We're back with another edition of the Federalist Radio Hour. I'm Emily Drshinsky,
culture editor here at the Federalist. As always, you can email the show
at radio at the Federalist dot com, follow us on Twitter at fdr LST.
Make sure to subscribe wherever you download your podcasts, and if you want
to support our work, you can head over to the Federalist dot com and
subscribe to the premium version of our website as well. Today we are joined
by Brian Blaze. Brian is the president of the Paragon Health Institute. You
can find more information about Paragon at Paragoninstitute dot org. Brian is so intimately
familiar with the topic of healthcare and conservative healthcare policy. He was a Special
Assistant to the President for Economic Policy at the White Houses National Economic consul from
twenty seventeen to twenty nineteen. He also worked on the House Oversight Committee their
government healthcare reform efforts, their entitlement program oversight and investigations from twenty eleven to
twenty fourteen. Then he went over to the Senate side, where he was
doing Republican the Republican Policy Committee's Health policy analyst work from twenty fourteen to twenty
fifteen. So if you're following that timeline, Brian basically has been involved at
the highest levels of the Republican Party and the conservative movements efforts on healthcare for
the last decade plus. And we talk a lot on the show about healthcare.
I can't pretend to ever approach healthcare expertise. I'm not that delusional,
but I do know that it matters a whole lot more than we hear about
it in the news and especially from people on the right. So Brian,
with that all said, thank you so much for joining us. It is
great to be with you. Thanks for having me, Emily. Yeah,
So Brian is the again. He's a president of Paragon, which is out
with a new paper actually on the failures of the Affordable Care Act. And
Brian actually some of these critiques as I'm reading the paper are actually being echoed
by folks on the left. They'll have a different solution, but when they
look at some of the failures of the ACA, they look at the prices
of coverage, quality of coverage. Even some people on the left that are
willing to kind of buck the establishment are saying, hey, something went wrong
here. Maybe a good place to start is just some of those big takeaways
from when you and your colleagues looked into the last decade plus of the Affordable
Care Act. Yeah, so one, it's misnamed, right the Affordable Care
Act indicates that what they were concerned about was the cost of health care and
the cost of coverage. But that's not what the overall aim of the law
was. The overall aim was to expand the number of people that had health
insurance, and there were two main ways that Obamacare or the Affordable Care Act
did that. The first was to have states expand their Medicaid programs. So
Medicaid is traditionally a program for the welfare program for certain categories of low income
individuals, kids, pregnant women, people with disabilities. So they wanted states
to expand their Medicaid programs, and the federal government offered a lot of money
for states that expanded their Medicaid programs. But the heart of the law,
what President Obama talked about at the time, was that they were going to
reform the individual market for health insurance. So the individual market is where people
who are working age, you know, have families that don't get insurance through
their employer. Where they go to purchase coverage. And they said, we're
going to create this robust, dynamic, awesome market where people are going to
want to go and buy health insurance coverage. And they put a whole bunch
of sort of new requirements on health insurance, significant subsidies for the purchase of
health insurance requirements, the so called individual mandate that people had to purchase coverage
or face a penalty. And what the Paragon Report really looked at was these
individual market changes. The authors, which are two actuaries that have studied the
law very carefully went back to what was promised and projected when the law passed
and compared it with actual results. And it turns out that the individual market
is only about half the size of what was expected before the laws key provisions
took effect, and that the average cost per new individual market and rollly is
more than three times what was expected. So half enrollment at triple the cost.
