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- [00:00]
Jonathan Cohn
Packages by Expedia. You were made to be rechargeable. We were made to package flights, hotels and hammocks for less. Expedia made to travel.
- [00:15]
Andrew Egger
Hey, it's Jonathan Cohn from the Bulwark here with my colleague Andrew Egger. We are here to talk about healthcare today, public health, rfk, vaccines and, and then government healthcare programs and what the Donald Trump and the Republicans want to do to Obamacare. Before we begin, if you like what we're doing here at the Bulwark, please Follow us on YouTube. Subscribe to our podcast subscribethebullork.com Andrew, you wrote this morning a real call to arms, I think, about some news that came out late last week from RFK at the Department of Health and Human Services about vaccines. Before we get into what your argument was, what was the news?
- [00:59]
Jonathan Cohn
I hadn't even realized until I read your newsletter this morning that we're really getting it with both barrels right now. Right? I mean, we've got this stuff that I wrote about happening in the White House at Health and Human Services, kind of like the destruction from within. And then on the other side of things, we've got congressional Republicans gearing up to make all these sort of cuts, from outside cuts to the money going in, changes to the programs in various ways. We're going to talk about all that. So let's start with what I wrote about, which is the RFK stuff. I don't think it's, it's blowing anybody's mind to hear that Robert F. Kennedy, Jr. Is not a major fan of vaccines. That's been basically a through line of his political project for decades. I mean, for, for going back long before he was ever on Donald Trump's radar as Health and Human Services, this is kind of the first thing he and Trump bonded over way back in the day was their shared suspicion that that vaccines were childhood vaccinations, were related to autism, which has been thoroughly debunked by many, many times since he got into hhs. He has been sort of laying the groundwork for, for a number of these things. He's been mostly working in kind of the messaging realm and the personnel realm. He's been saying a lot of things about, you know, vaccine injury and making a lot of claims about supposed insufficient safety testing for vaccines. And he has also been kind of shedding tons of top vaccine officials at the FDA and cdc, people who are resigning, basically saying they can't work with this guy communications high ranking HHS communications staff and the FDA's top vaccine official Both resigned back in March. And meanwhile he has been kind of bringing on some real cranks, some anti vax types in order to spearhead some of these quote unquote just asking questions type research efforts that he seems pretty confident are going to get the stamp of hhs, HHS approval to supposedly buttress this non existent link between vaccines and childhood autism. All of that was kind of preliminary. So that's all Big throat clear to what has happened the last couple of days, which is that we are finally starting to see kind of the first real putting into practice of this posture from rfk. Last week it was the removal of FDA authorization for Covid booster shots for most healthy adults under 65. So if you're over 65, if you have one of a number of conditions that in theory put you at higher risk or that the data has shown put you at higher risk for Covid, you are still authorized to get those shots. But for most healthy adults who are not seniors, that authorization is being pulled off of the table for boosters. So if you've previously had the shots, the annual kind of refresher shots to keep immunity topped off, that was last week, that was on Friday or maybe Thursday today or what I wrote about today, just yesterday, what RFK announced was kind of the, the second tranche of, of the same sort of thing where he, he, he this time came out and said that the CDC would be removing the same shot, the COVID vaccine, from its recommended vaccine schedule for healthy pregnant mothers and for healthy children. Children. So essentially what, what, what you're getting there is formerly, even under the, even under the, the, the scheme laid out just last week by the fda, pregnant women would still be able to receive that shot because pregnancy is, is correlated with a higher risk for Covid as well as Covid being still somewhat dangerous, you know, at an elevated risk relative to other populations for very young children. So the idea was a pregnant mother would get the shot, it would protect her and some antibodies to that child in the first, in the opening months of their lives before they're eligible to get their own Covid shot starting around six months. That's now off the table. RFK has pulled that in a video that he put out yesterday where he, he called it. What exactly did he call it? He said it was, you know, another step toward making America healthy again. So this is, this is kind of dangerous and frightening and alarming kind of on two tracks here. One is just the, what it, what it is. I mean, one is just that the news itself, right? If you are a healthy adult. If you are a pregnant mother, if you have very young children, you have less choice and less access to, to these vaccines, or you're likely to have less, less choice and less access with regard to these vaccines than you did a week ago. We can get into some of the technicalities. Obviously it's, it's not like they have been, it's not like they're completely off of the table. They, you could make the argument, and we don't know exactly how this is gonna shake out, but one could note that if you are a pregnant