Rae Woods: From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. A new administration needs an opportunity for policy change in healthcare, but how big could those policy changes actually be? Rae Woods: And how can healthcare leaders differentiate between just political hype and the practical policy changes that will make an impact in this industry? To make sense of it all, I've brought back strategy expert Ben Umansky and added a new voice, another strategy expert, Rob Lazerow. Hey, Rob. Hey, Ben. Welcome to Radio Advisory. Ben Umansky: Good morning. Rob Lazerow: Thanks for having me. Rae Woods: I'm going to try to ignore the fact that both of you have been my boss at different points in my career at Advisory Board, and instead just have a conversation about the future of healthcare. Rob Lazerow: And [inaudible 00:00:59] boss. Rae Woods: That's right. That is exactly right. Ben Umansky: I think your star has risen at this point. We're happy to be your guests. Rae Woods: We are going to be talking about policy, but I almost feel like we need to start with a little bit of a civics refresher. Maybe without going to Schoolhouse Rock on me, Ben, can you just take a moment to remind us where policy actually comes from? Ben Umansky: Oh, gosh. Well, I'll try to do it in a moment. We've got three branches of government. You've got Congress, they write laws, and they write laws that matter for healthcare. And we've seen that over the years with the Affordable Care Act chiefly among them. And we'll talk a lot about that today, I'm sure. Ben Umansky: There's another branch, the executive branch, which has tremendous authority not just vested in the president, but in all of the agencies, all of the departments, the rule making. If Congress writes a law that says, "The Secretary of Health and Human Services shall..." well, then the Secretary has got to do that. Ben Umansky: And that's up to the administrative departments, and there's a tremendous amount of power there. And then we shouldn't forget that the judiciary has some influence here as well, in terms of how far those first two branches can push, [inaudible 00:02:08] the nuances of how some of these things work in practice. So there's a complicated zoo here in Washington that it spits out policy, and at State levels as well, I should add. Rob Lazerow: And, Ben, don't forget that even within the executive, there's a difference between being given a new law from Congress that they then have to implement for the first time. Rob Lazerow: So we just went through that with the price transparency rule that went into effect at the beginning of the year versus a new administration coming in and issuing its initial set of executive orders, which have the force of law and tell an agency to go do something, but without having Congress having to act first. Ben Umansky: That's right. And some of those orders that we've seen from the Biden administration undoing orders from the Trump administration, none of which is involving Congress at this point. So yeah, a lot of moving pieces. Rae Woods: And so let's talk about the role of Congress itself. I am sure that you all have been hearing a lot of the conversation in the media comes back to what will happen with the Filibuster. We've actually talked about that a little bit on this podcast. But again, remind us why is the Filibuster so important in terms of what Congress can get done? Rob Lazerow: Well, what's important to remember about the Filibuster is it requires a degree of either bipartisanship or dominant control in the Senate. And that it requires a 60 vote majority, not a simple majority, to move any piece of legislation to that final vote, to end debate, so to speak. Ben Umansky: And we should remember that this is, in some sense, a feature not a bug. Although it's not in the Constitution, the Filibuster was actually instituted, I think, in 1806, the Senate Rules. But the Senate is there to slow things down. The Senate is a check on the passions of the House. And so that is something that the founders intended, to a degree. Ben Umansky: Now there's a real concern that things have been bogged down for years and years, regardless of who was in power. And so there's always this conversation about, should we dispense with this rule? Rae Woods: That's right. Ben Umansky: Should we allow things to go forward with a simple majority? And of course, the minority has an interest in that not happening. And so knowing that you may be in the minority in the future, the majority has been lowered to do this. And this has been a conversation for years, we're having it again now. Rob Lazerow: And we've seen a change, so there's no Filibuster to nominations, judicial or otherwise so that's why those can pass with a simple majority. We also are past the point of Strom Thurmond having to talk for 24 hours straight to uphold a Filibuster. And now it's much more of a procedural process. Rae Woods: That's right. And Ben, I want to take your point very seriously that every majority for forever has faced this temptation. And I think that's especially true now because the margin in the Senate is