What’s At Stake In Changes To Medicare and Medicaid: Chiquita Brooks-LaSure, Senior Fellow at The Century Foundation

Lindsey Smith:

Hi, I’m Lindsey Smith, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.

For healthcare providers, it's always important to have a solid understanding of Medicare, Medicaid, and the Child Health Insurance Program (CHIP) because about 40% of adults and nearly 50% of children in the US get their health insurance through one of these programs, or a combination of them. But perhaps it's even more important to know what's happening with these programs right now because of a recently enacted federal law that calls for a trillion dollar decrease in spending, resulting in potentially millions of people losing their coverage, cuts to clinical staff and medical services, and the closure of hospitals and clinics, especially in rural areas.

To help sort out the fallout from these changes, and get an expert take on other challenges in the healthcare sector, we turn today to Chiquita Brooks-LaSure, a senior fellow at the Century Foundation, who served as the administrator for the Centers for Medicare and Medicaid Services, also known as CMS, from 2021 until earlier this year. 

Prior to that role, she held various leadership positions at Manatt Health and in the Obama administration, contributing to major health policy initiatives at the Department of Health and Human Services and CMS. 

Thank you so much for joining us today.

Chiquita Brooks-LaSure:

It's my pleasure to be here. Thank you for having me.

Lindsey:

Awesome. Well, I'd like to start with learning more about you and what first got you interested in healthcare policy?

Chiquita Brooks-LaSure:

Well, I would say as a kid, I was always interested in science and had thought a little bit about medicine over the course of my education and also was extremely mission oriented from my childhood...just really wanting to have a strong sense of purpose. In graduate school, I gravitated a little more to education and social policy as places to really make a difference in this world. But I had a professor in graduate school and really became interested in health policy because I started to understand just how core it is to people really being able to live the American dream. 

My first job out of graduate school was working at the Office of Management and Budget. Part of my job was to focus on the CHIP program, which had just been passed in 1997, and I started in 1999. My early experiences with children, and particularly their parents being filled with joy and pride to get their children enrolled in the CHIP program, really helped me to develop such a strong sense of wanting to see everyone in this country to have access to affordable health coverage.

Lindsey:

That's a really great backstory and it's really interesting to see how those early experiences can spark a lifelong passion for public service. So, along your career journey, you served in the administrations for four different presidents, spent time on Capitol Hill and also worked at healthcare consulting firms. What did you learn through all of those experiences about how to affect change in healthcare?

Chiquita Brooks-LaSure:

I'm really glad that I've had the opportunity to have so many different experiences and work with so many different types of people.  I think I would say I learned a couple of things. One, I think is just really about the art of compromise and how important it is to take in the input of a variety of stakeholders when you're trying to change some kind of policy. That's particularly true in healthcare. I'm sure it's true in many worlds, but in healthcare in our country, we are reliant on multiple perspectives to make changes. The government does not directly deliver healthcare. The government pays for a lot of healthcare. There are private entities that have to do things. There are states that have to do things. And over the course of my career, I've worked with and worked on so many different types of implementation and even coverage expansion.

That was something that I tackled in the Bush administration as a career official because after September 11th, there were people who lost their jobs and the Bush administration wanted to give them health coverage. They wanted to do it in a certain way, which was different than how the Clinton administration wanted to do it, but the ultimate goal was the same: to get people coverage. I really learned through that experience that there are multiple ways to achieve similar goals, and we need to think broadly when we're trying to get from point A to point H about there being multiple ways to get there, and sometimes it's more important to get to H than it is that the path to get there looks a certain way.

Lindsey:

I really like what you said there about the art of compromise and taking input from such a variety of stakeholders. I want to talk a little bit about the piece that you recently wrote to mark the 60th anniversary of Medicare and Medicaid that gave a great overview of who the program serves and the impact it has had on Americans. I thought it'd be a good way to set the table for our discussion to have you provide some of that context to us.

