Author John Seabrook with his book, The Spinach King, The Rise and Fall of an American Dynasty.
On this episode of BookNotes Plus with our host, Brian Lamb.
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So just first tell us a little bit about your background in health policy and about your organization, the Center for American Progress.
unidentified
Yeah, so I've worked in health policy my entire career.
In addition to being a health policy expert, I also get the pleasure of being the phone of friend to everybody in my life as they're going through insurance milestones and have a brother on Medicaid, how to have parents on Medicare.
And the Center for American Progress Action Fund, where I have the pleasure of doing my work, is a nonpartisan, independent policy institute and advocacy organization that advances bold progressive ideas and leadership on behalf of all Americans.
All right, so let's talk about the 60th anniversary.
This marks the day that President Johnson signed the Medicare and Medicaid program into law.
What were these programs intended to do?
unidentified
Yeah, so Medicare and Medicaid were part of the big great society programs that were intended to make America a competitive and great country.
At the time, it wasn't a very radical notion to pass a law that would ensure that no American would go hungry, that no American would go without health care, that no American would go without access to a public education.
And the Medicare and Medicaid programs were intended to bring health insurance and health care to the most people possible.
The Medicare program is probably the program that most people are familiar with.
That is the program that is primarily for people who are older, for American seniors and people living with disabilities, some disabilities.
The Medicaid program is a program that originally was designed to support and still is designed to support very low-income people in this country.
In 1965, when it was established, it primarily served children and pregnant women.
Over time, it's been expanded to include low-income people generally.
And these are two dramatic policy successes that have just changed the face of health insurance in America.
But healthcare didn't cost as much as it does now.
unidentified
That is true.
And over time, we've made many scientific advances that we want to invest in because we care about people living longer and healthier lives.
You know, we care about curing cancer and making sure that people are able to spend time with their grandchildren.
But yeah, so if we go back to when these programs were established, right, and we reflect on what these past six years have been like, it has really been just decades of really exceptional progress on the healthcare front.
So we started with these two programs, Medicare and Medicaid.
In 1997, we expanded, the country expanded even more health insurance coverage to more poor children through the Children's Health Insurance Program.
The Affordable Care Act in 2010 was a sea change that offered an insurance pathway to now 24 million people who didn't have insurance through their jobs or needed to buy it on their own.
And then the Inflation Reduction Act did a lot to actually lower the cost of prescription drugs, which I neglected to mention.
In 2003, the Medicare program began covering prescription drugs.
And now, thanks to the Inflation Reduction Act, it is even cheaper to buy coverage through the Affordable Care Act marketplaces.
I mean, it's been a tremendous, tremendous half-century of progress that the One Big Beautiful bill is really designed to destroy.
We're going to talk about that, but first a few numbers.
So here is enrollment numbers currently.
Medicare has $68.6 million, Medicaid 71.7, and that children's health insurance program you mentioned $7.3 million in that.
Let's drill down a little bit on Medicare first, just kind of setting the stage here for Medicaid.
So it has four parts, and we'll get that on the screen for you.
There's the hospital part, the medical insurance, that's B. C is Medicare Advantage Plan, which is the confusing one.
unidentified
Yes.
Because that's private and right, that's right.
So Medicare is actually two programs.
There's a public, like the original version of Medicare, which about half of people who are enrolled in the program are in.
And then in 2003, the Medicare Modernization Act opened a pathway for a real meaningful pathway, I should say, for private plans to compete and be an option for coverage.
That is the Medicare Part C program.
So when you become eligible for the Medicare program, you can choose traditional Medicare or Medicare Advantage or the private alternative.
And it's about 50-50 in terms of what the enrollment split looks like.
Let's talk about Medicare and Medicaid spending because that's what the One Big Beautiful Bill, proponents of that bill say that they are addressing.
So Medicare grew 8.1% to one, so over about a trillion dollars.
Medicaid grew 7.9% to $871 billion.
And the national health expenditures grew 7.5% to $4.9 trillion.
That's total.
That's coming from CMS.gov.
Is that kind of growth sustainable?
unidentified
Yeah, so healthcare, it's not a secret.
Healthcare in America is expensive.
We spend a lot of money on healthcare in this country.
I think we tend to conflate what's driving the costs of the increased cost of health care with increased enrollment, which is not necessarily the case.
We spend a lot of money on this and healthcare in this country because healthcare prices are so high.
And there's a very, very, very large degree of market dominance and consolidation, which allows healthcare providers to charge high prices and doesn't really include incentives for insurance plans to lower those prices sufficiently.
