Thanks so much for coming to Grand Rounds. We have a treat today to hear from Dr. Cameron Webb. Dr. Webb is an assistant professor both in the School of Medicine and also in the Public Health Sciences. 

He served as a White House Fellow from 2016 and 2017 and since then has made himself well-known here at UVA and in our community. He's a principal investigator for the Health Equity Law and Public Policy Research Lab. And he's also the director of Health Policy and Equity here at UVA. 

Today he's going to give us to talk on the American progress note, a health reform update for health care providers. It should be very interesting. We'll try to leave some time for questions. Cameron, thanks for being here. 

My pleasure. Good afternoon, everybody. So I have the enviable task of talking to you guys about health policy. And so I wanted to think of some really creative ways to do that. I have-- no lie-- about 80-some slides. And some of you saw my size of my file. Oh my gosh. I've never seen a file that big. 

But the reason is that there is so much that you can cover. For the medical students, I actually teach this over a total of seven days in about 45 minutes here. And so I want to try to cover as much as I can tell you. There will be slides that I fly through. And there will be places where, if you guys want to stop me, we can dig a little deeper. We will. 

But my thought on this is to give you guys a primer for what I like to call the Thanksgiving test. And the Thanksgiving test is essentially, everybody goes home for Thanksgiving. And they have some either really nice, awesome relative or some really jerkish relative who is like, yeah, but what about such and such for health policy? 

And because you're a doctor, they expect you to know everything there is to know about it. And so I want to prime you guys so you at least seem like you know a little bit of something. And we'll go from there. So that's kind of the plan. 

Just to start, I have no actual or potential conflicts of interest in relation to this presentation. I wish I did. That would mean I had more money. But in 2006, I did spend six months working in the White House for the Obama administration as they worked to implement and execute the Affordable Care Act. I mean, look at the eye contact. We're pretty much best friends. That's my buddy. I call him Barry. That's not true. 

And so that's one disclosure I think is important for you. But also, in 2017, I spent six months working in the White House for the Trump administration as they worked to repeal and replace the Affordable Care Act. So you can imagine the bit of confusion in my brain. That's Omarosa, everybody's favorite villain. 

That's my certificate with Donald Trump's signature-- boom-- White House Fellow hanging out with the Trump administration. And then that's my last day as I'm chucking deuces on my way out the door. So it's interesting because I see this having spent a lot of time thinking about health care policy at the federal level from both sides. 

I want to start off just by talking about health care being front and center. And if you're looking at this slide, what you see is-- on the left, there's a Gallup poll that's talking and asking what individuals say should be the top priority for the president and Congress. And this is in January of last year. 

But what should be the most pressing issue? And you see that the economy came in first. And health care came in second above terrorism, above jobs, above the budget deficit. Health care was really important. 

In the really small font on the right, you see-- again, they broke it down into economic and non-economic issues. And you see that under the non-economic problems, health care came in third after the government and poor leadership and immigration. And these are write in. So it's not like they had options. But I think health care always comes in as a really critical issue. And like I said, from a policy standpoint, it's definitely front and center. 

And so I wanted to frame this as a chief complaint. And so one decade after debating health reform in the start of the Obama administration, the health care system is still sick in this country. And so the question is, how should we fix it? That's kind of the prompt that we have today. We have a system that we know isn't working optimally. How do we go about fixing it? 

What I would submit to you guys is that most of the time when you have these lectures, people will present a lot of policy ideas to you. I kind of want to do the opposite because it's not really about the policy ideas. It's more about understanding what the problem is. And I think as a internist, I've got a better frame for you. 

And if you look over the news over the last few days-- this is just in the past couple of weeks-- the Trump administration filing a formal request to strike down the ACA. What is Medicare for All, and how would it work? How many of you stayed up late watching debates these past couple of nights? So you've heard a lot of this discussion. The rest of you are like, we're residents. Why would we stay up doing that? 

Then you have a bipartisan effort in the Senate to address health care costs. And then you have a Trump executive order that came out earlier this week. So there's been a lot of action in this space. 

And again, it's not about the litany of potential policy solutions as much as it is understanding, what are the true problems? That's going to help you guys find a-- and I think the goal here is for you to find your sense of your true north in terms of what policy solutions you think make sense. 

So since this is Medicine Grand Rounds, we'll do it like this. Subjective-- we'll start there-- the current attitudes on the state of American health care. Objective. We'll look at the data describing the current state of affairs. Then we'll assessment, a differential for what's wrong with American health care. 

And then finally, we'll get into some of the plans. So we're viewing leading proposals for how to fix our health care system. And then, of course, there's always an addendum-- how to be an effective advocate for your policy preference. So that's our goals for the next 35 minutes or so. Like I said, I'm going to fly. 

So we'll start with subjective. And I think the attitudes are really important. If you hear that this is the most important and most pressing domestic policy issue, it means that voters, citizens, residents are saying this is something that's really important to them. 

So this is a Gallup poll that's done every year. It was done in November of 2018. And it's Americans' ratings of health care quality, coverage, and cost. So this is going to help you understand what your patients are thinking about our health care system and why they may be clamoring for reform. 

Again, this poll was done in November. It was a telephonic survey of a little over 1,000 individuals, 586 men, 451 women. And you see that the first result is that most Americans are dissatisfied with the cost of US health care. Raise your hand if you're surprised about that. So nobody is, right? So if you look at the number who are satisfied, about 20% of Americans are satisfied with the cost of American health care and about 79% dissatisfied. 

