tv White House Domestic Policy Council Director Joe Grogan Discusses Health... CSPAN November 9, 2019 6:45am-8:01am EST
to welcome you all to her breakfast. for reporters if you're not familiar with the alliance a nonpartisan organization dedicated to convening and educating the health policies and we are so thankful to support the alliance with the series with that support to see guest and panel discussions over the last couple of years including joseph rogan i believe you have the distinction to have our first repeat guest he joined us a year ago as an associate director we look forward to hearing about your new role and healthcare priorities for the domestic policy council thank you for being here and we will get it started.
>> on behalf of the alliance these are important alliances we believe strongly that well-informed press is important to the washington dc world and the dialogue is important we really appreciate you joe willing to come and subject yourself to the questioning of this group. senior director here. joe and i have known each other for quite some time working in the bush administration together. we appreciate you coming here today joe has had a distinguished career in the private sector of public service so we welcome him back again. the only admonition is when we turn it over to q&a state your name we are live on c-span2
welcome to our viewers it is their benefit so they know who is asking the question where you are from. with that take it away. >> thanks for having me back is good to see you reporters again and for those i don't know i look forward to the opportunity to be asked questions and share our views on the healthcare of the trump administration the way the domestic counsel policy functions of the other issues we are confronting as well. just to start with how it functions and what it is we do on a daily basis, other administrations perhaps have had more a linear defined area of responsibility for senior white house officials that
this president has a very entrepreneurial style consistent with the way he has lived his life and expects senior leaders to pursue issues in an entrepreneurial manner it requires us to work in a horizontal and collaborative fashion. a lot of times there are stories in the dc media how the attention in this white house or senior leaders first of all tension is not a bad thing but they are overblown wildly. the senior leadership of this administration gets along extremely well. i have spent a lot of time walking the halls visiting senior leaders offices getting alignment before the oval office. we have robust and open discussions in front of the president this week we had a
meeting with the president and 14 people were there to brief on an issue for which he had to make a decision. we could not find the senior leader of the team who disagreed so we went and found somebody else to find the counter so the president can understand the different side of the view and ultimately he made a decision. he works well when he watches people way both sides of an issue than he can make a decision. i love working in this white house. it's a lot of fun. i like the senior leadership team that doesn't mean we agree on everything but that is fine. what i find is if you respect each other and work well together with the best interest of the president and the people first and foremost. beyond that my philosophy is there are some issues of which
we are lead and healthcare is one. labor, where we are not we want to support and be as helpful to have a policy agenda larry kudlow what is lead for tax policy if something crosses over into the domestic policy like healthcare which is the big achievement of this administration is to fulfill the individual mandate to say this is something that should be repealed it is at odds with our values as a whole host of other issues may not be lead but i go in with a principal to say this is in my opinion. it comports for here is
another take. we lead when we have the baton in support when somebody else does it is moving the ball forward for the president in american people. sometimes what people in this town struggle with because mister trump is so different than the traditional politician is to say what type of approach is he taking? he is not ideological. he does not come in with 50 years of campaign donations from vested interest and a defined philosophy except he likes to solve problems. he will ask a bazillion questions to figure out the right answer. is not necessarily interested in their opinion because of their title or status but he wants to know from experts.
i have watched him look over cabinet officials and ask a question of the 20 or 30 or the one - - -year-old staffer in the office sitting on the couch because he wants to know a variety of opinions and wants to know the opinion of people that are expert on any given subject. he told the story on the uss jerry ford asking the maintenance crew if the preference was for the magnetic launch or the old steam launch and they said steam and they said because if they break we can fix it and that they went into a description how to load a plane into position and why steam makes more sense. i can submit to you i cannot think of a president in my lifetime asking the guys that do the actual work each and
every day with their opinion is. now that decision i'm sure would anger defense contractors or procurement officers and project officers who were behind that but this is the president who doesn't care about offending special interest to people based on title he wants to get to the right answer for the american people and is willing to talk to anybody who has expertise in real-world experience. i know there is another impression people can't hack it in the administration they come out and they wilt under the president's question. tough to be frank he asks tough questions of a lot of people and puts them on the spot. a lot of people can't handle it. that is the president style. he wants to make sure you understand what you are talking about and have the courage of your convictions and it is an environment that i enjoy and a lot of other
people enjoy. some traditional dc dwellers can't handle it but that is not the president's problem. that is their problem if they whine about it to the media or anonymous after the fact than it should be taken with a grain of salt because they have left for a reason. this president is almost indistinguishable i have gotten calls at 715 in the morning i know he's been a very light one - - late the night before many people around him cannot keep up. - - is the way it is. with healthcare consistent with the president's view there are a lot of problems that need fixin fixing, we have taken the approach that is not bound by any particular special interest. would be easy for the president to say i will solve the drug problem by throwing more taxpayer subsidies into
the system to help people do out-of-pocket co-pay per go instead he challenged manufacturers and all publicly and rhetorically that we have three major legislative agendas drug pricing legislation is one of them. would be easy to have gotten the deal to appropriate more money and spend more taxpayer dollars to solve the drug pricing problem. that's not what he wants to do. he wants to lower list prices and clear out those convoluted incentives that expose people to excessive cost consistently across the healthcare agenda you have watched him and his team confront issues other administrations have ignored perk i worked in this town during the obama administration.
