Looking ahead to health policy and politics in the 2020 election: A conversation with Julie Rovner

Looking ahead to health policy and politics in the 2020 election: A conversation with Julie Rovner



good morning everyone thanks for coming out for this event to start your day I'm Johnny onion I'm the director of IH bi it's my pleasure to welcome you and to welcome our honored guests Julie Rovner for the fifth annual IH bi director's lecture we're launching a new format this year as opposed to a podium presentation by our visiting speaker we've opted to go with a fireside chat though we don't have the fire going yet on the screen so hopefully you'll stay warm but it's my great pleasure and honor to welcome Julie Rovner who's the Robin toner Distinguished Fellow and chief Washington correspondent at kaiser Health News where she also hosts the weekly podcast what the health Julie joined kaiser Health News after 16 years as health policy correspondent at National Public Radio where she helped lead the network's coverage of the passage and launch of the Affordable Care Act she's an expert on health policy and the author of the book healthcare politics and policy a-to-z she's been awarded the National Press Foundation's Everett McKinley Dirksen award for distinguished reporting of Congress prior to working at NPR Julie covered health policy for the national Journal's Congressional daily and for Congressional quarterly most importantly Julie's a proud alum of the University of Michigan and former managing editor of the Michigan daily where she still serves as an advisor to the the student team leading the Michigan daily so please join me in welcoming Julie back to your alma mater so our format this morning is I'll start out with a series of questions for Julie to launch our discussion and then about halfway through our hour-long session we'll open it up for questions and comments from you in the audience we'll have two microphones that I HPI staff will be helping to bring to you if you have a question just raise your hand if you're following this session on Twitter or want to tweet about it it's at hashtag HP i-19 so Julie to start a fairly broad question but how would you characterize the current tone of health reform in DC polarized you know I started covering health policy so long ago that it was not just bipartisan it was nonpartisan it just wasn't a big partisan issue because it wasn't a big national issue at the time they were talking about the deficit and the Cold War the ending of the Cold War this was the late 1980s education was a pretty big issue at the time but healthcare was really not Congress mostly when it came to health care tinkered around with Medicare I came on just after they put in the DRG system and just before they redid the the physician payment and it was very technocratic and they were you know there are some serious experts in Congress and they did their job and Republicans they generally worked with Republicans most of the things that came out were consensus and then in 1991 everything changed when Harris Wofford ran for the Senate and basically ran on a platform saying that health care should be a right which nobody had ever done before shockingly beat the sitting Attorney General of the United States Richard Thornberg had been the two-time governor of the state and suddenly health care was a huge political issue and we haven't looked back since and you know Bill Clinton came in sort of cemented the idea of health care as a partisan issue and I think sort of with every succeeding decade it's gotten more and more partisan until we get to this point where there's very little that they seem to be able to do hmm so if we think now we have a Congress where the Democrats control the house the Republicans control the Senate and President Trump obviously has an important role to play in health policy do you see any prospects on the horizon for any bipartisan changes to health care over the next year and a half before we go back to it the presidential election well I should say that you know that for all the polarization that the on the health reform side there has been some bipartisan action kind of below that they did macro big big important bill sort of reconfiguring the way they did the physician payment and and and renewed chip in 2015 and that was a not just bipartisan it was unanimously bipartisan which was amazing because it was an enormous piece of legislation but while they were busy fighting about whether or not to repeal or replace you know the Affordable Care Act they were doing macro we're seeing them try to do that this year on drug prices and on surprise medical bills but as we have discussed on the podcast and I have written in this case bipartisanship might not be enough because there they're gonna have to make somebody in industry unhappy particularly on surprise bills it seems to be kind of a zero-sum game they're either gonna make the payers angry or they're gonna make the providers angry you know think everybody agrees and we should get patients out of the middle and that you shouldn't send you know out-of-network surprise bills to people who have no way of knowing that they were out of network but who's gonna pay for that is another issue I ran into someone after I did my story I was sad because he gave me a over croix this wonderful quote that said yeah they agree on the surprise part they don't agree on the billing part so that's actually an issue that some of our colleagues here at HPI are studying we have a program called policy Sprint's where we try to bring evidence to bear more rapidly than traditionally academic groups have on important issues there in the state or federal limelight in the case of surprise billing do you have a sense of how that may play out is there any upper tunity for compromise there and maybe also for those in the group who may not be fully familiar with the term surprised billing sort of how would you explain it or how have you heard some of your colleagues yeah that's part of it is how you define it I mean surprised bills are generally whenever a patient gets a bill they're not expecting but when in the context of talking about legislation they're mostly talking about emergency bills where it's an emergency and so you end up so you go out-of-network because it's an emergency that you think are supposed to be covered and more commonly when you go to an in-network facility and get a bill from an out-of-network provider usually either the ER doctor or an anesthesiologist or a pathologist someone who works in the hospital but is not in network those are those are really what Congress is looking at they're not looking at the sort of general spread of oh my god you thought this bill was gonna be $100 and it's 8,000 which is also a surprise bill but that's that's not that's a different issue that's more of a transparency issue than the surprise bill issue but there really is this sort of setting up of sides of you know the basically everybody wants the