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The ACA Turns 10: Reflections Of Four Industry Leaders

2020; Project HOPE; Volume: 39; Issue: 3 Linguagem: Inglês

10.1377/hlthaff.2019.01722

2694-233X

Alan R. Weil,

Pharmaceutical industry and healthcare

InterviewAffordable Care Act Health AffairsVol. 39, No. 3: The Affordable Care Act Turns 10 The ACA Turns 10: Reflections Of Four Industry LeadersAlan R. Weil Affiliations Alan R. Weil ([email protected]) is editor-in-chief of Health Affairs.PUBLISHED:March 2020Free Accesshttps://doi.org/10.1377/hlthaff.2019.01722AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractThese leaders celebrate the ACA’s successes, reflect on its shortcomings, and explain the politics that led to passage of the landmark act.TOPICSAffordable Care ActHealth reformPoliticsMedicaidPrivate health insuranceUninsuredPharmaceuticalsSustainable growth rateOrganization of carePaymentIndividual mandateMarketsLegislationTen years ago President Barack Obama signed the Affordable Care Act (ACA) into law, achieving a goal that had been out of reach for his predecessors. Despite the obvious benefits that universal health insurance coverage would confer on health care providers and insurers, historically the most notable posture of the health sector has been opposition to increased government involvement in health care. From the hiring of Ronald Reagan by the American Medical Association (AMA) to speak out against Medicare’s “socialized medicine” to the insurance industry’s “Harry and Louise” ads that helped bring down President Bill Clinton’s health reform plan, the voice of health interest groups has been loud and strong.Hoping to avoid the fate of his predecessors, President Obama made engagement with health care industry groups a central element of his strategy for enactment of the ACA. Four important groups with a stake in health reform and the power to change public opinion and legislative votes were physicians, hospitals, health plans, and the pharmaceutical industry. On May 11, 2009, President Obama announced that the AMA, the American Hospital Association (AHA), America’s Health Insurance Plans (AHIP), and Pharmaceutical Research and Manufacturers of America (PhRMA) had agreed to work with his administration to reduce the rate of growth in health care spending by 1.5 percentage points in each year from 2010 to 2019. This laid the groundwork for negotiations on what became the ACA. These four organizations—each with distinct goals and constituencies—emerged as key players in the politics and content of the ACA.Alan Weil, Health Affairs Editor-In-Chief, sat down with Matt Eyles, Nancy Nielsen, Rick Pollack, and Billy Tauzin to discuss the factors that led to the ACA’s passage, as well as the law’s shortcomings and successes. Eyles has been president and CEO of AHIP since 2018. He was vice president for government affairs and public policy for a health plan at the time of the ACA’s enactment. Nielsen was president of the AMA from 2008 to 2009. She serves as the senior associate dean for health policy and a clinical professor at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo. Pollack has had a thirty-two-year career at the AHA. He was executive vice president at the time of the ACA’s enactment and is now the organization’s president and CEO. Tauzin, a former congressman from Louisiana, was president and CEO of PhRMA from 2005 to 2010. He is senior counsel of Tauzin Consultants, a government affairs firm he cofounded in 2011.What follows is an edited transcript of an interview conducted with these four leaders on December 2, 2019, at the offices of the AHA in Washington, D.C. The full interview can be heard at http://www.healthaffairs.org/podcasts.Alan Weil:Take us back to the debate over and ultimate enactment of the Affordable Care Act. You each represented membership organizations. What was most important to your members at the time?Rick Pollack:Coverage expansion was the window through which the AHA looked at the whole issue. That was the top priority, and we knew everything would flow from that. And we thought it was a moment in time—a moment in history where we could expand coverage to literally millions of people.Nancy Nielsen:That was number one on the hit parade for the AMA as well—in addition to getting rid of the SGR [sustainable growth rate], which we just detested. We had started the “Voice for the Uninsured” campaign in 2007. We were very committed to trying to cover the uninsured and to reform some things that we thought needed reform in the insurance industry. But it was really important to us to get people covered. It had become such a problem, with almost 18 percent of Americans under age sixty-five lacking health insurance—and we knew how bad that was.Matt Eyles:I’ll add that as a representative of the industry responsible for providing coverage, certainly coverage was at the center. And finding a pathway to getting everyone in America covered—that was first and foremost for AHIP. The other critical piece was looking at the affordability of the system and seeing the path that we were on, and at some level still are on, and whether or not we could address some of the key drivers of costs.Billy Tauzin:From our standpoint at PhRMA, we saw the bill as a great opportunity to expand the availability of health care to people in America who were obviously suffering lack of access. But we also were very concerned about protecting the discovery and development process here in America that is producing so many treatments and cures for disease in our country and around the world.Contrast With Prior EffortsWeil:What differentiated this time from previous