mother, healthy pregnant mother, you still technically qualify under the FDA authorization from last week. But now the CDC has taken it off the schedule. So maybe you can still get the shot, but maybe your insurance won't cover the shot. That's all the stuff that needs to be kind of worked out in the days ahead here. But at a base level, there's just less access to these vaccines than there has been in the past. The other track on which this is sort of alarming and should, should alarm us like we should, we should see where this is going is that a lot of the arguments that, that, that RFK Jr. Is making here are not at all constrained to this shot. I mean, I think, I think what I wrote this morning was this is kind of low hanging fruit, Covid boosters, right? There's not enormous uptake for these shots already in the American population. About a quarter of the population is up to date on their Covid boosters. There's a wide kind of public perception that Covid is this thing that happened and over now and maybe you already had some shots, maybe you already had Covid, maybe you feel like you're basically covered. And so for RFK to start here is kind of like it's kind of, he's establishing a beachhead, right? But the arguments that he is making about this shot where he is saying it wasn't sufficiently tested, you know, we don't know what the harms are. We, we need to go back and do placebo testing on this stuff and, and you know, really kick the tires on these authorizations and make sure they're, they're legit. These are arguments that he has made for years about all vaccines, specifically lots of pediatric vaccines that are, that every kid gets today. You know, the, the MMR vaccine is, is the measles, mumps and rubella vaccine being a particular target of his, where he has made identical arguments basically saying, oh, it's never been placebo tested. It's never, you know, how could we know, how could we know how safe it truly is? And so there really isn't a limiting principle. I'm sorry, I'm talking for forever here, but I'll just end with this. There really is no limiting principle on what RFK is saying about vaccines and what he is likely to do with vaccines if he would do this for the COVID shots. There's really no limiting principle on him, against him taking similar action with regard to all kinds of other shots on the, on the childhood vaccination schedule, except for perhaps a perceived greater political cost. If RFK is saying, you know, here we're doing this with the, with the, the COVID vaccine for kids, I mean, that's, that's already really amazing that he's monkeying with the pediatric vaccine schedule here. But it is the latest shot to be added to the vaccine schedule. Right. It's only been, we've only been vaccinating kids against Covid for a few year. Few years. We've only had the COVID shots for a few years. So you can see in his mind, this being kind of like a trial balloon. Right. We'll see how they take this one. In theory, this one should go over a little smoother than other ones would. So let's see how we do here and then, and then proceed from there. But that, but, but again, that, that is really the only thing between us and where, where, where we're talking about these exact same kinds of decisions for a whole wide variety of shots that RFK has criticized in the same terms as he has used to criticize this shot that he is removing from the schedule today.
- [08:56]
Andrew Egger
Yeah, well, and one of the things that you put in your article, which I would recommend to everybody, by the way, but I thought was such a tell, was that when he presented this on YouTube, he didn't phrase as, you know, he didn't say the, he phrased it as what you remember, the exact phrase. But, you know, this is the latest advance in making America healthy again. And just framing the COVID vaccine as a threat to American health, which is just a mind blowing. I mean, I know we're used to that from Kennedy and we're used to that kind of talk from people who are anti vax, who have more and more purchase in our conversation. But the idea that this vaccine that has saved millions of lives around the world and would have saved even more here if more people had taken it, and now being presented as a threat to American health, just really, it shows you how upside down this whole conversation has become one thing I want to ask because I want to go right to this issue of sort of, you know, the sort of him testing the waters because. Which is what you argue in the piece. And I think that is so important. Just before we get to that real quickly, this was sort of weird, right? I mean the process here was kind of odd. We haven't gotten full details yet in writing. I mean the sort of CDC announcement came was the FDA announcement. One of them came in the New England Journal of Medicine. One of them is done on a video on social media. We haven't gotten fully fleshed out paper on this from the or digital equivalent of paper, I guess is what we use now. But you know, it's not as if the HHS has put out detailed guidance. As you said, there's some contradictions between what one set of recommendations or another. We don't. This was. Does not appear to have been done in consultation with the normal boards of experts who advise the secretary. There isn't even, it's not even clear who's in charge of the CDC right now. Am I correct that we don't. There, there, there's. There's, as far as we can tell, it might just be an A facto Robert Kennedy. I mean, is this, is this a, is it. Should we be alarmed by this at all? Is there any. Does that, does that. I mean, you know, that doesn't seem like exactly the way we should be making these decisions.