Giving sort of the law, the key provisions of it get a failing
grade relative to what was told would happen at the time. And how much
of this has been realized with the more time passes. I mean, I
actually remember at the time a lot of this was fairly clear. Some of
these predictions were pretty easy to make. But as more time has passed,
how has that, I guess, sort of exacerbated or shown the problems that
were always at the heart of the law. Yeah, so if you go
back, if you take the time machine, I guess back when the exchanges
launched at twenty thirteen, you know, a lot of the criticism at the
time was, well, it's just a bad website, Like the government can
figure out how to get a functional website. So it's sort of these mechanical
problems that are at the root. But you know, the overall construction would
have been great if we could have gotten the website off the ground. So
in twenty fourteen, you know, enrollment was about where it was expected to
be. In twenty fourteen, were about eight million people signed up for these
exchanges, and that was pretty much on par. But it turns out that
the exchange plans tended to be very narrow network, meaning they didn't cover a
lot of doctors and hospitals, and just weren't that appealing to people who didn't
get large subsidies to purchase the plans. So enrollment increased in twenty fifteen to
about ten million people and has stayed at that level through twenty twenty. So
the individual market was really and that is along the way I mentioned in my
intro the individual mandate packs penalty that was eliminated by Congress in twenty seventeen,
and President Trump signed that into law. So the individual mandate repealing that penalty
didn't really have any effect either. It just turns out that what we learned
was the only people who really purchased products in this market were either those that
had really expensive medical conditions and they expected to use lots of medical care,
or low income households that got very big subsidies to purchase these plans. If
you were in the middle class, if you're relatively healthy, these plans weren't
attractive, and people weren't purchasing these products from the studio that brought you.
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are astounding just looking at this. The cost to taxpayers Paragon rights has
been thirty six thousand, seven hundred and ninety eight dollars per additional private insurance
enroly and twenty thousand, seven hundred and thirty nine dollars per additional non group
enrollly, which is more than triple the CBO's original projections of around ten thousand,
well actually around eleven thousand and around seven thousand, respectively. These numbers
are astounding, and I guess I wonder why it does from your perspective that
this isn't being treated like a five alarm fire by people on the right.
So that's a great question. I say. First, the way that we
measured the efficiency was in this and with the actuallys in this paper, they
looked at what's the new government spending divided by the number of new people that
got coverage, and that sort of gives you a measure of efficiency for these
changes. How much are taxpayers bearing for each additional enrollly, you know,
I do think that Republicans viewed it as a real serious problem and a good
political issue for them through twenty sixteen. So when people started losing coverage and
it was clear that President Obama assurance that people wouldn't lose plans that they liked.
Back in the fall of twenty thirteen, when millions of people started realizing,
oh, I am losing coverage that I like. Right, that was
a real major problem, and there were some band aids put in place by
the Obama administration to sort of paper over that problem. But Republicans got unified
control of government in twenty seventeen, and one of the reasons is because of
how unpopular Obamacare was at the time. And I think it is an issue
of the dog that caught the car, and they just weren't prepared with a
plan for what to do to replace the aspects of the ACA, and they
had gotten into sort of this repeal and replace slogan. This sounded good but
didn't have any substance behind it. It shouldn't have been the slogan. I
would have liked to repeal most of the ACA, but that the political exercise
in twenty seventeen was really what can we do to repair and reform the ACA
and get rid of the worst aspects of it. And I think the failure
of the party in twenty seventeen to really coalesce around something, to figure out
what could pass both Houses of Congress and be in improvement left the really bitter
taste in the mouths of Republicans. So I get asked now by reporters like
they wanted to know why aren't Republican presidential candidates talking about healthcare? And my
answer is because there's so much else they can be talking about right now,
Like people are concerned about lots of things with President Biden and his competency,
They're concerned about the general economy, They're concerned about rising energy prices. Like
healthcare is a complicated issue. There's serious problems with our healthcare sector, but
it's not where Republicans have a bad experience in twenty seventeen. And I think
there's just so much else in the political landscape right now. So some of
the serious policy issues on healthcare are being neglected. I think for those reasons.
Yeah, that all makes sense. And if we peel that sort of
layer of the onion back even further and then get to the next layer,
the question of why there hasn't been a real rallying consensus point about what to
replace the ACA with. I'm fascinated by your perspective on that brand because you're
sort of behind the scenes as the Trump administration and Republicans in Congress for a
really long time, we're trying to land on something and almost it got very
close with you know, basically at the very last minute, the late John
McCain, you know, was one vote away became that one vote of separation.
But it still stands out that even with a unified government, Republicans,
after you know, ten years of replaced, didn't have something to kind of
rally around, and that was, you know, an easy thing to do.