What's interesting is if you look at personal health care costs-- so not the cost of American health care, but personal health care costs that individuals spend. Those numbers are a little bit different. And you see there are also differences by insurance type. So in Medicaid or Medicare, about 70% of people are satisfied. And remember, it's just 20% satisfaction in health care costs broadly. 

But for personal costs, 70% of people with Medicaid or Medicare are satisfied, 51% with private insurance. That's a significant difference there. And then you look here. It's not breaking down on partisan lines. Republicans are 60% satisfied, Democrats 61% satisfied, independents 52%. So partisanism doesn't explain people's satisfaction with their personal costs. 

Now, if we look at health care quality in the US, the majority of Americans do rate the quality of health care positively. So a lot of times when you think about health reform and what we're hearing, you're hearing a lot of talk about costs in health care. You're hearing a lot of talk about access in health care. 

And there is this notion called the iron triangle in health care. It's cost, quality, and access. And no matter what in the policy space, if you change one of those things-- you really drive down the costs-- that's going to impact quality. That's going to impact access. If you change something with access-- let's say you really increase access-- that's going to impact cost. That's going to impact the quality. 

So you always have to keep those three things in mind. And so in terms of people's opinions, I think quality is that leg of that iron triangle that people are the most satisfied with in this country. But that doesn't tell the full story. And I'll get to that a little bit later. 

And then finally, one in three Americans rate health care coverage in the US positively. One in three, so 34%, rate coverage positively. They think it's excellent or good. That's pretty low. 

Now, it's interesting when you look at personal health care versus national health care-- huge gap here. So in terms of people thinking that they have excellent or good health care coverage, , personally, almost 70% of people do. But for the nation, they think it's around 34%. So their perspective is that our nation-- 34% of people say our nation provides good or excellent coverage. 

And the same is true with quality. 80% of people feel like personally, they have good quality of care. But they say, for our country, about 55%. And we saw that in the last slide. 

And last one here is really just looking at some of the breakdown for individuals, so the quality of care you receive. And here, nationally, when you compare the quality of care you receive in your health care coverage, again, most people feel like they have excellent or good quality care. 

And then going down further, if you look, there are differences by race and ethnicity. So in terms of quality, 84% of whites believe it's excellent or good, 72% of non-white, similar differences in coverage. And then if you look on partisan lines, not as big of a difference. 

So the key here is people's subjective impressions. You're not seeing these huge differences based on partisan leanings. So start to keep that in mind when we think about some of the plans that we'll see. 

The second piece is subjective. This is a study that my lab actually put out in the fall of 2018. We did a survey of 1,000 physicians via the AMA physician master profile. We got 129 responses. And the breakdown is 62% male, 35% female. The age was older than 40. I was going to say it's older people, but I'm almost 40. So it's very young and happy people. 

Race and ethnicity-- you see the breakdown there. Political leanings-- so it was a 43% liberal, 32% conservative, 17% moderate. And then you see we also have the breakdown for the practice location and also the specialty just so you have a sense of who's answering these questions. 

And quickly, these are questions about physicians' impressions of our health care system. This from across the country. The first is health care spending continues to rise. As a physician, what level of concern do you have regarding this trend? And the majority of physicians, regardless of their political leanings, were either extremely or somewhat concerned with that trend. 

If you look at how many of your patients faced out-of-pocket health care costs that were a significant barrier to their care, you see that many or few-- you see a lot of folks are at least acknowledging or identifying that the patients face costs that are a barrier to their care. We defined "barrier" as something that negatively impacts the way your patients seek or receive care. 

And then moving forward, how would you grade the quality of care provided to the general public? No surprise here. I thought they were all going to say exceptional. But you see at least most physicians saying good quality or high quality. 

And then finally, this is-- they're a list of policy proposals that we had physicians weigh in on. And one of them was transitioning to a system where a single public agency, single payer, organizes the health care financing. And you see your first significant difference here. 

So conservative physicians-- almost 80% oppose the notion of a single payer. Liberal physicians-- 75% favor a single payer. And so pretty big difference there. And so that's why when you see that total, when we talk about physicians being a monolith or, let's hear the voices of physicians on a policy, it's hard because there are going to be some critical differences there for us to keep in mind. 

All right. Let's jump into the objective. So we did our subjective, now objective, a look at the data describing the current state of affairs. 

First data point is something you guys have all heard, the percent of GDP that we spend on health care. And currently in 2017-- that's the last data we have available-- it was 17.9% of our gross domestic product is how much we spent on health care. That's almost a fifth of our economy on health care. So that's a huge number. 

And then if you look, this is compared to other peer nations. And you see the US-- this was 2016 data-- at 17.2%. And then the next closest was Switzerland at 12.3% then France, Germany. Everybody else is much lower. The average is about 8.8% of your economy. 

And so there's a theoretical concept. And it's, is this number bad? Inherently, is 17.9% percent of our economy being spent on health care-- is that bad? Because you can make the argument, hey, we're really invested in the well-being of our citizens here. Or health care is the country's largest employer. We are really investing. It's the new steel. So you can make those arguments. 

Here's expenditures by spending category. And I'll show another slide that shows this a little bit better. But you see, what I like is it has the annual growth on top. And so from year to year, you're seeing the percentage that the spending on health care has grown. You see 3.9% in 2013, 5.3% and 3.9%, 4.4%, 4.8%, 5.7%. That's percent growth in expenditures. 