other they say let's not do this to the patient but they each wants the other side to pay for it okay and are there any state models for solving this problem that you're or does it need to be solved at the federal level there are a bunch of state models in fact a lot of people are using there's a New York law that uses what's called baseball arbitration because it's what Major League Baseball uses where the the provider and the payer go in and they give their instead of sort of negotiating they give their last best offer and the theory is that that will be realistic that they won't ask for the Sun and the moon because the arbitrator basically picks one hour betrayed er doesn't pick a middle Arbor arbitrator figures out which one is most fair and picks that one so there's an incentive to pick a realistic number but payers don't like arbitration because they feel like it's going to drive up the the the average costs basically you're going to end up higher they would rather have a benchmark some percentage of Medicare or some other benchmark you know what whatever the average is and the providers are terrified of that because they feel like then they'll get there the payers will kick people out of network and push down the benchmark so both sides are afraid of malfeasance on the side of the other but they do have to do it it does have to be federal and not state this was the problem with the patient's Bill of Rights in the Affordable Care Act because of ERISA more than half people with employer insurance have insurance that is not regulated by the state that can't be regulated by the state it can only be regulated federally so if they're gonna fix this they're gonna need Congress to do it now another issue you raised was prescription drug costs whether there could be any bipartisan agreement there what's the current status and I know even the Department of Health Human Services that trump administration have put out through their own proposals for regulatory changes that might help to control prescription drug prices where do you think we stand both in Congress and with some of the HHS proposals well there's a lot of pushing Congress to boost generics you know make it make it harder for brand name companies to prevent generics from from coming to market Tran price transparency getting behind the black box of the the PBM wholesaler retailer prescriber issue I think that's gonna be a lot harder you know but even some of these generic bills you know there's the the idea of Congress passing a bill to ban brand name companies from paying off generics not to come to market that thing's been kicking around since the late 1990s so it's not like we haven't seen these things before and they haven't passed I know it's by part it's like yeah it's been bipartisan but you know we'll at some point we'll see at some point you know the Tibet when my early years covering health care the tobacco industry if backhoe industry didn't want it it didn't happen until it did and I think we're gonna see the same thing with the drug industry at some point the drug industry doesn't want it and at some point Congress is going to say really our constituents are clamoring for this more than you are giving us money well we'll see where that tipping point comes I don't think we're quite there yet so you brought up tobacco and that sort of leads to another area where I was actually quite surprised to see some potential bipartisan agreement Mitch McConnell and Tim Kaine coming out with a proposal for raising the age for purchasing tobacco products to 21 it's actually an issue we've been following here in Michigan we have a team at our school Public Health supported by iti that's been looking at the implications of making that change here in the state of Michigan both for the young adults affected as well as the the business community that provides tobacco products and the enforcement the law enforcement community that would have to enforce any new law what do you think about an example like that have you followed that purpose talked about it on the podcast I put this in the category of what I call companies suing for peace that they would rather sort of be there and raise that they want to raise the tobacco age from 18 to 21 in theory because then high school seniors would no longer be able to buy e-cigarettes which is the issue at the moment for their younger classmates that sort of a justification of raising it from 18 to 21 but there's a command this is a bill that's sponsored by you know a Senate Majority Leader McConnell obviously from a tobacco state Kentucky and Tim Kaine the vice presidential candidate in 2016 from tobacco come tobacco companies state Virginia because there's a competing bill that would not only raise the age to 21 but it would ban flavors including menthol it would ban all flavors and I believe that the flavors are not just in a cigarette but in in tobacco too and I think they're not so excited about that so they think they'd rather have their bill than the other bill okay so I want to shift gears we're entering a presidential campaign certainly on the Democratic side it seems like every day we have someone new declaring their candidacy for president I think we're at an even two dozen yes we were joking at dinner last night will there be more candidates on the stage or people in the audience when we have the presidential debates so how would you characterize sort of the spectrum of views about health reform now within the Democratic Party as it may affect the upcoming campaign we've got sort of one group of the Democratic parties supporting strengthening of the Affordable Care Act getting the marketplaces to work more effectively expanding Medicaid in the states that haven't yet expanded it we've got some arguing for a public option which was originally on the table nine years ago when the Affordable Care Act was being debated but then didn't make it into the bill and then we've got Medicare for all as sort of the most dramatic change in our health care system how would you characterize sort of the camps within the Democratic Party and how this may play out both in Congress where there's a lot of pressure on Nancy Pelosi potentially to bring a medicare-for-all bill to a vote or some other health reform proposal as well as sort of the upcoming presidential campaign I think people tend to get confused I think that the effort to do you know what they call ACA 2.0 or shore up the Affordable Care Act do undo some of the things that the Trump administration does I think that's a legislative strategy by Nancy Pelosi to protect you know we hear what we see here and see all of these new progressive Democrats in the house but the reason the house as a majority is because it has a Democratic majority is because Democrats want a lot of the swing seats that are you know either districts that voted for Trump or traditionally Republican districts and Pelosi in order to stay Speaker those people are the ones who are gonna have to keep their seats I