Why is that so? I think hardly. It was a process that
was in place. So Republicans have fifty two seats in the Senate in twenty
seven team and had to use the reconciliation process, and the reconciliation process allows
you to pass legislation in the Senate with just fifty votes. But the primary
the provisions that you affect through that process have to be primarily budgetary, so
you couldn't get at all the harmful aspects of the ACA or all the reforms
that you would want to do through the reconciliation process. So initially there was
a thought, well, we'll do it in two steps. We'll repeal the
parts of the law that we can repeal through reconciliation first, and then we'll
come and we'll do replace and replace. Mate, you need to have bipartisan
support to figure out what the replace was. In retrospect, that's the play
call that should have been run. But the decision was made not to run
that play. It was to do repeal and replace simultaneously, and it was
just too complicated for Republicans to figure around what the replace mechanism was going to
be. I can say so the congressional effort failed in twenty seventeen, but
the Trump administration, and this is a large part of what I did when
I was in the White House at the time, was figure out what we
could do administratively to help people that had been most harmed by Obamacare. And
there's really there were two sets of people that were most harmed. One it's
sort of middle class families without employer sponsored insurance that faced doubling tripling of premiums
and deductibles because of Obamacare. And the second was small businesses in their workers,
which were increasingly not able to offer coverage because of how Obamacare had increased
the price of coverage. So the Trump administration did rules that allowed small businesses
to band the gather to offer coverage, something called association health plans. We
opened up alternatives that weren't subject to any Obamacare rules and regulations called short term,
limited duration insurance, and we allowed employers another way to offer health insurance
where instead of the employer having to select the health plan for all the workers,
the employer provides a contribution that the worker takes which is not taxed,
and the worker can then take that contribution and buy a plan in the individual
market that works best for them. So there were some actions that the administration
did on its own that I think relieved some of the pain that people faced
from Obamacare. But you still have all of this inefficient, wasteful spending,
these subsidies that go directly to health insurance companies, and that are linked to
the premiums. So this is one of the problems with the Obamacare financing is
that you have subsidies, and the subsidies go up dollar for dollar as premiums
go up, So all of the premium increases over time have been borne by
the federal taxpayer. The enrollees are pretty insensitive because they don't pay the rising
premiums over time, and insurers can price knowing that they're enrolled. Lease are
not price sensitive that it is the taxpayer that's picking up the full cost.
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again, as somebody who's worked really closely on these issues for a while,
people tend to see the healthcare industry almost as a monolith, but of course,
special interests are different, whether you're talking about hospitals or pharma or any
of these other kind of blocks of the industry. That individual they might have
interests that are competing with other interests and it creates, you know, sort
of a spider's web to untangle. Can you tell us more about that and
more about how that affects the system that we have, maybe about how that
affected Obamacare, because that's something people don't talk about a lot actually, So
so many of the decisions on how to allocate resources in healthcare are made by
the government. And when the government has that much power over what prices are
paid, whether things get reimbursed, right, you've got allocation through the political
process rather than through the market process. And the political process often advantages the
incumbent providers and firms and protects them from competition. So at both the federal
and state level, we have enormous amounts of regulation that are really just to
protect incumbents from competitive forces. So we've got things that protect doctors from competition
from nurse practitioners and from physician assistants. We've got policies like certificate of need
to protect hospitals, so certificate of need are the least competitive policy that I
have ever heard of. In order to expand supply to bring on say you
want to bring on X ray machines or MRIs in many states, you have
to get approval from a government board to do that. And the government board
is often controlled by the incumbent providers. So what incumbent providers are going to
want to open up more competition to them, so they get these certificate of
needs, and then you've got sort of provisions that advantage big insurers at the
expense of smaller insures. So you you know, in healthcare, it's why
one of my main sort of principles is we just need to deregulate just about
everything to uh, to lessen the political allocation and sort of the regulatory capture
that occurs in healthcare. And yeah, I mean, this is going to
sound like such a simplistic, like crude understanding of all of that, but
it's one of the areas where it's so grossly overregulated and then at the same
time does need some I guess, basic guardrails, and that's you know how
we ended up with like the individual mandate, which was determined to be constitutional.