- [11:01]
Jonathan Cohn
Yeah. So this is one of those things where like any, any different surface that you choose to scratch this surface on, you're uncovering something else that's like, oh gosh, what on here. You are correct to note that last week's announcement had had more official trappings on it. Right. It was, was a couple of top HHS doctors with this op ed in the, in the New England Journal of Medicine kind of laying out the case for it. Whereas this most recent change, the, the, the change that was just announced yesterday was just this social media video and in fact seems to have been rolled out so quickly that there is still accessible or was still accessible as of when I was writing this morning guidance on, on the CDC website. That seems the new rollout where they were, they were talking about, you know, how, how pregnancy is it presents an elevated risk for. For, for complications in hospitalizations with COVID and pointed to the different CDC meta analyses that, that, that demonstrated that. So, so we're in this bizarre kind of no man's land where obviously RFK is the guy who's making these Calls like his word kind of goes. But, but we're, we're sort of outside of official channels to a certain degree. The one other thing that I would say about that is, is the role that the, the, the CDC's Advisory Committee on Immune Immunization Practices usually plays here. Ordinarily you would see a recommendation like this come after consultation with that committee. That's what that committee is for, is to kind of give HHS and the CDC guidance on, on, you know, vaccine policy rollout. And usual. Usually that committee is very simpatico with the Department of Health and Human Services, obviously, because that's, you know, they're, they're, they're working hand in glove to push forward the best science. When RFK Jr was confirmed, one of the key pledges that he made to the last Republican holdouts against his confirmation, specifically Senator Bill Cassidy, was that he was not going to monkey with that committee, that he was going to, you know, let them do their work and move forward. That has not happened. I mean, RFK back in February postponed and now it appears to have just been canceled. That committee's first meeting of the year. Usually they meet three times a year. So they did not meet the one time that they were supposed to have met so far under the Trump administration. They are now scheduled to meet next month. But this, this, this announcement about these Covid shots preempts that meeting. It predates it. Right. It's not, it's not coming on the, on the back of, of some conversation from that meeting. It's, it's going into that meeting, assuming it happens at all. There's been reporting that RFK is planning to fire some members of that committee. So like just, just in that context, I mean, it again just sort of underscores one that he essentially was lying to, to various members of, of of the Senate in order to sell them on this, this very thin fiction that they were, they were sort of hoping to, to be convinced of. So they weren't that hard to convince that he was not actually going to be a threat to, to current vaccines currently in circulation, but also just that he's sort of systematically undermining these sort of regulatory, not regulatory, these sort of advisory bodies behind the scenes as well as just making these sort of top level changes at the level of policy.
- [14:20]
Andrew Egger
And can we just pause for one second to note the irony here? I mean, the whole energy behind the sort of skeptic, you know, the more popular skepticism of the COVID shots and the anger at Fauci and the anger at the scientific establishment. So much of that was about supposedly decisions being made in ways that were not transparent, that didn't take full account of the science made by a few handful of people sort of superimposing their own views on the available data. And whatever you think of those arguments, and I think among reasonable people, there's a spectrum for did the public health community make some bad decisions? Did they not consult widely enough? I think there's room for some debate there. But wherever you are in that debate, what we are seeing now now is a version of that on steroids. I mean, this is just, this is, this does appear to be Kennedy imposing his will on in exactly the ways, as you said, that he promised he wouldn't. And as you say, and I want to let's go to the other part of your article which is, you know, this feels like a test. It feels like he sort of, I thought, you know, I'll let you know when you just when I was reading your piece about this, my mind, this is quite the pop culture reference, but my mind flew right to Jurassic park, the movie when the Raptors are testing the vulnerability of their pen. And it felt it does. And you sort of make the argument that in effect Kennedy's trying to test how far can I go talk about that? And sort of, you know, there was an analogy used I thought was quite good.