you cannot get a meeting in the obama administration with a senior official that did not involve aca. there's 13 million people with the affordable care act as a hundred 80 million and the employer-sponsored market there were problems they would not address at. hiv, what major hiv initiative occurred? if it did i did not see it this president has called the illumination of hiv to confront the opioid epidemic which exploded during the obama administration the match was that was fueled by tax fate - - taxpayer-funded programs and prescribing guidelines put out by cdc that should have been addressed more quickly. the list goes on and on. transparency hopefully we will
have another announcement this month maybe december a lot of people don't want customers in american people to see where the money goes in the healthcare system for go they thrive on opacity and the arbitrage in the healthcare market of lack of transparency. there is a lot of money flowing through the healthcare system and unless we get at confronting some of those vested interest to our making a lot of money year over year the american people will continue to be exposed. the kidney health initiative that problem one - - program have not been modernized since nixon with the development of influenza vaccine is another example. back to opioids year-over-year
declines in opioid death which is significant on drug pricing also year-over-year declines for medicine for the first time in 50 years. that is a direct result of the president drawing attention to this issue and forcing manufacturers to negotiate more aggressively. while working on the healthcare issues with this president it is a wide open aperture and it is a one issue. he says give me a problem a it is a wide-open aperture. it isn't one issue. he hasn't concentrated on one problem. he says give me a problem and you guys figure out how to solve it and i will back to you and i don't care what special interests are whatnd lobbying group we may offend, just work together and solve it. on healthcare the last thing i
will say when i opened it up to questions, it is probably the best integrated team of any subject this administration confronts. on healthcare when we have a meeting with the president you will have a lot of people in the meeting. sometimes we have to have them in the roosevelt room because a lot of people are interested in the subject, but kellyanne conway will show, larry cut will shop, the white house counsel will show up and we work really well together on the staff level and the principles level, we bring a lot of views and perspectives, that's why there are some issues where a member of the team will say can you take the lead on this executive order or this particular issue because your person is ideally suited to move it forward.
it is a great team of people to work with that confronts hard problems, hard challenges and it is a pleasure to be a part of it. >> thank you, a good overview. i will ask two quick questions. the two questions are out of what you just said, how do you then work with the department and the second question is are there one or two issues you work on? i don't need a detailed answer but one or 2 questions you work on that the public doesn't know a lot about that you enjoy or think are important and enjoy that your staff works on, just give a little more depth to what the dpc does? >> we do a lot of issues maybe we are not out front and center on on a daily basis, yesterday we had an event at the white house in the oval office with
victims of communism, this is the first president to sign a proclamation to recognize the 100 million people killed by communist regimes. we had a group of people who suffered under communist regimes come income until the stores to the present, the domestic policy council sponsored that event and then went out and spoke to the press and some were on television today, the american people recognize the importance of fighting for freedom and the struggle against communism, a lot of people see this president respects religious institutions and wants to make sure people are free to practice their faith. human trafficking is another issue we are working very hard on. an issue that exploded with the rise of the internet, the dark
web, some of the stories that we here are pretty awful. it is not just labor trafficking but sexual trafficking, not just international but domestic. it is not just international criminal gangs but domestic gangs and family members often and it is a tragic situation. workforce development is another issue. i worked closely with ivanka trump on that, education issue so there's a whole host of issues, every culture issues that we work on sometimes and anything we can be helpful on that we have bandwidth, we roll up our sleeves -- >> how many staff is there? >> over 20 right now including details so we take a lot of
detail leave from departments to go and help on a specific issue. i have somebody from the interior department who is a very talented attorney helping on regulatory issues, we work closely with the office of management and budget on regulatory issues, the president has got a wonderfully refreshing view of regulation in that maybe we should pause on constantly defaulting to regulation and solve every problem by regulation and clear out the underbrush and recognize some of these regulations are outdated or have created more harm than good and let's deregulate and this administration has been really aggressive on that. i hired somebody who had been at the department of justice, very talented attorney to help us work on that with the office of management and budget. so that is also about our relationship with the department. we have a great relationship with the department. the white house drives policy but we have an open door as far as people have good ideas they
