[Script Info]
Title: 
[Events]
Format: Layer, Start, End, Style, Name, MarginL, MarginR, MarginV, Effect, Text
Dialogue: 0,0:00:00.56,0:00:02.52,Default,,0000,0000,0000,,Let's talk a little about the ACA.
Dialogue: 0,0:00:02.52,0:00:06.71,Default,,0000,0000,0000,,You might say the Affordable Care Act, \NPatient Protection and Affordable Care Act
Dialogue: 0,0:00:06.71,0:00:11.23,Default,,0000,0000,0000,,of 2009, well, isn't that very\Ndramatic health reform legislation?
Dialogue: 0,0:00:11.23,0:00:13.13,Default,,0000,0000,0000,,At many levels, it is.
Dialogue: 0,0:00:13.13,0:00:18.92,Default,,0000,0000,0000,,It's the first federal law that\Nsimultaneously regulates
Dialogue: 0,0:00:18.92,0:00:26.42,Default,,0000,0000,0000,,health insurance, and healthcare services,\Nand health, which is related to,
Dialogue: 0,0:00:26.42,0:00:30.07,Default,,0000,0000,0000,,but distinct from medical care.
Dialogue: 0,0:00:31.03,0:00:36.20,Default,,0000,0000,0000,,How did the ACA overcome these\Nobstacles?
Dialogue: 0,0:00:36.20,0:00:40.58,Default,,0000,0000,0000,,These fiscal and interest group\Nand rationing related obstacles
Dialogue: 0,0:00:40.58,0:00:46.75,Default,,0000,0000,0000,,that had prevented the \NClinton reforms and a series of
Dialogue: 0,0:00:46.75,0:00:50.54,Default,,0000,0000,0000,,other proposals throughout\Nthe decades for being taken seriously?
Dialogue: 0,0:00:50.54,0:00:58.66,Default,,0000,0000,0000,,Well, the ACA comes right after\Nthe Great Recession of the mid 2000's.
Dialogue: 0,0:00:58.66,0:01:03.48,Default,,0000,0000,0000,,And that Great Recession came with - \Nbrought with it, a federal commitment
Dialogue: 0,0:01:03.48,0:01:09.14,Default,,0000,0000,0000,,to stimulus funding, that made health\Nreform fiscally palatable.
Dialogue: 0,0:01:09.14,0:01:15.26,Default,,0000,0000,0000,,Not fiscally welcomed, still subject to\Na number of restrictions, but possible.
Dialogue: 0,0:01:16.62,0:01:19.34,Default,,0000,0000,0000,,The ACA also appeased the interest \Ngroups,
Dialogue: 0,0:01:19.34,0:01:25.72,Default,,0000,0000,0000,,pertained managed competition\Nframe, a major role for private insurance
Dialogue: 0,0:01:25.72,0:01:30.22,Default,,0000,0000,0000,,companies, a guarantee of additional\Nbusiness for American hospitals, and
Dialogue: 0,0:01:30.22,0:01:36.18,Default,,0000,0000,0000,,to a lesser extent, American physicians, \Nand, the ACA was forced
Dialogue: 0,0:01:36.18,0:01:39.06,Default,,0000,0000,0000,,to renounce rationing.
Dialogue: 0,0:01:39.06,0:01:43.76,Default,,0000,0000,0000,,To pledge no death panels, something that\Nreally should never have been taken
Dialogue: 0,0:01:43.76,0:01:45.73,Default,,0000,0000,0000,,seriously to begin with,
Dialogue: 0,0:01:45.73,0:01:51.75,Default,,0000,0000,0000,,but also to limit the way in which the\Nstudy of healthcare delivery,
Dialogue: 0,0:01:51.75,0:01:57.15,Default,,0000,0000,0000,,the process improvement commitments\Nwithin the ACA could actually be applied
Dialogue: 0,0:01:57.15,0:02:01.91,Default,,0000,0000,0000,,to individual entitlements to coverage for\Nparticular services.