- [15:53]
Jonathan Cohn
So the contrast here, I think, and I think it holds up is essentially with how Elon Musk was running Doge in the early days of, of the White House. I mean, he was, he was very emphatically moving according to this move fast and break things sort of, sort of strategy where, where, you know, they would just, they just turn random things off across the federal government and just see what happened. And if they turned off anything that turned out to be like load bearing or really important, no big deal, we'll just turn that back on, you know, no harm, no foul. What that ended up doing was provoke a massive backlash far in excess to what you likely would have seen if they had, if they had gone more carefully and less ham fistedly and you know, hired fewer nuclear scientists and cancer researchers and all those sorts of things and you know, veterans at the Department of Veterans affairs. All of which kind of built into this public backlash that tanked Elon Musk's popularity and did end up pretty directly leading to Trump choosing to, to sideline him as part of his project. I mean, Trump, Trump has, Trump is not going to sideline himself. Trump is going to, to follow, you know, the things that he wants to do kind of come what may, but he is softer on the people around. If he sees specific advisors of his or specific ancillary parts of the MAGA project as, as starting to be a drag, starting to, you know, reflect badly on him, he has shown a willingness to pivot off of them. And I think that that is, we're kind of at that moment here with, with RFK where he is operating more cannily than Musk did. He is, he's going more carefully. His, his aims are no less radical, certainly. I mean, more radical and I would.
- [17:33]
Andrew Egger
Say more radical if anything.
- [17:35]
Jonathan Cohn
Yeah, yeah, yeah, but he is, he is, he is not sort of blundering around in the same kind of just like bull in a china shop doofus kind of way that Musk was. And that makes it harder to marshal public opposition in a way that like, you know, Musk was kind of like a perfect figure to become a focal point for protest because it was also ham fisted. And because his, his personality is so large and his brand is so strange and because he has these car dealerships all over the nation that are just an obvious place to show up and protest at, like all of made it really easy to kind of focus public protest against Elon Musk. And I think what we're going to, what we're going to see now. Well, I think it's an open question what we're going to see now because I think that we are entering a moment where, where, where RFK is is sort of whipping the tablecloth off of his anti vaccine project here a little bit at a time. Right. And, and, and the question is, will we be able to see absent, you know, absent the, the shock and awe stuff and absent all those factors I just talked about that made it easy to protest Musk, will we see the same kind of public backlash against Kennedy? Because I think you will have to see that kind of public backlash if there's to be any hope of, of kind of getting Donald Trump to, to, you know, yank this guy's chain and say, okay, all right, you know, like let's not get carried away here, let's slow roll some of this stuff. Because again, that's the only thing that is that that's keeping, keeping us from seeing what's happened with this shot rolled out across a bunch of other shots. Because the same arguments that he has rolled out against this one are arguments he has made for years against a whole bunch of others.
- [19:14]
Andrew Egger
Yeah. And you know, look, there are ways vaccine companies can sue. I mean, if the it does seem like they are. This is the process that is being used at FDA and cdc. I'm gonna bet based on what I know about those processes, what I know about the Trump administration, they are probably not going through the proper legal channels, which means that companies that want to challenge this probably be able to find pretty solid legal grounds. But the problem is this isn't just about companies getting permission to develop these vaccines and sell them. They have to find it profitable. Vaccines are frequently not profitable and if HHS makes it difficult and if it throws up these, they're just not going to make these vaccines until we get to another knock on wood. Let's hope we don't True crisis situation where suddenly we're scrambling and then who knows what happens if we have Secretary Kennedy in charge and people forget as ham fisted as the first response was to Covid under the first Trump administration, a lot of people in his administration were quite skilled and smart and he had a lot of people on top of things working for him. And the idea that instead of an Alex Azar or some of the other former officials in the Trump administration, we would have Kennedy managing a pandemic response now is one of the scariest thoughts I can imagine.
- [20:40]
Jonathan Cohn
Yeah. All right, let's leave Kennedy there. We're doing happy note. This is a double stuff episode cuz you also wrote about a whole different thing also on the subject of health care getting demonstrably worse probably in the near to immediate future or maybe not. Who knows, who knows whether they're going to pass this thing. But let me sort of grab the wheel from you here and talk to you about your newsletter, which also up today. And I had no idea of a bunch of the stuff that was in this. I think a lot of people have no idea of a bunch of the stuff that you were writing about today because what you have done is basically pull together a bunch of little changes to the health care sort of policy apparatus that Republicans are putting forward in this big beautiful bill that just past the House and stitching it together into a full picture that I found very informative. So can you just talk me through a little bit about what are some of the things that Republicans are putting forward in this big beautiful bill as far as specifically changes to the Obamacare sort of policy regime. And why is it that these sorts of things have not been a bigger part of our conversation about about this legislation?