mean somebody you know what was the the the line about Alexandria kids you know Cortez's that I forget was like you know a toaster could win in that district which was not intended to it really wasn't intended to be an attack at her was pointing out that that is such a democratic district that if you run anybody with the D after their name they're going to win not true in a lot of these other in a lot of these swing districts and so what Pelosi is trying to do is find sort of the least common denominator that moves forward the agenda but also you know they all the Democrats ran on healthcare they want to have something to show on health care then there's a separate parallel debate going on about how to expand coverage so there's this perception that Pelosi is only for fixing the Affordable Care Act she's not for any kind of coverage expansion I don't think that's the case she says it's not the case I've heard her then you have sort of the continuum and we're seeing this in the presidential campaign of how to expand coverage if you're going to move beyond the affordable care act what do you do and it sort of started out with just the Medicare for all and we had at the beginning of the campaign when there were only seven or eight people running they were pretty much all co-sponsors Lisa once in the Senate of Bernie Sanders Medicare for all bill well since then we've started seeing concerted attacks on Medicare for all by industry they've gotten together the insurance industry but I would say that that even more than the insurance industry the hospital industry because they're terrified of getting paid Medicare rates that just completely freaks them out so we're also seeing on the Democratic side pathways to some sort of major transition so now you get the Medicare for more and the Medicare at 50 and the Medicare for America and there's sort of different incarnations of how to expand coverage without basically getting rid of the entire insurance industry and what's interesting is it on the campaign trail a lot of these Democrats who had been Medicare for all Democrats are starting to endorse some of these interim steps and talking about it in the context of I'm for both I would like some day to be at Medicare for all but maybe in order to get there you know I think I think we're actually far enough along in this debate for the first time as debates going on for quite a while to talk about well what would a transition look like the transition would almost be harder than then you know then the system itself how do you get there from here and I think some of these are sort of strategies of getting there for here and I think that's where we are in the in the debate right now which i think is probably a healthy place for us to be as a society we should really be talking about this I mean the Republicans are thrilled the Democrats are talking about Medicare for all because they want to you know come in and beat up on it but at least there's a dialogue going on well what would we like our health system to look like and if we go back to the first point about strengthening the Affordable Care Act is there any prospect with a Republican Senate and Democratic House for a bill to make it to the President's desk that would address some of the shortcomings or stresses within the Affordable Care Act um probably not and the reason is abortion which of course is what almost felled the Affordable Care Act in the first place there was a bipartisan bill last year was it last year the year before I think it was last year that they almost got through to you know to put back the cost-sharing reductions and to make it easier for states to do reinsurance and I mean really pretty benign stuff and it got hung up because the house the then republican house decided that they wanted to put a permanent Hyde Amendment into it and the Democrat said yeah not happening because that's been sort of the the threshold abortion fight in Congress for a while the Hyde Amendment is on the labor Health and Human Services education appropriation bill in theory I well in actuality it has to be renewed every year in theory they could take it out although they don't have the votes to do it but the one thing that the Democrats will not stand for is putting it into permanent law they at least want to maintain the idea that they can make it go away for those in the audience I think many have heard the term Hyde Amendment but may not know what's actually in the Hyde Amendment the Hyde Amendment which was at which my favorite piece of tribute was not actually originally written by Henry Hyde because the final language was was drafted in a conference committee bans federal funding of abortion primarily in Medicaid but it's been expanded to a lot of other programs there basically there's no federal funding of abortion in that currently in cases of rape incest or life the mother the only exceptions there was not always a rape and incest exception in the Hyde Amendment which a lot of people don't know but I spent like the first three years on Capitol Hill covering the fight about that and and it does it you know it lives in the annual spending bill so it has to be renewed every year it gets changed from time to time there was a there's a year where they had to sort of renegotiate because there was so much Medicaid managed care they had to make sure that it extended to managed care plans not just to two states and providers so it's been it's definitely tinkered with over the years but you know abortion it obviously is a hot issue of the moment but it's been a recurring hot issue for a long time anytime you're talking about government funding of healthcare so much of your health policy reporting has been on reproductive health issues in the past several weeks we've had several states pass major changes to their abortion laws how do you see that playing out much of the discussion is that the laws are being passed so that cases can be brought to the Supreme Court Roe vs. Wade can be revisited by the new court the current court how do you see that playing out as a health policy issue and as it moves through you know from the state legislatures into the federal court system well one of the things that obviously we've seen is that it's sucking up a lot of the oxygen right now that that would otherwise be used to talk about other health issues that we're back to sort of abortion being a very front burner issue you know what's prompted this is that the perception that there are now five votes on the Supreme Court to strike down roe v wade and so what you're seeing are redder states passing abortion bans and other content restrictions in an effort to be you know the state that part of it is an effort to be the state that gets to the Supreme Court that gets it overturned but also part of it is to be ready in case roe v wade is overturned conversely you're seeing a lot of bluer states passed laws basically eliminating pre roe abortion bans what what Roe basically did is it didn't say abortion