← Bulwark Takes
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- [00:00]
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- [01:00]
Jonathan Cohn
Hey, it's Jonathan Cohn from the Bulwark. We are here to talk about the one big, beautiful bill moving through Congress and what it's going to do with, for or maybe to American healthcare. Our very special guest today is the governor of Kentucky, Andy Beshear. My kind of governor. He can get wonky and talk about policy, but also talk about what policy means for real people. Governor Bashir, welcome to the Bulwark.
- [01:25]
Andy Beshear
Thank you for having me.
- [01:27]
Jonathan Cohn
So, you know, let's just set the scene here. We're recording this Friday morning. Senate Republican leaders are putting together their bill, their version of this one big beautiful bill that's got tax cuts and does a lot of other things, cuts, food assistance, potentially clean energy. And of course, the big one, the health care cuts that we're going to talk about in a second. They are still working on what's going to be. They're talking behind closed doors. They're dealing with Senate parliamentarian. We haven't gotten a score yet from the Congressional Budget Office. And they say they want to vote this weekend and get a bill to the House next week and onto President Trump's desk by July 4, which is a week from now. I have never seen anything like this in government. You've been around government. Is this how you guys make laws in Kentucky? I mean, is this the usual kind of process?
- [02:10]
Andy Beshear
It's not how you make good laws in Kentucky or anywhere else. I mean, this setting of the deadline and then trying to rush it through, even though millions of Americans will be impacted, even though they're rewriting new sections and likely forcing people to vote on them before they read them, when governance Turns bad is oftentimes when you construct these timelines and or create a process where not everybody knows every piece of each bill. And just look back on the number of House members that are now saying, I didn't know this or that was in the bill. First, that's their job. I mean, they should know everything that's in a major piece of legislation. But second, the process shouldn't be such to where we get laws that impact the American people that the legislators or those in Congress don't fully understand.
- [02:59]
Jonathan Cohn
And we're going to get into the weeds of this in a second. I'm just curious. I mean, you must talk to members of the delegation. You must talk to, you know, trade associations, local people talking to them. Have you had a conversation like any of the senators, U.S. house saying, what are you guys doing? What do they say? I mean, how do they defend this process or do they not defend it or do they not talk about it?
- [03:17]
Andy Beshear
We're pushing as hard as we can to make sure this bill does not pass because of how devastating it will be. You know, across Kentucky, every association is against it. Our Kentucky Hospital association, which is not a liberal group, is fully and entirely against it. Our rural hospitals and their leadership are fully against it. Leaders from county judges to mayors that will see massive job loss are against it. It seems like the only people that are actually for this bill are congressional Republicans. And I'm not sure if that has to do with appeasing the ego of the president and pledging your undying loyalty, even if it harms the people of your district or if it's about them saying, we're in charge and we're going to do this just to show you. I always thought that your job when you go to Congress is to represent your people. And when you look at either our congressmen or our senators, if they vote for this bill, they're going to kick 200,000 people off their health care coverage, they're going to close 35 hospitals, and they are going to effectively fire 20,000 health care workers. How if you represent the people, could you do something that so directly harms them?
- [04:27]
Jonathan Cohn
Let's sort of talk a little bit about Medicaid in particular, because that's the biggest. I mean, there's a lot of cuts to the Affordable Care act, which are also very important. Maybe we'll get to those in a few minutes. But I want to talk about Medicaid first, because Kentucky is such an interesting state for this. You know, Medicaid, when they set up the Affordable Care Act, Every state could opt in and expand Medicaid to cover everybody up to or just above the poverty line. A bunch of blue states jumped in. California, Massachusetts, the usual suspects. The only red state that jumped in early was yours, was Kentucky. That was your father was the governor at the time. And so you've got 10 years of experience with this expanded Medicaid program. Still, you know, a lot of red states don't have it right. Florida, Texas, Georgia. Talk to me about the role that. I mean, you're in a red state. I think a lot of people there, I'm going to guess, think about government programs. They're too big. There's too much government. We have too much regulation. What is Medicaid doing for Kentucky that's worth the money?
