The Host
This month marks host Julie Rovner’s 40th anniversary reporting on health policy in Washington. Over that time, she’s covered a vast range of topics, from the response to the AIDS epidemic, to Medicare and Medicaid changes, to the fight over the “Patients’ Bill of Rights” — and a half-dozen major reform fights, including the introduction of the Affordable Care Act and the efforts to repeal it.
In honor of the occasion, Rovner invited two of her longtime sources to chat about what has — and has not — changed in health policy over the past four decades.
Click to open the transcript Transcript: 40 Years of Health Policy[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello from KFF Health News and WAMU Public Radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for KFF Health News. Usually we’re joined by some of the best reporters covering Washington, but today we’re bringing you something special. I hope you enjoy it. We’re taping this episode on Friday, Feb. 27, at 4 p.m. As always, news happens fast, and things might have changed by the time you hear this. So here we go.
I have two special guests today, who I will introduce in a moment. But first I’m going to explain why I chose them. I started reporting on health policy in 1986, covering health and welfare on Capitol Hill and at the Department of Health and Human Services for what was then the Congressional Quarterly “Weekly Report.” This month marks my 40th anniversary on the health beat, and as anniversaries so often do, it got me thinking about everything I’ve seen and covered, including a half a dozen major health reform fights, a dozen budget reconciliation bills, years-long fights over everything from the Patients’ Bill of Rights and human cloning to bioterrorism and a pandemic. It also got me thinking about where I thought the U.S. health system would be four decades after I began, and where it actually is. And I thought it might be fun to reminisce with a couple of people who not only were there when I started, but who also taught me a lot of what I know. So without further ado, let me introduce my guests. Chip Kahn just stepped down as president and CEO of the Federation of American Hospitals after 25 years in that post. Chip previously worked in both the House and the Senate for the major health committees and also headed the Health Insurance Association of America, the industry group now known as AHIP. I’m pleased to announce that Chip is not actually retiring — that, among other activities, he’s going to be a colleague of mine here at KFF as a senior fellow. Chip will also host a podcast starting later this spring on the business of health care. Chip, thanks for being here, and welcome.
Chip Kahn: Really happy to be here and celebrate with you.
Rovner: Joining Chip is Chris Jennings, who not only worked in the Senate for a decade, but also worked in the White House as a senior health staffer for Presidents [Bill] Clinton and [Barack] Obama and advised President [Joe] Biden as well. Today, Chris is president of the health care consulting firm Jennings Policy Strategies. Chris, welcome and thanks for playing along.
Chris Jennings: Julie, it’s been great to age together.
Rovner: So let’s start with a little bit of a tour of each of your careers. Chip, you go first. How did you first get started in shaping health policy, and what was your trajectory to today?
Kahn: It was a scary long time ago. I guess I got started in politics in 1968, actually, when I met Newt Gingrich in New Orleans and then managed his two congressional campaigns. But then I went to graduate school in public health, and finally broke into the Hill in 1983 and worked for a year for Dan Quayle, and then worked in the Senate, worked in the House, went out and worked for the health insurers, came back and worked in the House again during the ’90s — many, many years of health policy. And then, as you said, for almost 25 years, worked at the Federation of American Hospitals, representing 20% of the hospital industry and all the health policy battles.
Rovner: And behind your head it says “AEI,” so in your not-retirement, you’re going to be here at KFF, and you’re also going to be at AEI [American Enterprise Institute]. What else are you planning on doing?
Kahn: Well, other than being a think tanker … and a podcaster, I’m looking at a number of areas where I’d like to do some writing on the health policy issues that I’ve been involved with over the years, and maybe try to impact their future by some of the things I have to say. That’s my, will be primary, although I’m also working with the dean of the School of Public Health at Tulane on developing a health policy center there. And I do photography, street photography, and I’ve got a project there too. So I’m not retiring. I’m just moving on.
Rovner: You are busier than I am, and I thought I was busy. Chris, how did you come to health policy?