Chiquita Brooks-LaSure:

Yeah, I really like to reflect on where we've been and when you think about where we were as a country before Medicare and Medicaid were created and where we are now, it is just an incredible story. Many of us do not know the history of how health coverage happened in this country, but most people got coverage through their employers after World War II because when employers set wages, there was a ceiling. So to attract workers, employers decided to put the money into providing health insurance coverage. But insurers didn't want to cover older people because they weren't healthy and they cost a lot of money. This was leading to a burden not only on people who were seniors and people with disabilities, but really for multiple generations.

I think that what we've seen today -- now that we have so many seniors and people who need assistance from the government to help afford their insurance -- just what a difference that has made. It's helped our economy, it's helped people to continue to live productive lives in various ways. And it's had an effect outside of health, right? Desegregation is one example of the difference that Medicare made because hospitals, when Medicare was created, were discriminating based on race. 

I live in Virginia and I had a daughter, who is 11 now. When I was in labor, my husband was talking to a couple of women who were in the hospital at the same time, and they were saying how even though they lived in the area their whole lives, they were born in DC because the hospital where I gave birth was segregated sixty some years ago. This is just one example of how much caring about our health has had a broader influence on our country. 

So, many commercial insurers really pay attention to what the Medicare program is doing. One of the things that I think we're seeing today in therapeutics and drugs that are coming to market is you need to make sure that those kinds of treatments will be covered. If you are an up and coming company and you're trying to decide what you're going to invest in, you want to invest in something that you know is going to be covered. And often it's Medicare -- and increasingly the Medicaid program -- that are going to be the answer. So those are just a couple of examples of how important having healthcare in our country is, not only to the people who are enrolled in those programs, but for the rest of us as well.

Lindsey:

That's really helpful context, and it's incredible to think about how those programs have evolved and expanded, to your point, of Medicare and Medicaid didn't just insure people, they did so much more than that and really kind of transformed US healthcare by modernizing hospitals, enforcing desegregation, reducing medical poverty, and establishing a foundation for ongoing reforms on how care is delivered and even financed today. So, a huge impact there. 

There have been so many changes to the programs over the decades, including what was included in the Affordable Care Act. Can you tell us more about that?

Chiquita Brooks-LaSure:

Yeah, so the Affordable Care Act...it's hard to imagine and really think about where we were, but 15 years ago, people -- if they didn't have employer coverage, if they weren't in Medicare and Medicaid -- they would have to buy coverage in the individual market. And for many people it was incredibly challenging. If you had a health condition, an insurer could say, I won't cover you, I will only cover parts of you. And sometimes people would have health insurance offered to them, but it would say, we're not going to cover anything related to your lungs or a certain body part. 

You as a woman would be charged more than a man because women use healthcare at higher rates than men, partly because we give birth to children as well as tend to be consumers. And just imagine as a 25-year-old woman, you're being charged more than your male counterpart just because you're female, regardless of any of the choices you made.

That was the world that we were in, and people who had really high health needs would hope that they could get paid coverage through a state high risk pool. We had a third of the country who was declaring bankruptcy because of healthcare costs, so it was actually really affecting our economy. Again, it's hard to remember, but the Affordable Care Act was born at the start of the Great Recession. I was on Capitol Hill at the time, and right before President Obama was elected, we were in the process with President Bush trying to do the bailout and get our economy back on track. And it's just again, an example of how healthcare is just so linked to the state of our economy. 

In the Affordable Act, there were many changes made putting Medicare on safer footing. We closed what was called the donut hole at the time, improving drug benefits for the Medicare program, and it really importantly expanded Medicaid. At the time, Medicaid coverage had dozens of different categories, and you'd have to meet those categories in order to get coverage. The Affordable Care Act intended for everybody below 138% of the poverty level to be eligible for Medicaid. Unfortunately, that has ended up as a state decision, so we have forty states that have expanded Medicaid, but still ten who have not. 

