Just steps away from Rep. Donna Shalala’s Longworth office is the Department of Health and Human Services — the powerful agency she ran for all eight years of Bill Clinton’s presidency.
The Florida Democrat is the first person to join Congress after serving as an HHS secretary (President Ronald Reagan’s first HHS head, Richard Schweiker, and President Trump’s first HHS chief, Tom Price, both held congressional seats before their agency appointments). “I may be a freshman, but I’m not a rookie,” Shalala likes to tell constituents and House colleagues.
She’s not on the Ways and Means Committee or on Energy and Commerce, the House’s two top health-care panels. But Speaker Nancy Pelosi (D-Calif.) has appointed Shalala to the Rules Committee, a perch allowing her to showcase her deep policy knowledge. Last month Shalala managed debate on a bill that would have required the House’s chief lawyer to defend the Affordable Care Act against a lawsuit from GOP-led states.
I recently sat down with Shalala to get her thoughts on Medicare-for-all, Obamacare, the Trump administration’s drug pricing efforts and more. Shalala said she wants to reach universal coverage not with a whole overhaul of the system but through incremental steps, argued that Medicaid might be a better vehicle than Medicare for doing that and expressed optimism there will be bipartisan work to bring down drug costs.
Here’s our conversation, with some edits for clarity and brevity.
Health 202: You have such an interesting perspective as former secretary. What do you hope to accomplish overall now that you’re in Congress?
Shalala: I want to improve people's lives. I know lots of people that can't afford health insurance. We've got to figure out a way to get everybody covered and we've got to use, in my judgment, existing vehicles to do that. We have these platforms: Medicare, Medicaid, the Affordable Care Act, the Children's Health Insurance Plan — that's number one.
Number two, we have to get integrated care. It's much too fragmented. I ran academic health centers. Oh, my God. You have a doctor for every part of your body, but they don't necessarily work seamlessly together. Most of our costs are in chronic care. So we have to figure out ways to manage that within the health-care system and we have to do it efficiently and effectively. We have to take on prescription drugs and we got to do it without gimmicks like importation.
Health 202: You’ve noted your district has more individual insurance marketplace enrollees than any other district in the country. Are you hoping to make any improvements to the ACA?
Shalala: We would very much like to make some improvements in the ACA. I was always worried the subsidies weren't deep enough. Because you're basically capturing a group of people who had lousy health insurance or didn't have any health insurance, who don't get big increases in their pay. I've always felt that we have to go deeper into the middle class with subsidies.
I also am no fan of high deductibles, even if the primary care is free. We just saw during this shutdown that most people can't even come up with four hundred dollars.
Health 202: So what can be done about the high deductibles we’ve seen in the marketplace plans?
Shalala: Congress would have to provide subsidies and close some doughnut holes. A deductible is basically a doughnut hole. I would be particularly interested in [deductible] subsidies for people that have slightly higher income because I think that they're the people that are really having a challenge.
I also would do some other things. Let people buy into the Medicare program at 55. We proposed that at the end of the Clinton administration. We didn't get anyplace with it, but we'd figured out a way that you could do it without it costing the trust fund any money — by just charging people a little more … to get into it early. I would argue that an early buy-in might help us reduce the need for high-risk pools. So I'm always looking for simpler ways on existing platforms as opposed to inventing something new to help us get to universal coverage and affordability.
Health 202: How are you feeling about the Obamacare marketplaces as they stand now? Because as you know we did see average premiums go down this year.
Shalala: Well, it's interesting. We had high enrollments in Florida. The places where we struggled with marketplace is the more rural areas, the smaller towns, the places where it's hard to get the kind of volume that you need. Some insurers pulled out but it was because they didn't get big enough market share. So in densely urban areas it worked best, particularly if you get the kind of patient mix you know you wanted to get.
But in Florida it's an interesting phenomenon. We got huge enrollments because we have no big industries that can easily accommodate a large percentage of the population [with employer-sponsored coverage]. People said to me, ‘You have all those enrollments in south Florida Cuban clinics.’ You have a set of clinics basically with Latin American doctors in South Florida. Many of them Cuban. And you have hospitals that had large, large numbers of low-paying patients and everybody had an economic incentive to sign people up.
