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Drew Altman with Voices of Power

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Monday, November 2, 2009; 8:36 AM

LOIS ROMANO: Welcome Drew Altman, President and CEO of Kaiser Family Foundation, a leading voice and think-tank on health care issues. Thanks for joining us.

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MR. ALTMAN: Thanks very much. Great to be with you.

MS. ROMANO: In your view, what must a bill have in order to be a step forward in health care reform.

MR. ALTMAN: Well, you know, we're having this debate because the American people, average working Americans, became really worried about and are having real problems just paying their health care bills, and that's having a real impact also on their family budgets and their ability to pay for other things, pay their rent and mortgage or put a kid through college.

We've forgotten a little bit that that's where this came from. That's why health got traction again as a political issue.

So the main thing I actually want to see--us health care people tend to talk about this in terms of health care goals, access to care and the quality of care. The first thing I look for is, is this legislation actually responsible--responsive in a meaningful way to the meat-and-potatoes pocketbook problems that average Americans are having, paying for their health care which brought us this debate in the first place. That's number one for me.

MS. ROMANO: Do you feel like these plans or versions of these plans are doing enough for that bread-and-butter part of the population, for the lower-income part of the population as well?

MR. ALTMAN: Well, you know, you could always do more--

And they've drawn this line in the sand at a trillion dollars over ten years, which they don't want to go beyond. They think that's a politically important line in the sand, and that imposes some constraints. But, actually, yes, I do. The two components of this legislation that really address those pocketbook concerns of the American people are quite significant and would actually be historic. The coverage expansions and subsidies--they could do more--are really significant and tangible.

You know, we talk about a trillion dollars. Well, most of that money, we talk about it going to insurance companies, but, really, it goes to people to help them pay their health insurance bills. And those health insurance market reforms, we talk about that as if the only one really in the legislation is the one that says insurance companies can't turn you away if you have a preexisting condition. But, actually, it's a comprehensive set of fundamental changes in how insurance works to make it work more fairly for people, the way it should work. Those two elements of the legislation really directly address the real problems that people have, the problems that brought us this debate in the first place, and that's a really significant change.

MS. ROMANO: With President Obama trying to cap the cost of these plans at $900 billion over ten years, does that make the discussion about subsidies very important?

MR. ALTMAN: It is a really important discussion, and one of the things that's happened is, as so much of the debate lately has focused on this hot-button issue [of] the public option. Flying under the radar screen and not getting as much attention are these bread-and-butter consumer issues about will the policies be affordable for people who now have to buy health insurance coverage, are the subsidies high enough, is the coverage that people are going to get going to be adequate.

And I think, as we get to two bills and then one bill that the country can really focus on and that people in the media can really focus on, that issue of the affordability of the coverage will rise to the surface and will become a really big issue.

Ms. Romano: Do you think all the important issues in the health care reform debate are being aired right now?

MR. ALTMAN: I think the public option issue has diverted attention from lots of other issues, and I think this issue of affordability will emerge as a big issue. And there's a tradeoff as they design this legislation between keeping the overall sticker shock, the price tag of the legislation down and the generosity of the subsidies they can give to people and the comprehensiveness of the coverage that people get, how high--how big those deductibles will be that average middle-class families are going to be asked to pay.

And that's a very big issue. It's going to be a big issue not just for the people who are in these exchanges, who get these policies, but for the American people generally who look at this and say is this a fair deal, is this a good deal for people who now have to have health insurance coverage.

I think this is the sleeper issue still. This affordability issue.

And it's hard to understand. They're focused on the public option. They haven't gotten to it yet. So this issue of affordability, I think, is a sleeper issue because it's complicated, hard to understand how coverage works, what an actuarial value is, how the subsidies work at different income levels, and because they're focused on the public option. Everyone is so focused on the public option right now, but I think as they get to one bill that everyone can put under a microscope, then this issue of the subsidies and the coverage will really rise to the surface, and we'll have a much bigger debate about that.

And that's the consumer issue. It's the real meat-and-potatoes consumer issue in this legislation.