quite literally as thin as it can get, 50 Democrats, 50 Republicans, vice-president Kamala Harris acting as the tie breaker. Ben Umansky: Correct. Rae Woods: But I think it's important to remember that the Democrats aren't necessarily in lockstep, especially when it comes to healthcare. What kind of an effect is that having? Ben Umansky: Oh, it's huge. And I think you'll see this play out for years to come. If you think about those 50 votes in the Senate, who is the face of the Democratic Party in the Senate? Well, you could argue it's Chuck Schumer who's majority leader, partisan institutionalist. Ben Umansky: You could argue that someone like Bernie Sanders represents a large wing of the party. He's chair of the budget committee now, definitely a powerful figure, pretty far left figure. But Joe Manchin from West Virginia, conservative Democrat, pro-life Democrat, opposed to a lot of restrictions on fossil fuels and stuff because he comes from West Virginia. His vote counts just as much. Ben Umansky: And so that means that this is a party that, to hold the 50 votes, has to hold both of those wings and everybody in between. And that is a tremendous challenge for leadership, leader Schumer in particular, but really for the entire caucus to find something that is going to be comfortable for all wings. Rob Lazerow: And something that I keep hearing about is this idea that we'll see who's the king or the queen of the Senate who will be able to hold his or her 50th vote and extract whatever policies he or she wants from it. Rob Lazerow: I'm actually waiting to see if that plays out or if we'll see the emergence of a group of Senators who come together and form a more centrist block, who can sway policy from the middle. Rob Lazerow: Because as much fun as it sounds to become the king or the queen of the Senate, it sounds exhausting. You're always in the hot seat, and it probably makes for a pretty uncomfortable re-election campaign. Rae Woods: And the bigger point I hear both of you making is that, quite literally, every single vote matters. And it also means that every single Senator can be the 50th vote, meaning they can put in whatever piece that they really care about as part of the rule making process. Ben Umansky: Well, and they could also fail to be. So let's think about the fact that if anybody doesn't show up some day. Rae Woods: That's right. Ben Umansky: Because they've gotten ill, because they've gotten COVID, because they just took a day off. Suddenly, that bare majority is down to 49. We've seen Senator Leahy hospitalized in the last week and a half. There are a lot of very old people on both sides of the aisle. It is a picture that could change at a moment's notice, and that will complicate things. Rob Lazerow: And vice president Harris doesn't get to come in and become the 50th vote. She can only cast her vote if it's a 50/50 tie. Rae, I feel like we skipped a step. We might have to go back to our civics lessons. So we started talking about the Filibuster and 60 votes, and now we're talking about 50 votes, and I think we missed something in the middle, the reconciliation process. Rae Woods: Yeah, let's get into it. Why does that matter so much here? Rob Lazerow: So the reason it matters and frankly, the reason that having 50 votes on the Democratic side is so much more important for them than having 49 votes is that there is this process called budget reconciliation where the Senate can pass a law without needing the 60 votes to end debate. It's called the reconciliation process. Rob Lazerow: But the problem is it can only be used literally to reconcile the budget. It's only supposed to be used three times a year, one for a spending bill, one for a revenue bill, and one for a bill around increasing the tax limit. So the advantage for Democrats is there's a process that they can use to pass legislation with their bare majority. Rob Lazerow: The downside is it can only be used for things that are budgetary in nature. And in fact, Republicans can object to anything and it goes to the parliamentarian who would then decide if it is budgetary in nature. And you can only use it three times a year, so it's not this hammer they can bring out over and over again, regardless of how much you're going to hear about it in the news. Ben Umansky: Yeah. Rob, let's look at an example of this in practice. Very recently we've seen, on the one hand, the Democrats propose this very large, further stimulus, one point something trillion dollars. And it's got a bunch of stuff in it, and minimum wage legislation, all kinds of things they want. Ben Umansky: And one option they have is to try to push that forward through reconciliation. Hold their 50 votes, get the parliamentarian to sign off on it, not a slam dunk, by the way, and get big things done. Meanwhile, you got 10 Republican Senators saying, "Hold on, let's meet somewhere in the middle. Let let's have a much smaller bill, but you're going to get some bipartisan support." Ben Umansky: The Democrats have a choice now. And Bernie, chairing the budget committee, pretty influential figure in this. This is going to be a decision