Winston Fellowship Weekly Report

Kripa Sreepada July 22, 2016

Winston Fellowship Weekly Report Week 5: July 18-July 22

Monday, July 18

Stuart Altman, Professor of National Health Policy at the Heller School for Social Policy and Management at Brandeis University: It was such a pleasure meeting Dr. Altman, who has experience working on every single health reform effort in the past 50 years. We learned about the progression of the health reform debate from the 1930s until today. It was so important for us to learn from Dr. Altman, who provided a long-term view of the fundamental issues driving the need for health reform. This provided an invaluable context that will assist us as we approach health policy issues in our careers. Dr. Altman insisted that it is difficult to pass health reform that increases coverage while also containing costs. For this reason, the next major health policy issue is how the government decides to limit what it spends and what the private sector will do about it. This is a cost-containment issue, not a coverage issue, and it will require delivery system reform. He advised us to pay attention to state-level delivery system reform. Dr. Altman also cautioned that long-term care is a microcosm of what the U.S. health system could be if we do not fix it; a deep divide in public versus private spending resulting in disparate quality of care and health outcomes.

AFL-CIO: We met with Bill Samuel, Director of Government Affairs and Tom Leibfried, Legislative Representative of Government Affairs at AFL-CIO. Tom and Bill explained AFL- CIO’s two-pronged perspective on healthcare advocacy: consumers and health plans. Consequently, in their advocacy efforts, they must work hard to balance the goal of affordable healthcare for workers with the interests of health plans, which are jointly managed by management and labor in most unions represented by AFL-CIO. The most important issues for Bill and Tom were the Cadillac tax, which they want to delay and repeal for the purpose of assuring affordable health coverage for workers, and raising the minimum standard plan on the ACA exchanges from silver to gold. Tom believes the high levels of cost sharing in the United States are what make our country’s health system unique and particularly difficult to reform. Bill and Tom also believe Congress’s failure to commit to its risk corridor payments is the reason why health insurance co-ops and marketplaces are struggling to perform. It was meaningful to learn from Bill and Tom about the great level of influence AFL-CIO has over healthcare, particularly for Democrats. They played a major role during the ACA negotiations, and it was interesting to learn how industries who came to the negotiating table early on did not feel as much of a pinch from the law on the back end.

America’s Essential Hospitals (AEH): We met with Bruce Siegel, President and CEO, and Beth Cameron Feldpush, Senior Vice President of Policy and Advocacy at America’s Essential Hospitals. They are both very passionate about their work and hold a high regard for their members, which are 275 essential hospitals in 37 states. We learned the history of how AEH defines an essential hospital. Today, these are the hospitals that do what others will not: care for the uninsured, act as first responders in public health and natural disasters as well as fatal gun shootings, serve as community hospitals, and be driven by a mission to care for the most vulnerable patients. Bruce stated that AEH’s overall goal is to assure the federal government does not believe Medicaid expansion in all 50 states will solve all problems for essential

1 Kripa Sreepada July 22, 2016 hospitals. They still must work to cover undocumented immigrants and to protect money-losing services. Beth is working with Congress on legislation to fix risk adjustment, which is contributing to health disparities, and to fix hospital star ratings to account for socioeconomic status (as AAMC mentioned as a key policy priority during our meeting a few weeks ago). It was great hearing about AEH’s health policy strategy and what they view as the greatest challenges still facing essential hospitals post health reform.

Dinner with Elizabeth Lee and Catherine Oakar: Elizabeth and Catherine treated us to dinner just around the corner from our office at The Hamilton. It was very relaxed, and they made many recommendations on additional organizations and individuals we should try to meet with. They also helped us appreciate the bigger picture of the fellowship and the reality that many fellows like themselves may have not decided on a “textbook” placement decision. I also loved seeing how many incredible experiences they have already had largely because of the springboard provided by the fellowship.

