Judul : New York Health Care Exchange
link : New York Health Care Exchange
New York Health Care Exchange
- good evening, everyone. my name is joy connolly. as provost and senior vice president of the graduate center,i have the privilege and pleasure, really,tonight of welcoming you
New York Health Care Exchange, to the graduate center of the city university of new york. for those of us who are watching us, those of you who are watching us through
livestream, i'm waving to you. thank you for joining us from afar. as many of you know, this building is the home of pioneering research, of nobel and guggenheimand pulitzer winners and of ph.d students whopresident chase robinson and i are never tired of saying teach about 200,000 cunyundergraduates every year. we're especially proud to rank among
the country's top 10institutions in awarding doctorates to studentsfrom underrepresented minority groups. tonight marks the latest installment of our very contemporary, timely series, the first 100 days, programming in an eight-part seriesdesigned to help us all navigate this unusual, especially divisive political era.
conversations over the past weeks and in the next few weeks havedelved and will delve into trade, inequality, power and other timely themes, allfeaturing graduate center scholars and other national figures. we hope you'll come back often. it's our hope, honestly,that we'll develop, in the course of these conversations, we won't just gain exposure to new ideas,
but we'll develop new habits of thought and especially new habits of dialogue across political views so that we learn to talk not only with thepeople who agree with us, but with the people who don't. this evening's event is especially timely. just over a week ago, as we all know, republican leaders failed to repeal the affordable care act.
in the face of thisdefeat, president trump warned that obamacare would, and i quote, "explode," but speakerpaul ryan has just said we're gonna be living with obamacare for the foreseeable future. president trump hasalso vowed to cut taxes and reduce support for programs that help the poor, such as medicaid and food stamps.
he and senate majorityleader mitch mcconnell have both promised that republicans won't touch medicare and social security. all this political maneuvering, then, begs for clarity. what is going to happen? what's gonna happen to obamacare and the rest of the social safety net over the next four years?
who's going to benefit? who's going to be harmed in the process? what's at stake for the more than eight 1/2 million people in our hometown, in new york city? it's been increasinglydifficult to decipher policy positions in themidst of all this hyperbole. we're fortunate, veryfortunate, to be joined tonight by four experts who can help us
answer these vital questions from different vantage points. this discussion is emblematic of what we do best at the graduate center and what we do every day. this is an incubator of vigorous debate, reflected in our doctoraland masters programs, our 30-plus centers and institutes and the dozens of eventsheld here every week.
for these and many otherreasons, we're pleased to present this event, an in-depth talk with some of the nation'smost prominent scholars and policymakers. let me now introduce them. mary travis-bassett. if you can (laughter) nod. (laughter) thank you, mary. is the commissioner of the new york city
department of health and mental hygiene. she's dedicated her longand impressive career in medicine and public policy to advancing health equity here innew york and overseas. prior to her current appointment, she led the african health initiative and the child well-being program at the doris duke charitable foundation. as deputy commissioner of public health
and disease preventionunder mayor bloomberg, she directed key initiatives, such as the bans on smoking and trans fats in restaurants. sheldon danziger, thank you, president of the russell sage foundation, is a nationally recognizedexpert on the effects of economic, demographicand public policy changes on trends in povertyand economic inequality
and on social welfarepolicies in the united states. previously, he held three titles at the university of michigan, distinguished university professor of public policy at the gerald r. ford school of public policy, research professor at thepopulation studies center and director of thenational poverty center. our own janet gornick at the end there
is a professor of politicalscience and sociology. she's also the director of the newly named stone center on socio-economic inequality and director of the us office of lis, formerly the luxembourg income study. she's also a lis senior scholar. a prolific scholar and author, she focuses much of her research onsocial welfare policies and their impact on gender disparities
in the labor market and income inequality. michael strain is the director of economic policy studiesand resident scholar at the american enterprise institute. his research interestsspan labor economics, public finance and social policy. the editor of two books on economics and economic policy, he's published op-eds and essays in leading news outlets,
such as the new yorktimes and national review, and he's a regular contributor to the washington post. finally, leading thediscussion, is policy expert, advocate, think tank executive and writer felicia wong. she is the president and ceo of the roosevelt institute,and is well known for championing policiesthat fight inequality.
under her leadership,the roosevelt institute gained widespread attention for its report rewriting the rules ofthe american economy, which provocatively called inequality a choice, reinforced by public policy. last year, the new york times magazine quoted felicia as describing america as, and i quote, "afear-catalyzed gated community "for a privileged few, and a violent,
"racially hostile lord of the flies race "to the bottom for the rest of us." (murmuring) - [felicia] i said i was afraid of that. i didn't say we were there yet. (laughter) - good, thank you for that clarification. we could be slightly pessimistic and not totally pessimistic.
that's good to hear. in all seriousness,tonight felicia will talk with these leaders andscholars from both sides of the political aisle who are known for shaping and analyzing social policy. on behalf of all of usat the graduate center, we thank them and wethank you for taking part. have a good evening. (applause)
- thank you so much. is this on? is this on? great. good evening and thank you to joy and to janet and to karenand the entire cuny team. in an age where moreinformed civic engagement is absolutely criticalto healthier public life, cuny's public programs are a welcome and vital part of our city's lifeblood,
and i'm fortunate, asare we all, to be able to take part. as joy said, i'm felicia wong, and i run the roosevelt institute. we're a small think tank here in new york. we're dedicated to makingthe human-centered values of both franklin and eleanor roosevelt real in the 21st century. i will be moderating tonight.
we're very lucky to have four terrific and very diverse speakers. it's kind of an embarrassment of riches, and we have a big topic,so we'll get right into it. our question for theevening is what can we expect from our socialsafety net in the era of a donald trump presidency? let me tell you a little bit about what's going to happen.
everyone will lead off, i think, with a two minute or so statement about what they hope for. hopefully not a fear-catalyzedgated community. what they hope for. maybe a little bit about what they're concerned about. then we'll start someround-robin questions amongst the entire group.
i think we'll go until about 1/4 of eight. there's so much here thatwe'll be able to have, i think, a very robust conversation. let me just say a little bit about what i think we mean by safetynet, about what is both on the table and notnecessarily on the table for this evening's conversation. i think we're going totry to define safety net as follows: we meangovernment cash and services
that go to support thepoor or the near poor. the goal of the safetynet, which in many ways was the product of theroosevelts' new deal, at least the modernsafety net, is to protect people from the very worst ravages and hardships of life. we can also think aboutthis as interventions to rectify the inequalitythat's inevitably caused by the market.