that they're going to face over and over, as long as this is the balance of power in the Senate. Ben Umansky: How important is the commitment to bipartisanship that president Biden campaigned so heavily on and I think, to a great degree, really believes versus what he also believes, which is that you need to get stuff done? And then there are priorities and you owe something to the base of the party. Again, it's not going to be an easy road by any means, but they do have options. Rob Lazerow: You're highlighting the fact, Ben, that unified control isn't just trying to keep the 50 votes in the Senate together, but it's also coordinating with the House and its fairly slim majority. Not as tight as the Senate, but still pretty slim. And then the White House unified control, it requires a lot of unity and coordination. Ben Umansky: And now you hear about AOC, maybe primarying Schumer for his Senate seat. So there are some tensions in the Democratic Party across the Houses as well. Rob Lazerow: And in the Republican party too, though. Ben Umansky: [inaudible 00:10:09]. Rob Lazerow: So we, right now, talk of primarying Liz Cheney out in Wyoming. Rae Woods: That's right. That's right. And everything that we've talked about thus far are... I almost feel like there are these braking forces. Maybe even, they were put in place in order to be a brake. But they're ultimately things that may prevent big radical change from happening when it comes to policy in general, but in particular health policy. Would you agree? Ben Umansky: For sure. Not to say there won't be changes. Any issue as significant as healthcare that touches so many jobs, that touches so much money in the economy, that is felt at every kitchen table, things are going to happen. Ben Umansky: But that doesn't mean that we should be expecting ACA 2.0 in that overhaul the fundamental underpinnings of the system the way that, to some degree, we did see at the beginning of the Obama years, and we thought we might see it again in the Trump years with the repeal and replace conversation. I don't see things going in that direction, at least at that scale during the next few years, at least. Rob Lazerow: Well, and let's look at two moments in that history period that you just mentioned, Ben. So one, let's go way back to more than a decade ago when we were all watching and commenting on the debate around the Affordable Care Act. Rob Lazerow: And we saw even with the Democrats in the Senate, having 60 votes, how complicated that process became when Ted Kennedy got sick and passed away and was replaced through the special election by Scott Brown. Rob Lazerow: And suddenly, the Senate couldn't vote again and the House had to pick up the Senate's bill and implement it, even though that wasn't the original game plan. So we saw how precarious 60 seats are, 50 isn't 60, but 50 also isn't 63 or 64 to give you some wiggle room. Rae Woods: That's right. Rob Lazerow: Roll the film forward. And then Republicans realized, even with a majority and the ability to use reconciliation, they couldn't get everything they wanted done. And repeal and replace fell short with John McCain and Senator Collins and Murkowski. Ben Umansky: Yeah. Rae Woods: So all of this means that we might not be expecting some of the revolutionary changes to healthcare that maybe was talked about on the campaign trail. And this is a good moment for me to add in that Advisory Board is a nonpartisan institution. Rae Woods: I want to talk about the other moderating force beyond the practicalities we've been talking about thus far. I have to believe that one of the reasons why we might not be seeing revolutionary change happen in healthcare is that we are currently living through a healthcare crisis. Rob Lazerow: Absolutely. And the number one thing that I think voters voted on, regardless of how they voted, was Coronavirus and responses, and whether to continue with the Trump administration policies or begin to pivot to the Biden administration's policies or at that point, Canada Biden's policies. Rob Lazerow: But that's the big issue policymakers were elected to solve. And that's why so much of the early focus, both from the executive orders, as well as the legislation that Ben mentioned before that's being debated right now is about COVID relief. And so much of the focus is on vaccine distribution. Rae Woods: Yeah. Do you think that that is going to be the only major change we see in healthcare, is the focus on the pandemic itself? Rob Lazerow: I don't think it can be, but the pandemic is the big story right now, and it eats up all the oxygen in the room rightfully. So I think it's hard to push on other major policy objectives while that still is looming. It's hard to imagine a big conversation about reversing hospital price transparency right now. Maybe that's not in the realm of big things, but this is still a seismic issue for policymakers to be dealing with. Ben Umansky: Yeah, I think about it at two levels. One is the public debate level. And I agree with Rob entirely that for so long, as many of us are still hiding in our basements, and not going to