unsuccessful efforts?Nielsen:Looking back at the Clinton effort, I really believe that they thought no smart people had ever tried to tackle this before. And so you had policy wonks and Ira Magaziner in the room and nobody else. Then all of these very complex things came out, and it was destined to be shot down by all the stakeholders because they had been excluded.Eyles:I think that’s exactly right. What’s really interesting is to compare and contrast what was mostly a top-down approach in the nineties with a recognition by the Obama administration that Congress was a critical partner and needed to help lead in a fundamentally different way than what we had seen fifteen years prior to that—and engaging the stakeholders from the beginning.Pollack:And the other thing that was really distinguishing—with Clinton, they kind of brought out a bill and gave it to Congress and said, “Take this.” With the ACA they did it the other way around. They let the legislature legislate.Tauzin:That’s exactly right. I was a member, during the Clinton efforts, of the House Energy and Commerce Committee. And that’s exactly the way we saw it. This was just being handed to us in a way that Americans had not had a chance to digest it and understand it.Engagement With Congress And The White HouseWeil:To what degree was your work on the legislation with the White House, with Congress, or with both?Nielsen:It clearly was with Congress, where we had multiple meetings. But it also was with the White House. The White House would call meetings. And if you remember, cost was the overriding factor, and we were all going to have to give something in order to “bend the [cost] curve.” But staffers from our association were in multiple meetings with the committees of jurisdiction over many months.Pollack:It was driven by the White House and Sen. Max Baucus (D-MT). Those were the driving forces behind this more than anybody else. And it’s funny you mentioned the “bending the curve” exercise. All of our groups were around the table, and the administration asked: “What can you do as a (fill in the blank) to reduce health care spending by $2 trillion over some period of time, or something like that as a goal?” And I always view that as being less about the substance than it was their effort to avoid what happened during the Clinton administration—which is, at the outset you had the industries largely opposed to what they were doing—and this was a way to get people lined up to say, “We’re going to work with you.”Tauzin:The president would call these meetings. I attended one of them, but I had to sort of sit in the back with the staff because he didn’t want lobbyists in the meeting. I had to bring one of the CEOs with me, so I brought them.Pollack:We had the same experience.Public OptionWeil:If expanding coverage was the most important goal, what was second most important for your members?Nielsen:We didn’t rank our priorities, but we did not want a government takeover of the doctor-patient relationship. That was very important to us. If you will remember, there was the possibility of a public option for a period of time, and it was pretty clear that the government plans that we already had were underfunded and a new one would only worsen that situation.Eyles:That was the biggest issue for health insurers—the potential for a government-run public option. Insurers said that would be untenable and would change the equation about whether or not the industry could be supportive of what was being advanced.Tauzin:That’s where we were at PhRMA. We made a decision early on that something was going to pass and that we ought to be part of the effort to get it done right, and avoid the public option and the public takeover of health care in America.Pollack:The real thing that the AHA was also looking for was delivery system reform. It was our view that the way to achieve efficiencies was through reforms of the delivery system, and we needed to begin the journey that we’re still on: a journey from the fee-for-service system to different forms of what is now called value-based payment. We knew that if we were going to expand coverage, there was going to be a demand for some element of affordability and better value. And in our view, the way to get there was through innovation in the private sector, in the delivery system—as opposed to command-and-control regulation.Reaching AgreementNielsen:I want to talk, though, about some dissension, because in the AMA we have people representing the whole political spectrum, not just one party—despite what people used to think. And so what happened is, as soon as “Obamacare” became an epithet that stuck, people who were opposed to Obama were on principle opposed to the ACA before they had any idea what it was.Among our ranks, the most obvious element was the individual mandate. Our policy was very clear. We have had an individual mandate as part of AMA policy for years. We had worked with economists. It was, of course, a Republican idea. It came out of the Heritage Foundation. But as soon as it was part of “Obamacare,” it became the whipping boy.Weil:So here you are. Repeal of the SGR and malpractice reform are major issues for you. You don’t get the first, and all you get on malpractice is some demonstration grants.Nielsen:We got nothing worth talking about.Weil:Yet, ultimately, the AMA endorses the bill.Nielsen:We did support the bill. I remember it vividly. It was for the board a moral issue. We did not get the SGR. We thought we might get it later, but we were not going to get it then. We already had dissension in the ranks. But were we going to stand in the way of twenty million Americans getting health insurance? The answer was, we could not. That would have been the wrong thing to do. I still think we made the right choice for history. I really do. But we paid a price in our membership for several years. Membership has gone back up now and continues to rise, but it was a tough time.Eyles:The insurance industry overall was dissatisfied and disappointed with provisions that were put in with respect to a number of the market rules. The minimum medical loss ratio was high on the list, when you’re putting in essentially a government margin control.There were a host of other ones: the age band issue and rate compression, and knowing what was going to befall younger consumers by going to a 3:1 age band. And we’ve seen that actually play out in premiums. We have not seen younger individuals take up coverage as much as they probably would have under some alternative scenarios. Standardization is one thing in terms of being able to ensure that consumers can compare like benefit plans, but were we a little too prescriptive in terms of how we designed some of those elements? There were a host of issues that we had challenges with.Weil:And in the end, AHIP did not support the bill, is that right?Eyles:AHIP was one of the first industry groups to express support for what the ACA was trying to achieve. But the combination of the market rules I’ve mentioned and the single largest industry tax in the bill—$150 or $160 billion, or about $15 billion a year—made it hard to swallow. Leading up to the vote, the administration and some congressional leaders started to demonize the insurance industry as a way to generate public support for the bill. We were quite vocal in our concerns and never formally signed on.Pollack:For us at the AHA, we signed on. And the biggest point of tension was the $155 billion or more that we had to forgo in Medicare reimbursement. Remember, at that time we thought we were going to get thirty-two million people covered, until the Supreme Court ruled on the optional approach to the Medicaid expansion. But I think our experience was exactly like what you described with the AMA board. For us it was a moral question, it was a moment in time—and that was something that we thought was worth stepping up to the plate for, in order to get thirty-two million people covered.Ultimately, the rest of the other national hospital groups and all the fifty state hospital associations came along. We were in constant consultation and communication to ensure that we stayed united. And I think that the associations were all aligned and united. Our members had some different views, but ultimately it all came together.Tauzin:Keep in mind, PhRMA didn’t agree to sign on to the bill until the very end. It was because we were deeply concerned about the public option and whether or not the House would get the Senate to agree to their version.The House version was one we deeply opposed. When the special election to replace the late Sen. Ted Kennedy (D) happened in Massachusetts, and the sixtieth vote was gone and the House had to accept the Senate bill, it became much easier for us to come to a conclusion to support it because we had lost our worst fears of a public takeover of health care and a loss of this incredibly important place in the world where drug discovery and development is occurring like nowhere else on the planet.It was important to us when we did sit down and work with the administration, and the Senate committee particularly, that if we’re going to put up that amount of money—and there was dissension about that among the members, but they came together unanimously on every other issue and on that issue, eventually—we wanted to make sure that the money was spent well.One of the things we wanted to make sure was that the hole in the doughnut, Part D, was covered with our contributions. We wanted to make sure that the fees that would be assessed against the companies were fairly in proportion. We had an agreement, for example, that the larger companies within PhRMA would pay larger fee percentages than the smaller companies in fairness, because big companies could afford it better. We wanted to make sure that we avoided things like cost-effectiveness and the systems that we saw in Europe.Weil:How much communication was there across your industries during this time?Tauzin:Oh, my goodness. It was a lot.Nielsen:We were all in the room together, and everybody knew what was happening. I don’t think there were a lot of surprises.Tauzin:And we knew where we disagreed. Except for the fact that the insurance industry didn’t support it in the end, we pretty much worked together around those disagreements to the extent we could.Pollack:There were really two conversations going on. There was the global one, and then there were the individual ones in terms of trying to work out what each interest group wanted to see in the ultimate package.The ‘Affordable’ In ‘Affordable Care Act’Eyles:I do wonder now, though, where we have a little perspective, whether it was shortsighted not to include anything around cost at that time. When you look back and when criticisms are levied at the ACA, a lot of it is right. The law is all about coverage. No one really thought about affordability. And had we taken some modest steps to think about cost, whether in comparative effectiveness or some other areas, would we be having maybe a little different discussion today around affordability? Because the biggest issues today still are around affordability. We want to get the remaining people covered, but had we taken some incremental steps to think critically about cost, would we be in a little different spot today than we are?Weil:None of you have