i think we think of itin four major buckets. the first is all the big health programs, medicaid, obamacare and perhaps the ahca, as proposed. some days it's re-proposed, some days it's not re-proposed. we'll get into that here. the second bucket is the other major anti-poverty programs,things like food stamps,
tanf, wic services. there's a range of services that are specifically anti-poverty. we're also gonna touch, and i think this is janet's unique contribution, on work and family policies, childcare, paid leave and other kindsof working family policies that are just criticalin the modern economy. finally, we'll talk a little bit about
whether we can expect tosee any kinds of changes in the large social insurance programs, social security andmedicare, in particular. that's a very big set ofpolicies to talk about. there are some thingsthat we are going to keep, or try to keep, off thetable for the evening. we're not gonna talk about police violence and criminal justice reform. we're not gonna talkabout immigration policy.
we're not directly going to talk about k-12 education. we're not gonna talk aboutinfrastructure investment. even though all ofthese things, of course, affect people's income and poverty, we're not really going to talk about them directly this evening. i also don't think this isgoing to be specifically about taxes or about fiscal policy,
although it's hard to get away from taxes because eventually youget into the question, well, how are you goingto pay for that program? we may touch on it, but again, this isn't centrally about tax policy. that is at least myattempt at a definition of what we're going tobe discussing tonight. i'd like to go ahead and get started by asking janet to kick us off
with two minutes on what she hopes for. - thank you, thank you, felicia. it's a great pleasure to be here with this great group. i would say i agree with this, by the way, this brief description of what we mean by the safety net. i've taught social policy here at the city university for 24 years.
i'm happy to say apleasure and a privilege. we begin all thoseclasses with the question about what are the boundaries around social welfare policy or the safety net. i think it's sort of a futile exercise to be too precise, buti would agree with that. i think it's important to note that these large social insurance programs, social security inparticular, are, in fact,
anti-poverty programs, even if they're not targeted on the poor. we think of them really as a large group, although all these different components, and i think this is a lot of what we'll talk about tonight,they function differently, they're financed differently, they're targeted differently. thus, they have differentpolitical logics.
partly for that reason, some of them might be in peril, some of them the new administration may try to cut. i use the term in perilto mean try to cut. i'm not a supporter of cutting most of our social programs. others of them, theymay try and not succeed. i think this is partof what we're gonna try to tease out, are there logics.
when the new administration came in, in conjunction with thecongressional results, as well, in november, ithought about three things. my first concern, likeso many, was what about the affordable careact, which so many of us had been watching for such a long time. i also thought about thelarge social insurance programs, but also about work and family. let me just say a sentence or two about
each of those. i was saying in the autumn that i actually was the least concerned about the affordable care act,which seems somewhat paradoxical because i, like so many, waited for many, manyyears and decades to see something like the affordable care act, but the reason i wasn't terribly worried was because, as we know, its opponents
shifted from talking about repeal to repeal and replace. i didn't think there was a replacement. i didn't think there was a replacement in the wings that was feasibleor politically viable. i don't think that was a brilliant bit of prediction, but i think, in fact, that's really what we saw was this sort of secret plan that was gonna come out
from the woodwork didn't really appear. excuse me. then when it did, it wasn't successful, for reasons i'm sure we'll get to. a lot of people have beensaying this for years. they had seven years to show replacement. there really wasn't one. the affordable care actis a conservative plan, so a better conservativeplan was hard to imagine.
the large social insurance programs, just simply to say, ithink most of you know trump said many times during the campaign, which distinguished himfrom his colleagues, that he was not gonnatouch social security or medicare. he tweeted a rather boastful remark, that he was the only republican candidate to say such a thing.
what does that mean? we don't really know because that view is not held by his colleagues in congress. i think this is a question. in some sense, i think some of us have sort of sat easily and thought, well, these programs are not gonna be touched, but we really have absolutely no idea if the congress will capture him
or he will capture themor what will happen. we just saw it's not clearwho has the upper hand. finally, we'll come back to this, but i sat up and paid a lot of attention when the trump campaign put out a program for childcare and paid family leave. extraordinarily unusual for republicans to do such a thing. we'll come back to that.
i don't wanna take too much time. that was unusual. they were not progressiveplans, either of them, but it was a sea changeto see those topics on the table on the republican side. i'm really eager to see what will unfold. - [felicia] great, thank you. sheldon, what do you hope for? (clears throat)
- i'm trained as an economist, so i just have fears and not hopes. i thought i would saysomething about my view about the safety net. i think the conventional wisdom, which the heritage foundation began saying at least 25 years ago, and almost every republican, althoughi don't think trump has bothered to think or talk about this,
will say, well, obviously, the safety net doesn't work. we spend trillions of dollarson government programs, and poverty stays high. then it usually follows the safety net creates a hammock or a trap that treats the poor. i thought i would begin by simply saying the safety net hasn't eliminated poverty
because the economy has generated so much more poverty and inequality than anybody imagined 25 years ago. if you actually look at thesocial science research, some of which i've done, a lot of which was funded by the russell sage foundation before i got there, let me just mention three particular areas. let's start with thejob-killing affordable care act.
i'll go in backwards order. as many people have noted, unemployment has beenfalling and employment has been increasing steadily since the end of the recession. the affordable care actworked to reduce the rate of uninsurance, and itpaid for it by taxing the rich, which is a pretty good notion of a program designed to help the poor
and reduce inequality. the previous one, thestimulus act of 2009, reduced poverty and unemployment at a time when the economy wasgenerating a lot of poverty and unemployment. a very recent article inthe public policy journal by hilary hoynes and colleagues shows that the increase in safety net spending on food stamps, tax credits and a variety
of other programs really helped cushion the very severe marketlosses that occurred during the recession. the third is the war on poverty programs that have gotten such a black eye in public discoursedramatically transformed the safety net. head start, pell grants,medicare, medicaid, food stamps.
again, if one looks, thecenter on budget routinely puts out information that shows how many millions of people aretaken out of poverty each year by various programs. in some sense, i think we're beginning in a period when the conventional wisdom and discourse, even in the best oftimes, has been hostile to safety net programs.