Health 202: The absence of the individual mandate penalty seems to have had less impact than expected. What do you think?
Shalala: I would love to have the mandate back. But I wouldn't put the mandate back without doing some of these other things to make [insurance] more affordable and more attractive and easier. But I do think whatever we do, our goal ought to be universal coverage — affordable, high-quality universal coverage.
Health 202: Do you think that we're going to get to a point eventually where Republicans embrace or at least accept the fact that the ACA is here?
Shalala: I think we'll get to a place where we'll get some Republican votes — depending on where they're from — for bipartisan fixes. For instance, my predecessor Ileana Ros-Lehtinen supported the ACA because of the number of people in our district.
The other thing I would do that I don't think anyone be interested in: I would raise [those who can stay on their parents' insurance plans from] 26-year-olds to 30 [year-olds]. And the reason I do that is because they don't want to buy insurance. A lot of them are stuck in graduate school or in the gig economy, and their parents would be perfectly willing to cover them and it wouldn't show up on their parents’ employer's health insurance because they're healthy.
I know what young people's lives are like because I've run universities. I know how long they are outside of the regular market. So I think if you did that and let people buy into Medicare or Medicaid — because Medicaid is far more comprehensive than Medicare is. I've talked to a lot of people that support Medicare-for-all. I said I wanted to do Medicaid for all. That's a better program. It's got long- term care. And they said, ‘Well, we can fix Medicare’ . . . very expensive to fix.
Health 202: Why have Democrats focused so much on Medicare-for-all versus Medicaid?
Shalala: Medicare has never been associated with welfare, with poor people. Medicaid has, that's number one. Number two: We’re at the Capitol. We're at the federal government. That's a Medicare program, not a Medicaid program. Just a handful of experts on Medicaid are in Congress and most of them have retired.
Health 202: Tell me how you feel about Medicare-for-all.
Shalala: They're going to have hearings. I don't know where to go because many people believe the people who have very good health insurance ought to be able to keep it because they have better health insurance than Medicare currently has.
The other thing is that I've said to people if you look at the Kaiser polls, Medicare-for-all falls apart once you start telling people what it will cost [and] that they'll have to give up their existing health insurance. I debated my opponents on Medicare-for-all. I had four or five opponents to my left. They were all for Medicare-for-all. I said, ‘Look, I'd like to expand access to Medicare,’ but we were at a labor union. I said, ‘Every person in this union has better health insurance then Medicare, so tell them that they have to give up their health insurance.’
Health 202: We know how well it worked for Obama when he promised ‘If you like it, you can keep it’ and then some people lost their plans. That's really potent.
Shalala: Absolutely. The principle is universal health care. Medicare-for-all is one way to get there. My preference is to be very pragmatic and fill in the gaps.
But I also want to move towards integrated care. And that is the fragmentation of the health-care system that drives everybody crazy. You go for an operation and here's what you ask: Does my insurance cover this? And the answer is yes. And then afterwards you find out the anesthesiologist was out of network and you say what does that mean. Who asks whether everybody is in network that's in your operating room? You don't even know who your anesthesiologist is. You have no personal relationship with your anesthesiologist.
Health 202: Let’s return to Medicare for a minute. What do you think needs to be fixed in that program?
Shalala: We haven't completely closed the doughnut hole in terms of drugs. There's bipartisan support to do that. My mother and aunts used to yell at me about that doughnut hole — why did we do a doughnut hole? And I'd say, ‘Well, it was a budget decision … they didn't have enough money so they left a hole in the middle.’ And they thought that was the stupidest explanation. I mean how do you explain it to someone that's 92? My aunt said to me, 'But I pay my taxes.’ (laughter)
Health 202: They’re in blissful ignorance of how Congress works, I guess.
Shalala: I remember going home that Christmas after [Congress passed the] Medicare Part D [prescription drug benefit]. And my mother said, ‘You know, you're going to have two mornings where you're really tied up.’ She said all of our relatives are coming over for you to sign them up for Part D cause they're totally confused about it. I literally sat on a computer and signed 14 people up for Part D. And she said, ‘You were the secretary of Health and Human Services. You know how to do this.’ I had no idea.