That doesn't mean that we shouldn't make sure that people have access to care in this country.
I think it's a fundamental right that every American should have.
And I would not agree that the pretext of this bill was to cut spending.
It seems like primarily the pretext of this bill was to finance tax cuts and to look at safety net programs as the primary vehicle for achieving those savings.
And we talked about this, Kristen, is that the problem is there's a high degree of fraud, waste, and abuse in that program.
I'm talking about tens of billions of dollars every year.
What we did is we went in to go in and fix that.
We introduced work requirements, which is a wildly popular notion in public opinion polling, because it makes sense.
Medicaid is a safety net program.
It is intended for the elderly, the disabled, young, single pregnant women, young mothers.
And those resources are being drained because you had able-bodied young men, for example, with no dependents who are riding the wagon.
That's not right.
It's morally wrong.
And it doesn't comport with the law.
So what we did in our Big Beautiful bill is we went in to carve those guys out of that program.
They have work requirements now, 20 hours a week.
They either have to be working, looking for a job in a work training program, or volunteering in their community, which is good for them and their surroundings.
We find dignity in our work.
We're proud of that reform.
And by the way, there was a Harris and Harvard poll that came out about two weeks ago.
And they looked at 17 of the 21 primary provisions in that big beautiful bill.
And 17 out of 21 are majority support in the public.
And that's after the onslaught of the mainstream media and Democrats lying about the bill.
So we're excited to go out into our districts in August and tell the truth.
Notably, I mean, as he has he says, well, as he does not say, the bill absolutely cuts the Medicaid program.
It includes a trillion dollars in cuts to that program.
I don't really, I think this gets down to semantics a bit.
Like, do you believe that cutting somebody from the program is a cut or not?
I mean, the Congressional Budget Office finds that millions and millions and millions of people are going to lose coverage as a result of these work requirements in particular.
The vast majority of people who can work on the Medicaid program do.
There's only about 8% of people.
We know this through surveys, lots of data.
There's only about 8% of people who can work on the Medicaid program who don't.
And these are primarily older women who exited the workforce in the last five years to care for family members.
I think there's something very telling in Speaker Johnson's comments about how the program is not designed for able-bodied men without dependents.
I wonder if the majority of Americans in this country believe that young men should not have access to health insurance.
I would contend that that's not the case.
The Medicaid program, federal Medicaid dollars have never been eligible to be used for undocumented immigrants.
This is, again, a problem that is not real.
We expect Josh Hawley is, Senator Hawley is extremely worried correctly about what these cuts are going to mean for his state because as he knows, this is going to result in billions and billions and billions of dollars in uncompensated care costs that are going to have to be shouldered by hospitals.
We expect that there are going to be hospitals that close.
We expect that, again, millions of people are going to lose their coverage.
Let's talk about illegal immigrants because this Medicaid is administered by the states.
Correct.
And there are states that can determine that they will cover illegal people that are here illegally.
So how, I mean, in the sense he is true.
So the federal government is saying we will not pay you to the states if you continue to cover illegal immigrants.
unidentified
Well, the federal Medicaid dollars are not allowed to be used for undocumented immigrants.
States that choose to do that use their own money.
They use state money.
They do not draw down federal Medicaid dollars to provide that coverage.
States are free to spend money how they would like.
That's why that provision actually fell out of the One Big Beautiful Bill Act where there was a provision in there that would have punished states in other ways because they chose to spend their own money to cover undocumented immigrants.
Usually, I mean, there are states, the reason that many states do this is to make sure that there's not a chilling effect for anybody to access coverage who needs it.
So primarily, this might be like a, you know, we're going to provide coverage to all low-income children, regardless of immigration.
We're not going to ask you to tell us to prove what your immigration status is.
And again, that's just to make sure that people are able to get the care they need.
It's not like a pathway rolling out the red carpet to bring in to bring in undocumented immigrants.
People Rely on Medicaid00:03:43
unidentified
But again, that is something that some states choose to do with their own money.
The federal government has never paid for those immigrants to receive Medicaid coverage.
I want to ask your guests, what are you guys doing?
I mean, it's great that you're on T-Spen and You're putting out the message that this one big beautiful bill is really going to hurt millions and millions of people who rely on Medicaid.
So, what else are you guys doing to combat the lies, the blatant lies that are being told by the Republicans?
I mean, they're saying, they're telling you we're going to cut $1 trillion from Medicaid and Medicare.