- [21:49]
Andrew Egger
Yeah, so the big picture here, just to remind our viewers, the big beautiful bill is a bill with trillions of dollars worth of tax cuts to offset part of that cost, and I emphasize the word part because this is a huge tax cut that's not going to be remotely paid for and it's going to add to the deficit. But to offset part of the cost, the Republicans in Congress are looking to cut spending primarily on social programs, primarily on health care. Now until this point, most of us who have followed this, most of this talking about, we've been talking about the cuts to Medicaid, which is the big programs that covers medical bills for 70 million low income Americans. We've been talking about Medicaid because those cuts are really big. It would be the largest cut in the program's 60 year history. If they go through as written in the bill that passed the house last week, 10 million, more than 10 million people could lose Medicaid. And because most of those people will not find alternative sources of insurance, the projections suggest, suggest that the number of Americans without health insurance would go up by 7 million people. That by itself is a huge deal. I mean, if there was nothing else in this bill, we would be focused on that as a major change, as something sort of major controversy. But it turns out that's not all what they're doing. In addition to the changes to Medicaid, this bill that passed last week has changes to the Affordable Care Act, AKA Obamacare. And when I say Obamacare, I mean very specifically the part of Obamacare that reordered and rewrote the private insurance market. And if you remember, if you go back in time, back before the Affordable Care act, if you didn't have insurance through your job and you didn't qualify for Medicaid because you didn't, you weren't poor enough in your state to fit, then you had to buy insurance on your own and you probably couldn't get it or you couldn't get a good policy if you had a pre existing condition. And even if you didn't have a pre existing condition, the policies were pretty darn expensive and a lot of people, even middle class people just couldn't afford afford them. So Obamacare, Affordable Care act set up, you know, sort of set up these marketplaces that were kind of designed to mimic an employer plan basically or a set of employer plans where basically anybody could get coverage. If you had a preexisting condition, you got charged the same amount, all the benefits, you know, at least met a standard to cover comprehensive benefits. And if you couldn't afford a policy on your own, depending on your income, you got financial help. These subsidies, which were worth quite a lot of money, hundreds of dollars, even thousands of doll year. These programs are set up today. If you want to buy a policy through one of these marketplaces, you know it as healthcare.gov in many states, or if you're in some states, run their own. So if you're in California, it's called covered California. There's a state run exchange in some other states like Kentucky, Massachusetts, et cetera. This program, this was the part of Obamacare. Again, if you know your history, it was pretty rocky start. The website didn't work there really. It was kind of underfunded for the early years. But over time they were able to sort of streamline it. They put some more money into it. And because of that, enrollment reached record levels last year. More than 24 million Americans now get insurance through these marketplaces, these Obamacare marketplaces. Now, back when Trump was president last time, they tried to repeal Obamacare, including getting rid of these marketplaces, getting rid of a lot of the financial assistance, rolling back those regulations. You may recall, that did not go well for the Republicans. Blew up in their faces. It was a real political liability. And ever since then, they've been not talking about repealing Obamacare. And if you remember the campaign, just a couple, a year ago, Trump once or twice, he put out a post on social media. Well, I'm thinking of doing something on Obamacare. He actually got a lot of flack for it and he kind of backed off from it. And if you asked Republicans in Congress like, we don't want to touch Obamacare, we're not gonna do anything. Well, narrator, they touched Obamacare. And the thing is, as you said, it's a little bit hard to see because unlike last time, there's now not one big change. It's a bunch of little changes. Many of them are technical, they're hard to parse, they're hard to explain. Even for somebody like me who, like, this is my job, right? I mean, this is job description number one for Jonathan Cohn. Explain complicated healthcare things in ways that make sense. And I find this challenging. I had to get on the phone with five different people in part because the language is confusing. Again, we'll have a little bit of a callback to the earlier part of our show where we're talking