Tuesday, July 19

Cari Young, Health & Science Policy Fellow in Sen. Whitehouse’s Office: Jennifer DeAngelis, Senior Health Policy Advisor in the Office of Sen. Whitehouse, connected us with Cari. We appreciated the chance to learn about Cari’s decision-making process that brought her to work for Sen. Whitehouse. We also learned about Cari’s projects, which included a report investigating the international tobacco lobbying activities of the U.S. Chamber of Commerce. It was very impressive to learn that the press reported on her investigation during her short period working as a fellow for Sen. Whitehouse. Cari also advised us on specific questions to ask of offices in order to better anticipate our roles as fellows. Ultimately, Cari said our placement decision depends on what we prioritize as most important.

Kristi Martin, Senior Advisor at the Office of Health Reform, US DHHS: We had a great conversation with Kristi Martin, who has 8 years of experience working for the federal government with positions at DHHS, OPM, and CMS. Before the end of the current Administration, Kristi is most interested in developing women’s health preventative guidelines, working on Medicare Part B drug payment, and working on issues impacting IHS (e.g. the definition of “Indian” is not consistent throughout the ACA). Given Kristi’s heavy involvement in ACA implementation and work in the Multi-State Program (MSP), we also engaged in an informative conversation on the greatest challenges impacting the state-run exchanges. Kristi believes the upcoming challenges for the state exchanges are changes in state leadership, finding sustainable revenue streams, and better serving consumers through decision support tools. We also discussed the root cause of failure for the insurance co-ops, which did not receive the robust support needed to survive in the insurance market, and whether a public option is politically feasible in the coming year. Kristi believes the Senate would be able to push the public option through if it were advertised under new terminology, but a financing structure similar to Medicare would assure the success of the public option. Regarding placements in an agency, Kristi advised us to be weary of changes in leadership due to shifting of political appointees and to work on stable projects to assure you have a critical role even when your mentor moves on.

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Brian Shuy, Senior policy Advisor for Congressman Andy Harris, MD: We learned a lot about Congressman Harris’ health policy positions, which are driven by his background as an obstetric anesthesiologist and NIH researcher. Congressman Harris sits on the Appropriations Committee, within which he is member of the subcommittees for the FDA and Labor, Health, Human Services, Education, and Related Agencies. Congressman Harris is most interested in working on issues pertaining to the NIH. Specifically, he wants to provide grant funding to encourage early investigators, to minimize research duplications, and to move toward institutional NIH reform. Congressman Harris also supports the 21st Century Cures package and is hopeful that it will contribute to finding a cure for Alzheimer’s disease, which contributes to trillions of dollars spent on the affected population. Given Congressman Harris’ interest in funding research, we discussed his position on funding to find a Zika cure. It was interesting to learn the conservative view of the issue. According to Brian, the White House asked for $1.9 billion in Zika funding, though their recommended package suggested cuts to other vector-spread diseases, suggesting that the funding is meant more as a bailout to Puerto Rico than combatting Zika. Furthermore, the White house has yet to spend all of its $593 million in funding that was specifically re- appropriated to fight Zika. Finally, as there is only one case of Ebola remaining, it is logical to dip into unused Ebola funds for the money requested to fight Zika. This explanation was a bit confusing for me, as it seemed to contradict Congressman Harris’ fundamental interest in assuring enough research funding for public health issues. Regardless, it directed me to better understand the full Zika package proposed by the White House. Brian also provided his valuable insight on how to succeed on the Hill.

Happy Hour at Lincoln Policy Group: Kim Zimmerman at AHCA connected us with former Sen. Lincoln’s firm, the Lincoln Policy Group, who invited us to a happy hour to honor the recipients of the BA Rudolph Foundation Scholarship. It was an intimate gathering at the Lincoln Policy Group offices, and we had the chance to meet Sen. Lincoln herself. She is very inspirational and encouraging of young women interested in any form of public policy or public service. My favorite part of the happy hour was learning Sen. Lincoln’s mantras for success: disagree today but agree tomorrow; if you’re passionate about changing an issue, then do something about it yourself; and look for the good in everyone! We had some great conversations and got a few more contacts for suggested additional meetings.