Jennings: Well, I know you’re a Michigan gal, Julie, but I’m from Ohio. And I came, actually, the same year that Chip came in, in 1983. John Glenn hired me as a very, very young assistant. I don’t think I got to know you until … 1986, shortly behind. But I remember in ’86 I was hired by the chairman of the Aging Committee, the then-chairman of the agency committee [Special Committee on Aging], John Melcher, and he held the first hearing in a blizzard on the Medicare Catastrophic [Protection] illness coverage Act, and I worked through … that was ’88-’89, we repealed the policy, as you will recall. By that time, you may have moved on to the National Journal. I can’t even remember when you were there and in NPR, but I followed you as you followed me. And I worked on another chairman, David Pryor, on the Pepper Commission, where I got to know Chip — love, hate, mostly respect Chip — on the Pepper Commission, which both succeeded and immediately failed.
Rovner: And we’ll get to that.
Jennings: And it set the stage, really, and that’s where I think people started to know me on the Aging Committee, on the Finance Committee, on the Pepper Commission. And then, I’d go on and on. But, of course, I was eventually tapped to help Hillary Clinton do the Health Security Act, where we spectacularly failed, but learned our lessons, and we moved on. And I was there for all eight years of the Clinton administration, set up my own consulting firm, went back into the White House, as you said, and have been proud to be involved with some, you know, both extraordinary successes and failures, but progress that I think sometimes people don’t acknowledge in this debate. So hopefully we get to talk about that as well.
Kahn: You know, Julie, one thing I think you can say about both of us is that there hasn’t been anything congressionally in delivery or financing, over your entire 40 years, that Chris and I were not involved in in one way or another.
Rovner: That was why I decided I wanted you guys. I well know that you’ve had your fingers in everything this entire time. Well, let’s go back to the spring of 1986, when I first started covering health care on Capitol Hill. Congress was just finishing the COBRA [Continuation of Health Coverage] budget reconciliation bill, for which the health care continuation provisions that everybody knows are named, even though that was just one of literally hundreds of provisions, of different health care provisions in that bill. And from the “Some Things Never Change” file, that bill was very late. It had been kicking around since the middle of the year before one of the first big feature stories I wrote that spring was about how the U.S. had no real program to pay for long-term care for the elderly, something that is still true today. What were you guys focused on in 1986?
Kahn: I think in 1986, as you said, every year during the ’80s and into the early ’90s, almost like clockwork, there was a budget bill, although some of those budget bills, like COBRA, lapped over. And I could, I could recite, until about 1990, I think, all the key provisions of every one of those bills. So whether it was Medicare in terms of payment modifications and payment improvements, or payment reforms, or whether it was Medicaid in terms of incrementalism, in terms of expanding to different populations. You know, we sort of saw it all.
Jennings: There were notable reforms. In fact, it’s important to remember back then, health care really was the domain of the Congress. Presidents, barely, you know, they were for technical assistance, they provided information. But the big players in health care in the ’80s were — and it’s a very impressive group of people, both members and staff. And I don’t want to sound like an old person, but those were days when you actually did get bipartisan policies done. They weren’t easily done, but they were done, and I think it’s important to recognize that. I go — you’re saying ’86, so I’m going to stick with ’86. But ’86 was a big year … I think that was also — when did we do COBRA? ’85-’86 we were implementing COBRA.
Kahn: It was done in ’86.
Jennings: Yeah, ’86.
Rovner: It was in COBRA.
Jennings: Yeah, yeah. So, you know, that is, again, a policy that a number of people actually do utilize and it’s very, very important.
Rovner: And EMTALA was in that bill.
Jennings: EMTALA was in that bill, yes.
Kahn: But besides these bills, and you brought it up, Medicaid Catastrophic, which was started a little bit after that, actually was a Reagan administration initiative. Dr [Otis] Bowen, the secretary of HHS [Department of Health and Human Services], was the major proponent. Then it became, obviously, very congressional. And so the major piece of health legislation that was just a health bill that wasn’t connected to one of these big budget bills, these big reconciliations, it passed, and it passed overwhelmingly in both chambers. After a lot of work, we could talk about that, if you want. And then within a year, you know, it was repealed. And one of the weird experiences of my life, was that, on the one hand, Bill Gradison in the House was one of the original framers of that legislation.
Rovner: Your boss at the time.
Kahn: One of my bosses at the time. But the day before repeal was considered in the House, I had to write for Bill Gradison a draft of a statement for him. And I, but I also worked for Bill Archer, who was one of the authors of the Archer-Donnelly amendment, which would repeal Medicare Catastrophic. So I also had to write a draft of a statement for him. Actually, let me say, I didn’t write them on the same day because I couldn’t bring myself to. But I was really sort of — I got to be careful here — “schizophrenic” on the issue, because I worked both on the legislation and then on its repeal.