- well, i wanna comeback to that eventually, and i wanna come back especially to your historical view, the roots of some of these programs and the roots of some of the political dialogue. but i wanna turn now to michael. michael, i'm interested in particular in your view and to seewhether you would agree in large part with sheldon's primarily
optimistic view of what the safety net has done to alleviate poverty. - yes. i do agree with sheldon in broad strokes. let's do a thought experiment. let's say that we woke up tomorrow and we eliminated all ofthe safety net programs that sheldon talked about,safety net broadly defined. do we think we would seepoverty go up or down?
poverty would increasedramatically, i think. it's very hard for economistsand social scientists to come up with estimatesof the total amount of poverty that'sreduced by the safety net because it's hard to constructa counter-factual one, all sorts of other technical reasons, but maybe the current safety net programs cut poverty rate in 1/2,something like that. if you think about a programlike social security,
these programs exist for a reason. people didn't come together in washington and say, "oh, okay, whatare we gonna do this week? "oh, i don't know, let's come up "with a food stamp program." we have the food stampprogram because people and children were dying of hunger. people decided that was notan acceptable situation. we have the socialsecurity program because
the elderly were dying in tenement houses of exposure to the elements and of disease and of all sorts of other horrible things. these programs sprang from real need and they address real need. now, they're not perfect. many of them are quiteflawed, and they need to be fixed and they need to be altered. they need to adapt to thecircumstances of today.
we all need to be clear that sometimes these programs haveunintended consequences. sometimes these programs do harm, as well as do good. but i think if you lookat what we have built over the last century, particularly over the last 70 years or so, it's a marvel and it's something that we should all be proud of as americans, that we've
come together and created these programs to help the people insociety who are most in need. - thank you. that's certainly something we're gonna have to come back to because i think what you have on the stage here is a range of conservatives and progressives, and yet you're hearinga lot of agreement here. the question is--
- you'll get some disagreement. (laughter) - i'm gonnacome back to that, too, but the question is what's the problem? before we go there, let's go to mary. mary, you run the department of health here in new york. you must hear much of this conversation about potential changes to various federal programs with some measure
of trepidation. what do you hope forand/or fear as we enter this new era? - the first thing that i wanna point out is that i was appointedby a progressive mayor, the first progressive mayor that we've had in new york city in a good many decades. i have a couple of interests. i wanted to learn frommy panelists because
my day-to-day job isactually looking after the health of the people of this city, promoting health, protecting health. i also really wanna convince the audience that we've come a long way, and we have a long way to go, and that i'm hopeful that people willunderstand what's at stake in the coming years. let me tell you a little bit more about
what i mean by that. obviously, we always pay for policies. we pay for them with ourtaxes, we pay for them out of our pockets, we payfor them with our bodies. many people here may not realize the price that we pay in thiscountry with our bodies. despite spending more than any other wealthy country, by far, when you compare our health outcomes to our peer nations,
we're at the bottom or near the bottom for everything. that's what you call, despite whatever the deal makers say in washington, a really bad deal. now we're in thesituation where a bad deal is gonna become a dangerous deal. what was at stake withthe affordable care act? well, in new york city,1.6 million people,
healthcare coverage was threatened if the affordable careact had been repealed. 200,000 of them people who use our public health system andwho had insurance coverage to pay for their care inthe public health system, which, as you know, is greatly threatened by the fact that many people use it who have no insurance. the other thing issomething called the public,
i'm gonna get this wrong, the prevention and public health fund. it pays for a lotta things. gives my department $12 million a year. it also contributed 12% of the centers for disease control budget. that would have been eliminated. now we have the executive budget. that's got huge cuts tohealth and human services.
$15 billion, 18% of thebudget, over 1/3 of that, to be borne by the nationalinstitutes of health, which is our scientificengine for research in this country. then we have agriculture,cuts to food stamps, the safety net thatwe've been talking about. when i think about thesafety net for health, it doesn't just includehealthcare services. it includes education, it includes jobs,
it includes housing, itincludes food security. it takes all these strands because among the many reasons that we don't want people to be unhealthy is thatwe don't want people to become poor. another fact about our current situation, even with the affordable care act, is that seeking andobtaining healthcare services was tipping a huge number, over 11 million
americans, about 1/4 ofpeople classified as poor, into poverty. we have a situation. we have a healthcare systemthat is creating poverty. that is not a system that is supporting itself. it's undermining itself. i'm hopeful that we're gonna begin having expanded discussions, andincluding starting here
in new york state, with our mayor, who is now talking about medicare for all, single-payer coverage plans. the affordable care actis worth fighting for and protecting, but we still have many problems that we have to address. - yes, thank you. well, i wanna come backto the specific effects here in new york, butfirst, i wanna pick up
on this hint of potential disagreement between the two of you,michael and sheldon, or agreement, because one ofthe very interesting things about your collectivepast is that you actually were part of an aei brookings study that brought together conservatives and progressives to try to develop a consensus view on anti-poverty programs. given the history thatyou described, sheldon,
of much narrative denigrating the effects of anti-poverty programs, saying that they weren't helpful or ineffective, that they were ineffective,it's very interesting that you both, from different sides of the political aisle,tried to come together, along with a dozen colleagues, perhaps, to work on a document that was going to bring people togetheracross partisan divides.
in this time of greatpartisanship, i'd like to hear both of you talk about what that experience was like and whether you think that experience can driveany hope for the future. sheldon, why don't we start with you. - sure. i think the last model we saw nationally was the greenspan commission in the '80s for social security, where it was realized
we've got a long-term problem with the social security trust fund. group of people came together. the solution was modest tax increases over a long period,modest benefit reductions over a long period. that's when the retirementage got raised to 67 for people who are young today. when my colleague ned gramlich was head
of a social security commission in 1994, he thought that was the same solution at the time. he came up with a plan that, when he presented it at theuniversity of michigan, at least convinced the academics. had modest tax increasesover a long period and modest benefit cuts. by then, i think, on acommissions of a dozen people,
ned got one person, and five people said i love your benefit cuts, but i won't vote for tax increases. five people said i loveyour tax increases, but i won't work for your benefit cuts. i think the group thatgot together decided we were gonna-- - [felicia] this was 18months ago, two years ago, something like that?