work, and the economy is hamstrung, the pandemic is issue number one, including for all other issues. Ben Umansky: Because if you think about the budgetary constraints from fewer tax dollars coming in because of a bad economy, you got to get this sorted. I will say that there's a lot that happens in healthcare that's not at the level of the mainstream public debate. Rae Woods: Sure. Ben Umansky: So there is rule making, there are iterations on your value-based payment programs. There are rules about price transparency, as you mentioned. There's a lot of stuff that is continuing to evolve. The civil service continues to function. Ben Umansky: And for those of us, as I imagine most of our listeners are, who are in the industry, yes, big things are going to happen. They just may not be legislative overhauls the way that we are accustomed to thinking about from a decade plus of ACA. Rob Lazerow: And your point about the civil service is spot on. So we have all of these Democratic leading policymakers who have been out of the executive branch for the past four years, and maybe they've been in think tanks, maybe been in academia, maybe been in consulting who are now coming back into power and have all of their ideas of what they should be doing with things like value-based care, for example. Rob Lazerow: So I know all three of us are anxiously waiting to see who will be nominated to lead CMS and lead the Center for Medicare and Medicaid Innovation, CMMI. And those agencies and those leaders are much more important for the executives that we work with day in and day out than a lot of the secretary level appointments we've seen so far. Rae Woods: I almost want to keep talking about these big changes that could happen in healthcare. Or if they were to happen, how would the dominoes need to fall in order to get there? Rob, you said that Coronavirus is issue number one. In your mind, what's issue number two and maybe number three? Rob Lazerow: So issue two for me would be coverage expansion. And that is a corollary of the crisis, and that's a corollary of the pandemic because of the toll it's had on the economy. Rae Woods: That's right. Rob Lazerow: So as people are losing employer-based coverage, that drives up uninsured rates. So I think there's going to be a push toward coverage expansion. In fact, we just saw in one of the most recent executive orders, a special enrollment period for the public exchanges, so that would be one vehicle for expanding coverage. So two would be coverage expansion. Rob Lazerow: But three, and this is in a longer time horizon, would be back to cost control. So because of the pandemic and tax revenues coming down with the state of the economy, we've now seen the projection of when Medicare's hospital trust fund will become insolvent, move forward from 2026 to 2024. So by the tail end of this current administration, that's going to require a solution. Rae Woods: And these are both huge challenges. And I should say that unlike the pandemic we're currently living through, these are challenges that we knew about for some time. In fact, they probably would have been goals of whatever the new administration was going to be, regardless. Rae Woods: It's almost like the dial has turned up a little bit because of the impacts of the pandemic and its downstream side effects. So let's talk about coverage. I know there was a lot of talk on the campaign trail about a public option. How realistic is that now? Ben Umansky: First of all, campaign promises are not policy, and we should always distinguish that. Not to say that we shouldn't hold politicians to their word, but we shouldn't always expect 100% delivery on that. Ben Umansky: It's a very, very uphill climb to something like a public option for all the reasons that we've discussed related to Filibuster, the narrow majority in the Senate, the fact that at least one Democratic Senator Joe Manchin has come out and says he's not in favor of a public option. A lot of dominoes would need to fall to get something like that done, at least in the way that we can [crosstalk 00:18:34]... Rae Woods: At least at the federal level? Ben Umansky: At least at the federal level. Right. So there is the potential for States to move on their own. And we've seen over the last couple of years, [crosstalk 00:18:42]... Rob Lazerow: Like in Washington. Ben Umansky: Washington start their own public options, although pulling back in some cases. Momentum's a little tough, budgets are a little tough. But I would also add that even at the federal level, I would not be surprised to see some branding effort around coverage expansion on the margins, whether it's Medicaid or exchanges or whatever else used to tick that box. To say, "Yeah, you know what? We did give a lot more people access than they had it before and it's a public option." Rob Lazerow: So, Rae, it's striking to me how much the conversation has changed since the Democratic primaries, because you jumped right to public option. You didn't even ask about Medicare for All because that is so far away from the possible right now. Rae Woods: Mm-hmm (affirmative). And we were just