Jennings: Julie, also, I just have to say there’s another irony that I think no one knows really about, but the lead sponsor of the repeal was John McCain. John McCain, who raised all the issue of the so-called surtax, OK? Do you remember this?
Rovner: I do. I wrote a big story about John McCain.
Jennings: People think John McCain is Mr. Savior of the Affordable Care Act, but he also repealed the most significant, at the time, bipartisan, bicameral health care reform bill that actually, we should also say, did include an incremental Medicare prescription drug benefit.
Rovner: John McCain was very sorry. He actually felt bad that he ended up … he tried to undo the repeal that he led.
Kahn: And also, there was a secret weapon in there, which actually was very expensive, which was a Bill Gradison initiative, which was to change the skilled nursing facility benefit so that Medicare would basically cover six months without three days prior hospitalization.
Jennings: Yeah.
Kahn: And that was something that CBO said, the Congressional Budget Office said would just cost a few 100 million dollars. It was actually costing billions almost immediately, because all the states immediately changed those dual-eligible patients, dual eligible for Medicare and Medicaid, and made them Medicare patients because of the six months. So there was even a long-term care provision in there, despite the fact that some felt that Medicare Catastrophic didn’t touch long-term care.
Rovner: Well, while we’re on the subject of the poor, be-knighted, repealed Medicare Catastrophic bill, which we all experienced, that led to the Clinton health reform bill. Chris, you were instrumental in that. What had you learned from the passage and repeal of catastrophic that you tried to put into place when you were working on the Clinton plan?
Jennings: Sure. Well, first, Julie, I think we learned from all of our mistakes, and you learn more from your mistakes than you learn from your successes. And sometimes you mislearn your successes in major ways. But I do want to say the one thing that we did not repeal in the Medicare Catastrophic [Protection] coverage Act was the Pepper Commission. And the Pepper Commission was the first attempt to do the comprehensive reform proposal, and it was reported out, but in a really humorous, terrible scene, which I won’t bore people with, but — Chip was there, and I was there, and it was painful, and that people actually almost came to blows over that policy. Physical, physical blows between my boss, David Pryor, and Pete Stark, of all people. So that’s another story. But yes, after that, there was a[n] election in Pennsylvania — and this is sort of interesting historical context — it was a special election by [Sen.] Harris Wofford, who won, and it was all about health reform. And his political advisers, interesting, was James Carville and Paul Begala, and health care suddenly became, comprehensive health care reform became, oh, this is a big issue. And every candidate who was running at that time — really, people who … no one even knew the people running, because no one wanted to run against George W. Bush — but Bill Clinton was running against it, and he, he ended up winning, as you know, and then he chose …
Rovner: It was George H.W. Bush.
Jennings: George H. … George H. was so popular that the primary Democratic candidates didn’t want to run against him. So people just said, I’ll just try. And, long story short, Bill Clinton wins. And he designates Hillary Clinton. And Hillary Clinton, because I had done some work for their campaign and helped in the transition, I was asked to become the congressional liaison. So now, what did I learn from that? Well, there’s so many things to learn, and we applied them almost all to the Affordable Care Act. And of course, we’re going to have to give Chip his — you know, Chip’s the star of “Harry and Louise,” and proudly contributed to …
Rovner: We’ll get to that.
Jennings: … the demise. But I will say, even if we had perfectly executed the Health Security Act policy, because of the time and the delay of it and how in the environment in which it was in, it probably would have been very, very difficult to pass and enact at that time. We can talk about that. But one thing we learned is it’s really important for presidential candidates to have a vision and a way to finance their vision, but not to micromanage exactly the specific policies you need to get congressional investment in those policies. And if you impose details, the details will get, will be picked apart before you get the momentum to pass legislation. And you won’t have time to get both members of Congress and stakeholders, who inevitably you can’t pick, you can’t have everyone be your enemy if you’re going to pass health care reform, and we succeeded in getting most everyone against us. That wasn’t completely my fault, but sure, I’ll take whatever responsibility there is. But those are two big reasons. You know me, Julie. I could go on forever, but I’m going to stop with that and let Chip take his victory lap or whatever.
Rovner: Yeah, because Chip, at that point, you were with the health insurers, who were not thrilled with the Clinton plan.
Kahn: Well, let me say this. I always have to say this when I talk about the Health Insurance Association of America. Bill Gradison went over there in early ’93, and he took me with him. I was his executive vice president at that point. And the health insurers that we represented were for some kind of universal coverage structure. They weren’t for the model that was developed by the Clinton administration that they took to Congress. But I think Chris made a very important point: All the noise from the campaign around “Clinton Care,” pro and con, there were a lot of things going on. First, a new administration only gets so many bites at the apple, even if they’ve got big majorities in Congress. And they chose to do their big budget bill and a gun bill, which were very difficult votes for many members of Congress, before starting, in September, on the Hill with the presidential speech to lead into health reform. So I think they went in with a clock that was against them, in terms of how much a new administration has. Second, I don’t think everybody completely understood it at the time, but we had congressional control by the Democrats of the House for 40 years, and in some ways, they were a bit bankrupt, and there were a lot of issues around, you know, their unity. And we didn’t know it until the election in ’94 — and Clinton Care had had some effect on that election — but we were about to see the Republican revolution taking place. But the soundings of that and the effects of that played out in Clinton Care. But, all that being said, if you believe that campaigns make a difference in policy process and elections, there were campaigns that said Clinton Care, as proposed, needs to change. And the Health Insurance Association of America did the Harry and Louise campaign, which I managed. And actually there was one point …
Rovner: I would say, for those who don’t remember, Harry and Louise were a couple of actors. Those were their names, actually, Harry and Louise, who sat around their kitchen table wondering how they were going to pay for their health insurance if the Clinton plan passed.
Kahn: And that concept came from over the summer, leading into that August, before the Clinton Care process began in Congress. Bill Gradison had been going around giving speeches, saying that health reform was going to be decided around the kitchen tables of America. So I told our advertising firm, First Tuesday [Strategies], go test that. And that’s how it all got started. And they came up with the concept, and we spent a lot of time on scripts. And our whole point was not to defeat but to raise questions and actually just get a seat at the table. Well, I could give anecdotes about why we didn’t get a seat at the table, and thus we began a campaign that was one of the components of the opposition to health reform that really defeated Clinton Care.
Jennings: And Julie, I’ll just say I think it’s important to note that we also played into it by complaining so much about [how] it got lot of free airtime, too. So then the media covered it even more than the other one. And so it was the amount of money they paid for those ads versus the amount of ads people who see that ads was an extraordinary ROI [return on investment] for Chip Kahn and Bill Gradison. But I do feel it’s important to note that a lot of the predicate for rationale behind and policy underpinning the Affordable Care Act, you’ll find a lot in the seeds of the Health Security Act, and then you’ll see them again in the debate between Barack Obama and Hillary Clinton. And in many ways, Hillary Clinton’s policy is more like what ultimately was passed and enacted in 2008 and 2009. So it’s a very interesting circle of the process. And the other thing that I think people don’t understand, is, right after that we had another health care debate, which was the “Contract With America” and, or on America, as we used to call it, and, and that was a huge Medicare-Medicaid fight, which didn’t, which also failed. But I think you almost had to have these two attempts to have an attempt to make some progress. That led to things like the Children’s Health Insurance Program and beyond, so all of which — and by the way, HIPAA, insurance reforms beyond that — which began to lay the predicate for it. Yes.
Rovner: All right. Well, we’re going to take a quick break. We will be right back.
OK, we’re back. In the 1990s, after the death of the Clinton health reform plan, there was this huge sort of flow of big, important health bills: the Children’s Health Insurance Program; like you say, HIPAA, the Health Insurance Portability and Accountability Act, which was a whole lot more than just the confidentiality provisions. In fact, my favorite piece of trivia is that there were no medical records confidentiality provisions because it was a requirement for Congress to write them, which they never bothered to do.
Kahn: If you want an anecdote on that, I’ll give you an anecdote.
Rovner: OK.
Kahn: That’s there because of me. But I can only take credit for a few things: diabetic shoes and HIPAA confidentiality.
Rovner: I do remember diabetic shoes, but I will not make you explain that. But do explain how the confidentiality … because HIPAA was actually about being able to change jobs without losing your health insurance — it was literally about portability of health insurance, and the confidentiality stuff got tacked on at the last minute.