And what's important about that number is that our economy grows a little north of 2% each year. That's what GDP grows. And so health care is growing at almost twice that clip and continues to do so. So when we talk about bending the cost curve and turning things around, you don't bend the cost curve with your spending being double GDP. 

The other thing is-- this is 2017. So this is the actual number. It grew 3.9%. But that is $3.5 trillion-- $3.5 trillion. OK. That didn't have the effect that I expected it to have. I'll try this again. I'll try this again. 

All right. So that didn't work. What is a trillion? We'll start there. What is a trillion? 1 million seconds ago-- how long was that? Just a guess. No wrong answers except for the wrong answers. 10 years. That's really wrong. 

[LAUGHTER] 

OK. Well, I'll use this one to get things started. That's 11.57 days. That was Father's Day. I know my kids don't both stare at the camera at the same time. It's OK. They'll figure it out. But that was a million seconds ago. It's Father's Day. We all remember Father's Day. It wasn't too long ago. 

A billion seconds ago-- how long ago was that? How many? 

Three years. 

Three years. OK. Other thoughts? OK. A billion seconds ago-- Full House was all the rage. It was the number-one show. It's 31.7 years ago. That's a billion seconds ago, OK? 

All right. A trillion seconds-- who's got a guess for me? Now I'm seeing some reactions to that trillion. Throw out a year. Who said that? [INAUDIBLE]. Get out of here. All right. 31,000 years ago-- 30,000 BC. Yes. 

[LAUGHTER] 

Yes. That is a trillion seconds ago. So I repeat-- we spend $3.5 trillion on health care in this country. Is that a lot of money? All right. And George, you're not allowed to talk anymore. 

[INAUDIBLE] 

[LAUGHTER] 

All right. I'm going to move you to the front of the class if you keep this up, Dr. [INAUDIBLE]. So these are the areas of greatest spending. So if you think about where we're spending that $3.5 trillion dollars, you see we spend about 33% of it on hospitals, about 20% on physicians. And you've heard a lot about drug pricing lately. That's 10% of this pie. 

So we'll look at it a little differently just because I wanted to break this down for you guys. So in terms of the different services and products available, this is the percent share. So that's kind of what we just saw on the last slide. 

And then this is-- that didn't work-- but the percent growth. And you see for hospital care, it grew by 4.6%. Again, that's double what GDP grew. So the spending on hospital care was double GDP. The spending on physician and clinical services also increased significantly. 

So again, we're thinking health reform. We're thinking about-- find the lesion. We're starting to identify some of those spaces. Retail prescription drugs-- 0.4%. Anybody surprised by that number? I was because all you hear in the news is how prescription drugs are-- we're spending way too much on them. But that's one of the areas of less growth. 

That's also why the Trump administration really touts the fact that, hey, prescription drug spending is going down a little bit. I'll show you some slides on that a little later. And those are the main ones I wanted to point out. 

And this is just the total amount spent in those spaces. So we do spend $1.1 trillion on hospital care, about just under $700 billion on physician and clinical services. And so this starts to help you orient to where the areas we need to focus some attention. 

This is per capita out-of-pocket expenditures. So for individuals, what are they spending out of pocket? And the average is about $1,124. This was in 2017. And this is looking at out-of-pocket expenditures in these different spaces. So you see the green line is actually prescription drugs. And you see that number is kind of a downslope. 

But you see the other two. That's physician and clinic services at the top, which is definitely on the way up, and then hospital services on the way up. I know the dotted lines make you feel like they're all runaway. 

But this actually helps understand prescription drug spending a little bit more because this is looking back to 1960. And you see the steep increase in the '90s, 2000s. It jumped again between 2010 and 2015. That was because of hepatitis C medications. It was helping increase then. But relatively, it's leveled off in the last couple of years. 

This is health insurance premiums-- again, looking at that. And you see just how incredibly those expenditures have grown in the last few years. This is from '99 to 2018. For single coverage and for family coverage-- big difference. 

And then this is life expectancy. So I don't know why it faded out like that. But you see the US-- so despite the fact that we spend all this money, our life expectancy is 78.6 years. So that's below a lot of our peer nations. 

You look at mortality. Again, we have higher age-adjusted mortality rate per 100,000 individuals than comparable country averages. And then I like using this statistic of years of potential life lost. That kind of helps frame a little bit of the morbidity piece as well. And you see that I think we're in 30th place among peer countries. 

Here, let's get a little more granular. Let's get down to Virginia. And you see similarly, years of potential life lost-- pretty significant across the state. 

In quality of care, the other piece-- and so that's part of my quality of care argument-- is looking at some of these metrics. But the other one here-- this is a Kaiser poll. But the percent of adults who have experienced medical, medication, or lab errors or delays in the past two years-- you see we're way above the comparative country average right there. 

And then finally, we're still on objective. I'm still just giving you guys some stats to frame your sense of what the problems are in health care. Insurance status is a big one, understanding who has insurance and where. And so about just south of 50% of Americans get their insurance through their employer. You see Medicare at 55 million, Medicaid another 49 million. You can add on another 400,000 because Virginia expanded after this. 

And then you've got Medicaid, CHIP. You've got the ACA exchanges at just over 9.1 million and then other. You see uninsured is at 29 million at this point. And so there was actually about 48 million before the Affordable Care Act. But with the different interventions, it's down to 29 million. 

In terms of insurance status-- again, tracking this over time-- what are the challenges there? You see private insurance still at about 70% who have private insurance. You've got about 20% of public insurance. You see the uninsured rate dipped. 

