Summary Advocacy Grand Rounds - 2024 Health Care Policy Priorities (Youtube) www.youtube.com
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Eric Sullivan Alright. So I think we'll go ahead and get Interested. And if folks are trickling in, we'll, you know, we'll catch them up. So welcome everyone.
Larry Levitt My
Eric Sullivan name is Eric Sullivan. I'm the chair of the access to affordable care impact area here at Doctors for America. Before we get started with today's session, just wanna take a quick second, to encourage everyone who is not already, a member of Doctors for America to officially join. Taking that important step, will both help in, encourage programming like what you're seeing here tonight, and then help us take bigger steps to grow in our reach throughout the country. And so by paying your annual membership dues, you'll be contributing to DFA's long term sustainability.
Eric Sullivan And so there are 6 different levels to choose from. 1 of our, staff members is gonna be dropping a link in the chat, for those of you who are interested in joining. And, and don't don't fear. There will be a recording of this session, available on the Doctors for America YouTube channel, after the session. So we're just gonna go over Quick few ground rules here.
Eric Sullivan And so, all questions are encouraged, and those questions can be dropped in the and a function. So I know some people might be more familiar with the chat feature in Zoom, but, for webinar setting like this, dropping in the q and a, which you can find there at the bottom. You may just have to go into the the more, settings, there along your bottom, Control panel, and then you can drop questions in there. We'll be able to see them and flag them for Larry. And, those questions we'll be getting to in the second half of the presentation after, Larry goes through some of the, stuff you'd like to like us all to know.
Eric Sullivan And then just keep an eye on the chat as well. Just like with the link to join as a member, our staff members here will be dropping some helpful links throughout the session for anything else that's relevant. Alright. So now with, all the boilerplate out of the way, we'll get on to tonight's speaker. So we're extremely excited to welcome Larry Levitt, from the Kaiser Family Foundation.
Eric Sullivan So I I have here a And very impressive bio that I'm gonna, read here, so hopefully won't embarrass Larry too much. But Larry is the executive vice president for health policy overseeing KFF's Policy work on Medicare, Medicaid, and the health care marketplace, as well as the Affordable Care Act, Racial Equity, Women's Health, and Global Health. He previously was editor in chief of Kaiser network dot org, which is KFF's online health policy news and information survey, and directed KFF's communications. Levitt, along with doctor Molly Anne Brody, worked with KFF's founding president and CEO, doctor Drew Altman, to oversee the organization. Prior to joining KFF, Levitt served as the senior health and policy adviser at the White House and the Department of Health and Human Services, Working on the development of the Clinton Administration's Health Security Act, and other health policy initiatives.
Eric Sullivan Earlier, he was also the special assistant for health policy with California insurance commissioner John Garamendi, a medical economist with Kaiser Permanente And served in a number of positions in the Massachusetts state government. Levitt holds a bachelor's degree in economics from University of California Berkeley and a master's degree in public policy from the Kennedy School of Government at Harvard University. And with that out of the way, I will now pass it on to Larry for tonight's session.
Larry Levitt Great. Thanks, Eric. I think I have to shorten my biography after listen to listening to that. So,
Eric Sullivan What I
Larry Levitt wanted to do, and I I, look forward to your your questions and the and the discussion. What I wanted to do is go through, 10 things, that I'm watching in in health policy, over the over the next year. And for those of you who know me, know I could probably do 50 things, but, certainly wanna leave time for for discussion, so so limited it to 10. You know, number 1, has to be the the election, which is, now in in full swing. And, Honestly, I fully expected this to be the 1st presidential election in quite some time where health care reform and the Affordable Care Act were not gonna be Front and center, as contentious issues.
Larry Levitt But as we've seen over the last few weeks, Trump may may change that, bowing on multiple occasions, to try to repeal and replace the ACA, once again, if elected. You know, I expect President Biden to primarily run on his record on health care, and, he has, in fact, fulfilled, I would say, his major Priorities, on health care, reinvigorating the ACA, reversing many Trump actions, and, achieving, giving the government authority To negotiate drug drug prices. I would expect president bride Biden to likely to to push further, for further action on on drug prices, collecting, government negotiation to the private sector in addition to Medicare, and then possibly, revisiting, unfulfilled promises, from from his first campaign, which was to create a public option Under the Affordable Care Act and and lower the age for Medicare eligibility. You know, regardless of how the Affordable Care Act or these health reform issues play, health care, particularly abortion rights, will certainly be an important issue after the Supreme Court's overturning of of Roe v Wade, could be especially important in some swing states and districts. For example, Arizona, which will likely have a ballot initiative, guaranteeing the the right to abortion.