is legal what Roe said is states you can't make it illegal so all the states that had abortion bans and there were a lot of them those bans were suddenly know and void but a lot of them are still on the books so if Roe ever went away those bans many of them would just pop back into force so that's why we saw some of these issues in states like Virginia and Massachusetts in New York trying to strike old laws from the book and having trouble talking about them in some cases that it caused in fact the Republicans loved talking about the you know the you know women having abortions you know right before birth which is not a thing but but it was a great talking point for the Republicans and of course now we're seeing all these bans that even have rape and incest exceptions you know if you look at public opinion on abortion it's oh it is has been pretty consistent and pretty mixed the public is generally for abortion rights but with restrictions and so the question is what kinds of restrictions when should have worked me a lot I mean there's very few people at the it should never be allowed and it should always be allowed almost everybody is in that sort of murky middle part and it's generally the closer to the beginning of pregnancy the more support there is in the public and the closer the end of pregnancy the less support there is so at this point the Democrats are thrilled because we're talking about these you know abortions and they're banning abortions at six weeks that's that sort of more abortion rights ground they have more of the public behind them than talking about you know very late abortions when there were the anti-abortion people have more the public behind them and what's the chance that any of these laws will make it to the Supreme Court and a decision in the next year and a half before the presidential election or is this likely to play out over a longer time period I don't know I thought what the court did this week was really interesting they'd had this Indiana law that was signed into law by Mike Pence when he was governor in front of them since January the court has a conference every week when they're in session and they decide what cases they're going to take so these are the cases that we know are at the conference a conference is not it's private so we never know exactly what's said at the conference but well we usually find out on Monday morning you know here are the cases that we've granted cert to because most cases at the Supreme Court they don't have to take some they do but usually abortion cases aren't among them and then and it's been before that and usually something will be on the conference docket for two or three weeks this Indiana law had been on the docket since January it had come up like 15 times I mean it was just nobody had any idea what was going on and the law has a number of parts one of them is banning abortions for race or sex selection or because of diagnosed disability another part and this has been passed by a number of states said that a fetal tissue from abortions and miscarriages had to be either cremated or buried or not treated as medical waste and the what the court ended up doing was deciding the case without taking it their work they wrote a per curiam opinion which means it's unsigned that basically split the difference and said yeah this ban not happening the cremation and and fetal burial can go into effect and we're not going to say whether or not it was an undue burden which is the current standard for the Supreme Court they a state can't put on restrictions that amount to an undue burden on the right to get an abortion but in both cases both the decision said but if another state comes back and wants to argue this again we're still open we're not really deciding it we're just sort of putting the Indiana law and you know it was basically an invitation to say this is not the last word on either one of these issues so it basically gave something to each side I read it as Chief Justice Roberts wanting desperately not to have a big abortion decision drop in the middle of the 2020 campaign it's sort of a long way of getting that kind of smacked of we're gonna we're only going to deal with things we have to deal with and if we're gonna do this we're not gonna try and blow up the country in June of 2020 whether they're gonna succeed I don't know you only need four votes to take up a case in these conferences so the Chief Justice really can't have to say for other jokes right yeah he would be that he would he's presumably the fifth who opposes abortion and not not entirely clear you know we know that under the Affordable Care Act case that he was worried about what would happen to the credibility of the court if they struck down a law that big there is a presumption that if this current Affordable Care Act case gets to the Supreme Court he was he's likely to do the same thing we know less about what he might do on abortion but we got a pretty good hint this week so actually and in a moment we'll open up to questions for the audience but you you let into my my next question which is that federal court case that was decided by a judge in Texas when the constitutionality of the Affordable Care Act was challenged at least for the third major time and that federal judge in Texas declared the law unconstitutional because the tax panel tea has been reduced to zero for people who don't have coverage under the individual mandate you know many legal scholars across the political spectrum think this case has very little merit and yet we still have more than a dozen Republican attorney generals who are advocating for it and it's expected to work its way up to the Supreme Court can you say a little bit more about what's at stake in that case the entire Affordable Care Act is at stake in this case the appeals court is having its hearing in New Orleans the week of July 4th I think it's the 9th but what that that week after there there will be oral arguments in this so it's it's moved up to the next level which is the federal court of appeals this case basically said that Congress in 2017 when they reduced the penalty to 0 they didn't get rid of the individual mandate itself but they reduced the penalty to 0 and because Chief Justice Roberts had written the opinion saving the ACA in 2012 saying not that it did violate interstate or that they couldn't use interstate commerce to have the mandate but it was a it was an okay use of the taxing power so what these Republican attorneys general are arguing is if there's no tax there's no law which is kind of a stretch I mean you could originally the Trump Justice Department argued that yeah we don't think that affects the entire law maybe the things that are most closely tied to that tax remember was intended to encourage healthier people to sign up so that maybe the Community Rating part would have to go and maybe the you know requiring insurers to take people with pre-existing conditions you know the really popular things those might