And the reason I have this slide up is so you can see where that rate was hanging out for years. It dropped between 2013 and 2015. Those are the years that the ACA was being implemented with the Medicaid expansion in particular. 

And then you see that it's kind of on this slow rise really since 2016 since the Trump administration came in. And we've seen a lot of different efforts by the administration to really undo some of the Affordable Care Act, including getting rid of the individual mandate, that sort of thing. So those are having an effect on our insurance numbers. 

I'll tell you why in a little bit why that alone isn't a reason why you should be upset. It's not just because you see that uninsured number going up. What does that actually mean? And what is this administration trying to accomplish? 

I like this slide because it shows the percentage of US adults without health insurance. And it gives you a sense of the timeline. So kind of what I was just describing-- you see the percent without health insurance dropped. And that's right there in the middle. Oh, snap. Where are we? Boom, right there. 

Individual mandate takes effect. And then after that-- OK, that wasn't working like I wanted to. But you see the Medicaid expansion in seven more states. So that's when you see your decreases in the uninsured rates. Then Trump elected, promises to repeal and replace. You see that number start to march back up in terms of the percentage without insurance, and particularly after the individual mandate was eliminated. 

This is uninsured rates and how they vary across the country. I'll tell you, with the exception of Nevada and Arizona, these are all non-expansion states in terms of Medicaid expansion. So that's why you have your highest uninsured rates. 

And so the assessment. So we've gone through a lot of different data now. And I'll tell you, in a 45-minute lecture, it's not possible for us to go through all of the challenges in American health care. So I know we're not going to cover all the different policy ideas. But I think here's where we start to really drill down on, what are the fundamental disagreements here? 

And I'll start with-- this is my billing and coding-- health care spending overload, chronic. So we have a chronic health care spending overload here in the country. And there's an economist who was really well known. His name was Uwe Reinhardt. He passed away recently. 

But he had this famous paper that was called "It's the prices, stupid." That's why our costs are so much in American health care-- because our prices are so high. And so that's important for all of the different policy interventions we'll talk about later-- that notion of pricing being key to them. 

And if you look, this is UV Medical Center. This is through VHI's data. But you see our gross patient revenue is-- this is gross patient revenue. That's $5 billion, $5.1 billion. Our contractual allowance-- that's $3.2 billion. That's how much we negotiated away with insurers. 

So with insurance companies, we negotiated away essentially $3.2 billion. And that left us with a net patient revenue of $1.5 billion. And that is compared to our total expenses of $1.5 billion. 

And so what's important to note on this side-- what I want you to take away from it-- is that we set our prices at a total of $5.1 billion so that we have the room to negotiate down to a level that gave us a razor-thin margin at 1.5. And that's why prices are so important in health care. It's your negotiating point. It's where you're starting. That's something to keep in mind. 

This is growth in expenditures. What's important here is-- in the chart on your left, that orange part is medical prices. And so when we're talking about growth in health care spending, you're seeing that medical prices between '04 and '07 or even between 2008 and 2013-- that was a bigger part of the growth in health expenditures. It's been less than that really in the last four or five years. And so we see that there's been some improvement there. So it may not be the prices, stupid. 

And then the other part is-- if you look at this chart on the right, you see that it's a couple of different things. But the use and intensity, that orange in the middle-- that's what I want you to take a look at because that's what's been growing. If you look at 2014 and 2016, when that's big, that's when we see bigger increases in our growth. So that use and intensity becomes important. 

And again, this is a chart looking at prices and use. And this is an important distinction. Because if our interventions are focused solely on prices, we might miss what's happening with usage. So here it's looking at changes in prices and quantity. So quantity is going to be your usage. And quantity is in blue. Prices are in green. And you see that it looks like usage is what's been going up in recent years. 

This slide is an important and fundamental point-- is that nobody should try to convince you that health care is a normal marketplace. That may sound like a partisan statement, but it's not. Health care is not a normal marketplace. 

Now, I'll give you the distinction because some people think conservatives believe that health care is a normal marketplace. They don't. They think it could be. They think it should be, not that it is. And there are a couple of reasons why. 

So the first is that in a normal market-- that standard supply-and-demand model-- the main interested parties are the buyers and sellers in the market. Here in health care, we have third parties, insurers, government, bystanders who often have an interest in health outcomes as well. 

Next, the buyers. In a normal market, the buyers are good judges of what they get from sellers. What about health care? Well, health care patients don't often know what they need and can't evaluate the treatment that they're getting. 

Next, in a normal market, buyers pay sellers directly for the goods and services being exchanged. Here, providers are paid not by the patients, but by private or government health insurance. 

Fourth, market prices are the primary mechanism for coordinating the decisions of market participants. That's a big one. It's the market prices that are the mechanism. Here, we have rules established by insurers more than market prices which determine the allocation of resources. 

And then finally, the invisible hand, left to its own devices, leads to an efficient allocation of resources. In health care, because of those other four points, that invisible hand of the market can't really work its magic. And so the allocation of resources can end up pretty inefficient. 

And so what do we do with this market in particular? Is it the notion that it's the nature of the beast, that this is a market that's not normal and we need to regulate it into functioning in a normal way? That is actually the view often that we see from the left. 

And from the right, it's that bureaucracy is to blame. And we need to deregulate. It's that it became an abnormal marketplace because you have so many government interests, so much government involvement in this marketplace. And so that's a key distinction I want you guys to take away. It's that health care is not a normal marketplace. What do we do to make it behave more appropriately to help curtail some of those costs? 