Larry Levitt I would say abortion, you know, aside from being a contentious issue in in the campaign, which it certainly will be, could be particularly important, for For turnout. You know, who who shows up to vote. And, of course, even if these health issues aren't debated or weren't debated, elections always have consequences, for the budget, for Medicaid. For example, Republicans nationally have been pushing work require Requirements in Medicaid, for access to family planning, and, of course, for appointing judges, as we saw under, the Trump administration. So as I said, abortion rights will certainly be a central issue, in the campaign, And the election has has consequences.
Larry Levitt You know, Trump, I think, could likely do much more administratively to strict abortion access, frankly, than than Biden could do, to promote it. There's no question we'll see continued state actions to both restrict and protect Abortion access. And, importantly, we will see a supreme court case, this spring on, The FDA's approval of, of mifepristone, of medication, abortion, which is which now, accounts for about half of abortions, nationwide. Talked about the Affordable Care Act. I think no question.
Larry Levitt The future of the Affordable Care Act Will continue to be an issue. Just yesterday, the Biden administration announced, record enrollment over 21,000,000 people, which is up 5,000,000 from from last year. A big part of that was the, enhancement of premium subsidies, first under the American Rescue Plan and then extended under the Inflation Reduction Act, those temporary subsidies, which have made coverage Substantially more affordable, which was the biggest knock, on the ACA historically, expire at the end of 2025. So whoever is the next president will no doubt be instrumental in determining, whether those subsidies get extended or or not. At the same time that we have seen historic enrollment in the Affordable Care Act, we are seeing millions of people being dropped from Medicaid As the continuous enrollment protection that existed during the public health emergency, is unwound.
Larry Levitt During the public health emergency, states were prohibited from disenrolling, from dropping anyone in exchange for, additional federal funding. And as a result, Medicaid grew by 23,000,000 people, over the course of the the public health emergency. That requirement is now being unwound, and our tracking so far shows that 15,000,000 people, have been dropped. And I would say significantly and maybe the most important number in all of this is that 71% of the people who have been dropped from Medicaid, have done have been dropped for, what are called procedural reasons.
Eric Sullivan So these are people getting caught up
Larry Levitt in red tape, not being able to complete the enrollment process, and may very well still be eligible for for Medicaid. Many of the people being dropped are getting coverage through the marketplace, and that is part of what has, led to the, the record enrollment this year. Many are getting employer coverage as well, but definitely not all, and some are certainly ending ending up uninsured. Also in Medicaid, some activity on on expansion. North Carolina became the latest state to expand Medicaid, Under the ACA, that leaves now 10 remaining states, primarily in the south, that have chosen not to expand, with about 2,000,000 people being caught in the the the Medicaid coverage gap.
Larry Levitt These are people who are not eligible for Medicaid, do not have incomes, above the poverty level, so are not eligible for the Affordable Care Act marketplace and are caught in a a gap where they have access to no affordable coverage at all. Number 5, I mentioned, drug drug prices, and the Inflation Reduction Act, which gave the government authority to negotiate drug prices in Medicare for the first time. The government has been prohibited from negotiating drug prices since the creation of Medicare Part D, the retail, drug benefit in in the program. And I think, significantly, this, not only will address drug prices, but is a potential foot in the door for a larger government role And restrict restraining health care prices generally. It is a modest first step, even in even within the drug sector.
Larry Levitt It Starts off with 10 drugs. Initially growing over time, there are lengthy exclusivity periods where drugs are not subject To negotiation, it does not apply outside of Medicare, but it is an important first step. And even those 10 initial drugs, represent a substantial portion of Medicare spending. The first prices, negotiated prices will be announced, in September, there are, not surprisingly, many ongoing lawsuits, challenging the government's authority to to negotiate prices, and an ongoing debate about innovation, the extent to which negotiated Priorities, could could harm drug innovation. The congressional budget office, estimated that out of an expected 1300 drugs to be approved over the 3 decades, that 13 fewer drugs would come to market as a result of, the drug pricing provisions and the inflation reduction act, and we don't know what those 13 drugs are.
Larry Levitt You know, would they be b 2 drugs? Would they be important innovations, to to people's health? You know, importantly, and this has gotten less attention, the inflation reduction act also included measures to, cap, insulin co pays in Medicare at $35 a month, and even more significantly, cap out of pocket drugs overall, in Medicare for the first time, And that cap is starting to take effect this you're. Affects, you know, relatively modest number of people, but for those people with very high drug costs, it could be 1,000 of dollars in in savings per year. The the other issue, I think, it is is bubbling up.
Larry Levitt I think as as physicians, you would probably say more than bubbling up, is is prior authorization and and claims denials by By insurers. This has become increasingly controversial and and increasingly a burden, for for patients and providers. Our analysis shows that in Medicare, there are about 35,000,000 requests, Priorities Prior authorization requests in Medicare Advantage, not in traditional Medicare, which was generally does not use prior authorization. 2,000,000 of those requests, are denied, and about only 11% of the denials, are are appealed. You know, we've seen some hospitals Leaving or threatening to leave Medicare Advantage, over the effects of prior authorization.