And then of course, creating Affordable Care Act coverage -- where all those descriptions that I described of how you couldn't get coverage -- now there was an option: Affordable Care Act, marketplace coverage, which was subsidized by tax credits to help make it more affordable. That has really been a game changer for over 20 million Americans who now have been able to afford insurance. And I'll tell you, I have given so many speeches over the years about the Affordable Care Act, and I would say probably every single time after I've gotten off the stage, someone has come up to me and said, thank you. I have been able to get coverage because of the Affordable Care Act. I don't think people fully appreciate just how many people's lives have been touched, even with little provisions, one of the most popular being that you are able to stay on your parents' insurance until you're 26 years old. 

Lindsey:

Exactly. And it's wild to think that this was implemented fifteen years ago. It doesn't feel like that long ago. I want to talk a little bit about the modern day scope of these programs and what you oversaw at CMS.

Chiquita Brooks-LaSure:

The CMS is probably one of the most important agencies that so few people have heard of. CMS stands for the Centers for Medicare and Medicaid Services and is responsible for over $1.456 trillion. It has the Medicare program, which is focused on people who are over the age of 65 or who have disabilities; Medicaid, which is for modest income people -- so mostly people who are at the poverty level or above if they meet certain conditions; and provides the primary long-term care services in our country. Also, almost half of the births of our country are paid for by Medicaid and the CHIP program. And then the Affordable Care Act is also within CMS as well as a lot of other provisions and responsibilities like the health and safety of thousands of facilities. So your hospital, your nursing home, your kidney dialysis center. The standards for a lot of those facilities also are things that CMS is overseeing.

Lindsey:

Wow, that's a lot within that division and really underscores the scale and complexity of the important work that CMS does. So, you personally have been recognized for advancing health equity and driving innovation across maternity care, behavioral health, and whole person care. With all that in mind, what do you consider the highlights of your time as CMS administrator?

Chiquita Brooks-LaSure:

I am incredibly proud of what we were able to accomplish over the four years. I would say the things that I'm happiest and proudest about have been our ability to expand coverage and make that coverage better in both Medicaid and the Affordable Care Act. Between those two programs, we reached over a hundred million people having coverage through those programs. We also strengthened Medicaid in some really important ways. You mentioned maternity care, and a lot of our focus during my time was making sure that we improve our maternal health outcomes. We got almost all of the states to expand coverage postpartum for twelve months, which is so important to making sure that mom and the child get the healthcare they need during that first year. But also making sure they were doing best practices and really ensuring that when people are going to the doctor, that they're getting the care that they need.

I'm incredibly happy and proud that we were able to get the Congress to pass allowing Medicare to negotiate drug prices, and we implemented the Medicare negotiation program the first year, saving billions of dollars for people and for the program, and importantly, making changes to drug coverage. So this year, thanks to the work we did, seniors now only pay $2,000 out of pocket as a result of the changes if they've enrolled in the Medicare drug benefit. 

I have spent so much time over the years just talking to so many people who were choosing between putting food on the table or paying for medicines, and so many people in this country are hurting because of prescription drug costs. One couple I met told me the husband had over $17,000 in costs a year. I think about just hearing people just cry about their drug coverage and how expensive it was. So, I'm really proud of what we were able to do there. So, those are my highlights and things I'm really proud of.

Lindsey:

Thank you for walking us through those highlights. Honestly, so many worth calling out and we appreciate you sharing those with us. So let's shift to the current situation. We've had a lot of major changes in Medicare, Medicaid, and CHIP. Can you summarize for us the biggest changes in the programs and what impact they will have, especially on individuals who rely on this coverage?

Chiquita Brooks-LaSure:

So, Congress just passed a bill that is really going to be very devastating to our programs in Medicaid, and Affordable Care Act coverage and even potentially will affect the Medicare program. So I would say there are dozens of provisions in the bill and I could walk you through every little one of them, but big picture, I would say they fall into a couple of buckets. One, they add more red tape to the process for people enrolling in Medicaid and Affordable Care Act coverage. I think we all know no matter what kind of healthcare coverage we have, that we'd all love it to be simpler. That's what we should be focused on. And time and time again, and this is decades long, when we add hoops to people, we make it more difficult for people to enroll in coverage. 