Dialogue: 0,0:02:01.91,0:02:08.19,Default,,0000,0000,0000,,And the most dramatic innovation\Nin the ACA, something that was called the
Dialogue: 0,0:02:08.19,0:02:13.56,Default,,0000,0000,0000,,Independent Payment Advisory Board,\Nmight have actually attached direct
Dialogue: 0,0:02:13.56,0:02:19.92,Default,,0000,0000,0000,,consequences to continued high growth\Nin healthcare expenditure,
Dialogue: 0,0:02:19.92,0:02:24.56,Default,,0000,0000,0000,,was never chartered, never constituted,\Nnever met,
Dialogue: 0,0:02:24.56,0:02:26.61,Default,,0000,0000,0000,,and was ultimately repealed.
Dialogue: 0,0:02:26.61,0:02:33.22,Default,,0000,0000,0000,,So, um, timing, where stimulus allowed \Nfiscal palatablity, appeasing the
Dialogue: 0,0:02:33.22,0:02:39.86,Default,,0000,0000,0000,,interest groups, and renouncing rationing,\Nmanaged to let the ACA thread the needle,
Dialogue: 0,0:02:39.86,0:02:44.11,Default,,0000,0000,0000,,and expand healthcare entitlements.
Dialogue: 0,0:02:44.11,0:02:46.02,Default,,0000,0000,0000,,But something else is going on here.
Dialogue: 0,0:02:47.20,0:02:51.70,Default,,0000,0000,0000,,Having a law that combines health \Ninsurance regulation, health service
Dialogue: 0,0:02:51.70,0:02:55.62,Default,,0000,0000,0000,,regulation, and health,\Nis extremely ambitious.
Dialogue: 0,0:02:55.62,0:03:00.24,Default,,0000,0000,0000,,It could only be that ambitious if there \Nactually had been some new insights
Dialogue: 0,0:03:00.24,0:03:04.30,Default,,0000,0000,0000,,into American healthcare\Nthat justified the ambition.
Dialogue: 0,0:03:04.30,0:03:06.01,Default,,0000,0000,0000,,And let me talk about a couple.
Dialogue: 0,0:03:06.91,0:03:13.16,Default,,0000,0000,0000,,First let me talk about what we have\Nlearned about our system
Dialogue: 0,0:03:13.16,0:03:17.97,Default,,0000,0000,0000,,that brings us from health reform\Nbased on rationing,
Dialogue: 0,0:03:17.97,0:03:21.07,Default,,0000,0000,0000,,to health reform based on improvement.
Dialogue: 0,0:03:21.07,0:03:26.77,Default,,0000,0000,0000,,The entire program that you're a part of\Nis a program about transforming and
Dialogue: 0,0:03:26.77,0:03:29.80,Default,,0000,0000,0000,,improving the healthcare system.
Dialogue: 0,0:03:29.80,0:03:32.76,Default,,0000,0000,0000,,Getting value out of healthcare\Ndelivery.
Dialogue: 0,0:03:32.76,0:03:39.08,Default,,0000,0000,0000,,Value was not a word attached to health\Nreform in the 1990s.
Dialogue: 0,0:03:39.54,0:03:43.14,Default,,0000,0000,0000,,When in 1994, a young management\Nconsultant and McKenzie and I
Dialogue: 0,0:03:43.14,0:03:47.81,Default,,0000,0000,0000,,volunteered as healthcare advisers\Nfor a California gubernatorial candidate,
Dialogue: 0,0:03:47.81,0:03:53.27,Default,,0000,0000,0000,,we decided that her platform in healthcare\Nshould be around value.
Dialogue: 0,0:03:54.47,0:04:03.13,Default,,0000,0000,0000,,Her policy adviser, also our age, now a\Nvery prominent media executive
Dialogue: 0,0:04:03.13,0:04:07.53,Default,,0000,0000,0000,,took us aside and put hands on our\Nshoulders, and kind of laughed at us
Dialogue: 0,0:04:07.53,0:04:10.83,Default,,0000,0000,0000,,and said "Nobody thinks about value\Nin healthcare. Certainly not if you're
Dialogue: 0,0:04:10.83,0:04:14.96,Default,,0000,0000,0000,,a Democrat. Think about access, think\Nabout quality, don't think about value."