Wednesday, July 20

Robert Moffit, Senior Fellow, Center for Health Policy Studies, The Institute for Family, Community, and Opportunity at The Heritage Foundation: We had a great meeting with Dr. Moffit, who was the second person this week to provide us with the historical context of the health reform debate (the first being Dr. Altman). His key takeaway for us is to understand that so much of what happens in health policy is driven by external factors that are not directly related to healthcare. In fact, health policy measures are often meant to solve an unrelated economic or societal crisis. Dr. Moffit asserted that some of the major problems with the U.S. healthcare system are because it is a mixed economy rather than a free market. Furthermore, the healthcare market is structured so that healthcare costs increase much faster than the rate of inflation. For Dr. Moffit, the greatest healthcare challenge is the tax treatment of employer- sponsored insurance. He also provided us with his plan to fix Medicare in order to address Medicare insolvency. Finally, Dr. Moffit lauded Joe Antos as the number one Medicare expert

3 Kripa Sreepada July 22, 2016 in Washington, D.C. I appreciated learning Dr. Moffit’s perspective, and it was such a privilege to be able to meet with someone named as a, “top conservative to meet in your lifetime.”

Sarah Smith, Health Legislative Assistant for Sen. Klobuchar: Sarah Smith brings great energy and enthusiasm for all of the health policy issues she gets to work on in Sen. Klobuchar’s office. I love how she described her job: she is paid to learn! It was interesting learning about Sarah’s daily activities given that she is an office of a member who is not on a committee of jurisdiction. She has a lot of leeway in defining Sen. Klobuchar’s policy priorities, and she is not as involved with hearings, which helps her explore health policy more in depth. From Sarah’s description, fellows in Sen. Klobuchar’s office would set their own health policy agenda and be heavily involved transforming a policy idea into a bill. Sarah provided us with some insight on the policy development process in Sen. Klobuchar’s office, which is very structured compared to other member offices we have met. Sarah’s health policy portfolio includes aging issues, in which she drafted a bill addressing the financing of LTSS. I made a note to myself that it would be very important to keep Sarah close, as her policy work is very aligned with my interests in aging policy through Medicare and Medicaid financing reform.

Congressional Budget Office (CBO): We met with Tom Bradley, Chief of Health Systems & Medicare Cost Estimates Unit, and his entire team. Tom provided us with an overview of CBO’s operation and his office’s primary role working on baseline projections. Their daily work is driven by the calendar. I was most interested in learning about the work they do for their clients after the President’s budget is released in February or March. CBO works with the House and Senate committees of jurisdiction and relies on those committees’ priorities to set their own agenda. I was also so amazed by the work that goes into the development of each CBO score. In a brief amount of time, CBO analysts must meet with key stakeholders who would be affected by a piece of legislation and agencies who have knowledge about how a policy would change different systems. From this information, they determine a score. However, CBO can also make adjustments in key parameters to help their clients reach a given goal. CBO is nonpartisan, holds all meetings confidentially, and does not put forth policy proposals based on the information it obtains. Tom and his team wanted us to know that CBO is not the enemy; they are trying to solve our problems! They recommended that, should we decide to work as a Hill staffer, we should meet with CBO early and often throughout the legislative development process. I really liked the timing of this meeting because it allowed us to have an appreciation for everyone’s perspective of CBO before we finally met with the organization. They are a key aspect of the legislative process, and our meeting was a reminder of the value it would be to understand the depth of how CBO scores in the health policy space.

Lisa Simpson, President and CEO of AcademyHealth: Lisa has a very impressive presence and background. She provided us with a list of people to meet with based on our individual interests, and she walked us through an overview of AcademyHealth’s key initiatives. Lisa informed us that they use the term “evidence” rather than “research,” as “research” depicts an activity that is too long-term and disconnected, while “evidence” is more relevant to today’s problems. In its advocacy efforts, which are very narrow given its non-profit status, AcademyHealth is most interested in advocating for science to advance healthcare. Lisa also provided us with advice on how to make ourselves valuable during our placements, and she pointed to the research sources we should use in our memos and other writings depending on the audience. My favorite line of

4 Kripa Sreepada July 22, 2016 advice from Lisa was, “Data make you credible, but stories make you memorable.” These are words of wisdom to remember as we strive to make ourselves valuable wherever we land.