talking about the difference between what can happen at the federal level versus at the State level, which immediately makes me think about the potential for Medicaid. Rob Lazerow: Absolutely. And we've seen States continue to slowly enter Medicaid expansion more recently through ballot initiatives. So we saw that happen in Missouri, and that's set to go live this year. There's now talk of ballot initiatives in three States. One of them is one of the two big prizes, Florida. Although I have yet to meet a hospital leader in Florida who thinks there is legs behind that, but we'll see how the process plays out. Ben Umansky: So it is a State level decision whether to expand Medicaid or not. The feds do have a little bit of thumb on the scale as far as waiver authority. So one of the things that we've seen over the years is you had a first crop of States who said, "Absolutely, we're in. Let's do it. Let's go." Ben Umansky: And then you had a second crop that said, "Well, we'll do it but only if... We want a little bit of tweaks in the rules here. We want freedom to do this or that," or whatever. And you saw conversations about things like work requirements, which we've run into some legal challenges, but all kinds of bells and whistles that States try to add on here. Ben Umansky: The posture of the feds, the posture of CMS [inaudible 00:20:40], whether those are approved or not, will go a long way to determine how many more States jump in, and what the state of coverage is in existing expansion States who may try to change those terms at some point. So that's something to be watching. Rae Woods: And that is a really good example of some of the small changes that might not be picked up by major news outlets, but will have a pretty serious impact on leaders in healthcare. Ben Umansky: Including across States. I think a lot of people will recognize that they need to watch what happens in their own State. But with Medicaid, you really got to watch the other 49 because policymakers are. They're looking at what experiments are tried and what the results are, and whether there's an element of that, that we should pour it over to our State. Ben Umansky: And this is a conversation that goes on in academic circles, in policy circles, in governance circles. No one has time to literally track all 50 States, but you should be aware of what kind of stuff is happening out there and where some of those experiments are. Rob Lazerow: And for example, we have more than a dozen States that have some form of Medicaid ACO right now. I remember when we used to point to Oregon as the main example, there are now plenty. Rae Woods: Yeah. So these are all levers that can be pulled for that challenge and actually, I should say, the goal of expanding coverage. But Rob, you said that there was another big challenge in the top three, which is cost. Rae Woods: I know the three of us have been talking about the affordability challenge for some time. And on the one hand, I agree that it's taken a back seat to COVID and the economic crisis. But on the other hand, it's not like our cost problem has actually gotten any better in the last 11 months. Rob Lazerow: No, it hasn't. I think part of what's happened is the cost conversation, it hasn't totally gone away, but it shifted from one about macro level, the cost of healthcare for America and much more micro, the cost of healthcare for an individual. Rob Lazerow: So I think about the bill of the month article that comes out from Kaiser Health News every month with someone's very personal story and generally a pun in there somewhere. Rob Lazerow: But a very personal and often sad story about their extreme example of healthcare costs often with a surprise bill, hence the bill of the month piece. So I don't think it's disappeared, it's changed. I think it will pivot back to the macro conversation though, as we get closer and closer to this insolvency issue. Rae Woods: So what is actually on the table for the Biden administration to actually address...? Let's take the Medicare solvency problem. Rob Lazerow: So I think there are a few things that are well underway. I think the site of care shift from hospital inpatient to other settings, or at least hospital outpatient reimbursed at a lower rate. That's out the door. That will continue. Rob Lazerow: And COVID has both accelerated, it's fragmented it, it's no longer this predictable path from site to site. So definitely expect that to continue. I personally am watching to see what happens on the value-based payment front. Rob Lazerow: There's a lot that CMMI and the Center for Medicare and Medicaid Innovation can do under its existing statutory authority through the Affordable Care Act, without needing anything else from Congress. And I'm curious to see what they'll do because remember, that's where the next generation ACO program came from. Rob Lazerow: That's where the bundling programs have come from. That's where the mandatory bundling program that then became half voluntary and still half mandatory came from. I'm waiting to see what the Biden administration does on that front. And the other thing that