Dialogue: 0,0:04:14.96,0:04:17.40,Default,,0000,0000,0000,,Well, today we think about value.
Dialogue: 0,0:04:17.40,0:04:20.80,Default,,0000,0000,0000,,Not only Republican candidates think \Nabout value, Democrat candidates think
Dialogue: 0,0:04:20.80,0:04:26.01,Default,,0000,0000,0000,,about value, and nonpartisan policy\Nprocesses focus on value.
Dialogue: 0,0:04:27.45,0:04:31.78,Default,,0000,0000,0000,,That only happens because\Nwe've actually re-framed
Dialogue: 0,0:04:31.78,0:04:35.12,Default,,0000,0000,0000,,the core of the health policy debate.
Dialogue: 0,0:04:36.60,0:04:41.08,Default,,0000,0000,0000,,When I learned basic health policy, and \Nstill if you learn health policy today,
Dialogue: 0,0:04:41.08,0:04:46.33,Default,,0000,0000,0000,,you describe a healthcare system\Ntypically around three parameters.
Dialogue: 0,0:04:46.33,0:04:50.21,Default,,0000,0000,0000,,And you all know what they are.\NAccess, and Quality, and Cost.
Dialogue: 0,0:04:51.40,0:04:58.24,Default,,0000,0000,0000,,And you think about these descriptors \Nnot just as legs of a stool,
Dialogue: 0,0:04:58.24,0:05:02.94,Default,,0000,0000,0000,,but as legs that need to be of roughly\Nequal length.
Dialogue: 0,0:05:05.13,0:05:10.33,Default,,0000,0000,0000,,Which means that in order for the stool\Nto balance and the system to work,
Dialogue: 0,0:05:10.33,0:05:15.01,Default,,0000,0000,0000,,you have to have the right amount of\Naccess, and the right amount of
Dialogue: 0,0:05:15.01,0:05:18.43,Default,,0000,0000,0000,,quality, and the right level of cost.
Dialogue: 0,0:05:18.43,0:05:24.94,Default,,0000,0000,0000,,And implicit in this cost-access-quality\Nframe, is the notion that
Dialogue: 0,0:05:24.94,0:05:28.66,Default,,0000,0000,0000,,our current system is in equipoise.
Dialogue: 0,0:05:29.65,0:05:32.53,Default,,0000,0000,0000,,And so there's a book that was written\Nin 1994.
Dialogue: 0,0:05:32.53,0:05:36.47,Default,,0000,0000,0000,,I could argue that it was actually, \Nyou know, outdated by the time it was
Dialogue: 0,0:05:36.47,0:05:41.20,Default,,0000,0000,0000,,published, but it was written by\None of the great figures in physican
Dialogue: 0,0:05:41.20,0:05:47.10,Default,,0000,0000,0000,,policymaking of the 1960s and 1970s,\Na physician named Dr. William Kissick
Dialogue: 0,0:05:47.10,0:05:51.12,Default,,0000,0000,0000,,who spent much of his teaching career\Nat the University of Pennsylvania, but
Dialogue: 0,0:05:51.12,0:05:53.91,Default,,0000,0000,0000,,who was also present at many of the\Nformative moments of
Dialogue: 0,0:05:53.91,0:05:55.52,Default,,0000,0000,0000,,American health policy.
Dialogue: 0,0:05:55.52,0:06:02.74,Default,,0000,0000,0000,,With Luther Terry regulating tobacco\Nat the passage of Medicare, and
Dialogue: 0,0:06:02.74,0:06:07.39,Default,,0000,0000,0000,,you know, with federal reform throughout\Nthe succeeding couple of decades.
Dialogue: 0,0:06:07.39,0:06:12.34,Default,,0000,0000,0000,,In 1994, Dr. Kissick wrote a book called \N"Medicine's Dilemmas: Definite Needs,
Dialogue: 0,0:06:12.34,0:06:14.79,Default,,0000,0000,0000,,Versus Finite Resources."
Dialogue: 0,0:06:14.79,0:06:19.98,Default,,0000,0000,0000,,And this captured the thinking\Nof 1993, 1994.