- [05:21]
Andy Beshear
Well, people in Kentucky strongly support Medicaid. They understand it differently now than Maybe they did 15 or 20 years ago. Medicaid covers the people we love the most. Half of Kentucky's kids are covered by Medicaid. 40 plus percent of all the births in Kentucky are covered by Medicaid. 70% of our long term care costs are covered by Medicaid. So who does Medicaid cover? Our parents and our kids. That's why it's so critically important. And I'm proud that Kentucky expanded Medicaid because what it's done is provide more access and affordability to all Kentuckians. First, between 4 and 600,000 Kentuckians that never had health care coverage got it. When we expanded Medicaid, we went from one of the highest uninsured rates to one of the lowest in the country. And in a state that at that time was number one, two or three in heart disease, lung cancer and diabetes, that is a game changer. And then what we saw is it helped us preserve and even expand rural healthcare. I mean, since I've been governor, we've opened two pediatric autism centers in Appalachia. It's the first time that parents with an autistic child haven't been told that the best thing they can do for their child's health care is to move. Since I've been governor, we've opened the first hospital in our largest African American community called West Louisville. In 150 years, we've opened clinics in counties that have never had a single clinic. So for the first time, people don't have to drive an hour to get care. And as we've built this out, we've seen different areas where we can actually spur our economy. You know, one of the fastest growing Rectors of the US Economy is health care. And if you have expanded Medicaid, it means that those hospitals that hire people have revenue coming in and can grow instead of providing care, which they have to, to people who aren't covered, and then struggle. But I got to see firsthand what expanded Medicaid meant when I became governor and the pandemic hit three months later. Because my dad had expanded Medicaid, we had rural hospitals that other Southern states didn't. That meant we had more beds out there when people were suffering. It means we were not overwhelmed, at least not as quickly as other states, and we were able to provide better health care. It means more people are alive today living through that pandemic and living through natural disasters than would have otherwise been. Health care is not just a basic human right. It's a difference between life and death. And so when you cut health care significantly, what you get is losing more people, and that next person could be your family member. Last piece I want to say is the expansion of Medicaid was so important for our economy. I mean, we are booming right now. We've got the most people ever working. We have the most jobs ever filled. We have the largest workforce in our history. And part of that is because we got our people healthier. I expanded Medicaid to cover vision, dental, and hearing. And the reason is pretty simple. If we want people to get back to work, they got to be able to see, to drive to work. So let's get them a pair of glasses. In the grand scheme, that's not all that expensive. If we want them to be safe at work, they need to hear the warnings. Let's get them that hearing aid to make sure that they can do that job and do it effectively. So expansion of Medicaid is smart. It helped our economies, especially in rural Kentucky. And the idea that most of these votes on this big, ugly bill would come from rural legislators or congressmen is just crazy.
- [08:53]
Jonathan Cohn
So now when I talk to the supporters of this bill, I talk to the Republicans, I talk to the conservatives who support it, they jump. They like to talk about the work requirements. So let's talk about that piece in particular, because that is the part that I think polls particularly well with the American people. That's the one part. If you look at polls, people support work requirements. The argument is pretty straightforward. It's like, look, this is taxpayer money. If people are going to get this government benefit, they should have to work if they can, or demonstrate that they have some reason that they can't. A disability. They're caring for a young child. And if they can do that, then they'll get to keep their Medicaid. That's all this bill does. It says, look, you work, get Medicaid or you try to work, if you can't, then you don't get it. I think a lot of people support that. They feel like, hey, I work hard for my money, I'm struggling with my health care bills, why my tax hours going to pay for someone who, you know, you'll hear the Republicans sitting at home watching, playing video games, whatever. How do you answer that argument? I mean, a lot of people agree with that.
- [09:52]
Andy Beshear
It's understandable that that would appeal to people. But the trick is in your description and how you describe what the process is, that if people can prove that they are this or that they are that, that they can keep their coverage. Listen, this, the goal of this bill is to kick people off Medicaid thinking that it saves the federal government money. And so what they're trying to do is people who are fully qualified and should be on it have to check more boxes, have to prove it every six months instead of every year. And if you don't, if you miss something on one of those forms, you lose your coverage for the next six months or so. So think about that senior who is getting long term care treatment, whose family doesn't get that box checked correctly and all of a sudden mom or dad they're going to have to care for in their home. Without coverage now, mom or dad may not survive and you're not getting to work nearly as much as you used to because now you're helping mom and dad further. If you reduce that revenue stream, rural hospitals are going to close. So not only are you trying to keep mom and dad alive now in your home, but you're driving them several hours to many doctor's appointments that they need to go to. So it doesn't make us healthier, it's going to make us less productive as a workforce, not more productive as a workforce. It's going to fire hundreds of thousands of healthcare workers across the country. And I guess the last piece is it doesn't even work for what they're claiming they're doing it for. It adds trillions of dollars to the federal deficit and debt. And for us states, the bill in a lot of places pushes costs on us and we have to balance our budgets. That's what we do as governors. And with hundreds of millions of extra expenses that the federal government's saying, nope, states can, can do that. Now you have an unbalanced federal budget that's gotten worse and you've blown a hole in state budgets. It's just this bill is bad in every part and it just doesn't work.