I'm not going to spend much time-- or actually, any time-- here in terms of assessment on inadequate outcomes and value. We can talk about value for days. But I think for the purposes of-- in fact, I've got 12 minutes left. I want to jump ahead and talk about health care access more in depth. 

And here's where I want to give another good distinction between Republicans and Democrats here. It's about access. What is it defined as? And for Republicans, they tend to focus on this notion of universal access, and for Democrats, universal coverage. Raise your hand if that surprises you that I say Republicans focus on universal access. Nobody likes raising their hand. 

So it surprised me. I agree with you in the back because that flew in the face of what I was getting from the media. Why are you saying they're for universal access? And I have heard a lot of Republican legislators say, I'm all about universal access. 

Well, the reason is that focuses on ensuring that people have access to health insurance, whereas for Democrats, they tend to focus on ensuring that people have health insurance. And that notion of access means a lot of different things. So access-- and this kind of hinges on the notion of, is health care a right? Or is it a market product? 

Republicans use the word "access" to describe a consumer-driven model for health care. That means there are sufficient facilities and providers for everyone. But it also enables people to decide how much they want to pay for health insurance and how much coverage they want. It assumes that they will make that decision as a rational consumer in this marketplace so long as there is adequate resources available. 

And on the other side of the spectrum, the Democrats use the phrase "universal coverage" to describe health care as a right. Instead, they're talking about it where the definition demands that there's a viable option for every individual. And this approach uses government-dictated directives to ensure that health care is available to everybody. 

So with universal health care access, people would not be obligated to obtain health insurance. So when I talked about uninsurance going up over the last few years, that in and of itself doesn't scare or upset a lot of conservatives because they're like, if those people made the conscious decision not to have insurance because they felt like that wasn't in their best economic interest, then that's their choice. That's part of their freedom. 

And so that's part of the mindset. It aims to repeal the burden of mandatory health care premiums and allow health care to be dictated by the consumer instead of by government. And there's a concern that this method of health insurance delivery will create a barrier for people who can't afford services they could theoretically obtain. 

We talk about the Affordable Care Act. And part of what happened is, for folks who maybe could just barely afford their insurance, if they chose not to get insurance, you had an individual mandate penalty that some people could face. And so there's a thought that it doesn't leave everybody situationally similar from a financial standpoint, doesn't leave them in a position where they're doing better financially. 

And if you look at universal coverage, the goal is for every or almost every citizen to have health insurance regardless of their ability to pay. It's about them having insurance, having a card. And that approach-- it regards health care as a basic individual right. And that was part of the goal of the Affordable Care Act. It was to move closer to making sure that everybody was covered. 

I'm going to jump ahead to, who are the uninsured, because I think that's an important point here. And you can kind of see it from this graph. But just understand that the blue bars are the uninsured. The green bars are the general population. 

And you see that males are a little more uninsured than women. I think the main ones I'll point out are Hispanic Latinos-- significantly more uninsured. You see from a socioeconomic standpoint, education level matters. You see that poverty level matters. And to some extent, occupation matters. 

And then I also want to show you this from the census. And you see that about 7 million of our uninsured-- it's about 28 million uninsured. About 7 million are currently not citizens of this country. 

And so when you factor in that number, if you were watching the debates last night, they had one of those calls. They said, raise your hand if your health plan is going to include undocumented individuals. And people didn't raise their hand. That's 7 million still going to be there. So keep that in mind. And keep in mind the impact that has on our health care system and the spending that they accrue. 

And then this is the reasons for being uninsured among adults. The number-one reason by far is that the costs are too high. They've lost their job or changed employers. 

So again, you're starting to think, OK, so what does a policy solution look like? Well, the costs are too high. They lost their insurance. They lost Medicaid. And when you hear about work requirements, the impact that has on Medicaid, think about that. Status change. The employer doesn't offer or is ineligible for coverage. 

And then you see just at 2% that no need for health care coverage. So that's the theory for why people make those decisions. Very few people actually don't have health insurance just because they're like, I don't need it. 

This is an important slide that I like to use because-- anybody who's taken a class with me has seen this slide before because I use it all the time. And it's that access is not just about having insurance. And so the affordability piece is so huge, such a key part. That's a big part of the conversation. And this actually looks at access both on the provider-facing side and on the patient-facing side. 

So at the bottom, that ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage-- those are the five domains, the five dimensions of a patient having access to care. And in terms of a provider being accessible, it's that they're approachable, acceptable, available, affordable, and appropriate. 

And so we have to really cover all those 10 dimensions, both patient facing and provider facing, if we truly want to provide access to care. And that's something that we do in different amounts with different types of plans. 

So I'll jump forward and jump into the plans. So we've talked a little bit about some of the partisan differences, and specifically looking at cost and looking at access. And those are important distinctions because they'll impact the kinds of plans that you'll see. So we'll just go over just a couple of leading proposals. 

I use this slide just to give you guys a little bit of a sense. So you've got Medicare for All. These are national health reform proposals-- Medicare for All, the public option. You've got the Medicaid buy-in, Medicare buy-in, the executive order that just came out last week-- or this week, rather-- improving price and quality transparency, and then a couple of that I'm not going to spend time, but drug pricing and surprise medical bills. 

Those are two that-- I put them in the middle because you've got bipartisan interest in addressing those issues. In the Senate, in the House, you've got a lot of folks who are interested in working on reducing the cost of drugs and then also on addressing surprise medical bills. 