mentioned IPAB [Independent Payment Advisory Board]. I couldn’t imagine we would get this far in the conversation without talking about it.Pollack:IPAB was an example for us where hospitals were exempt from it for several years. And that was attractive. Of course, we weren’t a fan of IPAB to begin with, because the only thing IPAB could do was cut provider rates on a fast-track basis.If perhaps they would have put issues on the table with regard to the sustainability of Medicare and Medicaid in the long run that may involve revenues, may involve benefits, may involve delivery system reform, may involve provider payment—maybe that would have been a productive discussion. But it ended up being constructed in a way that simply was just another vehicle in a very extreme way procedurally to cut provider payments. Even though we were exempt for—I think it was ten years.Tauzin:You’re talking about cost control. This was not a little feature. IPAB provided a bureaucratic board with the capacity to make decisions about health care that Congress traditionally makes about what we’re going to fund, to what degree we’re going to fund it, and how much we’re going to cut.This allowed this board to make changes that would go into effect unless three-fifths of the Congress voted affirmatively to override it.Pollack:And if you tripped the wire and the board didn’t act, the HHS secretary had the authority to do it on their own.Tauzin:Yeah. I mean, it was really not just a tiny issue.Nielsen:We all felt that we were very vulnerable. We all felt we’d be the turkey carved on the table.Weil:What more would you have wanted on cost?Pollack:Liability reform was one of them.Nielsen:That’s one. I think comparative effectiveness is really critical. I remember a very instructive conversation with the House Doctors Caucus, trying to talk about that. I’m saying, Physicians need to know what works better than something else because right now we don’t. With all due respect to personalized medicine, it would be really good to know. And all of them were trained as scientists as I was, yet the answer was: It’s a slippery slope, it’s going to be used for cost control. End of discussion.Eyles:I think around cost, though, from the insurer perspective, a lot of it translated into, “What would the cost of the product be that you are selling, and how much flexibility might you have to manage costs, to design more flexible benefits that might come in at a lower price point? How are you going to bring additional people into the system when you have a very weak individual mandate, and what’s that going to mean for the overall system?” Adding some of the things like the health insurance tax, which really just added to the premium. And knowing that you’re out there trying to sell your products to employers and then individual consumers, and they were going to be at a price point that was higher than you thought you could otherwise offer for a competitive, attractive product.Pollack:You know, in some ways we’re coming full circle on this right now. Right now, value and affordability and cost are really the critical issues that everybody is focused on across the board. Back then, history was to be made, and covering tens of millions of lives—that was the moral imperative, that was the moment in time. We’ll get to the other stuff when we need to and not let all this other divisive stuff get in the way of getting coverage to that point—what we hoped was thirty-two million people on the pathway to universal coverage. Now we’re still dealing with the cost.Tauzin:Yeah, let’s talk about some of those suggestions to control cost. One was importation. Getting cheap drugs in and lowering the cost for health care, for everybody in America. We already have a law that governs importations.Nielsen:But another aspect of the cost that really continues to be a problem is for young people. And it doesn’t do any good to have on the Marketplace, for example, options that they can sign up for if the deductible is so high that it’s outrageous. We simply haven’t accomplished that third arm of what the ACA wanted, which was bending the cost curve. We really have not.Tauzin:No, we haven’t. Medicare Part D provides that the government shall not interfere with the private negotiations between the insurers and the manufacturers. That language was not written by PhRMA. It was in seven Democratic bills offered during the Clinton administration. The provision was there to make sure that these would be private negotiations—that people on Medicare would get the benefit of these discounts that would be negotiated for them. It worked fairly well. It saved about $550 billion over ten years because of the discounts being negotiated.You could argue for government negotiation in Part D. But it wouldn’t really be negotiation—it would be price controls, much as what you see in the VA. It came up in the debate on the ACA that we again stood against, because in fact it’s working very well.Pleasant SurprisesWeil:What elements have been surprisingly positive?Nielsen:The creation of the Center for Medicare and Medicaid Innovation, which designed things like ACOs [accountable care organizations]—which allow physicians the flexibility to do what they need to do with their patients. We have a lot yet to learn about value-based pay, and value is sometimes in the eye of the beholder. But there are some really cool things that have happened and that we’ve learned. We need to watch those experiments and see how we can better use the resources we have to get better care to more people.Pollack:And what’s interesting, of course, is we started that journey—we’re ten years into it, and we still are trying