- no, no. you're talking about our group. - [felicia] sorry. - our group issued areport about a year ago in december, so 15 months ago. - [felicia] a lot of partisanship. not quite the level of partisanship that we're seeing today. sorry, that's what i was trying to.
- i think our goal was,knowing the history, was to try to do something in the space of poverty, opportunityand responsibility. we began by, i guess, agreeing we were gonna listen to what other people said. we were gonna agree to look at facts. i mean, this is shocking, that (laughter) people on both sides ofthe aisles could look.
then we said, okay,here's a set of issues. i'll give the example from the work area. conservatives wanted tohave more responsibility on the poor to supportthemselves and their families. progressives said, well,it's okay to expect responsibility, but ifyou expect responsibility and you're gonna cutoff benefits to people who aren't working, you've gotta make sure that they're not working because
they're rejecting work,not because employers are rejecting them. we agreed that the statement as written would be people were tohave, who were to get benefits, were expected to look for work and to take an available job, but there was this public service job of last resort or subsidized private job of last resort. i think we came togetherin a range of areas
on issues like that. - [felicia] michael. - yeah. it was very difficult. the people in the group all had established reputations. the people in the group all, well, most representedorganizations that occupy a certain space in ourpublic conversation.
it was hard. it was hard to come to consensus. it makes me hopeful because i think the reason that it worked, and sheldon can present a different view if he doesn't agree, first of all, there was a shared moral consensus. the consensus was fundamentally-- - it began with that, right?
you began by talking about the values that you shared. or was that part of the spine of that? - that took a little bit of time to come together. but the consensus that i think everybody in the room shared was that something needed to be done. that poverty was a serious issue.
it was an issue that admitted compromise and it was a big enoughproblem that people need to swallow thesubsidized jobs or swallow the extra responsibility on people who were receiving benefits in order to make progress. that was key. secondly, people in the group exhibited what i think i would call
intellectual empathy. that's something that is very rare in washington, where i work, and very rare in the public debate. we would gather, ithink about 1/2 the time we were at the russell sage foundation, about 1/2 the time we were at the american enterprise institute. we'd sit in these roomsfor seven hours at a time.
occasionally, well, not occasionally, pretty often, somebody would say something around the table thatwould just be abhorrent to 1/2 the room. but instead of throwingrocks, people said, "well, let me try and understand "what you mean by that. "let me try and pinpoint exactly why "or exactly where i don't agree with
"where you're coming from." that really helped. we had a big debate about whether we wanted to include funding for pre-k. i, among others, thought that that was really not the right thing for us to do in the report. many of the folks in the group who were on the more progressive side thought that
it was really necessary. couple months of goingback and forth about it. then one day, one of the progressive said, "well, is your issue basically that this "is a federal program? "what if we just suggested that "the states run their own programs?" well, i can live with that. that made its way into the report.
intellectual empathy wasreally, really, important. the third thing, ithink, that made it work was that we actually formed a bit ofcommunity with each other. - this was a eight-month program, project? - for like a year, maybe. - you got to know each other(speaks too low to hear). - [sheldon] it was supposedto be eight months, but it took a year. (laughter)
- spent a lotta time witheach other in person, corresponded a lot over email, talked on the phone quite a bit in bilateral conversations. take those three things,and now apply them to the current publicdebate, which is so nasty, so completely devoid ofintellectual empathy, where there is no sense of community. the same thing'shappening on capitol hill.
one of my great worriesabout the poverty space in particular, but not only about poverty in the trump administration, is that whatever moral consensus we have that even identifies areas of concern could end up being chipped away. - right. i actually would liketo have a conversation about whether you think that model
could be useful in a post-trump era, but let's come back tothat because i actually now wanna turn to janet. janet, you have beeninterested, you actually have shown some intellectual empathy. you've been interested, as you hinted, you've been interested in some of what the trump administration,ivanka in particular, but also president trump,have put out around
work and family policy. you see it as a change from what most republicans haveput forward in the past. how would you seek to build on this and/or do you take it seriously or is it a political ploy? - all good questions. just to back up for a moment, i think i would simply say, i know i've said this
already a little bit this evening, just to point to how unusual this is. during the campaign, thetrump campaign put out a very specific plan. i think people in this, people in the room here probably know, asa word of background, that the united states is really an international outlierin terms of programs specifically that support working people
who are also caring for children. we are the only rich country in the world that doesn't have, one of the very few countries in the world that doesn't have paid maternity leave,the only rich country that doesn't have paidpaternity or parental leave. we make extraordinarily few investments in childcare. we're an absolute outlieramong the rich countries.
then other things, just that are sort of in the background. we have a very low minimum wage. we have very few protections in the law that enable people to work part time or work flexibly with protection. it's a really roughcountry in which to work for pay, especially if you're in a low-income home and a low-wage worker
with limited skills. i've been working for many, many years on looking, in particular, at paid leave and childcare, which is almost never on the republican agenda. it was quite interestingduring the campaign and it got a lot of attention in the press that the trump campaignput out a childcare plan. it was a tax plan, but afairly substantial one.
then they put out a plan for paid leave, which called for six weeksof paid maternity leave to be paid out of the unemployment-- - [felicia] women only. - women only.- [felicia] women only. - the first thing to say is that both of these programs, in a sense, i was sort of excitedand pleased and happy to see that the issues were on the table.
why were they on the table? i would just say quickly i think there are three reasons, and so they tell you about the complexity and the fragility of the politics. one is obviously that hillary clinton was trump's opponent, asi think everybody knows. obviously, the whole discussion about a woman candidate, she hada very progressive program.
the chief economistfor her transition team was one of the country's leading experts on work and family. she was making it very clear that work-family policy wasgonna be at the center of her campaign and at the center of her administration. it was very convincing. i think they were simplycompeting with her.
second of all, the accesshollywood tapes came out. he was widely accused of being anti-woman, of course, and they needed to do something for the ladies, so that'sthe maternity leave. then, of course, his daughter, ivanka, who everybody knows hasbeen pressing him on this. they came out with these plans. in short, i don't meanto be too ridiculing, but the childcare plan was kind of absurd.