I mentioned the CHIP program and the start of it. There was a time when policymakers added requiring birth certificates to kids being able to get coverage. And it was the kids of Appalachia that struggled to get their birth certificates. They didn't have the documentation. I just use that example that it's time and time again that when you add all of these requirements, you make it harder for people, even if they're going to be eligible at the end of the day. When you add more requirements, there's more paperwork to fill out and I am very concerned about states’ ability to implement these provisions well, and that's going to be something that we will see over time.

But there's so many people who are reliant on these programs and the additional hoops that have been added, things like work requirements, things like doing eligibility every six months, things like you have to include more documentation than in the past to get Affordable Care Act coverage, things like you no longer are automatically enrolled -- which all of us are...I mean, you're automatically enrolled in car insurance and all sorts of things because that's how the world works -- and now they're taking that away. These are things that are going to make it harder. So that's one bucket. 

The second bucket of changes are things that will undermine state's ability to finance the Medicaid program. And a lot of them are, again, technical and we could walk through them, but at the core of it is there is a lot of pressure on states now to come up with additional dollars to pay for Medicaid coverage and that is going to be challenging for states to do because Medicaid is already either the number one or the second biggest part of a state budget. Drug costs and other costs are increasing for states, and so each year they're already in a place where they're struggling to pay. So, those things taken together are going to make it really challenging for states to continue to fund the Medicaid program at the rates that they need to be. Ultimately, that's going to put pressure on people, but it also will put pressure on the healthcare system. So many providers, hospitals, and other community health centers are going to feel the pinch as a result of this legislation.

Lindsey:

That's a lot of change coming with ripple effects across the entire healthcare system and beyond. You touched on something that I want to come back to regarding the providers and how this is impacting them. Do you have a sense yet for how providers are reacting to all of this and what steps would you recommend they take to adjust to these changes?

Chiquita Brooks-LaSure:

So, different providers are in different positions relative to the bill, but one place that we're seeing, I would say, the first real or the most dramatic reaction is rural hospitals. Most rural hospitals in this country are incredibly dependent on both Medicare and Medicaid to keep their doors open. Those of us who live in areas where we're close to a hospital don't understand what it's like in some parts of the country. I mean Alaska, which is the most rural part, there are people who have to get on a plane to get a mammogram. There are parts of Colorado that if the weather is bad, they can't pass through this road one to three times out of the year. I mean, there are people who live in places that actually being able to get to a hospital is a serious consideration and a serious concern.

There's an estimate that over 300 hospitals will close as a result of this legislation, so that is a place of, I think, incredible nervousness.  I think there was money put in legislation that could be used for rural hospitals and other providers, but we will have to see how the administration divvies those dollars out. 

But there's no question that I think providers who are affected are trying to figure out the lay of the land and what this is going to mean. And again, when you think about how the private sector reacts to changes, if there is uncertainty, they tend to pull back. I heard from one provider that the hospital stopped their planned expansion. They had planned construction, but now they have to figure out what's happening before they move forward. And so again, it's not clear. There are arguments that the cuts haven't taken effect yet, so why are hospitals already making decisions like that. There was even a hospital that said they were going to close their doors because of the pending changes, and there've been people questioning that. But the thing is, when a private sector organization sees that cuts are coming, they start to make adjustments in the face of uncertainty, and that's where we are. We are in a very, very uncertain time.

Lindsey:

And ultimately, is it fair to say that this has a big impact on patient outcomes at the end of the day?

Chiquita Brooks-LaSure:

Absolutely. I like to say that having insurance is necessary, but not sufficient. It's really hard to go to see your doctor on a regular basis if you don't have secure health insurance coverage. And then if the provider is also unstable in terms of not sure about the revenues, that causes changes in treatment. So whether it's not being able to keep your doors open or even saying, “forget it, I'm leaving medicine”....I mean, we have an issue where we do not have the workforce for all of the things that we need in terms of care in our country. We need more nurses, but also LPNs and certified nursing assistants, and we need to continue to have people wanting to become doctors. And if you feel like that this isn't a place for me, that makes the staffing problem worse. 