Thursday, July 21

Lunch with John Barkett and Devon Trolley: John and Devon treated us to lunch in Bethesda, which was a great area to see for the first time. We had a relaxed conversation about our favorite meetings and theirs, and they shared their advice regarding how to approach our placement decisions. They were advocates for the Hill as a door-opening first step, and they advised us on how to weigh the pros and cons of each placement opportunity. They cautioned us not to be too turned off by a potential mentor based off of only one interaction with him or her. John and Devon are also connecting us with more contacts to meet with over the next few months.

Friday, July 22

Jacqueline (Jackie) Usyk, Senior Policy Advisor for Congressman Cardenas: We are grateful that Jackie took the time to meet with us. She was originally scheduled to be at our first meeting with Congressman Cardenas’ staff, but she was traveling with the Congressman and was unable to attend. We learned about Congressman Cardenas’ health policy priorities, which are focused on the intersection between the justice and healthcare systems. Congressman Cardenas also supports research funding for innovative therapies and cures. Jackie spoke very candidly about her position and life on the Hill, and we appreciated her honesty. She discussed some of the challenges she faces while working on health policy with the health subcommittee staff of the Energy and Commerce committee. Specifically, Jackie discussed the policy implications of a lack of racially diverse committee staff and the problems with working on health policy that falls outside of the strict confines of committee jurisdiction. The first challenge regarding diversity prompted me to reflect on the depth of experience I have working on diversity and inclusion issues at Saint Louis University. This is something I never bring up during our informational interviews, and I wonder if I am doing myself a disservice. The second challenge Jackie mentioned was a reminder of our previous conversations with Robin Strongin. It is so easy to get wrapped up in the silos and confines of jurisdiction on the Hill, and this unfortunately limits innovative approaches to in health policy. We were grateful for the new insider knowledge Jackie shared with us.

Blue Cross Blue Shield Association (BCBSA): We met with Alissa Fox, Senior Vice President in the Office of Representation; Stuart Hagen, Managing Director; and Kris Haltmeyer, Vice President of Health Policy and Analysis. The focus of our discussion was the stability of the health exchanges. The BCBSA team pointed toward special enrollment periods and grace periods for enrollment as the key factors lending to instability of the insurance risk pool. Their non-profit status makes BCBS members committed to stay in the exchanges even when they are losing money, but it is understandable why for-profit insurers are pulling out. Moving forward, BCBSA hopes a new administration will consider implementing its recommendations for strengthening the marketplaces, as there is no hope on the legislative side. However, Kris made a valid point that our conversation and media attention is on the exchanges when it is truly only 10% of their business. In the group insurance market, premiums are stable and successful!

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Senate Finance Committee Subcommittee on Health, Majority Staff: We met with Erin Dempsey, Senior Health Policy Advisor, and Jennifer Kuskowski, Senior Policy Advisor. They explained the legislative process from their perspective using the Chronic Care Work Group as an example. I appreciated their attention to detail and realized during the meeting that the Chronic Care Work Group’s call for stakeholder comment was a major priority for NCOA when I worked there last summer. This increased my depth of appreciation for the thorough work of congressional committees, who must gather and incorporate all stakeholder feedback into their final product. We were surprised with the advice offered by Erin and Jennifer. Though they did not want to steer us from work on the Hill, they kept recommending the private sector as a noble place to work on health policy, and they seemed to be confused with the Winston Fellowship even after our standard explanation. However, they provided us valuable advice on how to find a Hill position after the completion of our fellowship.

In the News this Week: RNC Convention in Cleveland; Donald Trump Accepts the Republican Presidential Nomination; First non-sexual and non-mosquito transmitted Zika case in U.S.; Fox News CEO Roger Ailes steps down; Fatal mall shooting in Munich, Germany