it was an extraordinarilyregressive tax plan. the nonpartisan taxpolicy center described it as a gift to the rich. 70% of the benefits would have gone to households with income over 100,000, and 25% with households over 200,000. the plan for paid familyleave was for women only, which is just about 40 years out of date, relative to any other country,rich country in the world.
it's absurd. not only is it absurd, it's harmful. i was interviewed by the new york times. i'll simply say this. pamela druckerman wrotea piece about this. she asked me if i hadspoken to the republicans. in other words, i saidthat i had spoken to, the clinton campaign had called me for policy discussion, ashad the sanders campaign.
she asked if i had spokento the trump campaign. i said that i had not,but i would be thrilled if they would call me. i did mean that very seriously. i dared ivanka to call mevia the new york times, but she didn't. (laughter) the question is what will happen now? i have absolutely no idea. there is a sort of amarch over recent decades
in this direction. i think left and right, michael, maybe you can speak to this, recognize that the shift from sort of the welfare mother to the working poor woman and men, of course, that shift is complete. in fact, it was a colleagueof yours, michael, at the american enterprise institute said early this spring that the trump
white house was talking about a parental leave plan. i've scoured theinterwebs and i can't find any evidence for that, but apparently it's been said behind closed doors that they understand thatmaternity only in 2017 is really not a good idea. but anyway, it's on the table. i'm excited.
i hope they're serious. ivanka, call me. (laughter) i'm ready to help. - i have one comment and one followup before i go to mary. the comment is perhapsthis was narrowly political on the part of the trump administration, but you give reasons to suggest that this might be something broader than that.
marco rubio had come out much earlier with a childcare proposal of some kind. there may be reasons that are driven by the larger economy andlarger economic forces that people will eventually put this on the table in a seriousway at a federal level. just say one more word about why you think this is good for the economy. - well, that's a good question.
i do a lot of research across countries, so i think most of youhave heard of the oecd, the organization for economiccooperation and development. it's a group basicallyof 36 rich countries. they've issued several reports. they're really not apolitical organization. a big theme that they'vebeen writing about is the necessity to bringwomen's employment up across all of the rich countries.
they talk a lot about this, it's a sort of unpleasant term, wasted human capital, but meaning there's enormous numbers of women who are educated and skilled and prepared to work, but who are working intermittently and part time and are underemployed andout of the labor force because it's just an extraordinarily, we have a very hostile environment.
i don't mean in termsof sexual harassment, but i mean in terms of working conditions. there's a lot of wasted capacity. we also see birth rates falling in a worrisome way because people can't figure out how to have children and care for their families. it's certainly lowering people's wages and adding to the poverty problem.
i think there's a lotof instrumental concern about the constraintson women's employment, and that has been a discussion i think that has a certain bipartisan sense. we also know, i justmight add, that housing, excuse me, family demography has changed. huge numbers of households, the only breadwinner is, in fact, a woman, or the primary breadwinner is a woman.
to the extent that women aren't able to reach their full earnings capacity, which they're not fora lot of these reasons, it's creating povertyamong families and children and intergenerationalconcerns and so forth. - great, thank you. mary, our discussion for the last 20, 30 minutes has mostlybeen about federal policy. obviously this is a panel about the
social safety net in the era of trump, so that does make sense, but your job is to really make sure that people in new york are best offand least poorly impacted by federal policy. can you talk a little bit about who you think would be most affected if we saw the most draconian of cuts. - i think i've already.
is it still on?- it's on, yeah. - i first have to comment that i believe that there was the billpassed by both houses and vetoed by nixon that would have made (speaks too low to hear). (people talking) - [man] the microphone is off. - i thought it was off.- oh, is it? - there we go.
now you can hear me. i was just saying that there was a bill that was passed by both houses that was vetoed by nixon. it managed to make it through both houses with bipartisan supportthat would have made pre-k universal, butyour question was what would the costs be-- - here in new york.
i mentioned that 1.6 million people would have their healthcarecoverage at risk. of course, a key tothe affordable care act is the essential services that it assures without copays. as you know, a copay can be a real barrier to seeking care. we know that it is. certain key services, for example,
substance abuse treatmentor mental health services, are part of the essential plan. access to these serviceswould be greatly reduced. in new york city, we're in the midst of a still escalating opioid epidemic. we have record numbers of people dying of overdoses, most ofthem related to opioids, most of those related to heroin. we would be disarmed,in terms of treatment,
and there is effective treatment. but i don't wanna make it seem as though access to healthcareis the only determinant of public health. obviously, being healthyhas a lot more to it. it's hard to be veryspecific about anything. i think you'll hear that echoed through the panel 'cause westill don't really know what's going to happen, but at least here
in new york, we felt really heartened by the fact that a week ago friday, the replace part of obamacare foundered, and the repeal effort seems to have been disarmed for now. but i think that the best turn of phrase that i heard is we dodged a bullet, but the gun is still loaded. (laughs) it may still come.
all of these cuts in the executive budget and in the affordable care act would have a very marked impact onthe health of our city. there's no doubt about that. you mean how are we gonna plan to-- - pragmatically, given the-- - our goal is to fight this. - you have a multimillion dollar budget. you have thousands of employees,
scores of thousands of employees. - 6,000. - okay. - am i off?- 6,000 employees. how does one manage? how do you manage an agency with that level of uncertainty? - well, i think that our intention is to continue to advocate strongly
for what we view as bipartisan goals, which is to ensure that people have the basic services they need to have a decent life. at the moment, where i'm not being asked to come up with a budget that reflects the kinds of cuts that might be coming. i haven't got that budget to talk about this evening.
- okay, good. well, i can only imagine what it's like to try to plan in multiplerealities constantly. michael, i wanna come back to you. - i think we're all doing that, in many, many realms. (laughs)- well, that's true. you're a token on this panel this evening. not only the token conservative, but actually a token washingtonian.
i wanted to ask you. - unusual for me. (laughter) - which one? (laughter) basically, for the last 30 minutes, we've been talking in a very rational way about some of the policies we might like to see, some of the policieswe might hope to see if we got together interrific groups of 12 and spent a lot of time with each other
with intellectual empathy,but that is really, at least from what i read in the paper, that is not the world inwashington, dc right now. in particular, one of the things that is confusing and perhapssomewhat encouraging those of us on the progressive side is that there seems tobe a lot of confusion on the conservative sideof the aisle right now. i think those of us wholive in glass houses
should not throw stones, by the way, but nonetheless, there'sa lot of confusion in terms of what a conservative, what a reasonable conservativesocial safety net policy, writ large, would look like. can you tell us a little bit about what you think you're likely to see on your side of the aisle in the next three 1/2 years?