Health 202: Where do you stand on allowing the government to negotiate lower Part D prices directly with drugmakers?
Shalala: My view is the secretary ought to have the power to negotiate in the same way that the secretary of Veterans Affairs or a state Medicaid director can.
Health 202: That sounds like pretty much a nonstarter with Republicans in the Senate.
Shalala: Well, we'll see. Unless you have volume you can't bring down the cost. There are no tricks to this. Now, we could do something simple. We could adopt the formulary the VA uses. I mean, if you didn't want to let them negotiate, take existing negotiations.
Health 202: What do you think of HHS Secretary Alex Azar’s moves on prescription drug prices?
Shalala: I can't tell yet. He is very knowledgeable. Someone just asked me whether I thought the administration was going to [push for a bill allowing] negotiation on prescription drugs. I said look, if they use Azar to negotiate a bill he's at least knowledgeable. The question is how much direction does he get from [Office of Management and Budget] and the White House on it?
He's very sophisticated. He understands the pricing issues. He knows as well as anyone that you're only going to get discounts if you get volume. Look at what we did on AIDS drugs. I worked at the Clinton Foundation for a year. President Clinton negotiated with the pharmaceuticals and promised them millions of people for a highly discounted series of AIDS drugs. So you've got to negotiate out on the basis of large numbers of people to get your costs down.
Health 202: And Azar’s Medicare Part B demonstration would involve a pretty small share of Medicare drug spending.
Shalala: Yeah. We don't have to demonstrate it. We know something about markets.
Health 202: So you'd like to go bigger and bolder, essentially.
Shalala: Absolutely. Whether you can sell that politically …[but] we also have to be respectful of the research dimension of the pharmaceuticals. I do not want to destroy the industry in the process because they’ve got a pipeline that's important to everyone in this country, in the world. But I'm not anxious to pay for their ‘D.’ I'm happy to pay for their ‘R.’ The rest of the world, it's been cost shifting onto us, as the president has pointed out and as the rest of us have pointed out over the years. The rest of the world … they are negotiating on the basis of volume and they're getting lower prices and not paying for the ‘R’ part. American taxpayers are paying for the research part.
Health 202: Do you think there's going to be bipartisan work on health policy in the next two years?
Shalala: I hope so. We'll see. We'll see what they bite on to. I don't know. I do know that we've got some ideas and I've talked a little bit to the committee people, but I've really got to have longer conversations. I want to be very careful because all this stuff has to have hearings, it has to go through the committees.
I have had a lot of experience. I've sat on the corporate boards of health-care companies. I've run hospitals and big health-care systems and I've obviously been secretary, but my best experience has been talking to people and seeing what's bothering them. Out-of-pocket costs, I think, are a big issue with people. We've got to figure out a way to get our arms around that issue. These are bread- and-butter issues, but they're also issues for companies because the companies are going crazy because they don't know what their health-care costs are going to be next year. So there are a lot of interests in containing costs.
Health 202: It’s certainly something both parties are talking about.
Shalala: If you see the look on the face of home health-care workers who got Obamacare for the first time in their lives and got free primary care the first time they ever went to the doctor, boy, you want to extend this to everybody. I hope we can find some incentives to get more governors, including mine, into expanding Medicaid because a lot of Republican governors have done it — they've done it under waivers.
I give a final exam in which I ask the students to make one recommendation to the president of the United States to improve the health-care system for everybody. The kid that got the A-plus said campaign finance reform. Not bad. He was scared to death that I'd flunk him but it's a smart answer. Because around each of these changes there's an array of interest groups.
|You are reading The Health 202, our must-read newsletter on health policy.|
|Not a regular subscriber?|
AHH: After a nearly four-hour physical exam with 11 specialists, President Trump’s doctors said he is in “very good health” and is expected to stay healthy for “the duration of his Presidency, and beyond,” our Post colleague Anne Gearan writes.
No details of the Friday exam at Walter Reed National Military Medical Center were released, nor was it clear if more details would later be publicized.
“The memo did not include the disciplines of any of the specialists,” Anne writes. “Typically, a physical exam includes checks of height, weight, blood pressure and other standard measures. Trump said last year that he takes a statin drug to manage his cholesterol.”