can bring them to us. hhs just unveiled a notice of proposed rulemaking to reveal kickback laws and that was not an idea generated by the domestic policy council. it took over two years of hard work, that is another example of issues that the administration said too tough, let's do something sexier, let's let industry continue to suffer under onerous regulations but they are outdated and prevented a lot of creative contracting and the healthcare space, a lot of creative arrangements that would benefit patients and that is why we needed -- we have a great relationship with the department. a lot of back and forth every day. a member of the staff is on phone with any number of departments and the secretary
will swing by and say i've got an idea. we move it forward and it is a great group, a great cabinet. >> let's open it up for questions and remind you to state your name and where you work. >> my question is about drug pricing, urged congress to move forward on this, senate republicans are not in favor of it. does the white house support keeping the inflation gap provision? >> glad you asked that. we have always wanted a bipartisan solution to drug pricing. that even goes before the house of representatives was taken by
the democrats but it is a recognition of reality. nancy pelosi is the speaker of the house, you're going to need democrats to get something on the president's desk that he can sign and you need 60 votes in the senate to get something that the president can sign. republicans don't have 60 votes in the senate, so you've got to get democrats there. we are very supportive of the grassley wyden compromise. it is the product of a really good bipartisan collaborative approach to solving drug prices. and we continue to work with their staff each and every day. republican and democrat on improving the package that came out of finance. a number of things we are trying to accomplish. make sure premiums are kept low as we align incentives to drive drug prices down and give seniors a true catastrophic where they would pay 0 after they hit the catastrophic and pay no more, right now it is
8000. we loaded at 3000 roughly. that is a huge win for seniors, a huge win. as far as inflation caps are concerned they were not in the administration's proposal but they are the product of a bipartisan compromise and are linked to a bipartisan bill in my opinion. nancy pelosi's bill right now is unworkable, impractical and hyperpartisan it is not going to pass in its current form. the surest route to a bipartisan solutions that would be a real win for democrats, republicans, the president and more importantly the american people is grassley/wyden and we are working to get that moving. i've been talking to pelosi's people since before they took the house, before she was speaker.
i got calls from her staff. i was at the office of management and budget and they called me and said we want to work on drug pricing, i said absolutely, door is open. we will work in a collaborative fashion. there is only one red line for us and that do not take savings and plow it into the affordable care act for additional subsidies that will earn a presidential veto and a general directional approach is we don't want to punish market success. we want to address market failures. there are clear instances where co-pays our way too high, drugs are allowed to command the premium price far beyond the original vision and spirit of hatch/waxman and those are the things that should be addressed, not killing innovation or taking a product somebody invented that is really valuable to a lot of people and expropriating the intellectual property or the value of it.
we want to have new ways of innovation. we are on the cusp of a huge huge push of new medicines that would bring real value to people, genetic treatments that are coming online that are amazing. to watch that get killed would be a tragedy. there is plenty of ways to save money for people, taxpayers, patients, companies and have a more rational system without killing innovation. >> over here. >> what is it with the president and the other is on transparency, the administration framed the transparency proposal is helping consumers and insurers and the hospital said it won't help consumers, but it would
help them give them information they need to know. why not go with a pilot program on that which some suggested. >> i'm not going to get into what the president decided. the transparency pattern is not going to be solved in one step. or one fell swoop. we will make a number of push and a number of fronts. frankly it is implausible to believe more capacity, more confusion, more lack of clarity is going to help patients and drive costs down. we need -- the problems with addressing drug pricing and why it is so hard as these programs are really complicated and every time you want to make a change, frequently congress or regulators make things worse. one of the reasons why the grassley wyden proposal is so important.
it would dramatically simplify the part d program. transparency is -- it would be revolutionary if we had true transparency in the healthcare system. i find it be will the ring whenever i get a healthcare bill on a personal basis. i'm one of the people that ignores my good healthcare bill for good 90 days because the first two are certainly not true. they tell me i owe $40,000 for my most trip to the hospital and then it turns out after three months you owe $280 and that doesn't make any sense. surprise medical billing we are working on on capitol hill is another element to get more transparency in the healthcare system, reforming part d is another effort, the grassley wyden proposal has a provision to require less pricing to be attached so transparency should
be first and foremost in everything we do in healthcare, everything from a policy matter as a government. taxpayers and citizens should be able to understand these programs. we should get more data out there generally speaking not just in healthcare but in anything. transparency is very much a broad range and philosophical direction for this administration. the government knows better than the private market or american citizenry, the government knows less. if we have data let's get it out there. >> right here. >> do you have any announcements what the transparency regulation would be? >> know.