- well, i guess, buildingoff your comments, the gun may still be loaded, but they don't know how to fire it. (speaks too low to hear) - i think there's a bit ofa double-edged sword here. the safety net is not the focus of the republican party right now. perhaps that will make some people breathe a sigh of relief.
that also means thatit's a potential source of funding for things that are important to republicans. we saw in the president's budget that basically non-defensediscretionary programs, many of which help low-income americans, funding was cut for those programs. that was given to defense spending. it is likely that we will hear talk
of cutting the budget forsome safety net programs in order to fund tax cuts. if you think that the affordable care act is a safety net program, which i think is a reasonable view, certainly that is somethingthat has been targeted. whether or not they're able to regroup and take another swing at that, i think is very much an open question.
i think that the administration has some pretty clear goals. they wanna do tax reform. there is building desire to actually dosomething on infrastructure. they want to return tothe affordable care act. whether or not they'll be able to do that, again, i think is an open question. i think that the chancesof social security
or medicare being affectedare actually quite low. i think that the chances of going after some safety net programs that are not annually appropriated, reasonably low, but medicare, healthcare, those are things to keep an eye on. - what about block grants(speaks too low to hear)? - actually, so mary, i wasgonna ask that question next. this is for all of you now.
one of the things that would definitely be a significant structuralchange to the way most of these programs are provided, although we've seen some of these changes in the past, but block granting of healthcare programs, in particular, would be a very significant change. i'm not sure who to throw this open to, to throw this to, butcould somebody describe
what block granting is specifically and what the likelyimpact of block granting would be, both programmaticallyand politically? i don't know who wantsto take that question, but i think it's an important one. - it's really an important one, but i'm not sure that i can answer it in a general way. i can speak of it frommy personal experience
in public health practice. - wanna define block granting first? - it just means that a chunk of money is allocated, and it goes to the states as a chunk of money. the states are given guidance on what it should be spent on, but there's no line item guidance onhow that money's spent. the experience of blockgrants as i've seen it
is that they, one, shrink the budget, it's almost always a wayof cutting the budget, and it absolutely reduces accountability for how that budget is spent. in fact, it can be spentin all kinds of ways. it may not be spent on the, to support the activitiesthat it was nominally intended to. if we're talking aboutemergency preparedness,
for example, you might have a, the cdc might have a lot of ideas about what the framework ofemergency preparedness would look like. if it went to the states, they would not be able to hold the states accountable to the implementation of that framework. - could i just add to that? block granting has been discussed
for many, many years inrelation to many programs. it always makes liberals and progressives very nervous. i think, mary, you mentionedmany important points, but it's also importantto note if you take cash assistance forthe poor as an example, the block granting went hand in hand with removing the entitlementstatus from the law, which meant that, just a bit of history,
and i think that wasprobably one of the most radical changes in american social policy, certainly, in decades. in 1935, the socialsecurity act was passed, which created the spine of the american social policy system. that included a programthat gave cash assistance, basically, to single women and children, called adc.
it became afdc, what we know as welfare. that was an entitlement program. an entitlement programis one, what that means is that people who areeligible, it's required by law that they be served. in any case, during theso-called welfare wars of the 1990s, the law was passed in 1996, afdc became tanf, givenback to the states. but the big shock was thatthe entitlement status
was removed from the law. what that means now is that poor families with children are essentially at the mercy of the states in which they live. we have 50 different systems and so forth. block granting, not only does it, it often cuts funding, it doesn't have to, it turns discretion to the states, but it also, in my view, it also really
jostles the wholequestion of what it means to be a country becauseit's always been the case that there's been state-level variation, but after tanf, in particular, what does it mean to be a country? a child born in mississippi lives in a completely different world than a child born in connecticut. the point being thatblock granting medicaid
was on the table, itwas taken off the table, it was back on the table. to me, it sounds a little bit like a horror movie, but they're talking about block granting medicare. in any case, forgive mefor going on too long. at some point, michael, i'd love to hear why you're so sure these won't come back. trump and ryan are oneof oddest political duos
in political history. who the heck knows where they're going? isn't paul ryan a fan ofblock granting medicare? why do we think it won't come back with a roar? - there are block grants, and then there are block grants. what paul ryan is in favorof is premium support, which essentially is aper-person allocation,
per-enrollee allocation to the states, of funding that would beused on a particular program. that's different than saying, okay, it's the year 2017. the state of mississippigets x billion dollars for this program. we are going to adjust x by some amount going forward, and it's just gonna be kind of blinded on autopilot.
the same thing was true with medicaid. the medicaid fundingmechanism is problematic. it's a matching program. if the state spend $1,then the federal government matches that. in some cases 50 cents,in some cases 80 cents. that encourages statesto spend a lot of money. that's something that weshould be concerned about. we should also beconcerned about the quality
of care that medicaid recipients receive and what it actually does to their health. the reason we want healthinsurance is because we think it delivers good health outcomes, not just because it'sa nice thing to have. i think there is a decent chance that if the republicans take another swing at the affordable careact, they will include medicaid as part of that.
the kind of mechanics ofthe legislative process, it is not clear to me that they're gonna actually be able to do that. they're looking down the barrel of a government shutdownover the next month. then they will have to deal with that. then there's a debt ceiling fight that has to come up. before we know it, congress is gonna
be in re-election mode. they wanna do tax reform, they wanna do maybe some sort of infrastructure thing. there's just not a lottatime on the calendar to do these really big items. but i think we could see another swing at the affordable care act, and i think medicaid could be part of that. as far as medicare and social security
are concerned, you're certainly right that speaker ryan would like to do medicare reform. it's just the politics of that. it's not at all obvious to me why the president would want to do that. he said he doesn't wanna do it. he got a lotta support from people in that age group whoare medicare eligible,
certainly people who are going to be medicare eligiblein the next 10 years. it's obviously not something that he really cares about. i think the white housegenuinely cares more about paid leave, for example. there's a group ofpeople in the white house who, it's not just politics. they really would like to do that.