will continue, I think, is price transparency. Rae Woods: Yeah. Rob Lazerow: So we now have the hospital rule in effect. Jury's out on if it will actually reduce prices. Rae Woods: Yes. Rob Lazerow: That's its own conversation, maybe we'll come back to talk about that one. But more focus on health plans having to be more transparent and hospitals having to report their Medicare advantage rates starting right now. Rae Woods: Ben, what do you think? Beyond the levers of what we can do with value-based payment and with transparency, what other moves can the Biden-Harris administration really make here? Ben Umansky: First of all, I think there's a hope among, at least, a lot of folks in the industry that things like value-based care and site of care shifts will prove sufficient to satisfy Medicare's budget crisis. I'm skeptical. ACO programs haven't, as a class, really shown tremendous savings. Ben Umansky: There are inklings though, there are little bits where if this administration chose to double down and really enforce downside risk, push on models that do generate savings in a quick timeframe, that maybe that does something. We'll have to see. The same deal on site of care shift. Ben Umansky: It's a question of how much they're willing to push to get those results immediately versus generational transformation, failing immediate results. If that budget crisis that Rob talked about, hitting in 2024, the insolvency, if that's still on the radar, then you have to look to either benefit cuts, reimbursement cuts, or tax increases. Ben Umansky: Or I guess, a rebalancing of the federal budget towards Medicare and away from other programs. All of those are very difficult political sells for different reasons, but they may be necessary. And so what I actually watch is what happens to the overall health of the economy, which is a big contributor to what that tax base is and what the solvency projections are. There are a lot of tools, but none of them are that pleasant to pull out of the bag. Rob Lazerow: Ben, let me add one more to your list. You and I spend so much of our time talking to hospital and health system leaders, but I don't want to have just a provider-centric view today. If I think about site of care shift, value-based payments, so much of them more focused on hospital spending. Rob Lazerow: Will we see equal weight or at least, an increase in focus on things like pharmaceutical spending and other areas that contribute to healthcare expenditure, even if that's not the hospital trust fund insolvency issue we started with? Rae Woods: Both of you have done a good job throughout this conversation of moderating maybe what some us, including me, have heard about in the media. We've talked about the fact that the Medicare for All conversation has all but stopped, and that the public option is unlikely. Is there any major change that you do think would be possible in, let's say, the next two years, if not the next four? Ben Umansky: I think it's possible. It's certainly not guaranteed, but I think it's possible that if this administration continues what was the last administration's priority, but I don't think a partisan one, to push for transparency. Ben Umansky: To push for a whole lot more information out there in the market that you could see a very different competitive landscape in healthcare by virtue of, in particular, the negotiated rates being public. Ben Umansky: The fact that hospitals are now posting not just what they're charging but what they're receiving, payer by payer, procedure by procedure. Geez, as a healthcare researcher, I would have loved this at some point in the last 15 years, right? Rae Woods: Yeah. You probably would have made me go find them. Ben Umansky: I would have made you go find it, but [inaudible 00:27:50] not your boss anymore so I'm stuck with it. And there were other people who were going to be looking. And it's going to determine where patients are steered and how networks are designed. It's going to put pressure on the high cost. There's a lot that can come from that if that momentum continues. And I think the ball's in this administration's court to decide how far to keep pushing and at what pace. Rob Lazerow: And I'm going to stay on the money theme, but go a different direction and at least, go back to value-based care because there is a lot of power with the way that Congress set up CMMI through the Affordable Care Act. The fact that they can deploy and test new payment models and if they're successful, scale them up nationwide. Rob Lazerow: That's where track three of the Medicare shared savings program came from. So will having a new sheriff in town in CMMI... And I guess we'll see who the sheriff is. It could be an old sheriff, I don't know. Will they get much more aggressive about rolling out payment models and potentially mandatory ones? Rob Lazerow: Will we reconvene in four years and say, "Wait a minute, we're really in a value-based marketplace"? Granted, we're over a decade into that conversation, aren't there yet, but maybe this will be the four years. Rae Woods: Well, Rob, Ben, thank you so much for coming on