have to go the administration has subsequently reversed even that position and said yeah we agree with the judge in Texas and that's because you know the Republicans still have a lot a lot of the base if you look at the polls still wants to repeal and replace the Affordable Care Act they're still angry at the Republican Congress for not being able to do that so the Trump administration said yeah let's do that but impracticality you know the law is so enormous among other things it would D authorize the Indian Health Service because that was in the Affordable Care Act it would take away the the pathway that it created for generic biologic med patience I mean would you with those become unapproved I mean you know they're there's so many questions if the law was simply overturned it's hard to actually contemplate what it would mean for the healthcare system it's hard you can't really erase something that's now almost 10 years old and has touched almost every piece of the healthcare system so there is a presumption that if it gets to the Supreme Court and it might not but I mean the appeals court might say yeah no and then they might not appeal it any further but if it if it did get to the Supreme Court the expectation is that Roberts would be consistent and of course that's assuming that by the time it gets there still Roberts and four liberals so I mean there may come a point at which Roberts is not the swing vote but for the moment he is okay thank you now I want to open it up for questions for members of our audience we have one here and Sarah will bring you the mic the whole idea deny care based on their religious beliefs so what do you feel has the reaction to it within DC and where do you see that playing out well there were lawsuits filed against it this week we were waiting to see it's interesting I covered there was a conscience rule that came out at the very end of the George W Bush administration that the Obama administration I thought would just repeal and they actually didn't they ended up rewriting it so this is a rewrite of the Obama rewrite of the george w bush HHS conscience rule but it goes much further than even the original one from 2008 did and it is you know there there is this perception I mean that it's not just that it starts actually the one in 2008 really did start out and being about abortion because it had to do with ACOG requiring that OBGYNs who didn't want to provide a reproductive health service had to refer and there was big fight about that and that was what where the rule came from but there is this concern that it will extend not just to reproductive health but to to gay and lesbian people and trans people and anybody else you know they're there our stories about doctors who don't want to prescribe birth control pills to unmarried women that basically you know at what point does this end I don't know what the courts are gonna say about this it did not get litigated last time because it was so close to the change in administration that there was kind of no point in suing so I mean I'll watch along with you too to see what happens and I you know I guess it depends on where they sue and what judge they get but yeah I think it got I mean it did get a fair bit of attention part of it is that there's so much happening right now that there's just this enormous you know even just in health care I'm not talking about the the greater things that Washington is consumed with right now but even in health care there's so much happening now things things that would be enormous stories are getting forgotten about okay other questions and we appreciate everyone introducing yourselves as a way to get to know each other and whether the complexity that this audience certainly understands pretty agree the work of yourself than we used to I remember you know I covered the the Clinton health reform plan in 1993 and there were all these national political reporters covering it and it was abysmal it really was there are people who were just sort of dropped into the healthcare beat not knowing the difference between Medicare and Medicaid and suddenly asked to do all of this very complicated analysis of you know important policy decisions and I thought the debate was really subpar to say the least it was a little better with the Affordable Care Act maybe not a ton again big complicated easy to demagogue easier for reporters without a depth in the in the subject to do the horse race and the politics than it was to do the substance and I think it's so important I'm actually reading uber Rinehart's last book right now and you know most of it is I feel it's a it's stuff I knew because IVA taught me over the years so you know so well that I've internalized most of this but their discussions that as a society we just don't have and I think some of that is because we need to be led by journalists people who can take the expert work and translate it for a lay public and I really do think that that we are getting better partly because there are a lot of health journalists now who you know do have a depth of knowledge here and there are resources to get more knowledge HB I thank you very much and so it's better I think you know time will tell when we were about to launch into yet another round of you know major health reform debate and I'm I'm hoping that we'll do a better job still than we did during the ACA but yeah I think the Clinton plan was definitely the low watermark so truly I actually have a follow-up to Paul's question which is for our university audience here faculty staff students the work of the Institute for healthcare policy and innovation our whole community is often focused on bringing better evidence to bear for health policy decisions in the public and private sectors how do you and your colleagues as health policy journalists sort of look at work coming out of our University and others how can we make it more relevant how can we make it more known even if it could be relevant but if it's not known by you or your colleagues it may not influence the the reporting and the the commentaries that you're providing so what advice do you have I wish I could tell you it wasn't random but it's pretty random I think it depends what what as a reporter it depends what you're doing at the moment what your editors are it's not that's not always what you want to do but what your editors want to do what somebody is screaming about you know it's hard to sometimes it's hard to break through I often get stuff it's like oh my god this is such a cool story and I have a file and I put it in the file that I never see it again it is you know I wish I could give better advice on certain how to do this but you know be persistent call you know don't don't bug people this is it's a fine line between you know I look at all my email and there's a lot of it I don't necessarily respond couldn't respond to all of it but I do look at everything and you know and I see something's like that's interesting or that's something that we should