i think if they had unlimited time, unlimited political capital, they might, paul ryan might talkthem into doing medicare, but i just think in a world of scarce time and scarce political resources, it's just not likely to make it to the top of the list. - i agree, and i think medical care is different because ifaffects so many people,
and their advocates on the supplier side. obviously, the hospitals don't want you to pull the plug on federal spending. where i would be more pessimistic, as is my wont, would be food stamps, where there isn't this kind of either provider or that it broadly go. there are 40 million people who benefit from food stamps, but they're,
i try not to follow washington these days, but i believe somebody in power said, well, why do we need aschool lunch program? it's not clear it'sdoing the kids any good. i could imagine a proposal coming through to block grant foodstamps, which would have much higher politicalprospects of passing. the example, relatingback to what janet said, is food stamps is nowthe only entitlement.
if you read the book $2a day by luke shaefer and kathy edin, you seethat in the aftermath of the '96 welfare reform, food stamps has become so much more important. it's sort of 1/3. while other countriesworry about getting people to the poverty line,food stamps gets people to something like 1/3 of the poverty line, but it is uniform across the states.
the argument always is, well, states, if they're freed up fromall the federal rules, what if we block grant wic and food stamps and school lunch and meals on wheels, and let the states dowhat they want with it. that's where you getinto the tanf example, where the recession came and states didn't have money, and theblock granted tanf program, the caseloads didn'tgo up, and they tripled
in food stamps, which wasthe federal entitlement. i think that's the downside, and that may be where the republicansare more successful in moving to block grants. - that brings us to aninteresting and important political question, with respect to who are actually thealliances or the advocates in support of this range of programs? in particular, one of the arguments
that you've seen lately is that many of these programs, i think all those that you just articulatedor listed, sheldon, are vulnerable, in part because most trump voters were actually not poor. trump, in many ways, owed his victory to middle-class, primarily white voters without a college degree, whose incomes were truly in the middle.
some were between 50 and $70,000 a year. for the most part, these folks are not, in fact, the recipients of any of these programs, so there's less political support in the trump alliance, in particular, for these programs. does anybody wanna talk about the fact that there may be quiteweak popular support
for voters who, quote, "count," in this constellation for these programs? is that a concern that anybody has? i am. there's a degree to whichthe president's core base of supporters aremotivated a lot by anger. there have been somesurveys of public opinion that demonstrate that one of the targets of their anger are peoplewho earn less money
than them and who qualify, therefore, for assistance fromprograms they don't have. - we haven't constructeda whole lot of programs where they feel they're getting a leg up. i think that is a source of concern. i think it is true that there are, there's kind of some reshuffling of the kinda typicalalliances in washington. i think it's important,though, to keep in mind
that what we learn fromthe trumpcare fiasco. think about how big of a deal it is that that didn't pass. repealing and replacingthe affordable care act has been the motivating principle behind the republican party for seven years. they won back the house of representatives in president obama's firstmidterm election on this. it helped them recapture the senate,
concern about premiumincreases, specifically. it was a big factor in the 2012 campaign. it was a big factor in the 2016 campaign. it was part of whatfueled the populist anger that started the tea party. the republicans have the white house, the republicans have the house, the republicans have the senate. this is the first thing that they do.
this is item numberone, when the president has his maximum political capital. not only could they not get it passed, they couldn't get it out of the house. that is a devastating failure, in terms of politics. it tells you somethingabout the republican party. it tells you a lotta bad things about the republican party.
- [sheldon] you can seewhy i like conservatives like michael. (laughter) - maybe it tells you something good about the republican party, too, because the trumpcare was a bad bill. it would have resultedin bad public policy. - it was an incoherent bill. - it was not incoherent. it was, i think, perfectly coherent.
it would have created a situation where a whole lotta people couldn't afford health insurance, and sothey wouldn't have had it. it couldn't make it through. why couldn't it make it through? this group of 30 or so, house freedom caucuspeople, wanted some things that resulted in a rebellion of the moderate republicans.
i'm encouraged by this. i don't like the affordable care act. i think the affordable care act is bad public policy. i would like to seethe affordable care act repealed and replaced with something that's better, that would push healthcare in a more conservative direction. - can you say just two words about,
or two sentences, two paragraphs, maybe, about what you think that better, more conservative direction is? - i can. can i first say why i don't like the affordable care act? - it's just not working the way that you would hope. right now, there are 29 million people
without health insurance. 29 million in the united states. for all this talk aboutuniversal coverage, there are 29 millionpeople who aren't covered. the affordable care act is not meeting its own stated goal. if you look at what's happening in the states, you see that premiums for health insurance are going up.
you see that health insurance companies are exiting the marketplace. you see all these statesand all these counties where a person who wants to purchase health insurance has only two options. you see even a handful or two states where they only have one. that's bad. that's a bad situation.
it is the case thatpeople who are purchasing health insurance throughthese affordable care act exchanges are protected,to a large degree, by the premium increases,but all that means is that those costs are being socialized, and for a piece of publicpolicy that's gonna be around for decades. that just means thateverybody has to pay for them, and they're gonna go up and up.
i think that the designof the affordable care act is flawed. it does not do enough to encourage young, healthy people to get health insurance. as a consequence, the pool of people who are insured is, in some sense, too unhealthy, whichincreases the cost of care. that's the principle issue. there are other issues, as well.
the affordable care act leaves in place this link between where you work and your health insurance. i would like to see that taken away. the affordable care act-- - what would you like to see replace it? - i would like to seethose two things delinked. - [janet] michael, you'remaking a great case for the public option.