to discover what works and what doesn’t work. We knew that ultimately you could never achieve better value and better affordability if the incentives under the fee-for-service system remained. And we still have a long way to go, because the incentives under the fee-for-service approach are strictly volume, and there’s no incentive for prevention, and there’s no incentive for coordinating care.What was very important to us under the VBP [value-based purchasing] was that it not be used as a tool for budget cutting. It should be used as a tool for improvement. And keeping it budget neutral was a big piece of what we thought was very important and was in there.Eyles:So many experiments are going on now that have their genesis in the ACA, and I think many of us couldn’t have predicted exactly how those would turn out. But we knew that there was going to be this entity that was going to try and push things forward. And we’re learning a lot, but there’s still a lot more work to be done.Tauzin:Including the pilots on bundling, trying to move towards value purchasing and all of that.Eyles:I will mention another pleasant surprise: Medicare Advantage. Plans were being paid all over the board, depending upon where they were in the market. The ACA took about $160 or $170 billion out of the program, and there were projections that enrollment would drop substantially.The star ratings program has fundamentally changed how Medicare Advantage plans are serving Medicare beneficiaries and has been a big driver of improved care for Medicare beneficiaries, because it has provided strong incentives to focus on quality. And because we’re rewarding quality, it has substantially driven investments in those programs by Medicare Advantage plans.Pollack:I already mentioned a few, but I will add the 340B drug pricing program. We would have wanted it expanded even farther than it was, but the ACA expanded it to children’s hospitals and cancer hospitals and to critical access hospitals, and that was important. There were a series of changes that helped stabilize rural hospitals—although we’re still very much focused on dealing with that because we have a lot of problems in terms of ensuring that the rural health care delivery system stays vibrant—but also changes to meet the needs of how we will deliver care in the future.Tauzin:And keep in mind there was great trepidation over health care cost swamping the American budget. There were provisions put in the law that if we hit a certain percentage, it would trigger all sorts of things happening to deal with that issue. But privatization has literally stepped up as part of the reaction to that concern.The pharmaceutical industry doesn’t particularly like some of the abuses within the 340B program, but we supported the expansion of it. And one of the really nice effects has been the creation of more and more community clinics around the country. I started the first one in my district as a congressman against all of the medical community. They thought I was a communist or something, but they came to love it because it took patients out of the emergency rooms, it took them out of their waiting rooms where they couldn’t pay their bills anyhow, and now they’re getting preventive care. The 340B program has helped keep those clinics going.The other thing I want to focus on is that saving twelve-year data exclusivity for biologics has produced an incredible explosion of new products that are now available to caregivers around the country. I know it’s hard to cover them—they’re expensive drugs. But the fact that now they’re available to us has produced some enormous health care successes for our country. The cost of developing these products is enormous, and I know it’s difficult for us just to bear. But at least we have them—and our survival rates are going up, our cancer rates are going down. That’s a blessing.Eyles:Another thing that I’ll throw out there is the ACA has helped shift the perspective of our system to be much more consumer and patient centered than perhaps it was a decade ago. I know many insurance providers were much more business-to-business sorts of operations rather than business-to-consumer, and I think that that has spread broadly across our health care system by trying to tailor how health care is delivered toward individual consumers—so they can make better decisions for themselves and their families. It has been an evolution, but I think that consumer element of the ACA has been overlooked a little bit.DisappointmentsWeil:In addition to more work on the cost front, as you look back, what are the greatest disappointments?Pollack:What comes to mind is that people actually refer to this as universal coverage. On its best day, fully phased in with full Medicaid expansion, there were still going to be twenty-three million people that were not covered. The disappointment is that a lot of people thought that the job was done. But it was never done, and even the estimates showed that it wasn’t going to get there all the way.The other disappointment is that here we are ten years later, and we’re still fighting over this thing, and it’s still such a flash point. And we’re getting ready for another court fight on it—and it’s just hard to believe that ten years later, when we have a system that’s built on the private sector and has the potential of being effective in that regard, we’re still fighting over it. Rather than working to improve it, we’re fighting over it as a political issue.Eyles:And I would agree very much with what was said about the lack of bipartisanship and this having a big impact. If you think about the state of the individual market—which is what most people associate with Obamacare more than any other market segment, right?