talk about on the podcaster that's something that isn't that I've been thinking about and might want to put in a story I mean I do I don't necessarily respond but I'll put it somewhere so that it is you know obviously to some extent a lot of news organizations are led by what you know the the New York Times in the Washington Post in The Wall Street Journal right but that's I think that's less so than it used to be I think particularly in health policy journalists sort of you know go by their inbox we think about the various ways that information comes to you and your colleagues from press releases from tweets from you know table of contents from major journals you know coming out on a weekly basis sort of do any of those stand out or what what gets something to the top of your list where you might actually be pitching an idea – your editor because you saw something coming out in my case it's just something that I think is really interesting and new sometimes I might think it's something that I can recognize as news but that others might not I sort of because I have you know such a long history in this I can see it's like wow that's really different from what we've seen before and are there any examples of that you can think of once oh no I actually ended up doing the surprise billing story just because I was getting all of these emails from all of the stakeholders that I could see we're completely disagreeing everybody else saying this is really bipartisan it's gonna happen I'm like I'm not judging from my inbox it's not that was literally where that story came from it wasn't any one thing it was seeing the theme of each of those it's like oh this is not good these people are like completely these people want this and these people want this and they each don't want what the other one wants which is I'm not saying they're not gonna get some kind of deal but I'm saying it's not going to be as easy as it looks so yeah it is it really is hard to say and it's you know if I'm in the middle of working on something and something completely different comes across and I think oh I wish I had time to do that I mean there's some a lot of it really is just good timing occasionally there's something that's so big that you just have to drop everything and do it but more often it's something it's like oh this is kind of cool this would make a good story mm-hmm other questions from our audience aah FBI and one of the questions that I have related to abortion and said beyond the nature of the procedure itself there's a lot of outrage regarding some of the what I would see this like individual variations of provided practices related to dismemberment of the fetus and a person birth an abortion or leaving the fetus to die without providing any type of health care and I was curious to know are there legislation in states or discussions about the broader legal aspects of abortion that address needs more provider practice variations there a lot the Supreme Court did uphold a ban on partial-birth abortion which was actually not a very commonly used technique although there was a peer-reviewed study in one of the ob/gyn journals it said in in some cases that it was actually the safest method to use I actually went up to Cornell and interviewed a doctor and the high-risk pregnancy unit there who was who was not thrilled about this now of course a lot of states are trying to outlaw D&E abortion and that which is the most common procedure use in the second trimester that has not been tested in the court yet but there are a lot of and and I think and and is already illegal I mean that the the idea that the doctors are delivering fetuses and and and you know and watching them die or not provide that's actually that is considered murder if it is a viable fetus it's already illegal and there's already a federal law that addressed exactly that that passed in 2002 the Republicans in Congress are now using it because they want to sort of politically beat up on on Democrats who support abortion rights and I mean I think that's the other thing that's really happened to the abortion debate is it's become much more partisan it didn't used to be partisan it used to be ideological there were people who supported abortion rights and people who opposed them but they weren't necessarily all Democrats or Republicans that's less so right now there's very few Republicans that are left to support abortion rights and very few Democrats who oppose abortion rights although didn't see a Democratic governor this week in Louisiana signed an abortion ban Louisiana you know a very conservative state very long history of opposing abortion among Democrats in addition to Republican so it's some of this is sort of the the partisan part but some of it is we're waiting to see what gets the Supreme Court I John can come from HuffPost sometimes colleague of Julie's you haven't covered this is the third go-around Democrats talking about doing a big healthcare reform and I was curious your impression of the preparation process of thinking through their report how this generation compares to the one in 2007 I was talking about this compared to 1993 when Clinton administer talking about that weirdly enough I think there was actually more preparation both in 1993 and definitely in 2007 than there is now because in the one thing they learned in 1993 there had been a bunch of sort of smaller efforts there was a tax credit that ended up getting repealed because didn't work I think they basically came to the conclusion that you're gonna have to do this all in one piece you can't do it in little tiny increments that was that was the decision that was made and that was not made by Bill Clinton that was made by the Democrats who were running Congress and running the health care committees at the time was it you actually did need something more holistic wasn't that they wanted it to be bigger because they knew that would be disruptive but they knew that it would have unintended consequences and they were gonna have to address them so there was a lot of thinking about that in 1991 in 1992 getting ready for 1993 in 2004 the Affordable Care Act there was enormous groundwork laid before Barack Obama even thought about running for president in Congress you know Ted Kennedy without whom there would be no Affordable Care Act convened all of the stakeholders and they met for months you know that was a case I talked about suing for peace that was a case where the entire health care industry wanted to sue for peace nothing was working for anyone and they were ready to do something about it so it was this sort of magic moment where everybody was willing to sit down and say I'll give up this in order to get that so they had the drug industry and the hospitals and the doctors and the insurers and the business community I mean everybody basically and labor on all on one page and so when and there was this enormous white paper that Max Baucus put out I think it was the week after the Obama was elected I mean the groundwork was set and I think that's mainly it as you saw or have studied it almost fell apart an awful lot of times even with all the groundwork laid I don't think we're seeing that right now I think there's a lot of talk about you know we're just gonna rip up the whole system and start over which pretty much no country has ever done it's always been incremental I think we're just starting as I said to see people start to talk about the kinds of things that we would have to decisions we would have to make as a society the transitions that would be needed that you know people were sort of disappointed in this Congressional Budget Office report that came out a couple of weeks ago about you know things to think about with single-payer because it didn't actually score a single-payer bill but it was a really useful document for starting to think about here's what you would have to do and it had this very little help very hopeful little section and like look here's what other countries do maybe we should look at some of them because they're not all single-payer medicare-for-all in fact most of them are not single-payer medicare-for-all they have various iterations of how they do it that's the kind of thing that I think needs to happen and I think it's just starting to coalesce we have a microphone coming I promise rice flour I will probably not yeah I think there's been a lot of pressure on the budgets and on funding and I just wonder what you have taken some funding for health services research in the future good question that is a good question you know obviously this administration is not necessarily a fan of health services research they're not necessarily fan of evidence which is which is a problem it's not just the administration I mean this is this is a serious societal problem is that science is now considered to be up for you know partisan debate I think this is this is why we have a measles epidemic there are that this is this is a really serious concern but I think I don't want to say that this should be partisan in general Democrats have a have more of a desire to fund health services in general plus health services research you know things like arc were created in a bipartisan way in fact they were really started by Republicans during I think Bush won the first Bush administration so this shouldn't be and has not always been partisan some of it is the sort of effort to just that the federal feel like the federal government is doing too much anyway and they should do less so there's always sort of that concern and it's easy to take off things that are not delivering actual services in health care which is not to say the health services research isn't important but yeah it well I think continued to be you know as as the federal deficit once again gets larger there will be efforts to see where to cut and that appears to be you know an easy place to cut as you've noticed all the efforts to cut it have so far not come to anything and now the Democrats are in charge in the house so it's unlikely that there would be as much of a concerted effort as there might have been for the last two years but it's always going to be a threat and one specific issue in funding for health services research is the reauthorization of picori the patient-centered outcomes Research Institute which was launched nearly a decade ago along with the Affordable Care Act but now but the authorization as I understand it runs through 2019 it started with by part bipartisan support does it still have bipartisan support and and what's the prospect that P Cory you know is with us for the next five to ten years as through this Congress's deliver well I think part of that is the problem of the doubting of evidence that people are thinking you know that there is a perception that science itself is biased and so you can't believe evidence and I think that's going to come into play I haven't it hasn't sort of risen to the level of of having to happen yet it's possible that it could be slipped through but it's also possible that somebody will say why are we doing this and you know I remember when Congress first started talking about comparative effectiveness it was Republicans who were talking about it it was it was it was Republicans it started it was bipartisan but it has become you know again with the the sort of attacks on science in general and evidence I think it's going to be I don't know whether I'll say it'll be heavy-lift it'll definitely be a lift to get quarry reauthorized we have time for a few more questions I directed the University of Michigan Health System I have a question for you know in my whole life in terms of politics I don't think I've ever been in a place where it is effectively so personally where I'm so angry and so frustrated all the time this is somebody like you who is working in the middle of it seeing multiple sides question is where are where's the optimism and the is there light anywhere and we need to for resiliency you know how do you how do you overcome this we just wait it out I have forcing a dog seriously I mean the barn is like my no politics zone and always has been and it's nice that that is that is what I do for resiliency I just like go look at dog pictures go home go home work the dog you know I got a show coming up that that's sort of because you know I grew up in Washington I've lived other than my four years here I've lived in Washington my entire life and it does you sort of I'm old enough now that I feel like I've seen it come and go although this is really the level of insaneness that I have never experienced and kind of every day I come home and say I'm just glad my parents aren't here to see this it would have sent them greatly but it is you know there's this sort of you kind of cling to the I was a young teenager during Watergate and when it really did feel like the wheels were coming off and so you know we lived through that and I was actually writing the first draft of my book during the Clinton impeachment I just basically went home and worked 18 hours a day and fades zero attention to the news it you just you you hope and assume that the nation is strong enough to persevere so it was coming back to Ann Arbor part of your rejuvenation yes and it's lovely in the spring yes even though Julie had great challenges getting through the thunderstorms yes see yesterday so we're very happy that you made it to join us today the questions from the audience yes one in the back first of all thanks for being here I was super excited to hear you say that you think the journalists have a better background now to report more accurately on health care topics I was wondering how much of an obligation you feel especially in some of the more politicized science I guess I'll call it um to make sure you're educating your readers not just presenting the facts of the current story um there is an obligation I mean I feel like you know what I bring I have colleagues who do like amazing work with data which is not what I