They've got two big obstacles to get over still before they pass this legislation. One is making sure that the policies are actually affordable for people, now that they're going to require that everyone has health insurance.

And the second one still, which is a big obstacle, is putting together the final pieces of the package to actually pay for the legislation. Whether it costs 800 billion or 900 billion or even a trillion dollars over ten years, they're not there yet. I think they will get there, but they still have not reached agreement on what--reached an agreement on what those final pieces are to pay for it.

MS. ROMANO: Senator Reid's decision to--to put in the public option or the government-sponsored plan-as an option in the Senate version of the bill has set off this huge firestorm.

MR. ALTMAN: It's been blown up to be something a little bit bigger than it actually is because lost in the debate is the fact that as it is structured in the legislation, it's only people who are in the exchanges and not in Medicaid maybe up to 30 million people who would have the option of the public option, and it's thought by the CBO that a modest percentage of those people might choose it, maybe 10 million people by 2019. So it's significant, but all of the hullabaloo about it is bigger than it really is because it's such an important ideological issue for the left because it's an alternative to commercial insurance and for the right because they view it as a foot in the door to a big government role.

And so we've had a giant debate about the public option and a much smaller debate about all kinds of other critical issues in the legislation, at least so far.

And the public option is an important issue. I certainly think it's an important issue. but it has become such an all-consuming debate that it's diverted attention from many other issues, if not every other issue, including some of the really big issues, how to pay for the legislation, and the meat-and-potatoes consumer issues, especially the subsidies, the coverage. Is it affordable for people? That's really an issue that has to come to the forefront and warrants substantial public debate. There are many other issues as well, but some of the really big issues and the ones that people really care about--is this affordable for me, am I able to--is this going to really help me with my health care bills--those issues have slipped out of focus because the public issue--the public option has just sucked up all the oxygen for the last several weeks.

MS. Romano: Is there a way to hold private insurers accountable on costs other than a government option?

MR. ALTMAN: Well, you know, there are comprehensive reforms of the insurance industry in the legislation, but the one thing they didn't do in this legislation which was proposed in the Clinton health reform plan, which as we all know failed, they did not propose this time around caps on the increases in insurance premiums. They didn't say, "Your premiums can only go up two times inflation in the general economy." That--those--that kind of price controls or regulation, they just didn't think that would work this time, or they didn't think it would fly. Anyway, it's not in the legislation this time.

So, no, there aren't--I mean, one of the characteristics of the legislation this time is there are not strong controls over the increases that can occur in premiums in the future.

MS. ROMANO: Do you think that the administration, the Democrats, have done a decent enough job communicating what all this is about?

MR. ALTMAN: Well, I think, more broadly, what happened was, in the early days of this health reform debate, there was a lot of focus on things which the American people just had a hard time understanding. You remember all the discussion of bending the curve, and that's all important to do. And policy wonks think a lot about bending the curve, but the average American, one, doesn't know what the curve is and certainly doesn't know what bending it means.

And then we went into the town meeting wars of August, and during all of that time, average people just lost connection with what this legislation meant for them, and that left the legislation open for being defined by its critics, and that's really what happened over the summer and in August.

And they're still digging out from that, and so, in our tracking polls, you can just see very clearly the support for health reform began to decline not in August but actually before that in June and July and then took a big dip in August and then began to tickle back up again, and now it's back up, and it's stable. And nothing much is happening; it's not moving very much. And now it's become a matter of the inside debate on Capitol Hill and what they can agree on and what they can't agree on, much more than the public.

MS. ROMANO: You recently released the results of a poll--that showed that 57 percent of the population favored a government-sponsored option.

And that number then went up to 65 percent when you asked if they would be more comfortable if it just kicked in┬┐if they couldn't find anything with private insurers. What does that tell you about the citizens, what they're looking for?

MR. ALTMAN: Well, I think what it tells me is, you know, those of us inside the Beltway--or I'm inside the Beltway when I'm here from California, which is pretty much every week--have a hard time grasping this sometimes, but what the American people really want is help with their problems in the health care system and with their health care bills, and they're actually not part of or wedded to the particulars of the solutions.