Kahn: No, no, no. It didn’t. It didn’t. No, the point of HIPAA — and, frankly, I wasn’t the author of this; I sort of stole this idea — but HIPAA was either the seven-point plan or the nine-point plan. And the idea of the way we structured HIPAA in the House was to take four or five different things — and it was, it was much more than just insurance reform —and build out aspects of health reform, sort of small-ball health reform. And the confidentiality was one part of it. And we thought at the time that there was an administrative simplification portion of the bill, which came from a congressman from Ohio that, frankly, as a staffer, I was the one in the House that put that in the bill, and I and our expectation was that Congress would come back and do confidentiality, but we needed to require it, to set a framework for it. And there was one day when the bill was in conference, when Dean Rosen, who was working for Ms. [Sen. Nancy] Kassebaum …
Jennings: Yeah, it was Kassebaum.
Kahn: … called me and said, Do we really have to leave those lines in the bill? And I said, Boy, it’s really, really important. And the congressman from Ohio feels strongly about it, and Mr. [Rep. Bill] Thomas feels strongly about it. And so that’s why we got HIPAA, and then, then they couldn’t legislate on it because it was too sensitive, but we put language in, and HHS wrote the rules.
Jennings: I think it’s really important to note that in the olden days, when we started this, Congress actually gave much more explicit guidance to the executive branch as to how they implemented. HIPAA was a good example as a bridge to where we are today, which was we will do something. This is what we were saying in HIPAA. But if we fail to do so, we authorize you, executive branch, to implement the provisions of HIPAA, which is what ultimately the Clinton administration had to do. And a lot of that is because the Congress couldn’t agree on the details, as they often can’t, but they still want to be associated with the underlying policy. But anyway, it’s just another lesson of the life that we were at and where we are now.
Kahn: And when you say, wouldn’t agree on the details, the trouble is that the poison pills, those cultural issues, frequently come into issues here. I mean abortion and other issues, which are extremely important issues, but they’re cultural issues, and people are not generally willing to compromise on those. And those are the issues that ended up holding up things like confidentiality, which Congress should have acted on.
Rovner: Yeah, I want to get to the Affordable Care Act, but before I do, Chip, I want to talk about the strange bedfellows. Because I want … you were talking about in the context of the Clinton reform, that the stakeholders weren’t really against it. They were only against parts of it. I think I wrote in a monograph on this that everybody wanted to cut off just one finger, but, in the end, the patient bled to death. You wanted to prevent that from happening when there was the next round that became the Affordable Care Act, and you got together with Ron Pollack, who was, you know, a very liberal, also outside group. And you guys tried to put together a framework, right?
Kahn: Well, when I went to back to the Health Insurance Association of America in 1998, Ronnie Pollack and I got together and wanted to see what we could do. I mean, in a sense, we both really agreed that we needed various kinds of coverage expansions. We started incremental. And as part of that, the Rob[ert] Wood Johnson Foundation came in with a major initiative to fund us and to fund the conversations we began, and to fund other groups coming in and joining us in a big coalition. And, frankly, we were very close on some subsidization. We had a Republican and Democratic senator right before 9/11 and then 9/11 happened, and it just … killed us. And … we got put on the back burner. And so then we went through many years of Ronnie and I doing a lot of different efforts with many other stakeholders — around either doing small-ball expansions or pushing for the ultimate — and that, ultimately, I think, at least helped fuel what happened in ’09. I mean, a lot of things led to ’09, but at least, I think, our effort laid a base of commonality across stakeholders that made ’09 very different from ’93.
Rovner: Chris, you said that, you know, one of the things that you learned from the failed Clinton health reform is it … you’ve got to have at least some of the stakeholders inside the tent, right? … That seemed to me one of the big changes between 1993 and 2009.
Jennings: Yes, I mean, like every story that sounds black-and-white, there’s grays in those. But yes, for sure, and I do agree that the larger insurers knew the market couldn’t — at least the individual, non-group market had to be reformed so that they didn’t … they’d make their money on avoiding sick people. They needed to have a pool of people that they could insure, and it wasn’t an irrational, expensive, immoral health care system. So I felt, and to Chip’s credit a lot, and others, they wanted to have. … And actually, the other argument that happened in 2008 and ’09, there’s a lot of different things that came together. Bipartisan Policy Center was there. There was interest in doing comprehensive reforms that were very consistent with what the Affordable Care Act ended up happening. But there was also this notion of all the stakeholders were just tired of fighting, and it was like, Let’s get something together. There’s one last point that I think people neglect to cite, and I know Chip would agree. At the time, there was a concern that a lot of the savings from health care would go to something like deficit reduction or tax cuts, but not reinvested in health care for coverage expansion. And so when, you know, if you’re a stakeholder and you’re going to contribute something to the offsets, you want to be reinvested in your system so you have paying customers, and that’s why I think the hospitals and the physicians and the insurers all came together to say, let’s figure out a way that this can work. So that at least helps paint the picture about how you could tie it together.
Kahn: And one experience that I had was that I brought — I was then working by the early 2000s for the hospital association, the Federation of American Hospitals. And at that point, you know, obviously my members were supportive of the work I was doing with Ronnie. But there came a point, I can remember it to this day, in October 2006 we were having a meeting, and a number of the CEOs of the systems I work for came to me in a meeting and said, This isn’t good enough. There are just too many patients that we’re treating that don’t have insurance, where their finances are getting in the way of the care they need, and we got to have something comprehensive. So they moved away from, not that they didn’t support incremental changes, but they wanted to see the big picture done, and that led the Health Insurance Association — we were a small group — to develop our own plan, the health care passport. And there were other plans out there. And the increment, the very important thing about that plan and the others and the way that ’09 worked was that in the administration and in Congress, they wanted to build on what works in the system, and reform the individual market and lay in enough subsidization and expansion of Medicaid so that we could say everybody has the opportunity for coverage. Now we could say that was not that different from ’93 and ’94, but it was handled completely differently. And I think it was more sensitive to all the concerns of all those that were stakeholders, that were players. And that was the framework, but it was building on what exists with those kinds of playing with the knobs that really made the difference, that you could say everybody could have access to coverage.
Rovner: So as we’ve kind of talked about, up to 2009 health care was pretty bipartisan. I mean, you know, there were partisan fights. There are obviously fights that Chip, you noted, that were going to be perennial, like fights over abortion. But, generally, big things that got done got done with Democratic and at least some Republican votes, or, you know, Republican … in the case of the Medicare prescription drug bill, Republican and some Democratic votes. And yet, you know, in 2009, it just suddenly became partisan in a way that it still is today. I mean, what happened?
Kahn: Well, let me say it’s very, very important to think of the broader context and not just focus on health care for a second. A lot was changing. The Tea Party, we go on and on about how we got to where we are today, and the great divide. So there was a great political divide. There was no more getting … there was much less getting to yes in Congress. And I think that health reform, in a sense, suffered from that. And the other dilemma that health reform had, I think, which was it was successful because of the vast Democratic majorities. They didn’t need the Republicans. On the other hand, the fact that — and the Republicans wouldn’t play, so I’m not saying there was a possibility there — but the fact that it got done in a partisan fashion, you know, fit into a larger context that made it part of the divide. And, frankly, after it passed — and, obviously, hospitals were very supportive of it — there were a lot of Republicans that would never speak to me again.
Jennings: Yeah. And Julie, I think it’s important to recall that even back in ’93-’94, around the Health Security Act, there were Republicans who wanted to do this, but — and I’m sure Chip will yell at me about this — but Speaker Gingrich was not interested in having a health care achievement signed into law by Bill Clinton. He made that very, very explicit. So I think different people will say, When did partisanship around health care really start? But I would say there was a big one. Then we had the big fight around the “Contract With America,” and from then on, even though there were significant reforms that were bipartisan, I would call them important, but incremental, you know. And Chip’s right. I don’t think you could have gotten anything close to the Affordable Care Act on a bipartisan bill. Maybe he’d disagree, but I just, I don’t think there are some Republicans — I’ll tell, I can even tell you — who would say, Oh, if you’d only tried or whatever … I think [Sen.] Max Baucus [the Finance Committee chairman] really wanted, you may recall this. He worked for a long time. He desperately wanted to have bipartisanship. I don’t think that was going …
Rovner: Yes. And I sat in the hall during those meetings for weeks at a time. I remember.