The president has “visibly gained weight in recent years,” Anne adds. It’s no secret Trump prefers red meat, fast food and sweets, and other than golf, Trump is not known to exercise, she notes. Trump does not smoke or drink.
OOF: Sen. Michael Bennet, the Colorado Democrat considering a 2020 presidential run, criticized calls by some Democrats to eliminate private insurance in pursuing Medicare-for-all.
“Remember when President Obama said, 'If you like your insurance, you can keep your insurance,'" Bennet said during an interview on NBC's “Meet to Press. “And then a few people in America actually lost their insurance because of the way that the plan worked. Now what Democrats are saying is, 'If you like your insurance, we're going to take it away from you,' from 180 million people that get their insurance from their employer and like it, where 20 million Americans who are on Medicare Advantage, and love it. That seems like a bad opening offer for me.”
Sen. Kamala Harris (D-Calif.) raised eyebrows last month when she said during a CNN town hall she’d like to get rid of private health insurance. “The idea is that everyone gets access to medical care and you don't have to go through the process of going through an insurance company, having them give you approval, going through all the paperwork, all of the delay that may require,” Harris said.
OUCH: While Washington state’s worst measles outbreak in two decades continues, hundreds of people packed into a public hearing about a bill to make it more difficult for families to opt out of vaccination requirements for measles, mumps and rubella.
Most of the 700 or so people at the Friday meeting were opposed to stricter standards, our Post colleagues Lena H. Sun and Kristen Millares Young report.
At the hearing, Washington state Health Secretary John Wiesman urged state lawmakers to pass the bill and debunked claims from some in attendance that vaccines are dangerous.
“I want to remind you that the MMR vaccine is extremely safe and highly effective,” Wiesman told lawmakers. He added “all reputable scientific studies have found no relation between measles and autism.”
The bill would eliminate personal or philosophical exemptions to obtaining the vaccine -- but would still allow for medical and religious exemptions, Lena and Kristen report. The bill's sponsor, state Rep. Paul Harris (R), represents Clark County, the epicenter of the measles outbreak, and is planning to amend the bill to "tighten religious exemptions, too," they write.
“Washington is one of 17 states that allow personal or philosophic exemptions to vaccination requirements, meaning virtually anyone can opt out,” they add.
But the recent nationwide outbreaks have prompted lawmakers in Washington and several states to consider tightening immunization standards.
— Meanwhile, some teens are fact-checking their families’ antivaccination stances and seeking their own treatment, our Post colleague Alex Horton writes.
“In three states, at least three self-described teenagers told Reddit they have a common problem: Their parents are staunchly opposed to vaccination, and they fear for their health if they do not take action,” he writes. “Different state laws affect how old minors need to be to make their own medical decisions.”
An 18-year-old Ethan Lindenberger from Ogio explained he read scientific studies, including from the Centers for Disease Control and Prevention, and tried to persuade his mother to let him and his four younger siblings get vaccinated. “I looked into it, it was clear there was way more evidence in defense of vaccines,” he told The Post. But his mother resisted.
“On Dec. 17, he walked into an Ohio Department of Heath office in Norwalk and received a cocktail of vaccines for hepatitis A, hepatitis B, influenza and HPV, according to a shot record viewed by The Post,” Alex writes.
— Republican lawmakers are itching for hearings on Democrats’ Medicare-for-all proposals, hoping such public airings will give them a chance to home in on an opposing message leading up to 2020 elections, Politico’s Alice Miranda Ollstein reports.
“We should have the opportunity to have a hearing on a bill Democrats say they are for,” the House Energy and Commerce Committee’s top Republican Rep. Greg Walden (R-Ore.) said. “They’ve campaigned on it. Now, let’s find out what it is and what they’re promoting.”
Rep. Kevin Brady (R-Tex.), the top Republican on the House Ways and Means Committee, said lawmakers want to “pull the curtain back on Medicare for All so the American people can actually assess it.”
Meanwhile, Democrats are embracing these calls. “They think it’s going to be a ‘gotcha’ moment,” said Rep. Pramila Jayapal (D-Wash.), lead author of a Medicare-for-all bill. “But they have been wrong on this and continue to be wrong on it.”