So they don't sit around worrying about the public option or whether it will pay Medicare Plus 5 or whether there will be negotiated rates with providers or an opt-out provision. They just don't think about that. They just want some help with their health care bills.

And so, if you say would you like an option or a choice, they say, in huge numbers, "Absolutely. That sounds great. I'm all for that." If you tell them a terrible reason why it might not be a good idea, the arguments made by the critics, they say, "Oh, that sounds really scary to me."

MR. ALTMAN: "You know, I might be against that." And then, if you tell them, on the other hand, a really good argument why it might be even better than it sounds, well, then they say in even bigger numbers, "Oh, that's great. I might be for that." And what that says is that there's a small number of people out there in the public who really are zealously for this idea. Most people are not thinking about it every day, and public opinion is movable and malleable. And he or she who makes the best argument or is the most effective messenger for an argument will carry the day with the public on this.

That having been said, the public option will not be won or lost with the public. Right now it will be won or lost on Capitol Hill.

MS. ROMANO: The Democrats now say they're going to include a public option--And the one Republican vote that they had, Senator Olympia Snowe, is now saying she will join a filibuster--

How important is bipartisan support?

MR. ALTMAN: Well, I actually am one of those who thinks it's useful, important if you can get it, for something this big to be able to at least show a semblance of bipartisan support, even if it's somewhat cosmetic. And it also may be important to bringing along those moderate Democrats who are critical to actually passing the legislation.

It's not clear that they're going to be able to get it, but I certainly think it's worth the effort.

MS. ROMANO: Where do you think they are going to come out on this public option, now that they're in a firestorm over it?

MR. ALTMAN: It's really not clear to me.

I think this is a fishing expedition, one, to see if there is a form of the public option that can fly and that can get enough votes. I think, two, that the House really wants a public option. So this is a way of--for the moment to accommodating the House and, two, also the left wing of the Democratic Party for whom this is really a significant issue. They really want a public option.

That doesn't mean that there will be one in the end, and we certainly don't know, if there is, what form it will take, but, for now, I think it's a negotiating point, and they're trying to figure out if there is a form of one, you know, that might work.

MR. ALTMAN: I think the public option has become such a big issue because it has ideological dimensions for both the right and left. It's also a significant issue, but it's not an issue that warrants a hundred percent of the time of the health reform debate, you know, 24 hours a day.

And I would add that as significant as the public option is, if you flip on certain cable news channels, you will see, literally, health reform equated with the public option. Health reform is the public option. Real health reform is whether or not we have a public option.

So, you know, the President may have minimized it a little when it called it a "sliver," but it's certainly not wrong to say that it's a piece and it is not the whole the thing.

MS. ROMANO: . Health care costs are a huge burden on American businesses. Are there enough incentives in these different legislations to help the businessmen pay for this, pay for it for employees, or are we fast approaching a point where businesses will be no longer offering health insurance to employees?

MR. ALTMAN: Well, it's a big problem in this. The reason we've seen a sort of slow drip-drip-drip of coverage out of the employment-based health care system is simply that business can't pay the cost any longer.

I did a projection the other day that showed that if current trends continue, in 20 years the average cost of a family premium could be 30,000 bucks a year. So we're not on a good trajectory.

MS. ROMANO: Wow!

MR. ALTMAN: And that just sounds scary almost to, you know, absolutely anybody. It's one of the reasons that business has changed its tune and is now interested in seeing government--business doesn't like government playing a big role in our society, government play more of a leadership role on health care, and why you see more government support--more business support for health reform than we have seen in the past, and it's beyond rhetoric now. It's actual support for health reform. It's a big change from the last time around, the last big health reform debate.

MS. ROMANO: Do you see a time when the U.S. will ever drift towards a single-payer system?

MR. ALTMAN: You know, I don't know for sure, but I certainly think it will be a long time, and I know the single-payer people, you know, don't like to hear that because they believe so strongly in that approach, but we're at a point in time now when the approach is favored by the two wings, an all-market approach--people get a voucher, and they shop for themselves--and a single-payer approach are not in the cards.