we won't have -- probably speaking it is going to be unclear but it could be huge. look at the disparity in certain metropolitan areas among different procedures, some hospitals will pay 10 times as much with no improvement in outcomes for the same type of procedure. ambulatory surgical clinics versus hospitals, different sites of care so the key focus of the transparency thing to think about is it would be revolutionary if we had true transparency in healthcare pricing and it would open up huge opportunities for innovation to bring costs down. we don't have costs coming down this legislation in healthcare with all the innovation we have gotten. all these computers, the amount of power in those systems that would have cost how much ten years ago, 20 years ago, 30 years ago, why aren't we getting the same reduction in
prices in healthcare with the same improvements in quality? big part of that is government subsidies, lack of transparency, misaligned incentives. look at where we get price decreases. it is where the least government regulation, lasik surgery being the one that is constantly referred to and it is a great example. transparency is revolutionary and disruptive innovations, unclear where it end but it has got to be better than the current system. there is no way you can tell me the level of confusion that exists in american healthcare is beneficial for taxpayers, patients or physicians. >> i'm going to move around like this. for the benefit of our audience, go ahead, next. >> the administration going to
the international pricing index and republican resistance to that and on grassley wyden, what discussion has there been about adding rebates? >> the international pricing index regulation is under review. i can't go into a lot of detail. these are difficult issues. we are very focused on making sure any policy we roll out is solid. making sure the data is right and what we thought through potential unintended consequences. drug pricing is a difficult issue. we continue to make sure across all our healthcare policies to make sure they are solid from a legal perspective and a policy perspective and that we are not going to do something we will regret over time.
the second question? >> adding provisions to grassley wyden that would remove rebates or pass them through to patients. >> there was talk about that when it was being voted on in committee. i'm a skeptic of the rebates. i have been from the beginning. the first couple budgets the president sent to capital hill, i worked on the drug pricing reform provisions in our first couple budgets, telegraphed a great deal of skepticism of the rebates and also had specific proposals for legislative changes to get at the rebate problem. it is really hard. we probably spend more man hours on rebates than any other particular issue in healthcare. the amount of resources, national, economic, council of economic advisers, contractors,
cms, hhs, trying to figure out the different modeling about what would happen under various scenarios. to be clear the way rebates are currently structured was set up in the obama administration and this is another example of an issue that should have been confronted or another issue that we have inherited. if somebody has an easy legislative solutions the rebate problem i'm all ears but i would much rather focus on the simplification of the part d benefit and going at the direct remuneration issue, congressman meadows has a bill we are supportive of and are willing to work with members on tweaking to make it stronger. we've gotten a lot of good feedback from senate republicans and the transparency of some of this would help too. i would say this, restructuring the liability and the part d
benefit to put taxpayers less on the hook and payers more on the hook will get a lot of these rebates and interject more competition and aggressive negotiation in the private sector. just restructuring the benefit we have got without directly calling it rebate reform will be rebate reform. >> go ahead. >> having the us import drugs from canada. how is the administration planning to address that barrier to the drug importation plan and ways for drug companies to contract around the potential importation regulation when we do see it. >> around the proposal, the
president has been focused on this issue since he campaigned. the differential between us prices and international prices. members of both parties - when they have citizens crossing the border to buy drugs in canada because it is cheaper for them than it would be out-of-pocket in the united states and governors of come to the president and asked for the ability to import drugs. secretary a czar has made it clear that his concerns around this can be alleviated because of modernization of supply chain, tools that can allow for importation through a mechanism like this to make sure there is no adulteration. we are not talking about importing drugs from thailand via canada. we are talking about safe, effective drugs that could be imported into the united states if the state wants to do that.
we are working with states like florida and colorado and others how that could be achieved but it is feasible. i think we can do it and we will see. if it is disruptive to the market and forces countries to contract around it so be it. the current situation is untenable and is objectively irrational and the president wants is to address it so we are going to address it. this goes back to the point about the president not saying this is too hard, this is too difficult. he is a disruptor. it makes them industries uncomfortable sometimes, makes vested interest groups uncomfortable but that is the way it is. it is refreshing to be honest. >> the committee member of hhs, a public health emergency and regulatory or legal and operational.
is this an issue on the radar of the administration and do you encourage secretary a czar? >> it is on our radar screen but i don't want to get into deliberations and private discussions right now but it is an issue. i don't want to rule anything out are in right now. >> just wanted to check. administrator burma has set on multiple occasions that there's a choice between moving in a different direction toward single-payer or moving aggressively to quality based payment. the program you have been moving on in this area. one thing about policy rates, if the administrator wanted to push on this they could require hb plans to 100% adopt quality
programs and role commercial health plans into that role. is that under consideration or is there something more aggressive that you are looking for? >> more aggressive value based payment arrangements is one of the reasons we are moving to kickback to allow more of these things in a number of different contexts. it is a delicate balance. we don't want to force anybody into a value-based arrangement, when a patient doesn't choose to be there. preserving patient choice is front and center for everything we are doing. there are some patients we believe would do better in a comprehensive care value-based arrangement. others may choose not to. to use an example the electronic health records debacle of the last eight or
nine years is an example of what happens when we forget where the patient is in all this. the obama administration promised when they put 36 billion or whatever it is, astronomical insane number into the stimulus package, it was going to improve quality, bring costs down. none of it happened, none of it is interoperable. now we are working on finalizing a rule before the end of the year to make sure these systems can talk to one another. i don't know how many of you have been in an emergency room but the doctor comes in and doesn't make eye contact anymore. they are looking at the laptop and asking questions and it is an example of how our system is so screwed up that we have allowed ourselves to not think of the patient first and foremost and think if we give the government enough power and enough data we are going to
solve all our problems, not true. these are human beings at the end of the day. these are human beings that need to be taken care of and we need to make sure patients and physicians have the flexibility and choices they need to arrange, to make the healthcare choice that will make the patient healthier. and we should an executive order in october 2017 asking for a report. it allowed us to push out short-term limited duration plans, health reimbursement accounts which is going to be huge going for employers and employees to get different types of healthcare arrangements, more - we are about the patient being in control and being at the center of this. when we talk about forcing arrangements it is something we would be skeptical about.