I guess in a way, but uh, you know that was a
they had to really try to make that case. And so what is it,
you know, as somebody who's looking at these issues from the right,
you know, how do you make the case that regulating an industry so many
Americans feel like is taking advantage of them? You know? How how do
you think Republicans or conservatives can make that case just from a messaging standpoint,
because obviously it's it's difficult given you know, there were some real problems before
Obamacare came in, and a lot of people probably remember that good question,
you know. I think, uh, part of it is to say we
trust people rather than third parties, whether they be government bureaucracies or insurance companies,
to figure out what the appropriate care is at the appropriate time. And
I think we just like there needs to be more discussed of how government has
caused so many of the problems in our healthcare sector. And in some ways
they're hard conversations. Like one of the problems that we have in our healthcare
sector is that most people get their insurance through their employer. What other major
financial decision or product do people have if they don't make the decision over it,
they give it to their employer. There's no other there's no other product
like that. But people's health insurance is tied to their place of work.
So then if you lose your job, you lose your health insurance coverage,
which is a real problem. Right, So how can we get at the
government distortions that lead to sort of so many of those problems that we see?
And I do think like tying big government to big industry is a message
that conservatives should really hammer in healthcare like Obamacare, the main beneficiary of Obamacare
has been big health insurance companies. They've gotten hundreds of billions of dollars of
government payments in Medicaid expansion and in these subsidies. Right, if we want
to help lower income people get healthcare, the best way to do that is
to subsidize those people directly, maybe in health savings accounts, where they then
have control over how to spend the money on what works best for them,
rather than funneling all the money directly to health insurance companies or hospitals. Hey,
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Sarah, And you've mentioned this just a couple of times, naturally in
the course of the conversation. But the report does talk so much about the
expansion of Medicaid in particular, and I wanted to ask Brain if you could
flesh some of that out for everyone, just understanding what the ACA did to
Medicare and then understanding how that is sort of further distorting or interfering with the
market. Yeah, So Medicaid is the federal government reimburses, so states decide
sort of how to manage their Medicaid program and they'll contract with insurers to deliver
benefits to people that are enrolled in Medicaid. And then what the federal government
does is it reimburses state expenditures, and on average, it reimburses about sixty
percent of state expenditures. What Obamacare did is create this new population, able
bodied, working age adults and reimbursed the full cost of states spending on them
for the first three years of the expansion. Then the funding phase down.
But right now Washington is set to reimburse states ninety percent of the costs of
their Medicaid expansion in perpetuity. So two main problems. One, states now
have an incentive to over provide for this new able bodied, working age population
at the expensive traditional enroll lease. And we've seen states that have expanded taking
resources away from disabled individuals and away from kids and spending more on the expansion
population, so that traditional Medicaid recipients now have a harder time getting doctor appointments
because of Medicaid expansion. The second is it just creates really bad incentives.
So if the federal government is going to reimburse almost the entire cost of state
spending on anything, states are not going to get a lot of value from
whatever the spending in that area is. So we've seen just a surge of
enrollment and expenditures on the Medicaid expansion population without good results, like actually mortality
worsened in Medicaid expansion states relative to non Medicaid expansion states in the years after
Alabamacare took effect. And now I mean with some of the the COVID policies
that have kept people on Medicaid for the duration of public health emergency, I
mean, we have almost ninety million people this spring who are enrolled in Medicaid,
so more than one in four Americans getting their health coverage through a welfare
program. I was just going to ask you to talk a little bit about
how COVID, the Public Health Emergency affected all of this. You know,
things were going in a particular direction twenty nineteen, early twenty twenty. What
happened when COVID came in. So Congress in early twenty twenty was afraid of
people losing their jobs, understandably and losing their health insurance, so they required
they provided states additional money through Medicaid on the condition that states not remove anybody
from the Medicaid program, even people who were no longer eligible for the duration
of the public health emergency. Now why that might have made sense in the
short term, It turned out that the public health emergency lasted forever, like
the Biden administration just kept the public health emergency going. So people went back
to work like people weren't. Most people weren't unemployed that long because of the
pandemic. There was a real drastic decline in employment. But then people went
back to work pretty quickly. So people lost work, got went on to
Medicaid, went back to work, got employer sponsor insurance but remained on the
Medicaid program to the extent that we had eighteen million people, according to estimates,
enrolled in Medicaid who were not eligible for the program aus of this spring.