“The Republicans’ counterintuitive move seeks to exacerbate real divisions within the Democratic Party on how far and how fast to move beyond Obamacare and chart a course toward Medicare for All,” Alice writes. “Senior Democrats leading the House's health committees blasted the GOP request as ‘cynical’ and ‘disingenuous’ and said it would not affect their timeline for weighing the policy.”
— Democrats and liberal groups are targeting Sen. Susan Collins (R-Maine) for her support of Brett M. Kavanaugh after the newest addition to the Supreme Court dissented in a 5-to-4 vote to block a restrictive Louisiana abortion law.
They’re pointing to the dissent as a sign the newest justice would vote to overturn Roe v. Wade and side with conservatives in future abortion-rights related cases, our Post colleagues Felicia Sonmez and Michael Scherer report.
Demand Justice, a liberal group that opposed Kavanaugh’s nomination, is planning a more than $10,000 digital ad campaign in Maine to “inform voters of how Collins’ vote for Kavanaugh helped lead to the close call in Thursday’s ruling,” Felicia and Michael report.
“Democrats are particularly incensed at Collins, who delivered a 44-minute-long floor speech in October declaring her support for Kavanaugh,” they write. “At the time, Collins, who supports abortion rights, said she did not think Kavanaugh would vote to overturn the landmark 1973 Roe v. Wade ruling that legalized abortion.”
Annie Clark, communications director for Collins, countered by referring to Kavanaugh’s December vote in Planned Parenthood’s favor. “During his confirmation process, Planned Parenthood was Justice Kavanaugh’s number one opponent,” Clark said in a statement. “They went after him with everything that they had. And yet, when it came to a case involving them, he was able to put that aside and rule impartially and independently.”
— HHS is seeking the authority to reverse an Obama-era policy that barred foster care and adoption agencies from rejecting prospective parents based on their sexual orientation or gender identity. HHS’s Office of Civil Rights argues in a 2020 draft budget request that some of the country’s oldest religious agencies in places such as Boston, Philadelphia and Washington have gone out of business because of nondiscrimination requirements that are themselves discriminatory.
President Trump pointed to such a move at the National Prayer Breakfast last week, our Post colleague Ariana Eunjung Cha reports, telling religious leaders that such faith-based agencies would still be able to get federal funding to “help vulnerable children find their forever families while following their deeply held beliefs.”
"Faith-based agencies play an important role in foster care and adoption in the United States, and in some parts of the country are the dominant providers," Ariana writes. "Religious leaders say that HHS’s requested changes would not prevent qualified individuals from becoming adoptive and foster parents because there are many other agencies that will accept them."
It’s the latest move from an administration that has sought to protect religious groups that are key supporters of the president. “HHS specifically takes issue with the idea that an Obama-era rule barring discrimination on the basis of religion, sexual orientation or gender identity might force religious-based groups to have to place children in family arrangements inconsistent with their belief that marriage is the union of one man and one woman," Ariana writes.
Currey Cook, an attorney with Lambda Legal, which advocates for LGBTQ communities, said “No one in this is saying faith-based providers don’t have a place in the child welfare system. It’s great they are a part of it. What we are saying is that if you are accepting government funds and performing a government service, you should not be able to discriminate against people with those dollars."
— And here are a few more good reads:
- Health and Human Services Secretary Alex Azar and Centers for Medicare and Medicaid Services Administrator Seema Verma deliver the keynote address at the 2019 HIMSS Annual Conference in Orlando, Fla. on Tuesday.
- FDA Commissioner Scott Gottlieb is set to testify before a House Appropriations subcommittee on Tuesday.
- The House Ways and Means Committee holds a hearing on the rising cost of prescription drugs on Tuesday.
- The House Judiciary Committee holds a hearing on the Trump administration's family separation policy on Tuesday.
- The Senate Health, Education, Labor and Pensions Committee holds a hearing on managing pain during the opioid crisis on Tuesday.
- The House Energy and Commerce Subcommittee on Health holds a hearing on the ACA and protections for preexisting conditions on Wednesday.
Sen. Amy Klobuchar (D-Minn.) has officially entered the 2020 race: