On Thursday in the Orange County Convention Center in Orlando, HIMSS17 attendees were given uncommonly “insider-y” views of the national American political scene from two veteran politicians from the two main U.S. political parties, Republican John A. Boehner and Democrat Ed Rendell. Boehner, who served as a Republican congressman from Ohio’s eighth congressional district from January 1991 through October 2015, including service as Speaker of the House of Representatives from January 2011 through October 2015, and Rendell, who served as Governor of Pennsylvania from January 2003 through January 2011, met on the stage of the Valencia Ballroom on Thursday morning, for a public conversation moderated by H. Stephen Lieber, the president and CEO of HIMSS (the Chicago-based Healthcare Information & Management Systems Society), the conference’s host organization.
The conversation was very loosely structured, and while it did not result in any “bombshell revelations,” the discussion was quite frank in relation to the parameters of typical political conversations involving members of both major political parties, with Boehner and Rendell sharing fairly straightforward perceptions of the current political situation on Capitol Hill right now. And, perhaps without meaning it, Boehner left attendees with perhaps the closest to a newsy takeaway, stating pretty much without qualification that he believed that congressional Republicans’ stated intention to “repeal and replace” the Affordable Care Act (ACA) will not lead ultimately to repeal. but instead, to the “repair” that some Republicans have begun speaking of, of late.
Dissecting the past, present, and future of the ACA
After brief introductory remarks, HIMSS’s Lieber plunged straight into a broad discussion of the ACA—what had happened as that law was shaped and passed, how its current status looks in terms of potential repeal and replacement by a Congress with Republican majorities in both houses and with a Republican presidential administration, and how the legislation might look years from now. “Let’s go back to 2009-2010, and the discussion around the Affordable Care Act,” Lieber said to Boehner and Rendell. “What did the Democrats do right, what did they do wrong, what did the Republicans do right, do wrong?”
“What they did right was to make an attempt to offer affordable healthcare to all Americans,” Boehner said. “What they did wrong was to try to force people to be a part of that system who didn’t want to. And then they tried to force it through on a party-line basis. Things that are sustained are done on a bipartisan basis.”
Former House Speaker John Boehner and former Governor Ed Rendell converse with HIMSS's Steve Lieber
“I thought there were two goals” to the ACA, Rendell said: “to increase accessibility and affordability. We certainly succeeded in the first instance. Before Obamacare, there were 48 million Americans without health insurance coverage; that number went down to 28 million without health insurance” after the law’s passage in March 2010, “and we’re down to 8.2 percent uninsured now, which is the lowest ever. In terms of what he sees that could be improved, Rendell cited the need to add new innovations into the law, such as support for such innovative approaches as telehealth. “I’m the president of the board of Jefferson University Health System” in Philadelphia, he noted, “and we use telehealth throughout Pennsylvania, especially in rural areas. Many small communities have lost their primary care physicians altogether, and telehealth has done an enormous job” in terms of bridging essential gaps in medical care. The ACA, he said, “left a lot of things off the table in reducing the cost of the delivery system, he said, while immediately noting that all transformational legislation requires repeated changes and tweaks to respond to ongoing needs; he cited the original Social Security legislation as an example of this, while others have frequently noted that the original Medicare legislation has been amended in some form nearly every year since it was passed in the 1960s. “What the Republicans did was not trying to work harder to reach consensus,” Rendell added. “There was that group that started out with Sen. Grassley that I thought would be useful,” but which in the end did not cooperate with Democrats to pass the ACA as a bipartisan law. “But the remedy is easy: we should get rid of ‘Obamacare,’ and keep the Affordable Care Act!” he said, to knowing laughter from the audience.
“Take us back, though: you were in the House,” Lieber said to Boehner. “You had to have been part of some conversations, and at some point, it broke down.”
“No, no,” Boehner replied. “On the House side, we were never invited to be a part of a conversation. After it passed in the Senate on Christmas Eve, 2011, Ted Kennedy passed away, and it didn’t pass the House. And they couldn’t then change it in House and pass it again in the Senate. So they knew they had a flawed piece of legislation, but they never went back and fixed it.”
Of course, Rendell reminded Boehner, nearly all foundational federal legislation gets amended over time. “If they had opened the door,” Boehner countered, referring to congressional Democrats in the months following the ACA’s passage in March 2010, “we would have made some changes; but they had no interest in what we had to offer.”
“Now,” Lieber said, referring to congressional Republicans’ stated aim to “repeal and replace” the ACA, “are the Republicans going to do anything differently than the Democrats did” when they passed the ACA in 2010? “I don’t know,” Boehner said, pausing. “That’s going to be a work in progress. Most of the framework will stay there: coverage for kids under 26, [protection for those with] preexisting conditions… Subsidies for the working poor, will be different. What will be different is that CMS [the Centers for Medicare & Medicaid Services] will not dictate to every single state how things will be run. States will control the policies that are offered, like they control every other aspect of health insurance.”
But then Boehner went on to state that Republicans in Congress “are going to fix Obamacare—I shouldn’t call it repeal-and-replace, because it’s not going to happen,” he said, deriding all assertions that a full repeal will take place as “happy talk,” and adding that “In the 25 years I served in Congress, Republicans never agreed one single time on healthcare. When they started shouting repeal, repeal, and repeal, and then replace, I started laughing, because honestly, if you start with repeal, anything you pass after that is yours, you broke it. And second, if you pass a repeal without a replacement, you’ll never pass a replacement. So you have to marry them together, or you’ll never pass anything.”
In response, Rendell said, “Well, I think John’s right, but there are three groups here” in terms of the power centers involved in any efforts to modify, change, or replace the ACA: “the President, who wants to give everyone coverage; the Senate Republicans, who want to keep most things; and the House Republicans, who want a significant reduction in services. Because if you roll back the taxes and roll back coverage to pre-ACA levels, there’s no way the providers will make money or break even. There’s got to be some way to pay for the subsidies. The President did something recently”—through executive order—“that reduced enrollment from 12 months to 6 months, to tamp down enrollment” in the health insurance exchanges, he noted. “And it reduced gold and silver benefits in plans, meaning that people will have to pay more for what they’re getting now. And without someone like John in the House, I’m not sure it is possible: we’re going to have to sit down, put all the rhetoric aside, figure out what to get rid of and keep, and work on anything like we would on any bipartisan legislation. SS has been worked on time after time after time. So I think that repeal doesn’t make any sense without shoring up subsidies. It’s almost impossible to repeal the protections for preexisting coverage, without shoring up” the health insurance market.
“I think we should put a public option in,” Rendell went on, “and I’d have a whole lot more emphasis on affordability, and that includes the ability of the government to negotiate with drug companies. That bill comes up every year. And this is a Republican and a Democratic problem. And the expansion of Medicaid in the states will never happen if the House bill passes. But a simple change that would do wonders for the affordability of the system, would be drug negotiation.”
“At the [expense of] the cost of new drugs,” Boehner immediately countered. “In the United States, you have the ability to afford new drug development and have it get paid for. The rest of the countries benefit off of what we do in the US. And when you talk about controlling drug prices, it comes with a sharp edge on the other side of the sword. So it would require a balance, and I don’t see that balance. We don’t want to shut off innovation.” The answer to that, according to Rendell? The U.S. government should file a formal complaint with the World Trade Organization, “against every country that does fix drug prices and benefits off our backs. We should all pay for that research.”
When Lieber asked the panel of two what they thought of the idea of giving state governments more “flexibility” to manage Medicaid as they see fit, Rendell said, “It used to be a formula of 50/50: the states paid half, the federal government half, more or less, but under the ACA, the federal government paid 90 to 10 for expansion for the first few years. And a lot of governors took advantage of that, including a lot of good Republican governors.
“I think you’re going to see states have more flexibility in how they cover Medicaid populations,” Boehner said. “There’s a program in Baltimore, with Johns Hopkins, where they have 630,000 Medicaid patients, for whom they get a flat rate. It’s in their interest to keep those patients healthy, and that’s showing good results. So I think you’ll see more flexibility.”
“Well, there’s no question that John’s right, we should be allowing states to experiment. The ACA provided some grant money. But I can tell you that when Washington says, we’re going to give you greater flexibility, that’s a code word for, we’re going to give you less money.”