That's that balanced billing, where patients show up. And then suddenly they get a bill a couple of months later because one person who's involved in their care isn't in network. And so both at the state level and federally, folks are working to address that on both sides of the aisle. 

We'll start with the Trump executive order because that was this week. It already happened, and the rest are proposals. So this is an executive order that already went into place. 

So the goal of it is to help consumers know the prices and quality of a good or service and to make informed decisions about their health care. That's their stated goal. And the actions are that it directs different federal agencies to adopt rules, to issue guidance, and to develop reports with the goal of increasing the transparency of health care pricing and quality. 

Its effect is that it's not a change in the law or in any regulation. But instead, it's a directive to draft new rules or guidance. And this is a good time to say that we had the legislative branch-- that's Congress. Their job is to create laws. 

As the executive branch, there is also a huge opportunity to create rules, to promulgate rules. And they do that through the federal agencies. And so what President Trump did is he said to a couple of key agencies-- Treasury, Labor, and Health and Human Services-- he said, I want you to start working on this issue, drafting rules and submitting grants. 

So three things that it did, really. So it requires the disclosure of actual prices. That doesn't go into effect yet. HHS has, I think, 60 days to come up with a rule, to propose that rule. That will describe how providers are expected to disclose actual prices. Actual prices are what add up to that $5.1 billion that-- or I'm sorry. Those are our prices that we offer. But the actual number is that 1.5. 

What was the negotiated rate? That's what the Trump administration wants to be publicly available. And the next is maximizing access to high-deductible health plans and health and savings accounts, also health care sharing ministries. And then finally, they also threw in some pieces on research, quality, and surprise medical bills. 

And so just quickly to touch on the issue here-- because it sounds great. You're just like, OK, more transparency doesn't hurt anybody. Two groups think it will hurt people, the American Hospital Association and the American Health Insurance Plans. They say publicly disclosing competitively negotiated proprietary rates will reduce competition and push prices higher. 

Now, these are both industries. They both have an interest in these prices. So take that with a grain of salt. But we're talking about how markets perform. And this is a market-based argument. It's saying, by me publishing my negotiated rate, fewer people are going to participate in that. You're going to have less competition. And that's going to ultimately result in fewer people in the market and higher prices for a completely different reason. 

And I say this all the time, but health care is a lot like Jurassic Park. Nature finds a way. People are going to make their money one way or another. And I think that's what we have to keep in mind with any intervention here. 

The notion of transparency is also important because we're talking about consumers in a marketplace who don't have the full information. Can you imagine somebody acutely being sick and saying, wait, wait, wait. Take me to another hospital and not this one because I'm googling really quickly what their rate for x is as opposed to y. 

And that's not really how people make health care decisions all the time. So that transparency is going to have some effect. It certainly is going to help people make some health care decisions in a way that's more economically advantageous. But it's not going to solve everything. 

The second is Medicare for All. There are two bills on Medicare for All, one in the House and one in the Senate. And the one in the House was introduced by Representative Pramila Jayapal. In the Senate, it was by Senator Bernie Sanders. And he's been talking about Medicare for All for a while. 

So I'll talk about this briefly. In Medicare for All, every American will be covered by a government insurance plan. And that's after a short phase-in period. In the Senate, that's a two-year phase-in period-- or in the Senate, it's four years. In the House, it's two years. And it would eliminate employer-sponsored coverage completely. 

So in the debates that we saw over the past two days, they asked candidates to raise their hand if they want to get rid of private insurance altogether. Folks who were really in favor of Medicare for All in this format-- they would actually get rid of all private insurance. And then finally, they both envision Medicare covering more benefits than it currently does. 

So the Sanders bill would cover vision, dental, and prescription drugs, as well as long-term care services. House bill-- a couple of different things. But it would cover services with the Sanders plan ultimately. They would have to negotiate these two bills is the way that Congress works to figure out where they meet in the middle. 

But both bills would eliminate cost sharing completely. So that out-of-pocket cost-- they would get rid of that. No monthly premiums, no copayments for going to the doctor, no deductible to meet before the coverage kicks in. And I see I'm at just about 1 o'clock. So I'm going to go a little faster. 

But the key thing here is that previous estimate in the Sanders bill was $32 trillion. That's Trillion with a T. So think 30,000 BCE multiplied by 32, right? That's how much this bill would cost to implement. 

And it makes sense. You're offering everything to everybody all the time in some form or fashion. And so how and where do you create the controls on health care spending? I think the devil's in the details on this. And that's what people really need to press for. 

So here's a quick chart. Do Americans gain coverage for both of these? Yes. It does require a tax increase. $32 trillion is going to have to. And then government regulates health care prices. It's the only way to control costs in this kind of environment. 

I put the names of the other folks in this because you see Senator Sanders, Senator Booker, Senator Gillibrand, Senator Harris, and Senator Warren are all running for president. They're all on this bill. So it's something to keep in mind. 

So Medicare for All-- what's important to note is that there are a lot of different opinions on it. And for those who oppose, they oppose because they don't want government involved in their health care. Or it's too expensive to implement, limits choices and competition. For those who favor it, it's because they think that it offers universal coverage or that health care is a right or that it will make health care more affordable. 

And you see that this is a national poll right now. About 56% of Americans favor a national health care plan or Medicare for All. 39% oppose it. Attitudes shift, though, after hearing messaging about Medicare for All. This is really critical over the next-- until November 2020. 