Dialogue: 0,0:06:20.76,0:06:26.69,Default,,0000,0000,0000,,No society in the world, Dr. Kissick\Nwrote, has ever been, or will ever be
Dialogue: 0,0:06:26.69,0:06:30.39,Default,,0000,0000,0000,,able to afford providing\Nall the health services
Dialogue: 0,0:06:30.39,0:06:32.97,Default,,0000,0000,0000,,its population is capable of utilizing.
Dialogue: 0,0:06:34.15,0:06:40.32,Default,,0000,0000,0000,,This means that if you want\Nhigher quality healthcare,
Dialogue: 0,0:06:40.32,0:06:43.48,Default,,0000,0000,0000,,you're going to need to\Nmake it less accessible,
Dialogue: 0,0:06:43.48,0:06:46.10,Default,,0000,0000,0000,,or it will become more costly.
Dialogue: 0,0:06:46.10,0:06:52.06,Default,,0000,0000,0000,,If you want more accessible healthcare,\Nyou have to suffer an increase in cost
Dialogue: 0,0:06:52.06,0:06:53.66,Default,,0000,0000,0000,,or a decrease in quality.
Dialogue: 0,0:06:55.00,0:07:00.10,Default,,0000,0000,0000,,If you want less costly healthcare, you\Nhave to sacrifice either access or quality
Dialogue: 0,0:07:00.10,0:07:06.65,Default,,0000,0000,0000,,or both. That world of cost, access, and \Nquality, is the world that brought
Dialogue: 0,0:07:06.65,0:07:10.12,Default,,0000,0000,0000,,fewer rationing into the national health\Npolicy debate,
Dialogue: 0,0:07:10.12,0:07:12.99,Default,,0000,0000,0000,,but empirically, it's not\Nthe world we're in today.
Dialogue: 0,0:07:12.99,0:07:16.82,Default,,0000,0000,0000,,And many of the things you'll be studying\Nand have studied in this course
Dialogue: 0,0:07:16.82,0:07:18.41,Default,,0000,0000,0000,,confirm that.
Dialogue: 0,0:07:18.41,0:07:28.25,Default,,0000,0000,0000,,The IOM identified in 2010 dollars, \N750 billion dollars a year of healthcare
Dialogue: 0,0:07:28.25,0:07:31.51,Default,,0000,0000,0000,,spending that was wasted.
Dialogue: 0,0:07:31.51,0:07:35.32,Default,,0000,0000,0000,,That number is probably close to\Ndouble, today.
Dialogue: 0,0:07:35.32,0:07:40.74,Default,,0000,0000,0000,,Probably close to 1.5 trillion dollars\Neach year, is wasted,
Dialogue: 0,0:07:40.74,0:07:44.27,Default,,0000,0000,0000,,gets wasted on services that are \Nunnecessary, services that are
Dialogue: 0,0:07:44.27,0:07:50.07,Default,,0000,0000,0000,,inefficiently delivered, excess\Nadministrative costs, missed prevention
Dialogue: 0,0:07:50.07,0:07:57.28,Default,,0000,0000,0000,,opportunities, fraud, and a very large\Ncategory of mispriced services.
Dialogue: 0,0:07:57.28,0:08:02.34,Default,,0000,0000,0000,,Services that are simply priced much\Nhigher than a functioning market for
Dialogue: 0,0:08:02.34,0:08:04.97,Default,,0000,0000,0000,,that service should charge.
Dialogue: 0,0:08:04.97,0:08:09.78,Default,,0000,0000,0000,,And this is the frame within which\Nhealthcare reform exists today.
Dialogue: 0,0:08:09.78,0:08:15.04,Default,,0000,0000,0000,,We've gone from feeling constrained\Nby rationing to pursuing improvement.
Dialogue: 0,0:08:15.04,0:08:17.24,Default,,0000,0000,0000,,And that is extremely liberating.
Dialogue: 0,0:08:19.38,0:08:24.04,Default,,0000,0000,0000,,We may have reasons to ration certain\Nservices, and that rationing would still
Dialogue: 0,0:08:24.04,0:08:28.89,Default,,0000,0000,0000,,have to be done ethically. But we have \Nactually learned from twenty five years
Dialogue: 0,0:08:28.89,0:08:35.09,Default,,0000,0000,0000,,of research, that our current system\Nis not in equipoise, waiting for the next
Dialogue: 0,0:08:35.09,0:08:38.57,Default,,0000,0000,0000,,technology to challenge the\Naffordability of the system.