- [11:54]
Jonathan Cohn
So one of the arguments that you hear from the supporters, you know, you'll hear this, this line, I'm sure you've heard it. You know, we're going to the vulnerable, we're going to protect Medicaid for the people who really deserve it. And it's related to the work requirement argument. But there's a, there's a second kind of level to this, which is that, you know, as you know, the matching funds that you get from the federal government for the expansion, it's much more generous than it is for the regular Medicaid match. And so the theory is states are basically putting extra money, they're diverting money into the expansion population and as a result, services for the traditional Medicaid popular, people with disabilities, for the elderly suffer. And so, yeah, maybe you've expanded coverage to the working poor, but at the expense of, say, home community services for people with disabilities or nursing home care or something like that. What do you say to that argument? That this is basically you're robbing that. What ends up happening is states are robbing Peter to pay Paul. Peter, in this case being the people who really need Medicare, really deserve it, giving it to these working poor people who may be a lot of them, you know, don't necessarily need it as much.
- [12:58]
Andy Beshear
It is a manufactured false argument by people who in the same bill are trying to remove food assistance for people who otherwise go hungry. This idea that you're going to protect the vulnerable while tearing away food from, from kids, from seniors and from others is, I guess that's pretty bold by the people who are out there saying it. And as it relates to Medicaid, that's not how it works. The extra help that we get in expanded Medicaid or when universities that have medical programs are part of the care, just enhance the overall care that's provided. It helps those hospitals with the higher costs that they may have with those that have disabilities by being able to have a little extra revenue from the other members that come in. But that expansion population, remember, for the most part, wasn't covered before. And so what that means is these hospitals were having to provide uncompensated care. So what you're seeing now is with expanded Medicaid, you have hospitals that are financially at least doing better, are less likely to close because rural hospitals still struggle, but they're able to Subsidize part of the most expensive population, which is just folks that have the highest level of need with the rest of the group. But think about this. Without the expansion population, we don't get people in for their screenings. We don't find prostate cancer before we have to do full blown treatment. We don't find breast cancer before we have to do the full blown treatment. We don't get diabetes before it kicks in, when it's preventable or at least treatable on the early end. I mean, if we're just smart about the money, we know that prevention saves all of us a ton. And if you don't have people coming in to see their primary care doctor, if they don't have this coverage that expanded Medicaid provides, then they don't come in and ultimately your costs are more. The final thing I'd note is we saw with expansion in Kentucky because I got a, I got a front row seat that the final group of kids that weren't covered, we finally got signed up when we signed up their parents. And that's so important because hopefully we can agree that every child in America should be able to see a doctor when they need to. If I can just personalize some of this. I mean, I remember when, when the ACA was passed, I remember when my dad had the opportunity to put it into Kentucky law and expand Medicaid. And I remember the day that I'm in an elevator with him in Lexington and a woman walks on and bursts into tears and when she can finally speak, she looks at him and says, I'm alive today because of you. She said I had cancer and they called it a pre existing condition and no one would cover me. But with the expansion and with the aca, I'm getting the treatments I need and I'm in remission and this person who's standing in front of us would not have been alive. That's the power of health care.
- [16:02]
Jonathan Cohn
So you mentioned aca pre existing conditions. It's not yet clear what they're going to do to that. I mean there's some cuts that the parliamentarian has something to say about it, but there are going to be some cuts to the Affordable Care Act. So for you, I think connect, is that still what the exchange there is called? Yeah, people buying coverage there. Again, they said there would be some cuts to the, to the standards of insurance, the subsidies and then down the road there's this question of whether to renew the extra bonus, the supplemental subsidies that came in during COVID that have been that they've maintained it's basically taking a bunch of money out of the Affordable Care Act. How focused, how worried about that are you? I mean, that's a lot of money also going into your healthcare system. A lot of people got insurance in Kentucky through there.
- [16:40]
Andy Beshear
Oh, we should be worried about it. The Affordable Care act has been a game changer. Coverage for pre existing conditions. And then, and then that private sector market that does get some extra assistance making it work for people that have gotten that better job are moving off of Medicaid. Where is that next piece for them? In many ways you hear Republicans say we've got to address the benefit cliff and I agree with them. We've got to make sure that there's not a disincentive to take that next step. In many ways, that's what the state run health care exchanges are, that people are doing better and are doing well enough to where they should be able to move off of Medicaid. But the economics of some of the private sector regular plans or employer plans don't yet work for those individuals. That's why that market was so critical and so important. And what we've seen in Kentucky is it works. We're having more and more people sign up for it. That means more people are doing better, are getting better jobs are getting higher wages and we ought to continue to help lift them up and see that trajectory where maybe they go from Medicaid or expanded Medicaid onto the exchange and then ultimately off the exchange into a private employer's insurance.