So, just to think about the loss of taxpayer dollars there where taxpayers
are sending money to health insurance companies for people enrolled in Medicaid who have been
on other coverage, mostly like employer sponsor coverage four years, but whose states
have been prohibited from removing people because of these these sort of outdated pandemic policies.
And then here's, of course, the much more than a million dollar
question you're probably very used to fielding. Say, there's another unified Republican government,
what does you know the right healthcare policy look like? What what should
Republicans be pushing for? What can fix what feels like an overwhelmingly dauntingly broken
system. Yeah, so, I mean that's one of the reasons we have
Paragon is to think through what the policy ideas would be. And I would
encourage you know, the listeners to go to Paragon's website because on our home
page we actually have a set of one page briefing documents that lay out what
we think is a practical free market health policy agenda, and I'd say,
you know, on issues related to Obamacare, we need to allow people to
purchase the coverage that works best for them. So these one size fits all
health insurance plans like don't work for a lot of people. We should let
people purchase the plans that work best for them. And we obviously we need
fundamental medicaid reform. We need fundamental medicaid reform. One of the major policy
problems facing the country is the unsustainable levels of federal deficits. I mean,
our debt is now I think thirty three trillion dollars and the fiscal trajectory that
we're on. The main problem and paragons that work on this is federal health
programs. It's federal health programs, and it's the interest payments on the debt.
And the interest payments on the debt with the rising interest rates are a
real problem. But we've got to get The main thing we have to get
a hold of is the trajectory of Medicare, Medicaid and the ACA, So
refocusing reforming subsidy structures so that they're not inflationary and that so the spending is
under the control of the act visual person has like health savings accounts contributions instead
of these subsidies that just go directly to health insurance companies. Is I think
had to be a central focus of conservative reform. The Watch Doot on Wall
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just wanted to ask if you could take us behind the scenes of what it
was like, you know, to go through the repeal and the place years
on House oversight, then jumping over to Senate and then to the White House.
There was so much zeal behind repeal and replace, and obviously everybody remembers
this. It was, you know, basically the high point of the Tea
Party years. Everything. You know, there was so much and also like
so much populist anger that people kind of forget about. There were a lot
of average people that were outraged about what Obamacare was doing, not just on
the sort of practical pragmatic level, but also the philosophical underpinnings of Obama Obamacare
and everything that they were trying to do to the market. Can you just
take us behind the scenes and just talk a little bit about what it was
like during those years fighting on these issues, and then you know the arc
through the Trump years too. I love this question. It's thank you for
asking it. I don't get asked this question that much. So. My
career and health policy started in the spring of twenty ten when I was a
graduate fellow at the Heritage Foundation, and Obamacare passed a month later. And
the reason, one of the reasons I did my career in health policy is
because of Obamacare and because I know I want to focus on reducing the size
of government, maximizing sort of free enterprise and Obamacare was a real I mean
it was. It was the biggest It's been the biggest expansion of government over
the past several generations. So first going to the House Oversight Committee and really
developing what the oversight agenda was going to be for trying to figure out how
CMS was going to implement the law and point out all the problems with the
law. And we were the key committee that did the investigation, I mean
several of the investigations. But when Healthcare, the Obama administration launched the website
healthcare dot gov in October of twenty thirteen, and they hadn't tested the website,
so it was such a debacle. And we were I was leading the
staff work for Congress. I'm getting all the information about how bad it was,
and we were uncovering things that we would then send to you know,
the CBS evening news that would lead the CBS eving news coverage those nights on
just how few enrollees got covered under the law. I then went so I
did that for about three and a half years, and I could spend a
whole podcast talking about the investigations. I didn't Obama here then, but I
then went to the center Republican Policy Committee, and Republicans took the majority of
the Senate, and there was a Supreme Court case that was taken up at
the time called King v. Burwell, which was about the legality of subsidies
in about two thirds of states. And I don't won't get into the legal
issues, but I had spent a year working on that issue when I was
in the House over So Committee, so I knew the issue better than probably
any other congressional staffer. Supreme Court takes up the case and my boss,
Senator Barasso, gets tasked by Leader McConnell with developing a plan, legislative plan
if the Supreme Court knocked out those subsidies. So I sort of led staff
work for the first six months of twenty fifteen working through what the Republican replacement
plan would be. And at that point it became clear to me how difficult
the replace exercise was going to be because you had to get lots of different
ideas from across the party. And actually, I will tell you at the
time, Lamar Alexander was the chairman of the Senate Help Committee, which is
one of the two primary committees that is jurisdiction over healthcare. And his phrase
at the time was, if you like Obamacare, you can keep it,
but for the rest of you, we're going to give you another option.