we would want more transparency, more data for people to make the decisions that are best for them. >> just around the corner. >> where do things stand with flavor bands? are there any concerns either politically or being heard economically? >> the mazars -- the -vaping issue and e cigarettes, the la times reported how this is an industry that first started to come to the floor of regulators and policymakers during the obama administration, the decision was not to bring them into regulatory compliance we believed you cigarettes are a
viable alternative to combustible cigarettes. everybody recognizes combustible cigarettes are a problem. they cause cancer, they are bad news and all sorts of other health problems, pulmonary and cardiac problems. however, the option for adults is complicated by the fact that 5 million kids are using these things and that is a major public health challenge. consistent with my answer earlier we really want to make sure we are data-driven on this and striking the right balance between adult choice and protecting kids and that is been our focus as we look to finalize our policy. there has been latebreaking data in the past few weeks that we have been looking at so i can't tell you exactly where we are going to be or the timing but we want to make sure the data is solid and we strike the right balance between
protecting kids and giving adults the choices they need to stay off combustibles. >> how it could hurt them -- >> recognize the fda only has jurisdiction over nicotine so this is a world i don't fully understand. i was too old when it started. but you can get flavored whatever and smoke it without nicotine and people do that. you can also buy nicotine separately and mix it with the flavor and that is fine too. what we are focused on is the e-cigarette devices that have nicotine and flavors mixed in and making sure adults have
options they need to stay off combustibles and kids don't become addicted to something they otherwise wouldn't be addicted to. nobody knows how nicotine addiction plays out over the long-term. anecdotally there are scary stories including personal stories i've heard from parents and older brothers, older sisters talking about what has happened to members of their family but the data is in many instances early and that makes it complicated but we are very focused on making sure we do the right thing. >> is there any discussion about whether the plan would be adult elite -- adult only vaporing site and if it does include menthol what other cigarette companies be able to repackage it? >> i don't want to get into specific details until it is finalized and we would have to do extensive qa day on it.
it is a difficult issue. fda regulation in this space is really complicated. i hate tobacco issues and fda should not be regulating the stuff in the first place. this is a moronic idea, fda regulates drugs that help people and balance safety and effectiveness, it regulates devices which help people and balance whether they are safe and effective. this stuff is awful. tobacco has no redeeming qualities and it shouldn't be regulated by health agency like this. the 2nd cup of bandwidth on tobacco issues is a huge distraction. the fact that an fda commissioner like scott gottlieb or no sharpness or whoever the next one is going to be has to spend all this time on tobacco issues when they could be trying to figure out how to advance new
therapies that are going to cure cancer, solve cystic fibrosis, how to get more drugs to improve more quickly to help people get more competition to bring prices down and they are spending time on trying to navigate all this stuff, when i showed up at omb i told my team the doors open. any industry can come in with the problem bandwidth permitting. i don't want to do anything on tobacco and i got tobacco, tobacco, tobacco, everything. they want to explain we are getting screwed by the fda. we don't understand what the regulatory standards are. this is not the way the law was intended. i'm getting blown up by members of congress on tobacco, on and on and on it goes. it is a huge waste of time for a regulatory agency like the fda that should be helping us come up with the next wave of q is to be sucked in the mud on
this all the time and it -- the unintended consequences of this law are mind-boggling. think about all the time spent on this issue. it sucks. >> who should regulate tobacco? >> i don't know. it is not an official policy. is my personal opinion. i have a conversation with the president about who should regulate tobacco. it has no redeeming qualities. what are we doing with fda doing this? is just awful that we are wasting our time on this and you are wasting your time on it. >> mitch mcconnell -- and an election year, how do you get around that to to >> the frustration level on the
part of the american people with drug prices, the out-of-pockets they pay and behind drug prices, the frustration on the part of employers, health plans, i don't think there's any issue that we confront that's more front and center. you poll the issue it is the top healthcare issue consistently of what people complain about. this is an issue both republicans and democrats should be able to come together and get done. unfortunately, you know, there are some current complications on that friend. i think everything is set to do it. this is the right president to do it. this is a once in a generation opportunity to confront these issues in a non-ideological fashion.
we are in our third year, today is the anniversary of the election three years ago so we are starting a fourth year. we spent a ton of bandwidth pushing up policies to rationalize the system, protect patients and align the incentives, not have a bunch of government programs that are set up to drive high prices and i think it would be a win for democrats and republicans. there are a lot of members who want to do a deal. i get calls from democrats and republican members who want to help on the issue and i am hopeful we can get there. i don't see the way you see it that it's not in the best interests of nancy pelosi or leader mcconnell to get a deal done. it is everybody's interests to get a deal done. >> back row.