Jennings: Yeah, yes. You remember? I mean … and to the criticism of a lot of the Democrats, what are you holding up for? So unfortunately, there are elements of health care, and I think a lot have to do with coverage — Medicare, Medicaid, marketplace, the three M’s, if you will — that are very hard not to politicize. And unfortunately, public health has now become very politicized, too. So we’re having a smaller [unintelligible] of elements of health care that you can see bipartisanship. But … there are some, and I’m sure we were going to talk about that, but I look back and reflect about that debate, and I don’t see a possibility of where it would have worked and Barack Obama would have been able to achieve what he said he was going to achieve.
Kahn: Well, let me say a couple of things. First, I think, to modify your history. I think that in the House …
Jennings: Yes.
Kahn: … Newt wasn’t speaker at the time, he was minority leader. Clearly, there was nowhere to go with Clinton Care. I mean, the Republicans just were not going to go. I think you saw something quite different in the Senate. And there were many Republicans in the Senate, probably not a majority of the conference, but a very large minority who were willing to at least try … but I think the environment completely changed over time, and by the time you got to 2009, 2010, despite some kabuki theater on the part of some Republican senators, who I won’t name, who sort of played along, they were not going to cooperate. But let me say, one of the turns in history that’s important is that you’ll remember the Democrats had 60 votes in the Senate until the end, when, unfortunately, Sen. [Ted] Kennedy died. But actually, I would argue that it was his death, in a sense, that ultimately led to health reform passing, because a conference report on health reform between the House and the Senate probably wouldn’t have gotten all the Democratic senators. I don’t think Sen. [Ben] Nelson [D-Neb.] could have done it, so you would have had a filibuster against it. But by [Kennedy] dying, the House was forced to take on, for the bulk of health reform, the Senate bill, and they passed the Senate bill. Yes, there was a reconciliation later, but it was really, that was the framework for health reform, and in a bizarre way, it was the contribution of his death and the … House having to accept the Senate bill that led to health reform really passing, you know, by the skin of its teeth, even though there were these vast majorities of Democrats in the House and Senate.
Jennings: Yes, I think that’s a very insightful comment, and I rarely say that about Chip. [Kahn laughs.] So, no, I do all the time. It is, but Kennedy, the sacrifices Kennedy would make to become the ultimate legislator, even to go so far as to die. But I will say, I think that’s right, because there was a very significant frustration amongst the House Democrats, and they desperately wanted to have a true conference, and that would have made it very hard in the Senate. It would … have been hard to clear through reconciliation rules in the Senate. And there would have been lots of challenges, and, ultimately, this is why Nancy Pelosi gets most of the credit, and so too should Harry Reid. They brought it home in a way that probably was the only way to get it done. And subsequently, one of the problems was it probably wasn’t drafted as cleanly as we would have liked it to be. You know what I’m saying?
Rovner: Yes, I know what you’re saying. For those who, for those of us who had to follow this sort of ins and outs of the not being able to make technical corrections to it for its entire history — which, flash-forward to today, is there any chance of ever getting back to bipartisanship on health care?
Kahn: I don’t think on anything regarding delivery and financing that’s major is there much likelihood of consensus. Now, if you remember, not too long ago, there were bills on, you know, FDA processes and the such, and they were done in a bipartisan manner. And maybe some of those things at the edges. I think there are some hospital issues and others that still could be dealt with in a bipartisan manner. But that gets back to context. You’ve got to have the sun and the moon come together on political context that would allow some — I won’t call them marginal, but — relatively small changes to be legislated. Other than that, we’re in an environment right now where I just don’t see compromise on anything big, because the divide that we saw coming out of ’10 is still there. And if anything, it’s just deeper than ever.
Jennings: Right, and … although I don’t think Chip would disagree with … what I’m about to say, is, there are issues that are not so much ideological in coverage: biomedical research, transparency, even physician payment reform, rural health, telemedicine, community health centers. I’m just mentioning these out loud, because you’ll see bipartisan agreements on some of those things. But in terms of real structural reform, and particularly when you’re talking about where people get coverage and how much you subsidize it, boy, is that tough. In fact, I would even argue, and this is really unbelievable to say out loud, that cost containment in some fields, which is almost always impossible, is easier than how you spend the money. Because people don’t, can’t agree on the structure by which you would reallocate the savings to make health care work. So it is a frustrating time, which is why it’s hard to make the argument against people who say, then we need to have all one party or the other party to get something big done.
