00:36:32,280 --> 00:36:39,639 then went to the center Republican Policy Committee, and Republicans took the majority of 411 00:36:39,719 --> 00:36:44,320 the Senate, and there was a Supreme Court case that was taken up at 412 00:36:44,360 --> 00:36:49,599 the time called King v. Burwell, which was about the legality of subsidies 413 00:36:49,840 --> 00:36:52,599 in about two thirds of states. And I don't won't get into the legal 414 00:36:52,599 --> 00:36:59,239 issues, but I had spent a year working on that issue when I was 415 00:36:59,280 --> 00:37:01,840 in the House over So Committee, so I knew the issue better than probably 416 00:37:01,880 --> 00:37:07,679 any other congressional staffer. Supreme Court takes up the case and my boss, 417 00:37:07,840 --> 00:37:15,119 Senator Barasso, gets tasked by Leader McConnell with developing a plan, legislative plan 418 00:37:15,559 --> 00:37:20,559 if the Supreme Court knocked out those subsidies. So I sort of led staff 419 00:37:20,599 --> 00:37:25,920 work for the first six months of twenty fifteen working through what the Republican replacement 420 00:37:25,960 --> 00:37:30,719 plan would be. And at that point it became clear to me how difficult 421 00:37:30,920 --> 00:37:34,800 the replace exercise was going to be because you had to get lots of different 422 00:37:34,800 --> 00:37:39,239 ideas from across the party. And actually, I will tell you at the 423 00:37:39,360 --> 00:37:47,039 time, Lamar Alexander was the chairman of the Senate Help Committee, which is 424 00:37:47,159 --> 00:37:52,679 one of the two primary committees that is jurisdiction over healthcare. And his phrase 425 00:37:52,719 --> 00:37:57,039 at the time was, if you like Obamacare, you can keep it, 426 00:37:57,480 --> 00:37:59,880 but for the rest of you, we're going to give you another option. 427 00:38:00,119 --> 00:38:04,280 I hated that phrase. I didn't I think that was the right policy. 428 00:38:04,360 --> 00:38:07,159 I was like, we've got to repeal Obamacare root and branch in retrospect. 429 00:38:07,960 --> 00:38:12,519 Alexander was right, like, that is where we should have sort of tried 430 00:38:12,559 --> 00:38:15,440 to focus. Was, Okay, Obamacare has got all these problems, let's 431 00:38:15,440 --> 00:38:22,119 just try to give people and states escape patches from Obamacare. Like that that 432 00:38:22,239 --> 00:38:25,880 should have been I think politically, realistically, that's that's probably where we should 433 00:38:25,920 --> 00:38:30,280 have gotten. Anyway, the Supreme Court ruled the other way, six to 434 00:38:30,320 --> 00:38:35,760 three. They upheld the subsidies and the law. I then went to Mercadus. 435 00:38:35,800 --> 00:38:37,559 I was a Mericatas for eighteen months, sort of continuing to work on 436 00:38:38,039 --> 00:38:45,840 health reform and thinking about problems with Obamacare, need to repeal and replace. 437 00:38:45,239 --> 00:38:50,400 And then I got asked to go to the National Economic Council when President Trump 438 00:38:50,480 --> 00:38:55,320 got elected, and the National Economic Council coordinates economic policy for the president. 439 00:38:55,880 --> 00:39:00,719 And you know, the first eight months of that was the legislative effort, 440 00:39:00,880 --> 00:39:13,079 and it was really discouraging in retrospect to go through that and for the Congress 441 00:39:13,280 --> 00:39:19,760 repealed the individual mandate tax penalty. But you know, had an opportunity to 442 00:39:19,760 --> 00:39:22,760 do much more to help Americans who were hurt by the law, to reduce 443 00:39:23,760 --> 00:39:30,039 Obamacare's harmful provisions, and you know, we didn't get didn't get across the 444 00:39:30,039 --> 00:39:37,559 finish line. For me, it was very it was still like, Okay, 445 00:39:37,559 --> 00:39:40,800 there's still a lot of work to be done. I'm in a powerful 446 00:39:40,840 --> 00:39:45,440 position to try to help people that have been harmed by the law. So 447 00:39:45,519 --> 00:39:49,400 that really motivated my work for the next two years, right as in the 448 00:39:49,400 --> 00:39:53,239 White House where I did those you know, led the implementation of those executive 449 00:39:53,280 --> 00:39:58,119 items that I mentioned, and it wasn't easy to get some of those across 450 00:39:58,119 --> 00:40:04,239 the finish line, like there were there's divisions within the