>> john wilkerson on ipi, you want to add retail drugs for medicare and on rebate reform i know you're skeptical, i heard that loud and clear, the finance committee is trying to do something on it and so i would like to ask do you see any potential for insulin specifically and what do you think of using aggregate rebates instead of point of sale rebates? >> ipi is under review so i don't want to get into specific details on it. we are out of time for ideas. somebody has a rebate idea that train left the station. we need solutions right here right now. this package needs to be wrapped up in the next few weeks. i spent over two years working on the rebate issue. nobody has come up with an easy solution to it. it is one of the reasons the pelosi negotiation -- it's not
really a negotiation, why that thing has got to get jettisoned. not just that it has no chance of bipartisan support, it is impractical, unworkable, i don't know how it would work, it contemplates a whole new bureaucracy being created at hhs that is somehow going to divine what a drug's value should be when you've got academics, payers and drug companies and consultants all invested in figuring out how much of drug should be valued, there is no way that provision works which is why does not negotiation, it is dictating a price at the end of the day, and offer no company can refuse. the opportunity to retool that is over. the opportunity to play around with the rebates is over. i have been talking as i said since last year with pelosi epstein, very open,
collaborative, great conversations, wide open as far as ideas. we are done with ideas now. we've got to get a solution and get scored by the congressional budget office, we've got to get a deal on the president's desk. i have been hearing from the house side since january. six weeks we will have a bill, four weeks we have a bill, they were supposed ever cbo score never on the floor last week, didn't happen. they got to cut bait on some of these things that are not going to end upon the president's desk in the first place and this opportunity that is presenting itself. >> there is still some work being done so what areas could still be tweaked before they do that?
>> wyden compromise was built -- the money saved in the part d program was not redirected into the benefit. if we redirect into the benefit you get an even bigger bang for your buck. it is a bigger benefit for seniors, a bigger win for seniors so those are the types of things we are working on. i don't want - in making sure it is solid numerically, you don't get unintended consequences on premiums. we are really at a stage in a bipartisan basis of dialing in on the final specifics on this and there are other pieces as well, pay for delay piece, getting creates done, incentivizing bio similars to get that industry moving a little better to bring costs down with biologic markets. there are a lot of pieces that are moving, energy and commerce, ways and means, a lot
of great bipartisan work, senate judiciary, senate health, all have a lot of good stuff there. senator collins has gotten transparency efforts around patent listing for biologics that would be helpful. look at the biologics that have these submarine patents that pop up long after and protect the market exclusivity far beyond the original contemplation of -- her effort would be very well appreciated. there are a lot of things that are moving that could be tied together and that is where we need to be concentrating, not on new ideas. >> talk a little about the pending court decision for the affordable care act and if it were ruled unconstitutional what is the next step from the administration on that? >> the affordable care act was rammed through in the middle of the night without any republican votes and it has
been to the supreme court twice. it doesn't work according to its original building. it was supposed to give us universal coverage and it was supposed to allow people to keep their doctor. both central conceits, both central promises of the aca have not borne out so we spent $50 billion a year to drive the individual market from over 10 billion to slightly over 13 billion and we have 28 million people who are uninsured in this country. that is the failure of the aca so much so the democrats themselves now have moved beyond the aca and you see the dominant debate on the airwaves about medicare for all and medicare buy-ins. everybody recognizes the aca is a failure. this in full question at play,
a major constitutional one, the administration thought it was important to vindicate that and stand up for the rule of law. we will be prepared after the decision comes down with any number of permutations that get decided. it is important to recognize that nothing is going to happen immediately. the decision will be stayed pending a supreme court decision, this will surely go to the supreme court. it may not be decided before the election but even if it were i imagine the supreme court would stay its decision. we need bipartisan approaches. when we do things as one party renting something through that doesn't happen. as i started talking about in the beginning we spent eight years talking about the aca and avoiding all these healthcare issues that were percolating and in some cases exploding like opioids, like you
cigarettes that was beginning to manifest itself. if democrats and republicans were to come together in much the same way, there is a market failure, everybody in the administration recognizes preexisting -- people with preexisting conditions have a difficult time if not impossible time, the exchanges are made of preexisting conditions and people who are 100% subsidized. if that is what you want to accomplish, help the poor people with preexisting conditions you can do that more effectively and cheaper than the aca. we would be focused on protecting people with preexisting conditions and restoring the rest of the market in moving a lot of other healthcare initiatives and