Dialogue: 0,0:08:38.57,0:08:44.72,Default,,0000,0000,0000,,It is instead performing quite poorly,\Nand is ripe for general improvement.
Dialogue: 0,0:08:45.91,0:08:52.94,Default,,0000,0000,0000,,The ACA managed to thread the needle,\Nfiscal palatability,
Dialogue: 0,0:08:52.94,0:08:56.67,Default,,0000,0000,0000,,overcoming fears of rationing,\Nappeasing interest groups.
Dialogue: 0,0:08:56.67,0:09:01.67,Default,,0000,0000,0000,,And it managed to assert a role for\Nhealth system improvement.
Dialogue: 0,0:09:03.37,0:09:08.24,Default,,0000,0000,0000,,A role for improving efficiency and\Nimproving fairness in the system.
Dialogue: 0,0:09:08.24,0:09:12.91,Default,,0000,0000,0000,,But, it still did it in\Na very pragmatic way.
Dialogue: 0,0:09:12.91,0:09:20.18,Default,,0000,0000,0000,,And for me, the best indication of this\Nwas the brief set of remarks that
Dialogue: 0,0:09:20.18,0:09:24.76,Default,,0000,0000,0000,,President Obama gave in the\Nsummer of 2015.
Dialogue: 0,0:09:24.76,0:09:32.98,Default,,0000,0000,0000,,The occasion he was marking was\Nthe Supreme Court upholding the ACA
Dialogue: 0,0:09:32.98,0:09:35.14,Default,,0000,0000,0000,,for the second time.
Dialogue: 0,0:09:35.14,0:09:39.51,Default,,0000,0000,0000,,It had upheld the ACA against\Nconstitutional challenges in 2012
Dialogue: 0,0:09:39.51,0:09:42.19,Default,,0000,0000,0000,,in the case of NFIB versus Sebelius,
Dialogue: 0,0:09:42.19,0:09:48.16,Default,,0000,0000,0000,,and in June 2015,\Nit upheld the law against statutory
Dialogue: 0,0:09:48.16,0:09:51.40,Default,,0000,0000,0000,,challenges, issues of statutory \Ninterpretation,
Dialogue: 0,0:09:51.40,0:09:54.30,Default,,0000,0000,0000,,in a case called King versus Burwell.
Dialogue: 0,0:09:54.30,0:10:00.62,Default,,0000,0000,0000,,And President Obama celebrated\Nthis in the Rose Garden, but he did
Dialogue: 0,0:10:00.62,0:10:03.73,Default,,0000,0000,0000,,it in a way, that is, I think, \Nvery important.
Dialogue: 0,0:10:03.73,0:10:09.79,Default,,0000,0000,0000,,He acknowledged that the ACA\Nreally has a limited vision.
Dialogue: 0,0:10:10.62,0:10:17.39,Default,,0000,0000,0000,,It never had the courage to assert\Nexplicitly, social solidarity and a
Dialogue: 0,0:10:17.36,0:10:22.91,Default,,0000,0000,0000,,public commitment, but instead\Nit satisfied itself with improving the
Dialogue: 0,0:10:22.91,0:10:25.58,Default,,0000,0000,0000,,consumer experience of care.
Dialogue: 0,0:10:25.58,0:10:27.41,Default,,0000,0000,0000,,And President Obama\Nsaid the following.
Dialogue: 0,0:10:27.41,0:10:31.51,Default,,0000,0000,0000,,He said "Unlike Social Security or\NMedicare, a lot of Americans still don't
Dialogue: 0,0:10:31.51,0:10:36.36,Default,,0000,0000,0000,,know what Obamacare is, beyond\Nall the political noise in Washington.
Dialogue: 0,0:10:36.36,0:10:39.66,Default,,0000,0000,0000,,Across the country, there remain\Npeople who are directly benefiting from
Dialogue: 0,0:10:39.66,0:10:42.80,Default,,0000,0000,0000,,the law but don't even know it.