Any time someone mentions Medicare for All, keep this in mind. Attitudes shift when you describe it a different way. And if you were watching the debates, you might have even seen some commercials that were anti-Medicare for All because you can use messaging to really undercut it. 

So if you say that it leads to delays in people getting treatment, then people oppose it-- or that it threatens the current Medicare program or requires most Americans to pay more in taxes or eliminates private health insurance companies. Those messages mean that more of the country opposes Medicare for All than is in favor of it. But if you say that it guarantees health insurance as a right for all Americans, 71% of people agree. So the messaging really matters here. 

And so currently, just to compare it, in Medicare for All, you've got those seven who are in favor of Medicare for All. You've got more of the candidates who favor a public option, public option being having a national plan like a Medicare that people can buy into. They have that option to purchase that plan. 

The other two I'll talk about briefly are the Medicare buy-in and the Medicare buy-in. Some people called it Medicare at 50. You can, at the age of 50, get access to that entire Medicare network. So that's one that's been introduced. And you see there are a lot of folks who are in favor of that idea. 

And then similarly, a Medicaid buy-in-- that's going to be a state-based intervention. So states could offer to their residents to buy into the Medicaid program, which has some benefits, actually. Because at the state level, you have working, healthy people who are buying into Medicaid. 

You're actually reducing-- you think about the risk pool in Medicaid. They're going to be healthier and better employed. And so it's going to improve your risk pool in Medicaid. That's one of the benefits. And so that State Public Action Act was introduced in the House. And it has 46 cosponsors. The Medicare buy-in has 30 cosponsors. 

And then finally, like I mentioned, there's bipartisan consensus around some things with surprise medical bills, prescription drugs, and even with the idea of protecting folks with preexisting conditions. So those are areas where there's already some consensus, some agreement. But there's pretty big differences. 

And so before I jump to the addendum, the main thing to take away there from the Trump executive order is it-- the theory of the case there is that making prices more transparent-- you're going to improve that spending in health care because people are going to make different spending decisions. And that's going to be the key. And that's why he described it as possibly the biggest intervention in health care in a couple of years. 

And understand you have to cut through the bluster a little bit. But I really do think that this idea of transparency is the key to people making health decisions and not spending as much, whereas Medicare for All, the Medicare buy-in, the public option, Medicaid buy-in-- those are all ideas that are really focusing on the government increasing its market share and impacting prices that way. 

You have more government saying, hey, this is how much I'll pay. And we didn't talk about government negotiating prescription drug prices, that sort of thing. There's a huge buying power there. 

So finally, for the addendum, I'll just say, in terms of advocacy and organizations, every organization that we're a part of has an opportunity. This is ACP's advocacy, the American College of Cardiology, ASN, the American College of Gastroenterology. They all have a space for you to learn and understand about advocacy opportunities to go to the Hill and really speak out on some of these issues-- how it's going to affect your specialty or the practice of medicine more broadly. 

I mentioned legislative advocacy. That's a big one. So finding your representative here in Charlottesville or Albemarle-- our representative is Denver Riggleman, who was elected in 2018. He's actually here at UVA Medical Center today. He's visiting the new wing of the hospital, apparently. So I bumped into our government relations person a little while ago. And she was like, yeah, I'm waiting for the congressman. 

So knowing who your representative is and then also knowing your senator. So in Virginia right now, it's Tim Kaine and Mark Warner. Mark Warner is up for reelection November 2020. 

And then calling, writing, and stopping by when in DC. So most the time when I go to DC, I do pop over on the Hill. And I very rarely will meet with the representative themselves. But I meet with their staffers. 

And I think it's a great way to understand what's coming down the pipeline and what's happening. And you build some rapport. And I think in the future, when you have a big issue and you want to get your voice out there, wherever that moment may come, you already have relationships you can lean in on. 

Administrative agencies. This is a big one that goes underexplored. So the federal agencies-- they are the fourth branch of government. That's secretary of Health and Human Services, that whole environment. And it's huge because they will come up with a lot of rules. When laws are written, they'll say, the secretary will do x, y, and z. 

And so this is your opportunity to impact the rules that are created through the Federal Register, the site that I have to love. So in President Trump's executive order, Health and Human Services is going to post that rule about hospitals disclosing their prices. And that's where anybody who has something they want to say-- they can comment on that site. And then it's the responsibility of the agency to address every single comment that's submitted. 

And what has tended to happen in the past is that if you have a deluge of comments, they'll pull back the rule. They'll be like, look, we obviously need to do something differently. That happened with some Medicare Part B stuff a couple of years ago. It's something that's an effective way to advocate. 

And then finally, use your pen. Hometown newspapers, large distribution newspapers, op-ed space, or even blogs-- it's a great way for you to just say your piece and get some circulation in and get it out there. 

So with that, like I said, couldn't cover everything in the world on health policy. But I wanted to give you guys a framework and-- at least around cost and access-- give you some of the theory of how different sides are thinking. 

I'll tell you it's not that you just have horrible people on one side and great people on the other no matter which way you look at it. But it's more that they're just very fundamentally different theories about what we need to do to fix health care. And I think it's incumbent on you to have a better sense of what you think we need to fix health care. So with that, I'll take any questions that you have. 

[APPLAUSE] 

We'll take questions for a few minutes. And if you can just talk into the mic for those joining virtually so they can hear. 

Hi there, Dr. Webb. My name is Tyson Bell. Good talk. To continue this theme of the SOAP note, I noticed that you did a really good job of not inserting your opinion into any of this. So I'm going to ask for a consult. What is your opinion on Medicare for All versus the public option moving on to deregulation? 