addressing other problems and not ignoring them by dumping more subsidies into the system. i actually believe the protection of people with preexisting conditions will be the only lasting contribution of the aca. that is what you have bipartisan consensus on now. the president campaigned on it, he said it consistently, our efforts to think through what should happen post aca, protecting people with preexisting conditions is number one on the list and we work down from there. regarding what happens to people with preexisting conditions will be protected and if the democrats are in a position where they can prosecute a legislative effort to get medicare for all and wipe out health insurance for 180 million americans in the employer market totally
eviscerate the medicare program for seniors and disrupt the industry, it would be a disaster if they were in a position to do that. it won't work and it shows how bankrupt their ideas are to be perfectly frank with you. they don't understand the free market, they can't confront these issues, they go back to the mothership of central planning and say here's a solution, what if we give government more control. is that going to work in any area? it is crazy that we are having a serious discussion in this country around putting the government in control of all of our healthcare. it wouldn't work for the american people and it would take away so many options for people that employers like him employees like, humans like and it would be a real disaster if it was ever to get moving. >> what do you think are the
realistic chances given it is november, appropriations have been done, we have an election and it sounds like drug pricing is the top priority? >> if we get drug pricing we can get surprise building and if we get surprise billing and even so surprise billing has a lot of bipartisan support. i think there's an opportunity for compromise. in regular contact with the senate and the house, it is down to just a few issues. i do hope it can come together in the end. it is an easy issue for the american people to understand it's an obvious want to address and people shouldn't be going into the emergency room expecting x price and with the understanding they buy coverage for a reason and they wind up, sorry, this coverage doesn't apply in this instance and here
is your surprise. they are not in a position to bargain, they are not in a position to fully comprehend in many instances what is going on and they need help and unfortunately it hasn't already been addressed but i think the opportunity is there and we are close and it could come together with a bunch of healthcare legislation at the end of the year. i don't think it necessarily has to be attached. there are a lot of healthcare pieces, drug pricing that this could get attached to. there is going to be a lot of big bills at the end of the year. hopefully we won't just flush us mca down the drain. that is ridiculous. that would be a clear bipartisan win for the american people. the bill was passed every year for 57 years should be passed
so that should get done, the appropriations bills get done and we should get a good healthcare package before the end of the year. it is just a question of can you guys sit down and get it done. >> we have 10 minutes left so i am going to ask a question and then come back on this side after i asked the question. if you could think of your question, short answer, we have 10 minutes left, you might not be able to talk about this but one of the other big issues is the recent lawsuit, hiv aids issue, is that part of your plan to address this issue but also have elements of drug pricing in it as well? you talk a lot about disruption, doing things differently, how should we look
at that issue? >> the president called for the limitation of hiv transmission within 10 years. all the technology is there to achieve that. the social science data, pharmacological data, testing data. it can all be done. i am a veteran of the hiv initiative in the bush administration as you are. iran the president's advisory council on hiv-aids. it is an incredibly exciting time if you are a veteran of those policy fights to see the opportunity that presents itself. to the president's credit, he saw it as well and said let's go for it and raises it repeatedly, he raises it in our hand comment how excited he is about this, how this is somebody who lived in new york city during the height of the hiv epidemic and many people around him did not live through the height of the aids crisis so the opportunity is there.
it is a lot of -- we have deployed a lot of expertise, look at bob readfeel that the center for disease control, the team at hhs. we've got a lot of great people working on this and it can be done if congress appropriates the money. that is another thing we would like to see. it can be done cost-effectively and would be a huge win for public health and for the american people would transfer the lawsuit itself i have not been involved in it. i was not involved with my previous employer. i've not done anything on it since i have been here and it is in litigation now so it is up to somebody else to sort it out. >> over here. >> one of my questions - what you mentioned in your opening remarks, the view that medicaid expansion might have helped further the opioid epidemic.
>> a lot of people who were addicted to opioids have been on government programs weather was medicare or medicaid. this is something, we had treatment guidelines that encouraged and star ratings in medicare that encouraged aggressive pain management with opioids. somebody wasn't minding the store. look at the lawsuits that have taken place on the state level about what occurred with some of the marketing. i don't want to get into specific litigation but it looks to me like people were allowed to engage in conduct that was inappropriate and got a lot of people hooked on opioids. the opioid epidemic is an epidemic. you are talking tens of thousands of americans getting killed every year by the epidemic. the president doesn't drink or smoke or do drugs and he said let's confronted and kellyanne conway has been in front on this.