Republican Party on certain 451 00:40:04,320 --> 00:40:08,800 things and where things that were like first principles for me, like people should 452 00:40:08,840 --> 00:40:12,679 be able to use their own money to buy health insurance that works best for 453 00:40:12,719 --> 00:40:19,119 them. That was not a uniform view in folks that I worked with in 454 00:40:19,159 --> 00:40:23,159 the administration. So you have to like fight battles like that and look for 455 00:40:23,239 --> 00:40:30,159 opportunities and generate the best coalitions that you can going into these meetings. I 456 00:40:30,199 --> 00:40:35,440 got to brief the President several times on key matters related to health policy. 457 00:40:35,719 --> 00:40:38,679 And the last item that I mentioned that I got across the finish line was 458 00:40:38,719 --> 00:40:45,840 this policy where employers can just give workers contribution and the workers take that money 459 00:40:46,159 --> 00:40:49,920 and use it to buy health insurance that works best for them. That was 460 00:40:49,960 --> 00:40:54,360 about two years the work on that rule, and we finalized it in the 461 00:40:54,400 --> 00:40:58,599 summer of twenty nineteen, and I got to be the lead briefer to the 462 00:40:58,639 --> 00:41:04,000 President that day and then he announced it in a Rose Garden ceremony that afternoon, 463 00:41:04,119 --> 00:41:07,400 So that was sort of like the capstone of my time there. I 464 00:41:07,400 --> 00:41:12,599 got to have my wife and parents tom and be there for that, and 465 00:41:12,639 --> 00:41:17,920 then I was able to say, Okay, I did the best I could 466 00:41:19,320 --> 00:41:24,239 on helping people who've been harmed by Obamacare, and it is onto, you 467 00:41:24,320 --> 00:41:30,320 know, sort of the next next phase. So sorry for that. Politics, 468 00:41:30,480 --> 00:41:31,440 no, no, no, I think this is one of the most 469 00:41:31,480 --> 00:41:35,760 important stories in America politics, like the last one hundred years, and nobody 470 00:41:35,760 --> 00:41:39,159 ever talks about it anymore. Yeah, I mean, I agree with you. 471 00:41:39,320 --> 00:41:43,280 And actually one of the things that I was thinking of doing when I 472 00:41:43,360 --> 00:41:49,159 left was to write a book or a long essay on sort of the Republican 473 00:41:49,199 --> 00:41:54,679 Party's failure on Obamacare and what we could learn from it. But I just 474 00:41:54,800 --> 00:41:59,960 figured that, you know, there's a lot, there's opportunity costs everywhere, 475 00:42:00,239 --> 00:42:02,840 and I wanted to focus more on the future and what we could do to 476 00:42:02,880 --> 00:42:08,360 reform health policy going forward. And it would just have taken a lot of 477 00:42:08,440 --> 00:42:15,480 work to do that book or a long essay and uh uh. And also 478 00:42:15,559 --> 00:42:21,679 it would have been would have been discouraging again to relive so much of that. 479 00:42:22,320 --> 00:42:25,159 So it's just like, you know, you just the fight never ends, 480 00:42:25,760 --> 00:42:32,199 so you just have to go on and figure out what the next opportunity 481 00:42:32,320 --> 00:42:38,480 is and uh and get yourself best positioned, put the policy that the best 482 00:42:38,480 --> 00:42:43,159 policy ideas forward, and figure out how to build the coalitions and get those 483 00:42:43,239 --> 00:42:46,079 policies and acted, and fight the ideas that the other side has that that 484 00:42:46,440 --> 00:42:52,960 you know, increase government control over our healthcare. And again, Brian Blaze 485 00:42:53,039 --> 00:42:57,559 is the president of the Paragon Health Institute. You can go to their website 486 00:42:57,559 --> 00:43:00,360 at Paragon Institute dot org and read this report that we've been talking about. 487 00:43:00,760 --> 00:43:05,800 Brian, I just want to say thank you for giving us this really helpful 488 00:43:05,840 --> 00:43:10,639 briefing and reflecting on all your time fighting for health care policy. Thank you. 489 00:43:10,840 --> 00:43:15,199 Just final, of course, you've been listening to another edition of The 490 00:43:15,239 --> 00:43:17,880 Federalist Radio Hour. I'm Emily Dashinsky, culture editor here at The Federalist. 491 00:43:17,920 --> 00:43:22,440 We'll be back soon with more. Until then, be lovers of freedom and 492 00:43:22,559 --> 00:43:40,159 anxious for the fray.