Medicare for All or a public option ultimately moving for deregulation. I think a couple of things. I think universal health care-- my opinion is that universal health care in this country is inevitable in some form or fashion. I don't think that we're going to find a lot of creative ways to curtail costs. 

And once costs go north of 20% GDP, people are going to be clamoring for something different. We're talking about out-of-pocket spending. I think that there are really crushing effects of the cost of prescription drugs, hospitalizations, physician visits, et cetera. So I think it's an inevitability. 

I think that ultimately, there will be a race between the two parties to figure out who can do it their way. But I think that for me-- and just showing my partisan leanings a little bit-- what I'm most concerned about is what a single-payer system looks like in the hands of somebody who I fundamentally disagree with their views. 

And so I don't think that right now Medicare for All is the most practical solution, certainly not moving everybody into Medicare for All within the next two years. I think the costs are unsustainable at $32 trillion, especially when we're headed toward a recession in the next couple of years. So I think there are a lot of reasons why that might be a little bit aspirational right now. 

And I think that things like Medicaid buy-ins, Medicare buy-ins are probably the most politically feasible. And I think that things like a public option are actually pushing that a little more progressive but also really addressing that uninsured issue. 

So I don't think-- and you ended with moving toward deregulation. I don't know that that's the direction health care is going to go. I think all signs point to health care being more and more heavily regulated, much to the consternation of a lot of physicians. 

But I think it's a matter of how we can do that in a way that still puts patients over politics and puts them in the position to make their own decisions and doctors to make good decisions. And you got to have that room to operate. But that's kind of the tea leaves as I'm reading. 

Thank you very much. That was a great talk, Cameron. So we all freak out at that $32 trillion price tag. But what are we paying now? It seems like if we eliminate the insurance industry effectively and regulate prices in a more uniform way that it may be a much more cost-effective way to practice and to provide health care. 

Yeah, that's a good point. So right now we're paying $3.5 trillion for this year. And that $32 trillion is a 10-year estimate. But it's not that it's $3.2 trillion for 10 years. It's $3.2 trillion above current federal expenditures. So it's an additional $32 trillion. So it is an additional $32 trillion on our budget. 

That's hard. We have a huge federal deficit. I think that affects our bond ratings. That affects us as a nation. Now, that said, I don't know that our current spending is sustainable at $3.5 trillion. It's going to be $4.7 trillion. It's going to $5.2 trillion by 2027. That's the estimate. So those numbers are rising quickly either way. 

I think that your point is well taken. We're going to end up having to do something very different than what we're doing now. I don't know if that's the right intervention, not just from a financial standpoint. But I think from the individual liberties and freedom standpoint, I think there are a lot of people who feel comfortable with their insurance. And I think that's a hard thing for voters. 

And my biggest concern is political viability on that one. I think that it's going to be a hard thing to get passed, especially through the Senate. And so it may not be the most practical. But it remains an aspirational goal. 

And I think that if you had that, and on top of that people could buy private insurance if they were so inclined, and it didn't create a two-tiered health care system, maybe. But those expenditures-- that's a significant cost to incur. And I think whatever party chooses to do that might lose a couple elections in the next few years [INAUDIBLE]. We'll see. 

I'll go next. So maybe three points and questions. And following up on Dr. Wolf's point, I think one thing that we don't talk about-- you talked about costs, that there's a revenue side of this. 

And in fact, if the top 1% of the wealthiest in the United States would actually pay their due taxes, this is fundable. So I think there's a lot to this argument. But I think as a country, we have to make some tough decisions and hold people accountable in order to really improve the outcomes that we're looking for. 

The second thing is, I think we have to recognize that down several levels from where you're speaking, there are serious problems that we have allowed-- and I think as physicians we have allowed-- to occur in our health system that are very detrimental. One of the biggest ones is that the number of administrators that oversee the health care world has increased by 3,200% in the last 10 years. So there's now 10 administrators for every one physician in a hospital. 

Those are things that add cost and I would argue add very little value. Now, I think we've got to get control of that. And I think it's incumbent on all of us to really say enough's enough, that that's really a lot of silliness. 

Then the third thing I would point out is that when we talk about and we look at other countries in terms of health care spending, we're looking at-- those numbers are care of people who generally are ill. Most other countries who spend less than us-- not most, but some of them-- actually really think about improving the health of their populations. And when you include the amount that they actually spend on health care plus the amount that they spend on wellness programs, it's not that different than what we spend. 

But we are not really focusing on the health of our population. We're caring for people at the end of their life when they're sick. And I think we have to have that debate as well-- that we have to get our population healthier rather than really spending the money at the end of life. So a lot there. 

A lot, but I think all really good points. And I think the first thing is that it illustrates why it's so important have physician voices in these conversations. Because regardless of what your set point is and what you believe, I think the ability of a physician to go into spaces, whether federally or at the state level, and have these conversations-- it's huge. You're a trusted voice. And so I think that's a huge part of it. 

I think on administrative expenses, you're absolutely right. I think we talk about other wastes in health care. There are a lot of opportunities to improve. I know Andrew Parsons was here-- high-value care, right? There so much work to do there. There's a lot of other states to save dollars. And you can't cover it all. But I think you're hitting the nail on the head on several of them. So great points. 

I think we could be here all day, but it is 1:15. Thank you all for coming. And Dr. Webb, thank you so much. 

[APPLAUSE]