do or amazing investigative work I feel like I bring context and I like to bring context to stories that's something that's really important you know even so it's much to say this isn't the first time this is happening or this has happened before when this happen before this is what happened with it you know I tend to write stories sort of putting a bigger frame around things but I think it is really important not to just parrot things and not to just do that he said she said and you have no idea who's right you know some people say vaccines cause autism and some people say they don't there there's a lot there's still too much of that I can't take responsibility for everyone else in journalism but I think in general at least speaking for health policy reporters I'm not a medical reporter but for Policy reporters I think as a group we're doing a better job rich earth here in the middle our own health management policy one aspect of the green New Deal really kind of shift gears here a bit is the same sort of plan link.slide policy and health policy is that something that you see gaining traction more broadly the county linkage yes you know along with other determinants of health which are obviously more in many ways you know more predictive of how someone is going to do and help me you know health-wise then the medical care they do or don't receive the the environments effects on health I think are just starting to be kind of we don't have anybody covering environmental health at the moment but I think we will in the near future I think there are a lot more people who are and I think that those two areas are definitely coming closer together I have no idea what that's going to do for either one of them but I think it's definitely sort of good that we are trying to appreciate the health impacts of changing climate and there are a lot of them my name is great rental health library at the Health Sciences Library and when working with colleagues internationally and having experiences i'm ricki the global health sphere their health of the administration of health in the United States by for lack of a better word is often found to be perplexing and just as a personal note I I was born and raised in Canada and so I'm just wondering is is being um is DC are they seriously looking seriously looking at other health systems around the world to see if there's something they can take from that I don't think he can take DC as sort of a I think some people are that's why I was glad to see the Congressional Budget Office did it that's not usual on a Congressional Budget Office report to say look here's how other countries do it not that they couldn't find out I'm still about every three months I resurfaced a piece that Atul Gawande wrote in 2009 I think it's called getting there from here and basically what I learned from that piece that I had not known prior to that was that every single country that redid its health system basically I mean well they all built on what they had but they all built on what they had there was something that sparked it in Britain it was the end of World War two in Germany it was the the fear of socialism I mean they were you know even even the ones that it happened before everybody sort of had a reason for doing what they did and they all built on what they had and it's just and I thought it was it's such a useful it's like you know with with very few exceptions nobody has ever just ripped up their health system and started over and particularly not when it's a fifth of the economy so I think at some point as we get a little more seriously into the how do we get there from here I think people will start to do I think you know I went in 2008 when I get when I was still in PR we actually fanned out across Western Europe to to look at sort of in fact I think the name of the series or something like how they do it I went to Switzerland because I thought that that's what we were going to end up with I was right that because they have an individual mandate although we don't anymore but it was interesting to go to switch Allah I'm dying to go back because when I went in 2008 they had only passed there they'd only really sort of put this into full effect in 1996 they had a national referendum so it was still pretty new system I'd like to know what it's you know how it's doing 10 years later but it was really I thought I learned an enormous amount from doing that and I think that others could too so surely we're nearing the end of the hour on your weekly podcast what the health you often and the discussion with a question to your guests you call it your extra credit question what's an issue or story that's maybe flying under the radar that you think people should be paying more attention to and I'll expand it from this week to this month or it's a recent events but I'd if I were to pose that question to you what do you think is a health policy issue or a news story that we should be paying more attention to that's not through to the top of the headlines right now but could become more important over time well I think the conscience rule is one of the things that that really has potential to to very seriously change how health services are delivered in this country I think that that's been sort of underestimated and I think that you know it came it got a fair bit of publicity but I think they put it out on a Friday and you know again sort of news overtook it I think that that's one of the things I think the other one is probably what's going on with Medicaid although again sometimes that services and we're all talking about Medicaid but the sort of the fight over the partisan fight over Medicaid you know over what what is you know it becomes a broader societal question what is our obligation to provide health care for people who can't afford to pay for it themselves and when you say Medicaid you're referring specifically to Medicaid expansion or broader issues broader issues about Medicaid work requirements expansion how Medicaid pays for drugs there's a lot of Medicaid issues that are out there partial expansion whether it should be OK for a state to to only go up to to expand but only up to a hundred percent of poverty there's a concern that if they allow that that some states will then go go down you know that you may get some people covered who wouldn't otherwise be but you also may end up with people losing coverage so there's a lot of Medicaid issues out there well I want to give you a chance for the last word you've heard the the concerns and questions of our audience today what what thoughts would you like to leave us with from your visit here at your alma mater yeah please keep doing what you're doing it really is I mean we really do look at it that's I know it can be frustrating sometimes you feel like you're sort of shouting into a void but it is journalists at least still believe in evidence and it's nice to have so thank you well thank you Julie you

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