kellyanne conway deserves a lot of credit for focusing on this like a laser beam when she came in, we had year-over-year declines in opioid deaths so it is an achievement of this president, we had a larger addiction crisis in this country and it is important to recognize we can't just keep our eyes on one problem at anyone time. we have to be open enough to confront problems that maybe we don't want to confront. i don't know that anybody wakes up in the morning fired up to dive into the details of the tragedy that is occurring with addiction in this country but you've got to because it is important to the american people. it is important for our country and this is a president that has focused on fighting for
people you haven't thought about in a long time or haven't been front and center. american workers in the manufacturing sector of people in flyover country or families that are struggling with addiction. there is a long way to go but we have made a lot of progress and changed a lot of treatment guidelines and incentives to drive opioid addiction and i heard anecdotally, we will see if the numbers bear out from people, specific practitioners who said the opioid numbers will continue to trend down and we are just seeing the beginning of the fruits of our efforts. >> i heard that anecdotally that nature is changing what is going on everywhere. there seeing something and it is good news. go ahead. >> kimberly leonard of the washington examiner.
he expected deaths from opioids would start to climb again once the data comes in because of all the mixtures of meth and opioids and cocaine and opioids too sometimes by users who don't know this when drugs are mixed together. >> i'm talking about prescription opioids but you start mixing and we have a math problem in this country that is starting to kick off. it will be difficult to get arms around the fentanyl issue. it has been a big problem in many cases inappropriately with prescription opioids or sold on the street. it is not easy, but i would have to look at what he's
talking about specifically. we have seen year-over-year declines, the data i am looking at right now. >> there are a lot of losses in the conservative agenda in healthcare with the supreme court striking down religious cost control in the past two days. do you have any plans to more effectively implement some of those things? i talked to a former ocr director who says you could get the religious conscience rule through if you addressed some of the judges issues with it. >> i don't know what that approach would be. the president's agenda is often times thwarted by activist judges, one of the reasons why we had a celebration in the east wing this week, appointing 150 federal judges who interpret the constitution and not make up policy to suit their own ends.
we recognize the risk we run when we confront these challenges but the president respects religious institutions and respects people of conscience and some judges are going to be skeptical of that. we spent a lot of time to make sure our rules and regulations are legally sound but at the end of the day you do roll the dice whenever you are disruptive very liberal judge will come along but we will prosecute and appeal any case on any policy we advanced because we believe in it and we spent a lot of time to make sure it is solid. >> the final rule for a hospital operation including major cuts which have been overturned by federal judges. i'm curious why the administration -- with outpatient facilities and discount drug program, those
cuts were included even though they were not legal and with the thinking of programs like that. >> the policy is solid and we think we can win and we are not going to apologize. we are not going to get something done at the very least it highlights a legal change that should be made and we can go to congress and say the courts are sticking to us here or there and we need to clarify the law because we are on the right track and this is the policy we are pursuing and it will not be as robust as it could be without a legal change. if you are going to be aggressive in policymaking you're going to run a risk that a court will hold you up but at least then you expose an
opportunity for legislation to fix the problem and that goes for healthcare anyway. we can strengthen these fights and make our lives easier and i could leave at 4:00 every day but that is not the real approach. >> hospital executives in states that have transparency requirements with negotiated health plan rates and they said they use that information to negotiate higher rates because they know a neighboring house as rates because of transparency laws, you talk unintended consequences. to address that kind of unintended consequence? >> i will not get into what specific -- i'm happy to have more conversations about it. we recognize any policy may have unintended consequences and we work really hard to think them through but you also have a public comment period for precisely that reason.
the public has the opportunity to let us know you are on track, you're off track, make this improvement and we have consistently pursued sound regulatory policy procedures to give the public the opportunity to contribute and help us refine our rules. i can't stress enough how important it is for members of the public to get involved in the regulatory process, to make sure the government is doing the right thing and make them respond to the approach that is proposed. it will go out as proposed and we may make changes by the time it is final. >> we are out of time. is there any subject, discovered a lot of subjects. anything else you would like to throw out there that you didn't cover? >> maybe just we saw jobs numbers just come out last week
revised upward to 303,000 above expectation on job creation, we are at record low unemployment in the african-american community, 3.5% nationally, we are in a robust economic period, but healthcare specifically is an area that can contribute more to our gdp if we get more inefficiencies out and align more incentives and the way to do that is not to put government more in control of the healthcare system, to inject more choice, more competition and stay focused on why we are in this business in the first place which is the patient, the american citizen that needs healthcare and needs to be healthy. >> i want to thank everybody once again, a great turnout that demonstrates people are interested in what you have to say and hope you will come back again. may be a new job or still in this job at some point in the future.
you have moved, who knows what is next but we would love to have you back and appreciate your willingness to answer these questions so thank you very much, thank you all. [inaudible conversations] >> starting now it is booktv on c-span2. >> three days of nonfiction book programs this veterans day weekend was on our author interview show "after words" former speaker of the house of representatives newt gingrich weighs in on the threats the us faces from china. the presentation of the american book awards and new york university journalism professor pamela newkirk examines whether diversity programs are working at the next day of booktv on monday featuring secretary of the