- [17:56]
Jonathan Cohn
So the meta question behind both of these, I mean in this bill, right, is that basically is it worth spending all this extra money rather than cutting taxes? Because that's partly the choice here, right? I mean, the money that's coming out of healthcare is going into tax cuts. And some people say that all sounds great. We're insuring people, sure, but better we'd be better off putting that money into tax cuts. Better for the economy, Better for the people who got the tax cuts. Make the case against that.
- [18:19]
Andy Beshear
This is going to devastate the economy. Now if it shuts down 35 rural hospitals in Kentucky, those are the second largest employers in each of the counties. They're in behind the public schools. Every doctor, every nurse, every orderly, every custodian loses their job. And you know what? The ones that would qualify for that tax cut don't get it because they don't have an income anymore. I mean, you look at that amount of job loss in so many communities. This is not something that's going to stimulate the economy. And I think fewer people are going to qualify for the tax cut because of how hard it hits the economy. It's basically looking at one of the fastest growing industries across America and slashing it and claiming that those job losses won't happen. It's also going to make the workers of America less productive. Either they're going to be less healthy or they're going to be taking more time off to drive parents and kids to doctors and hospitals that are hours away. I mean, I think anybody who just steps back and says at least 20,000 Kentuckians are going to lose their job over this. No, that's not good for our state. And again, just the breakdown of numbers in Kentucky we think are at least 200,000 people lose their coverage. That's 200,000 people that are less healthy that might not be able to work. Now, 35 rural hospitals potentially close. And 20,000 Kentucky health care workers lose their job. So the argument for why it's bad for the economy is right there.
- [19:52]
Jonathan Cohn
Governor, I know you need to go. I want to ask you one last policy question on a different part of the bill. I live in Michigan. Everyone knows is a big automobile industry state. What people don't know is Kentucky is a big auto industry state. You have Toyota, gm, Ford, all have big plants there. I know also had a lot of investment in the EV battery industry. You're part of the battery belt. Now we look at the cuts to green energy and clean energy in the electric vehicles. How does that play in Kentucky? I mean, some people say that's good for the legacy automakers because they make more money on the car powered vehicles. But obviously you've got all these investments in factories and EVs coming. How do you weigh that out?
- [20:24]
Andy Beshear
Well, in Kentucky, we've built the two biggest battery plants on planet Earth. They're a joint venture between Ford and SK on. And all of our major automobile manufacturers are getting into the EV space because we know it's the future. And a lot of people have tried to fight the future and no one's ever won. In Kentucky, we saw with the energy economy what happens when there are major shifts and you're not on the front end of that shift, even if it takes time. What you can see are communities that are devastated. What they're trying to do to the EV tax credits and those credits in the Iraq are going to further slow our economy. So when Donald Trump became president, our economy was booming. Everyone wanted to invest in Kentucky and the United States. European companies that thought that they had invested too much in China and were over leveraged and were ready to invest in America because of the growth and the growth rate that we were seeing. It was a really exciting time. And then came tariffs and the brakes pumped on all of it. I mean, billions of dollars. And the sad part about it is Donald Trump stopped what he says he wants to do, which is the reshoring of American manufacturing. That's exactly what was going on through the ira through different incentives. They were building battery factories here instead of in South Korea or Japan. We were seeing foreign direct investments saying, okay, now is the time, and we see the stability and our downstream customers all require that we use cleaner energy and have a more sustainable product. So the irony in all of this is that Donald Trump's policies aren't only slowing an economy he said he'd grow, but are slowing the reshoring that would have otherwise happened.
- [22:14]
Jonathan Cohn
Are you hearing that from people? Are you hearing that from the industry there? Are you hearing from industry leaders that.
- [22:18]
Andy Beshear
I mean, even if you take it out of this, out of just this side, think about Churchill Downs that announced before the Derby they were going to at least pause a nearly billion dollar expansion. And the CEO said it very clearly on their earnings call. It's because of tariffs. It's because the cost of that could go up or down by 20% a project like that. And with that instability, you can't make an investment that big. Tariffs are Donald Trump's baby. They go directly back to him. He's solely attributable for them. And they are slowing, if not stopping reshoring that would otherwise be happening.
- [22:53]
Jonathan Cohn
Governor Beshear, thanks for joining us here on the Bulwark. We'll be watching the bill. We're watching what you do in Kentucky.