Dialogue: 0,0:10:42.80,0:10:45.22,Default,,0000,0000,0000,,And that's okay," Said President Obama.
Dialogue: 0,0:10:45.22,0:10:51.58,Default,,0000,0000,0000,,"There's no card that says "Obamacare",\Nwhen you enroll, but that's by design,
Dialogue: 0,0:10:51.58,0:10:55.37,Default,,0000,0000,0000,,for this has never been a government\Ntakeover of healthcare,
Dialogue: 0,0:10:55.37,0:10:57.06,Default,,0000,0000,0000,,despite cries to the contrary."
Dialogue: 0,0:10:57.06,0:11:02.62,Default,,0000,0000,0000,,And understand here, that he's\Ntalking about the fears of rationing.
Dialogue: 0,0:11:02.62,0:11:08.46,Default,,0000,0000,0000,,He's talking about the interest group\Nopposition to quote "socialized" medicine.
Dialogue: 0,0:11:08.46,0:11:10.32,Default,,0000,0000,0000,,But he goes on to say,
Dialogue: 0,0:11:10.32,0:11:13.39,Default,,0000,0000,0000,,"This reform remains what it's\Nalways been.
Dialogue: 0,0:11:13.39,0:11:17.77,Default,,0000,0000,0000,,A set of fairer rules and tougher \Nprotections that have made healthcare
Dialogue: 0,0:11:17.77,0:11:22.90,Default,,0000,0000,0000,,in America more affordable, more\Nattainable, and more about you,
Dialogue: 0,0:11:22.90,0:11:27.05,Default,,0000,0000,0000,,the consumer, the American people."
Dialogue: 0,0:11:27.64,0:11:28.95,Default,,0000,0000,0000,,This is significant.
Dialogue: 0,0:11:29.76,0:11:37.73,Default,,0000,0000,0000,,Equating consumers to citizens, \Nis in some sense, the best that
Dialogue: 0,0:11:37.73,0:11:41.21,Default,,0000,0000,0000,,America achieved in the\Npost-Medicare period.
Dialogue: 0,0:11:42.31,0:11:49.13,Default,,0000,0000,0000,,Other countries have public solidarity, \Nother countries have a collective
Dialogue: 0,0:11:49.13,0:11:57.32,Default,,0000,0000,0000,,commitment. The U.S. at best, has \Nconsumerism around healthcare.
Dialogue: 0,0:11:57.32,0:12:02.66,Default,,0000,0000,0000,,And I like to say, kind of contrary\Nto President Obama's assertion,
Dialogue: 0,0:12:02.66,0:12:09.62,Default,,0000,0000,0000,,that the law should have named its\Nprogram of health insurance.
Dialogue: 0,0:12:10.26,0:12:14.81,Default,,0000,0000,0000,,There should have been a card,\Nthere should have been a collective
Dialogue: 0,0:12:14.81,0:12:17.87,Default,,0000,0000,0000,,commitment, but that card and\Nthat collective commitment
Dialogue: 0,0:12:17.87,0:12:22.97,Default,,0000,0000,0000,,shouldn't have been towards \Nsomething named after
Dialogue: 0,0:12:22.97,0:12:25.73,Default,,0000,0000,0000,,President Obama, largely by his\Nopponents, but it should have
Dialogue: 0,0:12:25.73,0:12:28.04,Default,,0000,0000,0000,,been something that we all should care\Nabout.
Dialogue: 0,0:12:28.04,0:12:33.04,Default,,0000,0000,0000,,And so I've often sort of written \Nthat what we needed was not
Dialogue: 0,0:12:33.04,0:12:35.63,Default,,0000,0000,0000,,Obamacare, we needed Americare.\N
Dialogue: 0,0:12:35.63,0:12:41.12,Default,,0000,0000,0000,,We needed a patriotic symbol, we\Nneeded a source of solidarity,
Dialogue: 0,0:12:41.12,0:12:46.48,Default,,0000,0000,0000,,and that's what, even best\Ncase, we failed to get in America.