Larry Levitt And I think a significant backlash, is coming, Reminiscent of the, backlash against managed care generally in in the 19 nineties. They were just released regulations in the last, last couple weeks to Streamline the process, in public insurance programs, setting some time limits on prior authorization decisions, but that only goes so far. Also been recent controversies over insurers using computer algorithms for prior authorization, which Could potentially help the administrative burden, but I think raises thorny issues and threatens trust in the system. Number 7, I would point to, telehealth, which is not a new issue, but, but continues to be an issue. Some analysis we did with, Epic Medical Records data, showed that the use of telehealth during the pandemic, peaked at about 11% of outpatient visits, but importantly, 40% of visits for mental health and substance use.
Larry Levitt It's fallen off Generally, quite substantially, but but not for mental health in fact. And I think telehealth has the potential to change how mental health Care is delivered, on a on a significant and permanent basis. I would say looking at mental health generally, also continues to be a a a serious issue with, with with greater public attention. We recently did a poll, with CNN that found that 90% of the public believes that the nation has a mental health crisis. And I would say that's certainly true, But it's stunning for 90% of the public to agree on on anything these days.
Larry Levitt And, honestly, policymakers have not quite caught up With the public, on this, you're know, the whole bunch of issues, that are are challenging and and Still go largely unaddressed. Stigma associated with mental health, lack of providers, certainly. The narrowness of Insurance networks, where we have technically mental health parity, but but not in practice. And all of this results in high out of pocket costs, and and care delayed or, or foregone. For number 9, I would point to, to price transparency.
Larry Levitt You know, Trump, when he was president, did a lot to undermine health care programs, and Biden has reversed much of what Trump, did do. But, interestingly, 1 thing that was, lasting and and with bipartisan support, was requiring hospitals to disclose, their prices, and not just their charges, but their negotiated prices with with every insurance plan. This kind of transparency in health care has always seemed like a no brainer in theory, but it's honestly not Clear what the effect will be in practice. And with, you know, market the market power of hospitals, 1 can even imagine a scenario where this could lead to, to to higher prices. Also, the data, while it's Great to have it available is frankly, a mess.
Larry Levitt You know, mostly a reflection of how complex hospital billing is. But when you actually dig into the data and try to compare Priorities, across hospitals in a region or across plans for a given hospital, it's it's really very hard to do given, given the differences in in, in in contract reimbursement approaches across plans and and hospitals. There's currently an an effort to, potentially codify Hospital price transparency, in law, through an act of congress. That may happen. Or if it's gonna happen, it would be in the next month or so as part of a a spending bill to to keep the government open.
Larry Levitt That may come along with greater scrutiny and regulation of of Pharmacy benefit managers, but, honestly, as dysfunctional as congress is, the best bet, as always is is to bet on nothing happening, in in Washington. And finally, number 10, certainly an evergreen issue, but a big 1 is Trends in the health care, marketplace and and what's that what that means for costs and affordability, and patients. Over time, we have seen tremendous hospital consolidation. More recently, we've seen private equity, buying up All parts of the health care system, including physician practices, all of this results in an arms race with insurers, who have also consolidated Significantly. There has been, under the Biden administration, growing antitrust and regulatory scrutiny, of the health care sector.
Larry Levitt But, you You know, in many ways, the cat is already out of the bag unless you're gonna break up big hospital systems or or big insurers like we did with the telephone companies. You know, it's very hard to to turn back the clock. You can stop 1 merger or another merger, but that's not gonna make Big difference in the overall consolidation of the Interested. And frankly, the the most effective approach may be, to focus on anticompetitive practices Of an already consolidated, industry. I I also expect a growing scrutiny of nonprofit hospitals, quote, unquote, nonprofit hospitals, since nonprofit hospitals do make profit.
Larry Levitt We estimate that the the nonprofit hospital Sector, gets about $28,000,000,000 a year, in tax exemptions, and, Don't always certainly don't provide sufficient charity care, to make up for that tax exemption. But in many ways, Policymakers are questioning how much community benefit they they provide, generally. I think as part of that, there's a big focus on, The bill collection practices of hospitals, we estimate that there are a 100,000,000, Americans, with health care debt Of come some kind. Most of them are you're, so their debt is is from large coinsurance, co pays, And deductibles, totaling almost $200,000,000,000, a year. There's been some progress on that, for example, Around protecting people's, credit reports, but that doesn't erase the debt that that people are actually, incurring.
Larry Levitt And that gets at, and I'll I'll end here. It gets at what I think is the fundamental challenge in health care, which is, which is affordability. We've made tremendous progress, with the ACA getting people, insured and and, have brought the uninsured rate, in the country down to the lowest level ever, but we still have over 20,000,000 people, uninsured. And even among those who are insured, the costs are often just just too high. Whether it's the premiums people, have to pay in employer based insurance Or the high deductibles they they face.