Kahn: Now, let me say I think there could be some surprises next year if the Democrats took over in the House. You know, is there some possibility that there could be a big compromise with a Trump administration in the future on drug negotiation or drug costs? So I don’t want to say that there’s nothing that can be done. And I agree with, and I think I said, with Chris that there are these issues around the edges that could be dealt with, and the ones he outlined are the ones that I would agree with. I think the one big one is there is some possibility around drugs. But I think, other than that, I don’t see the Republicans being willing to help on Medicaid.
Jennings: And that is a cost containment as opposed to kind of a coverage, you know. And it’s sort of a one-off. It isn’t, you know, big, big reform. But I agree with Chip that there you could see Democrats in the House push something that [President Donald] Trump would endorse, that Republicans in the Senate wouldn’t like to pass but would. … They probably would want to have come up with an excuse not to. But that’s, that is a target area that could happen. Although, you know, I’m … Democrats aren’t catching, counting our chickens just yet, Chip. … We’re knocking on wood here. [knocks]
Kahn: Yeah, let me say, if the Congress doesn’t change, in terms of who has the majorities in both House and Senate, I don’t see anything major, other than some of the things, you know, transparency and some of these other issues, getting attached to something bigger. And then you’ve got to have context, as I said, the right context to have it. But I don’t see anything big unless we get split government. I think split government could lead to some interesting things in some of these areas. But what we think of as health reform writ large, right now, it’s just politically charged.
Rovner: We’re going to have to wrap up. But one thing that I’ve been sort of thinking about a lot is that we seem to be getting to this place that we were in in 1993 again, and in 2008 again, where everybody is unhappy with the system — that, particularly patients, even people with insurance, are unhappy with the way the system is working. Doctors are unhappy, hospitals are unhappy, insurance companies are unhappy. Is it possible that that’s going to push this big divide a little bit back together, at least in an effort to do something? I mean, clearly President Trump knows that people are unhappy with the cost of drugs, if nothing else in health care. Do you think we’re heading for another round of major health reform debate?
Jennings: It feels like that, Julie, for sure, ’91-’92-ish, or, you know. It does not feel like in any way. … I think people are really frustrated with costs, really frustrated with complexity, really frustrated with how they think the system is not necessarily responsive. They’re pretty good at kind of defining the problems, but in terms of developing a consensus around how best to do that, which is, you know, typically what people say, I want comprehensive reform that doesn’t disrupt me, you know, which is a hard nut to crack sometimes. But … it feels like we’re seeing it. And you’re going to hear a lot about talk, but I think you’re … the big thing will happen around a ’27-’28 period, when the two open electorates for presidency come up, and … this issue will be absolutely debated. But the big, big thing probably isn’t going to happen until the next president is elected.
Kahn: So let me say this, and I’m going to give a plug to KFF’s Business of Health With Chip Kahn, a podcast that will come sometime in April.
Rovner: Absolutely.
Jennings: He’s shameless.
Kahn: We’re going to … focus on AI [artificial intelligence] for the first three or four months. And I don’t want to say it’s going to change the world. It’s going to change the world. I don’t want to say it’s going to change health care. It’s going to change health care. Is it going to solve all these problems? I don’t know, but I think many of these issues could be different five years from now because of the effect of AI, and will doctors be practicing the same way they are now? Will all these issues of thousands of people working with green eyeshades in hospitals to make sure the claims are done right, they go to insurance companies. With respect to those thousands of people, it’s going to be AI. … They’re not going to have jobs anymore, and it’s going to change a lot. Now, is it going to solve any of these problems, or is it going to raise risks and challenges we can’t even foresee? I don’t know, but I think we’re going through, about to go through, an evolutionary period, and I don’t know what it’s going to look like on the other end.
Rovner: Well, I think that’s as good a place as any to leave it. I want to thank both of you. I could definitely go on for another hour, but we won’t. Chip Kahn, soon to be a fellow at KFF. Chris Jennings, Jennings Policy Strategies. Thank you very much.
Kahn: Thanks a lot.
Rovner: OK, that is this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer this week, Taylor Cook. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. We’ll be back in your feed next week with all the health news. Until then, be healthy.
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