And at the same time, they're telling you we're not cutting people off of Medicaid and Medicare.
So I'm not sure what you can do.
And what else can we do to help people to vote in their own best interest?
I mean, if you rely on Medicaid and Medicare for your health benefits and you vote Republican, you're literally voting against yourself.
And people who live in these southern and rural areas, they're going to lose these rural hospitals.
They're going to lose their health care.
And another tale in this One Big Beautiful bill is a lot of these provisions don't take place until after the midterm elections.
Why is that?
I mean, that should tell people something.
And you're going to have Republicans call after me and they're going to defend Donald Trump.
They're going to defend this One Big Beautiful Bill.
And a lot of these people are going to rely on these benefits.
So what are we doing besides coming on C-SPAP?
We have to put out a better and bigger message.
All right, Jack.
Well taken.
I mean, I think, as you just shared, the most important thing we can be doing is actually telling the truth about what's in this One Big Beautiful Bill Act.
I think something that we all need to remember is that this process, the process that Congressional Republicans used to pass this bill was intentionally fast, done mostly over the cover of darkness in the middle of the night and without any public input.
And the point was to make sure that nobody knew what was in this bill because once people know what's in it, they don't like it.
It's unpopular.
The provisions are unpopular.
And the fact of the matter is, this bill was actually passed without even knowing what the full impacts were going to be.
That was intentional.
And so now we're in a position, we're all in a position where we're trying to make sense of this in real time.
I talk to reporters all the time who ask, what does this provision mean?
And we have to work through it together to say, well, we don't really know, and neither does Congress.
And yet they voted on it anyway.
So we are in this very weird position where we're having to experience it and cut through a lot of misinformation.
It's very hard to tell accurate stories about a bill when the people who voted on it don't even know what's in it.
Diane in Morristown, New Jersey asked you this on text.
Unfortunately, during COVID, many ineligible people were put on Medicaid.
Now that COVID crisis is over, we have to address those people on the rolls.
It's unsustainable.
unidentified
Yeah, so what this person is referring to is during the COVID pandemic, states, there was a public health emergency and states were not permitted to remove people from their Medicaid.
It doesn't mean that people were ineligible for the program, but they put a moratorium on doing, on redetermining eligibility for Medicaid.
That ended.
The public health emergency is over.
Medicaid Unwinding00:06:00
unidentified
A process known as Medicaid unwinding happened and those folks were removed from the program.
People who were no longer eligible for the program were removed from it.
Luanna Atlanta, Maryland, you are on Medicare, Luanna.
Go ahead.
unidentified
Yes, I started working at age 13, which at that time was legal and was paying into Social Security and Medicare from that time.
I didn't receive Medicare until 65, 66.
And since then, I have received four different identification numbers for I just recently received a new one, maybe about two days ago.
And it seems to me that there's a rationale for why our numbers continue to change, as well as the fact that the supplementary insurance that I have is one of the best ones that you can pay for.
And I just want to know, why did I get a new card in this past week when I just got a new card half a year ago?
Well, I'm not sure about your individual circumstance or what sorts of cards you're getting.
My recommendation would be to call 1-800 Medicare to talk with one of their assisters about that.
But one thing to note, again, is as I shared before, the Medicare program usually has two coverage pathways.
You can go into original Medicare, you can go into Medicare Advantage.
And people who, no matter which pathway you choose, there's open enrollment every year.
Folks make different decisions, so it could be something like that.
Andrea, you have an opinion piece in MarketWatch with the headline.
If you thought Medicaid was a mess already, Trump's cuts only add to the chaos and the costs.
How is that?
unidentified
Yeah, so primarily this is going to happen in two ways.
One is through the paperwork, Medicaid work reporting requirements, which we know from state experience in places who have, in places that have tried to implement work requirements in the past, are just a bureaucratic nightmare.
So take, for example, the state of Georgia.
The Medicaid program in Georgia rolled out a program called Pathways to Coverage, which included Medicaid work reporting requirements.
So far, according to ProPublica, the state of Georgia has spent $90 million implementing this program, and I think like 2,000 people have enrolled.
50 million of those dollars have gone to allegedly Deloitte to stand up a program that nobody's using, even though 250,000 people are eligible for it.
We also know from state experience that primarily work requirements just kick eligible people off of the program.
That's what's happened basically in every place that's tried it.
And I think, again, this gets at, like, I understand the cynicism around the timing of some of the provisions of the bill happening under the midterms.
I agree.
I share that cynicism.