Larry Levitt You know, the average deductible is now $1700 per person, in employer sponsored Interested. And the underlying cost is is just is just so high. I mean, many of us don't see it, because our employers pay A big portion of it, but the family premium is now $24,000 a year on average, which is enough to buy a new car, and Buy a new car every single year. So, yeah, while we've made a lot of progress, we still have a lot of work to do.
Eric Sullivan Very well. Thank you so much. That was a very impressively efficient Run through through a lot of major issues there. So friendly reminder to our participants or The attendees, that, you can drop any of your questions in the q and a box there at the bottom, And we are gonna start filling those now. So, you know, have have at it, get everything you want in there, and we'll get to as many as we can.
Eric Sullivan So our first question here, we'd like you to kind of wax on the problem of under insurance, which has, I think, kind of connecting with your last point about, you know, even with the expansion of You're insured Americans, the issue of underinsurance is now, something that is being talked about almost as much. Just interested if you want to expand on that at all.
Larry Levitt Yeah. So I I, a few thoughts. What 1 is I I I don't think we have a good Definition of under insurance, frankly. I mean, it's a it's a big deal, but we are not good at measuring it. There are various measures like the percent of income people have to pay on out of pocket costs, or there have been measures trying to, like, add the deductible and the premium, that that people face.
Larry Levitt But part of the the the the the issue we have in in in, Collecting a handle on this is that most people, fortunately, are pretty healthy, in in any given year. It's a small percentage of the population that accounts for a large Percentage, of health care costs. So in any given year, you know, relatively small percentage of the population is gonna face Unaffordable, health care costs or be technically under underinsured in that year. But the reality is a much larger group of people, are, are are in fact under underinsured you're if they did face a major, health issue, they they would not have adequate insurance to to cover it. So I think, you know, the the the problem of under Interested It comes to several things.
Larry Levitt 1 is money. So, you know, facing a high deductible, which particularly for a lower modest income people, You're know, maybe may feel close to having no insurance at all. It's it's high, coinsurance, which we've seen increasingly, for example, on drugs, particularly specialty drugs, where people are paying a very high percentage of very expensive, drug prices. You know, and and it's, you know, some of what I talked about about prior authorization and and and claims denials, that you you you have this insurance. But if the care that that you and your your doctor feel you need, is not being authorized, by your insurer, that is under insurance, as as well.
Larry Levitt So so definitely a big problem, and and and I think, You're know, gets gets less attention than I mean, it's very easy to measure the the number of people uninsured and to show the progress we've made there. Much harder, to measure under insurance and and to show any progress. All the solutions are also hard. I mean, Yeah. For example, the Medicare for all plans, proposed by, senator Bernie Sanders and others, would have eliminated Cost sharing entirely.
Larry Levitt That certainly would have addressed the problem, of an an insurance. As a more incremental STEP, it's hard to think of ways to do that. For example, you know, the government could cap deductibles and say, okay. Deductibles are gonna be no more than x. But all that will do is raise premiums.
Larry Levitt So it's a it's a it's a hard problem to solve incrementally.
Eric Sullivan Thanks. Yeah. I I think, would agree with that. And I think just 1 1 other thing I'd I'd add from the physician side of things, and I'm sure many of our physician on the call here is Is the degree to which this is impacting the the patient physician relationship and and the recommendations that are being made? I know, like, just speaking for myself, You're know, I I have patients who face high deductibles and, you know, they'll ask me, you know, well, you know, how how worth it is it to get this test because it's gonna cost me x.
Eric Sullivan You know, and that's not something we often get taught in medical school. You were actually often explicitly taught not to consider cost and to just do, you know, what's right, for the medicine. But, that's that's easier said when you're a med student than when you're facing a person looking at, as you said, like, sometimes 4 or 5 figure deductibles. So, yeah, would agree. Very thorny issue.
Eric Sullivan So our next question, is about, What the question asker describes is the alarmingly high rates of maternal mortality in young black women. She would was wondering if you could address What could be done about this national emergency, and that the there may have been some attempts in the past with the omnibus legislation That was intended to improve the maternal survival of women of color. So interested in your thoughts on that general issue.
Larry Levitt Yeah. No. It's, you know, a a disturbing, problem, Certainly. And I, you know, I think the omnibus, you know, certainly included measures that that that, that would help. Things like collecting, postpartum care help helps as well, certainly, with mortality after birth.
Larry Levitt The, you're you know, it gets at just much, much harder issues to to to solve. You know, we we recently did a survey of people of color, and racism about racism, generally and specifically in in health care. And for example, we we found that, you know, many people of color, brace themselves, before, going going to a doctor visit. You know, pay attention to how they're they're dressing, so that they don't face, discrimination. You know, Those issues are very, very hard to get at, but but we have to get at them.
Larry Levitt You you're know, it it's, It it is those more frankly, in some cases, more subtle, discrimination, and and racism, that, you know, that ultimately affect the kind of care, people get.