- that's why i asked him. (applause) - i am not. - i didn't think so. i can just tell mary'sitching to get in here, but i'd love you to finish this. - i'll finish it fast. - no, no. (laughter) - the affordable care act confuses prepayment for routine services
with actual insurance meantas financial protection against unlikely events. the affordable care act does not do enough to pull people in and get them covered. i think that there's a reasonable way to move forward here. step one is to allowhealth insurance companies to offer health insurance plans that don't end up covering yourannual sinus infection,
that don't end up covering when you have a hangnail that won't come out, that actually are insurance against very serious, but very unlikely, events. those plans would be a lot cheaper. then for people who need financial assistance to afford those significantly cheaperpremiums, we pay for them. we redistribute money from the people
who are well off to those people so that they can afford them. where does that money come from? right now, if you haveemployer-sponsored health insurance, it's not taxed. that creates all sorts of problems with the healthcare system. you tax that, that givesya a big pot of money. that's a progressivetax that hits the rich
more than the poor. you use that to givepeople financial assistance to purchase the plans that they need. how do you enroll more people in the affordable care act? the goal should be universal coverage, but it shouldn't be universal coverage for ear infections. it should be universal coverage
for serious accidents, universal coverage for serious illnesses. i think we should lookat auto enrolling people. rather than the individual mandate, which clearly hasn't worked, let's just sign people up and give 'em the option to opt out, but have thedefault be enrollment, and let people choose to unenroll, but they have to activelymake that choice.
i think that would end up covering a whole lot more peoplethan the affordable care act has been able to, and itwould likely be cheaper. - i can't tell if, mary,you wanna get in here. - if this is working anymore. yeah, it is working.- it's working. i think you wanna get in here. - maybe janet shouldorganize another session on talking about alternatives to the
affordable care act because i'm not the best person to make the case against what you've just argued for, but what i would point out to you is that we've seen in new york city a 1/3reduction in the number of people who lack health insurance. among adults, this went from 21% down to something under 14%. for the population as a whole, and we have
fairly universal coverage for children, it went down from something just shy of 15% to a little over 9%. that's the lowest uninsured rate that we've ever documented. going from over 40 million to 29 million is not good enough, i don't think anybody's gonna argue withyou, but it's the best that's been accomplishedin a very long time.
it's because that peoplehave this coverage now that they're not willing to give it up, that this is an example of how politics become local. each one of thoserepresentatives was gonna have to go home and facepeople who potentially would have lost their health insurance. that the efforts toreverse, with this very mean-spirited plan, sayswe're gonna save money
easy by making sure peopledon't have health insurance. that was the design. yeah, it was cheaper, but it didn't achieve its purpose. they weren't willing to gohome and talk about that. but at the same time, i know that the received wisdom is that having a single-payer system or what people refer to as medicare for all is impossible
in our country, even though it's done in just about every other wealthy country. i don't agree with that. i think that that conversation is happening locally. it's happening in states as a bill here. that is closer than iever would have imagined. there's another alternative to what you're talking about, which is saying
that it's not gonna be a tax credit, which is what people love to do here, but it's gonna be an entitlement. it's something that we're gonna provide to the people of this country because everybody needs health coverage. these skinny plans are a rabbit hole. people need to have coverage for all
of their healthcare needs. i don't want some bureaucrat deciding what's serious and what's not. - we've got just a few minutes left. i'd actually like to take, i'd like to actually take us alittle bit into the future. imagine it is 2021. president trump is not our president. i really have no idea who our president
is going to be, but just imagine that the current state of uncertainty, confusion, lack of either intellect or empathy has come to an end, (laughter) but we have lived through four years of debates around how weshould cover americans, with respect tohealthcare, how and whether we should have work-family policies that recognize the numberof two working families
and that also recognize that we still have a lot of peoplein poverty who require food stamps and other kinds of cash or non-cash assistance. i'd like anyone who wantsto, is there any good that can come of this confusing, i guess you could call it creative period we're in now where people are throwing all kinds of ideas, many not great,
maybe some that areunconventional, though, against the wall, such that in 2021, when we have different and hopefully more steady political leadership, some better things can come to pass. that's what i'd like us to address. - if i go back to what michael just said, i think it's the, and wesort of saw that here, it's the difficulty tohave measured discourse
that 60% of the people might agree on. i like the idea of taxing employer-provided heath insurance. for a high-income person like me, i believe in income testing. i should not have a 25 deductible that i used to havewith my health insurance when i went for my annual physical, and now it's free.
i don't need that. i think the model is can you get, in a variety of areas, reasonable people who are experts? i heard somebody say, ajay chaudry and hiro yoshikawa have a new russell sage foundation book, which you can all rush out and buy, called something like an equal childhood,
where they have a plan, which they thought the new clinton administration would be interested in, forspending more on children from zero to k. i thought i heard them say something like trump's plan isn't bad for people between 50,000 and 250,000, ithink it cuts off at 250, if they would only add this on for people who are below 50.
but the problem isfelicia sort of thinking we're gonna get out of all this. i'm thinking 2021, the congress might be disbanded, and trumpand bannon may be running the country without. (laughter) - [felicia] i was the one who was afraid of the lord of the flies, apparently, so i'm trying to be my better self here. - i think in every area,it's just we're not
doing that, whether it's k-12. there are problems in the public schools, but vouchers aren't the simple solution. we're not in an environment, i think, we're in areas that are of deep concern to many people. you've got a mechanism by which people could sit down and work out a compromise that would improve the status quo
and would be viewed that way by a large percentage of the people. - just to pick up onthat, i would say that, i don't know who's gonnabe president in 2021. i can't even imagine. i think that this area of increasing social protections for working people, especially those who havecaregiving responsibilities, whether those arechildren or aging parents,
i actually think there is a huge potential for some bipartisan support. i'm encouraged, michael,by what you're saying about the paid leavebecause it's been hard to know what is really going on. i would love to hear, and i'd love to be part of that discussion. i've spoken to many, many audiences in washington over 20 years on this topic,
and i really would love to hear what they're thinking about. the reason, though, that i think that there's hope there, oncewe can sort of move away some of the craziness and the dysfunction of this current white house, is that it is actually an old story in the us, on both sides of theaisle, that people believe that if you work, youshould not be destitute.
if you play by the rules of the game, you should not live alife of extraordinary economic insecurity. we heard that language from the right during the welfare reform. if ya get up every day and you go to work, you shouldn't live alife of economic terror. even moving further up, why should people be so stressed out?
all i mean to say is that that is a place where i think that there'sroom for consensus. i remember senator stevenson from alaska, the late senator stevenson,who was quite conservative, was a supporter of paidfamily leave, actually. i actually spoke to him once. i said, "why?" he said, "'cause we have six kids "and i know how much work it is."
but the point is that that'sa place for consensus. if the trump administration,because of ivanka or whoever else orwhatever forces, can make this move forward, that would be historic. i would love to be part of that. - well, on that optimisticnote, i would like to thank all of ourpanelists, as we think forward to 2021 (applause) and abetter social safety net. thank you all for coming this evening.
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