about the hasty way these decisions are being made. Hhs well, this legislation was written hastily, and so there are provisions that contradict one another and they're not clear what they mean. And in addition, this whole thing got put together, the language, in about a week. So the Congressional Budget Office is still trying to figure out what it all means and what it would all do, but just broadly speaking and then we can dive into the details if you want, or we talk about something else. But there's sort of three categories of changes. One is the piece that I think the Republicans are most upfront about. There's no deception here. They want to take assistance away from people who are immigrants, legal, not illegal. Legal immigrants here who previously were able to get coverage through the marketplaces and get subsidies and now they won't be able to. And that, you know, look, that's part of the brand, right? We want to cut support for people who are coming to this country. You like that, you don't like that, but that, that's pretty straightforward. Second category is where things get complex. There's a whole set of changes to the procedures for signing up for coverage. When you can sign up, under what circumstances, what kind of documentation you have to provide. And, and, and it, each one of these is complex and they overlap with each other and they interact. But the best way to describe it, there's a think tank called the center for Budget on policy priorities. They call it sludge. And I thought that was a pretty good description. It just, it just throws up, it just makes the process of getting onto buying one of these policies really cumbersome, really difficult in a way that's almost, that is not almost that I do think is designed to discourage people from signing up. So that's the second piece and then the third piece is just a straight up cut to the amount of money that people are going to get in financial assistance and the kind of protection and a reduction in the kind of protection they'll get from the insurance. Again, you have to kind of dig into the weeds because they don't just say we're cutting it by X percent. There's, you know, you have to kind of understand like what they say when they mean, well, we're going to increase the allowable variance on the actuarial value and we're going to, you know, dial back the sort of assumptions based on, on we're going to restore funding for the cost sharing reductions. Each one of these is sort of convoluted, but if you, if you run the numbers, you see how it works out, you come out with a world where people are either paying more for their premiums, they are paying more for their out of pocket costs. And a lot of cases, when that is the case, you're going to have some people who are just going to say, look, I'm Just not going to get insurance altogether because I can't afford it. I don't think I can afford it. I don't want to get it. And so the number of people without health insurance is going to rise.
- [29:02]
Jonathan Cohn
So you're kind of in a situation here and people should just go to thebullwerk.com to read your piece. They are in fact coming after Obamacare to go kind of chapter and verse through some of this stuff. We don't need to necessarily belabor that here. But I think that the point you make that is the key one is the cumulative effect here is a couple things. One is to essentially just make the product somewhat worse in some respects, somewhat less, you know, favorable to the consumer in terms of, you know, dollar in to dollar back out ratio. But the other of which is, is sort of just turning the crank to make these procedural hoops a little tighter, a little smaller, a few more of them to have to jump through such that, such that more and more people are likely to, you know, you know, fail to do this or that or the other thing to qualify at all or to get insurance at all just to make it logistically more complicated to take a health, health insurance. And obviously that's, there's kind of a big debate always on, on these sorts of things where Republicans are, are saying, well, you have to throw up these barriers in order to reduce fraud in order to make sure everyone who qualifies for it really qualifies for it. And Democrats tend to say, well, you have to like, can, can can we also please try to make sure that the people who are qualifying for it who do deserve this under the, under the terms we've laid out are not just getting, getting, you know, tossed to the side because they have failed to like, do all the paperwork correctly or whatever. I mean that's, that's a whole debate. But I, but one, one point that I wanted to really drill down on here that you made because I thought it was so important is who you lose when you, when you make health insurance really hard to get and the, the difficulty that, that the extra financial strain that puts on the whole system. So can you talk about that a little bit?