—the fact that it was a partisan exercise has led, from the start of the implementation of the program really to the current day, to having it be much more challenged, much more unaffordable, especially for those individuals who don’t qualify for significant subsidies and have been totally priced out.Nielsen:Especially in states that didn’t expand Medicaid, people get caught in the coverage gap.Eyles:I was working at the Congressional Budget Office (CBO) during the Clinton health reform debate. I worked on a paper that came out from CBO in August of 1994 called “The Budgetary Treatment of an Individual Mandate to Buy Health Insurance.” It was a concept that was being advanced more in conservative health policy circles at the time—to say individuals should be responsible for making sure that they have coverage. And it has been interesting to see how now, twenty-five years later, we’re still talking about it, although from a very, very different vantage point.Tauzin:But the mandate to buy coverage also made it imperative that we expand Medicaid. Our industry supported that expansion around the country, because if you’re going to require people to have insurance coverage and you recognize that a family of four without Medicaid coverage could not afford to pay even the cheaper prices that were promised out of the ACA—you had to face that issue. Will you or will you not allow the states to expand Medicaid? And obviously that became a central part of the agreement.Nielsen:That’s one of the disappointments, because that would have standardized eligibility for Medicaid across the country and not the craziness that we still have and all the lawsuits that we’ve had. It was a big disappointment when that became a states’ rights issue.Pollack:And also, for us it goes back to, “What did you give up?” We accepted a reduction of $155 billion over a period of time in Medicare hospital reimbursement in exchange for coming on board and getting other things that we wanted accommodated. But, boy, that ended up playing out differently in different states. There are certain providers that had the benefit of expanded coverage in some states but not in others. And that created a lot of tension, and it still exists.Tauzin:It was a big issue just last month in Louisiana. The incumbent governor who supported the expansion had to defend it and barely survived reelection. It still creates tension. And you’re correct: It creates disharmony in the program around the country.Success, But Work RemainsNielsen:But I want to talk about the success—the real success. In 2010 almost fifty million Americans were uninsured. In 2018 it was down to about twenty-eight million. So good things happened.The tragedy is the Medicaid expansion. Had that really been universally applied as it was thought it was going to be, we would have halved the uninsured rate in Texas, in Florida—in all the states where it still is an issue. We would still have the affordability issue; that is a major problem. But there is nothing good about being uninsured—nothing. We can all agree on that. And the ACA certainly cut that rate dramatically. So we have to celebrate that part.Eyles:We do. I think that should be a big celebration, right? But the missed opportunity is we could have at a national level numbers that come closer to, say, what we see in the state of Massachusetts in terms of uninsured—which is 3 or 4 percent. There’s probably always going to be some sort of transitional nature. I don’t know if we would ever get to absolute zero, but we would be close.Nielsen:But we’re still fighting. We’re still fighting over whether this law is constitutional. I mean, we just don’t even have that answer.Pollack:Looking back, the bill passed in 2010 and didn’t get really implemented until 2014. And that four-year hiatus when the administration was working on the implementation gave an opening. And of course the midterm elections flipped the House at that point in time. And you look back and you see that there were four years there where the program was largely ramping up and being attacked, and it led to a political dynamic.Nielsen:It was a concept, not a benefit.Pollack:Maybe all of us, including the administration, didn’t quite educate the public enough in that period of time to get people more invested in it.Nielsen:If you’re going to pass a law, have the good things happen right away and have the things everybody hates be delayed. And make sure that the demonizing is immediately fought or preemptively decimated. Those are just some obvious lessons.Tauzin:Well, the other thing we can acknowledge is that this act could be improved rather dramatically if Congress got past all the demonization and really worked together to improve it—particularly for that crowd of Americans like the nine million who don’t get the subsidies but ought to be able to afford coverage if we can make some changes. It could easily make this act work better for young people as well as old people. What I’m saying is, if we can get past the constitutional arguments to where people could quit hoping that the courts are going to deal with it and Congress has to deal with it, there’s room for improvement.Weil:Thank you all for a very interesting conversation. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 2 March 2020 Information© 2020 Project HOPE—The People-to-People Health Foundation, Inc.PDF downloadRelated articlesThe Ten Years’ War: Politics, Partisanship, And The ACA02 Mar 2020Health AffairsThe ACA Turns 10: Reflections Of Four Industry Leaders05 Mar 2020Default Digital Object Series Listen to the audio interview here!