Eric Sullivan Yeah. Absolutely. That another another 1 with, a lot of a lot of very serious issues and, unclear solutions.
Larry Levitt So
Eric Sullivan So a question that I'm glad someone else asked because I it was on my list to to ask if we can, couldn't fill the time. But, asking you to kinda look into your crystal ball and prognosticate on the odds that the, ACA, enhanced subsidies will be extended or made permanent Under the various, you know, possibilities, the various permutations of power, coming out of November from, you know, Democrats control all 3, You know, White House, Senate, you're representatives, from all the way to the other side. And, you know, Certainly can pick any combination of of those there and that you think would be, interesting to know, but certainly on the extremes there, kinda curious as to your thoughts.
Larry Levitt Yeah. So it's, you know, I think if Democrats control the White House and and and both houses of Congress, it's it's very likely That the, the enhanced premium subsidies would would get extended. But, Even there, there are the cost issues. And and, frankly, the flip side of, of The record enrollment is that there are more people getting these subsidies, and the cost of extending them, is is higher, than was originally expected. Yeah.
Larry Levitt I think the scenarios are, you know, a very short extension of, you know, a year or so to to buy time, You know, more modest extension of, let's say, 3 years or so, or a permanent extension, which I think would be the preference of of most most democrats. You know, the the the subsidies will be expiring at the same time as, substantial tax cuts are are expiring as well. So in a situation where, you know, Republicans control Congress and the White House or there's mixed mixed control, And and, frankly, even if Democrats, control but don't have, you know, enough votes to, till, let's say, get it past themselves. There's likely to be some kind of I I think there's a likelihood of some kind of deal around the enhanced subsidies, and, extension of of the tax cuts, and probably has as has been the norm in in Washington lately, doing so without Certainly paying for it, entirely, with higher taxes or or spending reductions, Pay for us. You know, I I think the the, it will be important to, help people understand what the effects of not extending the Subsidies are.
Larry Levitt I mean, even for Republicans who don't necessarily support, the Affordable Care Act, there are now, you know, over 20,000,000 people, in the ACA marketplace, the vast majority of whom would face a substantial premium increase, if the subsidies expired. And in fact, if you look at where the biggest growth, in, ACA Marketplace enrollment has been, it it has been in red states, and in many cases, red states that have not expanded, Medicaid. I mean, in Florida, you know, I think roughly a quarter of the population know, the non elderly population is now enrolled in the ACA marketplace. You have substantial shares in North Carolina and Georgia, Interested. So, you know, the the, Republicans may not support the ACA, but they are also not necessarily gonna wanna get blamed, for a big big premier increase by their constituents.
Eric Sullivan Yeah. Definitely seems like a case of, you know, whoever is left holding the bag at the end when people are scrambling to afford their sky high premiums will will not be in a a good position. So, yeah, interested to see what'll happen in Either scenario or the many many various scenarios. So we have a complete questions, relating to the same topic, which is Of the holdout states for Medicare Medicaid expansion, what is it going to take to convince those state governments To get to expansion, we and, you know, had someone specifically interested in Florida, which is obviously 1 of the biggest remaining Pull that state along with Texas, but kinda speaking more generally as well.
Larry Levitt Yeah. So, The so the answer I would have always given, is it would take pressure from the hospital industry. You know, you would like to think that poor people, needing coverage would would convince states to expand. That's probably not the case. But, but the hospital hospital industry has a big stake in this, including in particular rural hospitals.
Larry Levitt You know, rural hospitals and expansion states have done a whole lot better financially than rural hospitals, in in non expansion states? Honestly, we we have not seen the lobbying from the hospital industry, to the extent that I would would have Interested, although it has, it has happened, and it is starting to to ramp up in in some states. I I do. There there was a a pandemic era incentive passed, by Democrats that I I I dismissed at the time, but I think is having a a bigger effect than than I expected, which is an additional fiscal incentive, for for states to expand. It enhances increases the the match rate on Medicaid, for a couple years, if If states expand.
Larry Levitt And the result is in in that in all these states, these non expansion states, if they chose to expand, they would in fact make money, for for 2 you're. They they would get, the expansion would not only be free, it would bring money, in into the state's coffers. You know, even aside from the kind of broader issue of, expansion bringing an enormous amount of federal money, in into a state. You know, that that was, I would say, instrumental in North Carolina. You know, it's kind of already peaking interest in in even in Mississippi, Georgia, potentially Kansas, so, you know, possibly even Florida.
Larry Levitt It's, so it it it it's it's kind of just enough to be attractive, you know, make it that much more attractive, for a state, Particularly in a in a period now where we are starting to see, state revenues declining, as pandemic aid expires, the Volatility of the stock market, decline of venture capital and startups. So I think I think that fiscal incentive is is even more attractive to to states. I'm not super optimistic that we're gonna see, you know, any any new states expanding this year or maybe even the following year, but, but but maybe may see some movement soon.
Eric Sullivan Great. Well, I know we here at DFA are certainly holding our, Crossing you're fingers and hoping to play our part in getting that across the finish line in a lot of places. So, another question, from The audience is, getting your thoughts on kind of consolidation in the health care industry more broadly, not just within The insurance market, which we've seen, but, also now with, you know, kind of vertical integration with PBMs and, other pharmacies, And then, you know, also including into provider practices as well.
Larry Levitt Yeah. No. It's, Yeah. We we've kinda had decades of of consolidation, but but it really the the nature of it has changed. I mean, so, you're know, we have seen, you know, PBMs essentially be consolidated with With insurers, and and be 1 of the same, in some cases with pharmacies, as well, with with CVS, kind of really rapid increase in in vertical integration, and health plans, buying up medical practices, particularly United.
Larry Levitt I mean, the the the scale of that is, is is quite Quite stunning. And, you know, it almost it I mean, in many states, there is technically still a ban on corporate practice of medicine, but, you know, Not even clear what that means, any anymore. And, you know, private equity, as well, Purchasing and and, rolling up or or consolidating, companies, which is, you know, in some ways, the most, troubling, just given how private equity operates and the incentives, that that they operate under, you know, for quick profits, you know, being willing to cut Cut cut labor dramatically. You know, where this all ends up, I I have no idea. I mean, I I am not optimistic that As I said, that we can we can turn back the clock and unconsolidate, these consolidated companies.
Larry Levitt So I think it really has to turn to, to the anti complete, practices. You know, the the activities of PBMs, the Anti competitive practices. The, practices of hospitals, you know, with all or nothing contracts. You're know, made secretary Becerra, when he was attorney general in California, made some progress on that, against Sutter Sutter Hospitals. But it's you know, the the health care system looks very different.
Larry Levitt And and I would say it it It's not only consolidation. It's really corporatization, of health care. I mean, it just it looks dramatically different than
Eric Sullivan it did a couple decades ago. And I know you alluded to this a little bit, in your answer just there, but someone else had asked about private equity specifically. Wondering if there's any evidence so far of its effects, positive or negative, you know, and and kind of, like, getting into the fact that, You know, for the physicians Priorities in particular that are getting bought out, you know, they're potentially seeing a big payday, but maybe not necessarily looking to the future and and kind of what the, you know, the cost cutting efficiencies will look like. So just interested if you had anything else you wanted to say on that topic.
Larry Levitt Yeah. No. I I would say, you know, some evidence, for example, in in long term care, in the nursing home sector. You know, with with with physician Priorities, the the evidence I've seen is is is weak so far, that that it makes a difference, in quality, which I I don't think means that that is in fact what happens. But, but we we have not been good at, and the data is hard to get, but we have not been good at, I mean, frankly, we're terrible at measuring quality anyway To begin with.
Larry Levitt But, you know, I I I just think the the evidence have not has not been, hasn't been demonstrated yet.
Eric Sullivan Yeah. That's fair. Alright. So, keeping in the same, kinda general topic, DFA is, as you may know, is is kind of interested in talking more about greed and health care more broadly, you know, the the kind of rampant profiteering that I think you're alluding too with the corporatization of medicine.
Larry Levitt And,
Eric Sullivan again, you you kind of touched on this a little bit, but, you know, what do you see as the way forward, to kind of combat that aspect of the American health care system.
Larry Levitt Yeah. You know, it it is I mean, I think a lot of it is shining a shining a light, on it. And we at KFF do that, you know, in our in our research and also in our journalism, through through KFF Health News, our our bill of the month, series. And and I think it's important in all of that to point to I mean, it's easy to point to anecdotes, you know, if someone getting an outrageous bill and, You know, battling a hospital or, an insurance company. But important to, I think, translate those into into systemic Systemic problems, and translate it into to policy.
Larry Levitt I mean, I I, Not everyone will agree with me, but, you know, I don't think we're gonna eliminate profit in in, in in health care. So the question is what what are what are the policy solutions, to to to address some of these issues? You know? Is it, is it caps on prices? Is it, you know, some cap on profits similar to to the medical loss ratio, caps apply to to insurers.
Larry Levitt There's a lot of focus on CEO salaries. CEO salaries are certainly not, you know, a small percentage of our of our cost problem, but where there are incentives in CEO contracts, that encourage, you know, profiteering behavior, that that certainly, is an issue. So, so I I think it's important to kind of Think about, you know, what what what are the policy solutions here short of just, you know, wanting to eliminate Priorities health care?
Eric Sullivan And, somewhat in a similar vein, we have a question about the, you know, kind of Seemingly unstoppable rise of health care costs, on a year to year basis. What are your thoughts on ways that we can be Sustainably decreasing overall health care spending, in the years ahead.
Larry Levitt Yeah. No. It's, you know, I've I've been at this A long time. And, you know, you I mean, you can go back decades decades to to where, you know, people pointed to Unsustainable health care cost growth and, you know, my god. What if health care, you know, becomes 12% of of GDP?
Larry Levitt You know, the world will end, and we Certainly blew past that, quite quite substantially. I think, first of all, I think people focus a lot. You know, it's it's the sort of slow boiling frog problem. Right? I mean, it it gets worse and worse over time.
Larry Levitt Health care costs grow faster and faster Then inflation and then workers' wages, but it's a it's a little bit at a at a time. And I think what Galvanizes, and and gets people to to pay attention is our our big year to year increases. And I think we may see some of that, over the next couple you're. We we saw a big jump in employer insurance premiums, last year, Signs that that may happen, again. Saw reports from, you know, some insurers recently in their earning statements that they're seeing Pretty big jumps in in, in claims expenses.
Larry Levitt So I think if we saw some some, you know, A complete few years running of of big increases, it would galvanize, attention. Question is then what to do about it. You know, I think The Inflation Reduction Act and and government negotiate the government government negotiation drug prices It's definitely a foot in the door. I mean, it is a it is an unprecedented, momentous step. I don't have a lot of faith that Washington is gonna do a lot here, but there is movement in states.
Larry Levitt You know, a number of states are now looking at Caps on overall spending, affordability boards, you know, even a a very red state, like Indiana, kinda brought the business community to the table, and is introducing, you know, some potential caps on on hospital prices. So, you know, I I think I think it'll I think the progress will happen at the the state level, and I think the progress will come by focusing on the extremes and the outliers, and it kinda gets back to that discussion of of, you know, profiteering in in health care. Then I think you the more you can focus on, you know, outlier prices, by by hospitals or drug companies, or private equity owned physician practices for that matter, that just defy logic. And then construct policy solutions that start to at least address those outliers that that kind of everyone can agree, are unjustified. Know, there's some potential for progress.
Eric Sullivan And I just wanna be sensitive to time. Probably room for Maybe 2 2 or 3 more questions, depending on where where the answers take us. So I got 1 that kinda ties back to, point number 1 on your list going back to the Jen. And wanting to you to elaborate further on what you see as the health policy agenda for Republicans in 2024, And why the, I think, probably question ask you're alluding to here, the the absence of an agenda isn't a bigger topic for discussion right now.
Larry Levitt Yeah. I mean so, well, a few thoughts. 1 1 is, you know, Republicans Rarely have a a a health care agenda or at least a a proactive health care agenda. You know, historically, voters trusted Democrats more on on health care. Republicans would much rather talk about, you you're know, inflation, immigration, crime, then then to talk about health care.
Larry Levitt The 1 time that Republicans well, the 2 times, frankly, Republicans have been successful in health care, was member 1 opposing the Clinton Health Security Act, and taking back, Congress, and then opposing The ACA or or Obamacare, and, again, taking back back congress. But, you know, as a proactive agenda, Republicans have generally shied away from it. The, you know, And and I think, honestly, Democrats face a bit of a challenge, right now, as well. You know, Trump's Talk comments, bowing to once again try to repeal and replace the ACA, is a bit of a gift, to Democrats because I think Democrats were looking ahead in a at a campaign, where aside from abortion, which I'll talk about, where, you know, they were gonna run on the record, of reinvigorating the ACA, passing government negotiation of drug prices, $35 cap on insulin co pays. But I I don't think Democrats I don't think there's consensus among Democrats about what the next steps are, in in health care, you know, what what the positive, agenda is.
Larry Levitt You know, we saw in the last presidential campaign, you know, a big debate among Democrats over Single payer, Medicare for all, and and more incremental steps. You're know, current president is certainly not gonna campaign on on Medicare for all. But I you know, even beyond that, I just don't think Democrats are are together on on what those what those next steps are. No. Abortion is very different.
Larry Levitt I think, you know, Democrats are very clearly behind, abortion access. Republicans, you know, for the most part, would rather not talk about it right now because they know the public, is also Largely in favor of, of access to to abortion. But but even Democrats there, you know, the the, I think it's a potent issue. I think it could drive turnout, but it it is not clear what even if Democrats, you know, control both houses of Congress and and the White House, Exactly what they could do given, what the Supreme Court, has done. You know, there will be a move to try to codify Roe v Wade, but that would take 60 votes in the senate and and, you know, very unlikely the Democrats would have that.
Larry Levitt Well, I
Eric Sullivan think we'll get 1 1 last question in here. So feel feel free to give your your, Just a quick answer if if you want. It's up it's up to you. But, last question here is on Medicare Advantage. And so the question is asking if you see any connection between Medicare Advantage being attacked on all sides recently, both, around prior authorization, which you mentioned, Frequent denials of of services, and then the kind of recent overtaking of fee for service Medicare and total enrollment by Medicare Advantage, and kind of interested in your thoughts on where you see that, kind of debate and discussion going forward.