Last year was talking with a group of oncologists and they were just talking about how much time they spend in red tape and how frustrated they were getting. Two of them were telling me 50% of their time is spent on administrative tasks and how it just makes you not even want to be in medicine anymore. So I think that these are sort of the things that it's hard to quantify and hard to really fully explain the impact. There are humans at the end of our healthcare system, and it's been a rough couple of years with COVID and then changes in the market like this.

Lindsey:

Really well said there. We do need more healthcare providers, and that's something at Osmosis that we are trying to play a very small part in helping educate the next generation of healthcare professionals. And since we are an education company and always looking for ways to fill knowledge gaps, I'd love to hear your perspective: are there particular topics that you think Osmosis should highlight in a video to help address some of these areas of concern?

Chiquita Brooks-LaSure:

Well, I just commend you for all the work that you're doing, and I think really helping people to understand how important it is for everybody that we're covering people is really, really important. I think that when I go back and think about the Affordable Care Act and the principles of why we thought it was so important for us to have universal healthcare in this country, I think some of that has been lost in this last discussion. 

As we move forward and think about the healthcare needs of our country, I think it's important for us to really make sure we're going back to important first principles. And that is, it's really problematic for all of us if we do not have people getting preventative care and primary care. Our costs will increase. If people can't go to the doctor until they've got something that requires major surgery, or paying millions of dollars to keep people on life support or decades of suboptimal treatment because their diabetes wasn't treated, their kidney disease...just all of these things and just how important it is to make sure kids are getting their checkups and some of these basic things.

I think it's just important that we go back to these first principles and work on the pain points in our healthcare system including the costs that are getting out of control, not spending all of this time fighting over who deserves to get healthcare and making it more difficult for other people to do so.

Lindsey:

That's a really great suggestion. For my final question for you, you've accomplished so much in your career. Many of our listeners are students or early career health professionals. What advice would you give them on meeting today's challenges and building their path in healthcare?

Chiquita Brooks-LaSure:

I would say a couple of things. I think everything that you experience in life is an opportunity to really learn. You learn from situations and your peers and you really bring some of your own experiences into your work. But it’s important to realize that your perspective is only one perspective, and that it's important to seek out other perspectives in order to really make change and to really understand the big picture. So often when I talk to people, if they've only been in one job, they can often just see things from whatever perspective that is and how important it is to make sure you're always broadening your point of view and learning about how other people see it. Even if at the end of the day it doesn't change your perspective, it's really important to make sure you're open to, as I said, different experiences and different points of view.

Lindsey:

That's such encouraging and great advice for our audience. Before we wrap up today's episode, is there anything that we didn't cover that maybe we should have?

Chiquita Brooks-LaSure:

Well, we covered a lot, but I think we have to continue to tackle some real pain points in our healthcare system. And again, I hope that we shift to looking at some of those things. There's prior authorization, there's making sure we do a better job on long-term care and people being able to stay in their homes and communities, but I continue to be hopeful and optimistic that we will continue to work to improve our healthcare system.

Lindsey:

That is a wrap on today's Raise the Line episode. Thank you so much for being with us, Chiquita, and for breaking down the pressing changes in Medicare, Medicaid, and CHIP, and for sharing your insights on the broader challenges in healthcare.

Chiquita Brooks-LaSure:

Thank you for having me.

Lindsey:

That wraps up today's episode of Raise the Line with Osmosis from Elsevier. A big thank you to Chiquita Brooks-LaSure for helping us unpack the complex and urgent changes affecting Medicare, Medicaid, and the child health insurance program, and also for sharing her deep expertise on the broader challenges facing our healthcare system. 

As we've heard, these programs aren't just policy, they're lifelines for millions of Americans. Understanding what's at stake and staying informed is more important than ever, especially for those of us working to improve health and healthcare. 

I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.