I hated that phrase. I didn't I think that was the right policy.
I was like, we've got to repeal Obamacare root and branch in retrospect.
Alexander was right, like, that is where we should have sort of tried
to focus. Was, Okay, Obamacare has got all these problems, let's
just try to give people and states escape patches from Obamacare. Like that that
should have been I think politically, realistically, that's that's probably where we should
have gotten. Anyway, the Supreme Court ruled the other way, six to
three. They upheld the subsidies and the law. I then went to Mercadus.
I was a Mericatas for eighteen months, sort of continuing to work on
health reform and thinking about problems with Obamacare, need to repeal and replace.
And then I got asked to go to the National Economic Council when President Trump
got elected, and the National Economic Council coordinates economic policy for the president.
And you know, the first eight months of that was the legislative effort,
and it was really discouraging in retrospect to go through that and for the Congress
repealed the individual mandate tax penalty. But you know, had an opportunity to
do much more to help Americans who were hurt by the law, to reduce
Obamacare's harmful provisions, and you know, we didn't get didn't get across the
finish line. For me, it was very it was still like, Okay,
there's still a lot of work to be done. I'm in a powerful
position to try to help people that have been harmed by the law. So
that really motivated my work for the next two years, right as in the
White House where I did those you know, led the implementation of those executive
items that I mentioned, and it wasn't easy to get some of those across
the finish line, like there were there's divisions within the Republican Party on certain
things and where things that were like first principles for me, like people should
be able to use their own money to buy health insurance that works best for
them. That was not a uniform view in folks that I worked with in
the administration. So you have to like fight battles like that and look for
opportunities and generate the best coalitions that you can going into these meetings. I
got to brief the President several times on key matters related to health policy.
And the last item that I mentioned that I got across the finish line was
this policy where employers can just give workers contribution and the workers take that money
and use it to buy health insurance that works best for them. That was
about two years the work on that rule, and we finalized it in the
summer of twenty nineteen, and I got to be the lead briefer to the
President that day and then he announced it in a Rose Garden ceremony that afternoon,
So that was sort of like the capstone of my time there. I
got to have my wife and parents tom and be there for that, and
then I was able to say, Okay, I did the best I could
on helping people who've been harmed by Obamacare, and it is onto, you
know, sort of the next next phase. So sorry for that. Politics,
no, no, no, I think this is one of the most
important stories in America politics, like the last one hundred years, and nobody
ever talks about it anymore. Yeah, I mean, I agree with you.
And actually one of the things that I was thinking of doing when I
left was to write a book or a long essay on sort of the Republican
Party's failure on Obamacare and what we could learn from it. But I just
figured that, you know, there's a lot, there's opportunity costs everywhere,
and I wanted to focus more on the future and what we could do to
reform health policy going forward. And it would just have taken a lot of
work to do that book or a long essay and uh uh. And also
it would have been would have been discouraging again to relive so much of that.
So it's just like, you know, you just the fight never ends,
so you just have to go on and figure out what the next opportunity
is and uh and get yourself best positioned, put the policy that the best
policy ideas forward, and figure out how to build the coalitions and get those
policies and acted, and fight the ideas that the other side has that that
you know, increase government control over our healthcare. And again, Brian Blaze
is the president of the Paragon Health Institute. You can go to their website
at Paragon Institute dot org and read this report that we've been talking about.
Brian, I just want to say thank you for giving us this really helpful
briefing and reflecting on all your time fighting for health care policy. Thank you.
Just final, of course, you've been listening to another edition of The
Federalist Radio Hour. I'm Emily Dashinsky, culture editor here at The Federalist.
We'll be back soon with more. Until then, be lovers of freedom and
anxious for the fray.