But one thing that is plain as day that goes at the heart of like this lie that the bill does not cut Medicaid is that work reporting requirements, these elements of the bill only save money if they kick people off of coverage.
So if a magic switch is flipped and instead of a bureaucratic nightmare, work requirements magically work.
Everybody's working.
Everybody's qualifying for their exemption.
Nobody's having trouble with paperwork.
Nobody loses coverage and no money is saved.
And the only reason these are in this bill and associated with millions of coverage losses to produce coverage savings, again, is to finance tax cuts.
These aren't, if you were designing a bill to strengthen the Medicaid program to make sure that it was delivering the best possible insurance product that it could, serving Americans in the best way possible, this is not what you would do.
You would not just invoke a number of policies that are designed to kick people off of the program.
Let's talk to David, a Republican in North Carolina.
Good morning, David.
unidentified
Good morning.
In regards to your guest and her comments, one specifically that no one knows what's in the bill when it was voted on, I thought the liberal Democrat side required that the bill be read completely.
So I think everyone knows what's in the bill.
Everyone, what they've done is they've formed their own opinions.
I don't understand why the left does not just let things play out.
Elections have consequences.
The majority of people voted for the policies that are being put in place in this tax bill, which does favor the middle class, that let this play out.
And if things work out badly for the current administration, they get voted out next time.
The latest trustee report from CMS says that that is going to be depleted in 2033 instead of 2036, as was originally thought.
Why is that and what can be done about that?
unidentified
Yeah, so again, we spend a lot of money on health care in this country.
We spend a lot of money on prescription drugs.
We have exceptionally high health care prices.
There is a lot to do to bring down the costs of care.
One way to do that is to slash and burn and just cover no one, right?
We don't have health insurance programs at all.
We cut the rolls.
Another way to do that is to actually tackle why health care prices are high and why health care costs are so high in this country.
We have a lack of transparency.
Again, we have exceptionally high costs of drugs.
We have very, very, very high hospital prices.
Those are things that are tacklable.
And with respect to the Medicare program, one source of significant overspending is the Medicare Advantage program.
So we, again, have talked about how there's this private version of the Medicare program.
The Independent Advisory Commission that advises Congress about Medicare spending finds that that program is overpaid by at least $83 billion a year.
We think that number at CapAction is significantly higher, and that's because of all sorts of loopholes and games that private plans are able to pay to game the system and increase their reimbursement rates.
There are many, many, many ways to bring health care prices and costs down.
I just don't think that the way to do that is to exclude people from getting health care services.
Yeah, so Medicare, again, Medicare Part C, Medicare Advantage, is the private version of Medicare that folks can buy into.
Many people choose to do this because the Medicare program is pretty complex and it's complicated.
If you go into traditional Medicare, right, you have Medicare Part A, you have Part B where you're paying a premium, you buy a prescription drug plan, Part D. Many people who do that also buy supplementary coverage, Medigap coverage, to help pay for the costs of their deductibles, their out-of-pocket payments, and all of that together can be a complicated thing to do.
The alternative, Medicare Advantage, bundles all of that into one private product.
It's cheaper for most people, but that comes at a cost, right?
In some places, right, that might come at a cost of buying into a product that only has a network as big as one county.
That's true for many Medicare Advantage products in the state of Florida, for example.
So you have restricted networks.
You have rules about what you're able to access and what you're not.
But many people make that trade-off because the costs are a little bit more affordable and predictable.
Those plans can also offer supplemental benefits like dental vision and hearing.
But many people, again, who have serious health issues, who are very sick, find those types of plans too constraining and choose to go into the traditional Medicare program as an alternative.
And let's just put on the screen the people that are eligible for Medicaid, and then I'll give you a chance to respond.
So it is low-income families, pregnant women, children, individuals receiving supplemental security income, that's SSI, individuals with disabilities, low-income adults in states that expanded Medicaid.
unidentified
Yeah, so the requisite for being eligible for Medicaid for the vast majority of people is being very low-income.
So even, again, children, pregnant women, adults that are on this program are poor people.
I mean, this is a function of how many people are living in poverty or just above the poverty line in America.
Even with Medicaid expansion through the Affordable Care Act, which allowed childless adults to access the program for the first time, only goes up to 138% of the federal poverty level.
I think for a family of four, that's maybe living on like $33,000.
It's not a lot of money.
The program also includes eligibility pathways for people like my brother.
He's severely intellectually and developmentally disabled.
He lives in the state of Florida.
He qualifies because he has permanent disability that he's had since he was a child.