Larry Levitt Yeah. So I I I think what you know, 1 thing we've seen recently is, is, health care providers, particularly hospitals, starting to attack. I'd be concerned about about Medicare Advantage. And and it's not about the prices because, you know, the prices Medicare Advantage Plans pay are virtually identical as the prices traditional Medicare pays, you know, essentially by design. The, it's it's really about claims denials and and prior authorization.
Larry Levitt So, you know, it's it's I it's something we we I I haven't seen before, which is providers being concerned about the the growth of of Medicare Advantage. Policymakers, you know, you're starting to see a little bit of, concern, as well, around prior auth and and claims denials, but also around, you know, just the amount of money. I mean, MedPAC, the congressional advisory committee for, for Medicare, recently came out with new estimates that, The enrollment in Medicare Advantage on average cost the government 23% more, for a similar beneficiary as traditional Medicare. So it's kinda no wonder that Medicare Advantage has grown so much because we have very effectively bribed beneficiaries, into, enrolling in these plans. I mean, what's not to like about, you know, 1 plan that covers your drugs?
Larry Levitt You don't have to buy Medigap Supplemental coverage, a lot of your cost sharing, is covered. You get extra benefits. You get gym membership, and all for 0 premium. I mean, it's it's it's, like, too good to be true. Plus you're have brokers, getting very generous commissions for signing people up in Medicare Advantage, so they're pushing it, as well.
Larry Levitt But, you know, when you've got A a Medicare trust fund, hospital trust fund that that, will become insolvent, and you're paying more money For people to enroll in Medicare Advantage than in traditional Medicare, you know, at some point, that has to become, a target, for, for for congress looking to save money. And in fact, it really kinda scrambles How congress, approaches, trying to achieve savings in Medicare? I mean, historically, it was really about, you know, Cutting hospital, reimbursement and cutting physician reimbursement. And right now, we have physicians on the hill trying to avoid, the the latest cut. You know, when you've got an over when you've got most people in Medicare Advantage, that that formula doesn't doesn't work For for Medicare savings anymore.
Larry Levitt But you have policymakers in a bind. Right? Because you've got all these people in Medicare Advantage Plans, You know, very generally very happy with them because of the 0 premiums and the extra benefits. If you try to cut federal reimbursement, to those Medicare Advantage Plans, you know, you will see some of those extra benefits get cut. You might see premiums, charged For the plans and constituents are are not gonna be, not gonna be happy.
Larry Levitt You know, and I I think you have the added challenge of, the more and more enrollment shifts to Medicare Advantage, you know, how do you tether Reimbursement rates, how do you tether payment rates to traditional Medicare, which becomes a shrinking, portion of of of the system? So It's and then, finally, I would say combine that with the fact, that these plans are enormously profitable For for insurers. I mean, for example, you've got Humana, you know, 1 of the largest insurers in the country, which is now almost entirely dependent on on Medicare Advantage, for its businesses and has, in fact, given up, commercial, insurance, as a market. You know, the the the only growth, for most of these private insurers have come from Medicare and Medicaid, in in recent years. So, you know, you've got a sector very, very dependent on this market, and and you could bet that they will lobby heavily to avoid any any cuts in in federal payments.
Eric Sullivan Alright. Well, sounds like there'll be stuff to talk about in 2025 then. So, yeah, thank you so much, for getting in so many questions and and thoughtful answers. So we'll, you know, get get to our wrap up here. So just wanna thank, both you, Larry, for coming out tonight and and giving a a really thought provoking conversation and and answers to the here and also to our participants for giving such good questions, that I think really fostered a great discussion here tonight.
Eric Sullivan And, again, remind anyone for anyone who kinda missed Question here or there, the the recording will be available very shortly on the Doctors for America YouTube page. And so just a few other reminders, Before we, say good night, just wanted to thank everyone on the call for what they do on behalf of patients. That's both for health providers and then Everyone else in, you know, the broader health care space, even if you're, you know, just someone in the community, you know, you're a key key component of Keep me everyone healthy. And we're we at Doctors for America are hoping to represent, your views, and hopefully bring Patient centered, policy is forward, in the months you're ahead. We have many social media outlets, that we are involved in.
Eric Sullivan So Doctors of America can be down on Twitter. Not not going by x over here. LinkedIn, Facebook, you can stay up to date with All of our events or programs, ways to get engaged across those various platforms. And then, another plug, Please, if you can, if you're interested, join as a formal member. Dues can be down to, very low levels.
Eric Sullivan Whatever you can afford, helps us provide this sort of programming. And then finally, if you are a DFA member, you are eligible to receive CME credits for tonight's tonight's talk. So the link for that will be dropping here in the chat very shortly. So thank you all again. Thanks to Larry Lovett for coming out.
Eric Sullivan Thanks to everyone for showing up and and listening and participating, and we can't wait to see you for our next event. Right? So everyone have a good night. Thanks so much.