- [30:44]
Andrew Egger
Yeah, for sure. I mean, as you said that there is a real tension whenever you have a program where you're limiting eligibility in some ways between so of successfully narrowing that group of people to who you want to target and narrowing it so much that you overcompensate and then you make it harder. And one of the things we know from reams of Academics, this is not like a hypothesis that's untested. We know this for sure, is that in the very specific case of healthcare, if you make it harder for people to enroll or if you make it more expensive, that not everyone is going to react the same way. And the reaction will be somewhat predictable once you think about it, which is that people who have chronic illness, people who know they're going to have serious medical bills, they're going to jump through the hoops, they're going to go over the obstacles partly because they know they need that health insurance, right? They know they need to pay for their medication, for their diabetes. They know they need the high blood pressure. They know the need they have the whatever their ongoing medications, medical needs are. They know those bills are coming. So they, Ahab, are very motivated, you know, as economists would put it, to get that insurance. And probably if you know the world, if you know this world, if you know who has a serious chronic medical problem or if you yourself do it, kind of part of life is learning to deal with bureaucracies. You're always dealing with insurance companies. You're always dealing with government programs. So you're probably not going to be quite as daunted by it. And you probably have the documentation. You're more likely to know where your documentation are. You're more likely to know who to call when the thing doesn't upload properly, that sort of skill set. So you're. Those are the people who are going to get to it. They are going to be much more likely to get insurance, even if it's difficult. On the flip side, the people who are healthier, people who aren't used to this, people who are that sort of more marginal customers, like, yeah, it'd be nice to have health insurance. It's probably a good idea. I'll do it tomorrow, I'll do it next week. What? The upload didn't happen, right? What's going on? I got to make a phone call now. I got to make another. Maybe those are the people you tend to lose. And the problem is in an insurance system for private insurance, any kind of insurance pool, the whole principle of insurance is that you're spreading medical expenses among a broad, broad group of people. And so what you want, we talk about this as what we call the 8020 mix is sort of the ideal, platonic ideal in health economics, where in any sort of group of people, 80% of the healthcare expenses are concentrated among 20% of the people. And the theory is that for the remaining 80% of the people, it's their premiums that they're paying in that covers the medical expenses of the people who have them. You know, and the idea is that this is a fair arrangement because over time, you know, we all run the risk of getting sick. We could all get in an accident, whatever.
- [33:31]
Jonathan Cohn
We sell in and out of the 20% at different times in our lives.
- [33:35]
Andrew Egger
Exactly. So you want to get that. That. That sort of a healthy risk pool, as we would call it, where you're getting plenty of healthy people in. Well, if you start to lose those healthy people now, you' situation where the insurance company is saying, wait a minute, we're not getting enough in premiums from the healthy people to cover the bills from the people who have serious medical needs. What do you do? You raise your premiums or you lower your benefits. Okay, well, guess what happens once you do that. Well, now the people who are healthy are even less likely to sign up because some of the insurance has gotten more expensive. And this creates a cycle. It sometimes gets called a death spiral, which is a little bit of an exaggeration. Typically doesn't really result in the end of these insurance arrangements, although sometimes insurers do pull out of markets. More commonly, what happens is just premiums get very high and to a point where really it's only a good deal for people who are in bad health. And here's the irony about all of this, is that that world I just described, where you're not getting enough healthy people because the insurance is hard to get, and does it. We experience that when the Affordable Care act first came online, it was a big reason why the program was not popular in its early years. And one of the things that we learned over time, as is often the case with these large programs, is to make the program work better. You tweak the system in terms of how people enroll, in terms of the way the amount of financial assistance that comes in to get that healthy risk pool, we're finally there. It's working pretty well right now. And not coincidentally, the program is pretty popular. What this bill would do is it would effectively turn back the clock to that period where it didn't work so well and where it was less popular. And you can draw your own conclusions about whether that's a virtue or a bug in the minds of the people who wrote this bill.
- [35:29]
Jonathan Cohn
All right, well, I'm sure we'll be watching all that going forward again, it's remarkable to me that this has not been a bigger part of the conversation around this bill. I guess that's One of the problems with a bill that is this big and this beautiful is there's just so much to talk and argue you about that. So beautiful to get missed. Yeah, right, exactly. But, but I, I imagine we're going to be hearing more about it and thank you for doing the, doing the reporting to push that forward. I think we can leave it there.
- [35:51]
Andrew Egger
Right?
- [35:51]
Jonathan Cohn
We've, we've talked a long time. This has been kind of a, like I said, a big old double wide. You know, people, people yell at Sam Stein for, for like being the interviewer who interrupts and all those sorts of things. But now, you know, you get, you get a couple of yakers like Jonathan Cohn and myself on to, to just let, let one another go crazy. We pad these things out to two and a half hours. So we'll stop there. We'll cut it out for, for, for coming on to talk through some of this stuff. Thanks you all for, for watching, for listening. Hope you head to the bullwork.com and subscribe. Subscribe to the YouTube channel. Thanks for all. Thank you all for watching and we'll see you next time.