There are many people who are on the Medicaid program who are also seniors.
They're people who have Medicare as well.
These are called dual eligible people.
If you need nursing home care, if you need to live in a nursing home, that's not something that the Medicare program typically pays for.
You either have to pay for it privately or qualify for Medicaid coverage for that kind of care because you meet income eligibility.
Also worked in health and human services for a period of time and retired military as well as corporate and other areas.
I did work in HHS.
And I would like to say that I watched the reading or a good portion of the reading of the bill in Congress and noticed that in the wall of Congress as it was being read, there was a substantial number of representatives who were not in attendance.
So the actual person that you're interviewing there is correct in that many of our congressmen are not aware of all of the bill's impacts.
Secondly, I'm working in HHS.
I do understand the problems that the funding is going through.
But I'd like to just make sure that folks are realizing that their congressmen are not actually participating on both sides.
So they're still here legally, but they have not reached a green card.
That's correct.
unidentified
That's correct.
So there will be categories of legal immigrants who have paid into the system and some folks who don't even have a green card pathway necessarily, but again, they are legal immigrants who will no longer be eligible for the program.
So that is one change that this bill made.
Another is there was a rule under the Biden administration to make it easier for very, very low-income people, very low-income seniors on Medicare to access savings programs that they're eligible for.
So if you're not fully dual eligible for the Medicaid program while you're on Medicare, if you're very low-income, you can also, you can qualify at least for savings programs that help cover the costs of your deductibles, your premiums, your out-of-pocket payments, especially for things like prescription drugs.
So for a couple on Medicare who's making like $33,000 a year, that program can help them save about over $8,000 a year in Medicare costs.
And there's a provision in this bill that gets rid of the rule or gets rid of implementation of the rule to make that streamlining easier, to make it easier for people to access programs for which they're eligible.
And we anticipate that as a result of that, over 1 million Medicare beneficiaries aren't going to be able to enroll in those savings programs.
So they're going to see very high costs that they otherwise shouldn't have to be paying for.
There's another change in this bill that we had a under the Biden administration, there was a change to require minimum staffing ratios for nursing homes.
Things like, you know, at a minimum, you have to have a registered nurse at a nursing home 24 hours a day.
This bill would block that rule.
And as a result, we expect that there will unfortunately probably be thousands of Medicare beneficiaries or benefit people living in nursing homes who might die because they don't have safe facilities.
So there are a number of changes in this bill that will hit Medicare.
Democrats have been in control for 12 of the last 16 years.
What exactly have they done to reduce medical costs?
Andrea seems to be putting this all on Republicans.
unidentified
Well, that is certainly not my intent.
And I can outline what Democrats have done to reduce health care costs.
I guess probably going, well, we'll go back to 2010.
First, they introduced the Affordable Care Act.
As a result of that, Medicaid became a coverage pathway for people without children who are very, very low income in this country.
We now have an Affordable Care Act marketplace.
You are allowed to buy insurance without any thought about pre-existing conditions.
Medicare Reforms Introduced00:01:42
unidentified
Young people are able to stay on their parents' insurance plan until they turn 26 years old.
There are a number of different preventive services every year that people can get for free without cost sharing, like mammograms, colonoscopies, vaccines.
Those were pretty significant successes that lowered the cost of health care for millions of Americans and allowed people to access insurance.
During the Biden administration, the Inflation Reduction Act was passed, which allowed Medicare to negotiate prescription drug prices for the first time, drive down prescription drug costs.
It also instituted a $2,000 annual out-of-pocket cap on Medicare Part D expenses.
So now nobody on Medicare will pay more than $2,000 a year for their prescription drug coverage as a result of major legislation.
It also capped insulin costs at $35 a month for people on Medicare, introduced cost-sharing.
I mean, there's a lot.
But we have to remember that in spite of how President Trump is running his administration, right, the president is not a king.
There are multiple branches of government.
Congress, the executive branch, the courts all have to make, they all have a role to play.
Unless you have a supermajority, it's not like any one party can like do everything that it wants on its whims.
But I mean, I would say that the Democrats have done a lot to lower the costs of health care.
Let's talk to Mark in New York, Line for Democrats.
Good morning.
unidentified
Good morning.
The last time this young lady was online or on the show, she was a counterpart and somebody was on the phone.
You're both talking about health insurance.
And the last time you were on air, your counterpower, Jason, you shut you out when you were about to make a comment on federal funding for corporate health insurance.
And I looked it up and it was like $500 a month per person, $1,000 per couple, and it goes up from there.