And so what we're really looking at, if you view it through that lens, is we're looking at some form of a centrist deal that brings together elements that the right likes and that the left likes and builds on the existing system. It's a little bit messy, but that's all that can fly right now in our political system.

MS. ROMANO: Strategically, do you think going for an entire health care reform package was the right way to go, or would it have been easier to take it in segments?

MR. ALTMAN: I think it was absolutely the right way to go. I think that if they went for a small incremental approach, that's all they ever would have gotten, that there are these unique windows of opportunity that come when the public gets really concerned, when you have a President that makes health care a top priority, when you have a party in charge that makes health care a top priority.

Do you know that the average time between these giant health care debates in our country has been almost 20 years? So we'd have to wait a long time.

Now, that doesn't mean that, you know, if things don't work out this time, they wouldn't try and back off to a smaller plan, a more incremental package and something that they can all agree on, or that there aren't forces in the Congress who don't want to do that even now. There are some, but there are these windows of opportunity, as I said, every 19 or 20 years. So you sort of have to go for it when they're there.

MS. ROMANO: And you have talked about during these time periods that one of the most important ingredients is leadership.

What kind of leadership have you seen this go-around?

MR. ALTMAN: Well, these health reform moments don't happen without presidential leadership, first of all. It's really that simple. So that's number one, and this would not be where it is without the leadership from the President.

He could easily have said, "We're dealing with an historic recession. Let's just put this aside for a while." He didn't do that. So that's one reason we're having this debate.

Secondly, also, though, leadership in the Congress last time around, we didn't see that. We just saw presidential leadership and also the willingness on the part of powerful committee chairs to put their turf aside and work together which, as a student of Congress, is historically unusual, if not unprecedented. So we're seeing leadership at that level as well and in other places, including in the health care system also.

Now, there's been, you know, some criticism. There are those in various places who would like to see the President more involved in the details on a day-to-day basis, but I think you have to carefully husband presidential leadership in these debates because presidential authority is not unlimited, and you can't expend it. And when there still are five bills, that's probably, you know, a time to be careful and to not use up the leadership power that you have.

On the other hand, when we get closer to two bills and one bill, I would just personally expect to see, then, the President become not just Health Reform Advocate in Chief but sponsor of the legislation himself, embracing the details of the legislation much more. Ultimately, the only counterweight to the "forces of no" in health reform that matters in the country is the President.

MS. ROMANO: So there's a moment when you expect that he'll just step in?

MR. ALTMAN: That moment is soon.

Exactly when, I'm not sure, but I think it's pretty soon.

MS. ROMANO: Is the U.S. obligated to provide every citizen with health insurance--health care--let me ask that again. Is the United States obligated to provide health care to all of its citizens?

MR. ALTMAN: The way I would answer that question is to say that it is certainly something that we should do. And I don't know anybody--you know, right, left, or center--who doesn't believe that at some level. The debate is about how we get there, and, unfortunately, that debate about how we get there has been a really bitter and difficult debate in our country. And the tough part of it is, if you scratch beneath the surface and look at the difficult part of it, it is fundamentally about redistributing wealth in our country; that, ultimately, it means, as some of us who have to have more, have to pay, you know, a little bit more, so that others who have less can have health care. You can slice it and dice it a million ways with this kind of tax or that kind of mandate, but, at the end of the day, that's what's involved, and we don't do that too easily in our country, too happily, or too willingly.

MS. ROMANO: What do Americans fear most about health care reform?

MR. ALTMAN: Since the beginning of health reform debates, the third rail in health reform has always been the fear that average Americans sometimes have--or they can be scared into feeling this way--that they're going to have to change their own current health care arrangements. They're going to have to give up--someone is going to make them give up their doctor, their hospital, or their current health insurance when they don't want to, and when they get even a whiff that that might happen, that's when they run for the hills.

And there actually is nothing in the current health reform proposals that would force them to do that, but critics are very aware that people can be easily made to worry about that. So that's at the heart of the attacks.

And, secondly, people in our country, while they want a lot from government, they don't like the idea of big government. So, when you can make health reform into a referendum on Big Government, then also people can get nervous as well.


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