Radio Advisory. You made my job super easy as a part of this conversation. You know what's coming, my final question. What do you want our listeners to be focused on right now? Rob, let's start with you. Rob Lazerow: So we've alluded to this a couple of times across our conversation, but let me say it more directly, policy making at the State level. So for all the conversation about what's happening federally and who controls the Senate so much of what's going to happen in the next two years, next four years, whatever timeframe you want, is going to happen at the State level. Rob Lazerow: So we talked about how Washington has a public option. Oregon, New York, Colorado, they're among the more than dozen States with Medicare ACOs. Here in Maryland, where I live, there's an all-payer rate system. Rob Lazerow: These are all things that happen at the State level, so we can't focus exclusively on what's happening federally even if that's where so much of the news coverage is right now. Because a lot of what's going to affect your day-to-day and your local market is State-based. Rae Woods: Ben, how about you? Ben Umansky: I would tell folks not to lose sight of the existing reality that any new policies would apply to. So here's what I mean by that. A lot of people spun up about stuff like public option. "What would it mean for us? Could we handle that? What would it do to our margins?" Yada, yada yada. Ben Umansky: And I could say, "Hey, don't sweat that. Don't worry about that. It's not going to happen, Filibuster," et cetera, et cetera. And I do believe that you probably shouldn't sweat that particularly, but I think it's very important to think about why you're worried about it at all. What is it about... Suppose we're talking to hospital and health system leaders. Ben Umansky: Why are your margins so thin that a migration of the payer mix toward a public option would be disastrous, or could be? Why are you concerned there? Why do you think that your system can't adapt quickly enough to unforeseen changes? Why are you concerned about changes in access or telemedicine policies or any of these kind of things? Ben Umansky: What does that say about yourselves? And do you have a strategy that is addressing those...? I don't want to say deficiencies necessarily, but points of concern. And I think a lot of leaders are doing that, but this is a time to have that introspection, as much as it is to look at the outside world and say what might happen to us. Rae Woods: Thanks, Rob. Thanks, Ben. Rob Lazerow: Thanks, Rae. Ben Umansky: Thank you. Rae Woods: Clearly, there's so much happening in healthcare and we want to help you make sense of what might just be a news clip in the media versus change that's actually going to impact your organization. We'll be talking more about that on this podcast, but you can also visit our website, advisory.com/biden-harris will tell you what you need to know about the new administration. (silence). Rae Woods: Just like last week, there is so much happening in healthcare. So I want to take a few minutes to give you an update on what else our research team is watching for. Republicans have been pushing back on just how much should be spent on COVID relief. Rae Woods: So Senate Democrats have begun the process of passing the next stimulus bill through the budget reconciliation process. And at the same time, president Biden is continuing to push for a more centralized approach to vaccine distribution. The goal here is clear: boost speed, efficiency, and give Americans more access points to be able to get a vaccine. Rae Woods: There is a ton of vaccine news, so bear with me on this one. I almost feel like we're going to need to do another episode on vaccines. Johnson and Johnson has officially applied for emergency use authorization for its COVID-19 vaccine. Rae Woods: I should say that my partner is actually an employee at J&J, but when our team looked at the publicly available results, we were happy with the strong protection against hospitalizations and death in every population tested. And couple that with its easy storage and one dose administration, the J&J vaccine could speed up immunizations. Rae Woods: There's also some albeit confusing data coming out for the AstraZeneca vaccine. Early reporting celebrated strong safety and efficacy, but the results don't yet indicate whether this vaccine reduces the transmission of the virus so we'll need to watch for some more information. Rae Woods: With all this quickly changing news about vaccines, I want to underscore that no vaccine should be deprioritized. But we may see some efforts to target the specific benefits of a vaccine to the specific challenges of an area. Think using one to stop transmission in areas of an outbreak or more easily reaching rural or isolated regions. Rae Woods: For now, it's unclear whether the U.S government will implement policies like that. And finally, we're officially watching for the Supreme Court's ruling on the Affordable Care Act. Their opinion could come out any time between now and the end of their term in June. And remember, as always, we are here to help.