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CD145: Price of Health Care

Feb 26, 2017

Former Congressman Tom Price is our new Secretary of Health and Human Services, making him the chief law enforcement officer of health care policy in the United States. In this episode, hear highlights from his Senate confirmation hearings as we search for clues as to the Republican Party plans for repealing the Affordable Care Act. We also examine the 21st Century Cures Act, which was signed into law in December.

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Bill Outline

H.R. 34: 21st Century Cures Act

Bill Highlights

Title I: Innovation Projects & State Response to Opioid Abuse

  • Authorizes funding for research programs, if money is appropriated
  • Authorizes $1 billion for grants for States to deal with the opioid abuse crisis
  • The effects of this spending on the Pay as you Go budget will not be counted

Title II: Discovery

  • Creates privacy protections for people who participate as subjects in medical research studies
  • Orders the Secretary of Health and Human Services to a do a review of reporting regulations for researchers in search of regulations to cut, including regulations on reporting financial conflicts of interest and research animal care.
  • Allows contractors to collect payments on behalf of the Secretary of Health and Human Services

Title III: Development

  • Gives the Secretary of Health and Human Services additional data options for approving drug applications
  • Expedites the review process for new "regenerative advanced therapy" drugs, which includes drugs "intended to treat, modify, reverse or cure a serious or life-threatening disease or condition" or is a therapy that involves human cells.
  • Allows antibacterial and antifungal drugs to be approved after only being tested on a "limited population"
    • The drugs will have have a "Limited Population" label
  • Speeds up the FDA approval process for new medical devices that help with life-threatening or irreversibly debilitating conditions and that have no existing alternatives.
  • Devices addressing rare diseases or conditions are allowed be approved with lower standards for effectiveness; this provision expands the definition of "rare" by doubling the number of people affected from 4,000 to 8,000.
  • Each FDA employee involved in drug approvals will get training for how to make their reviews least burdensome.

Title IV: Delivery

Title V: Savings

Title VII: Ensuring Mental and Substance Use Disorders Prevention, Treatment, and Recovery Programs Keep Pace With Technology

  • Authorizes money to be used for mental health services and substance abuse treatment

Title IX: Promoting Access to Mental Health and Substance Use Disorder Care

  • Creates a telephone and online service to help people locate mental health services and substance abuse treatment centers.

Title XIV: Mental health and safe communities

  • Creates a pilot program to test the idea of having court cases with mentally ill defendants heard in "drug or mental health courts"

Title XVII: Other Medicare Provisions

Additional Reading

References

Sound Clip Sources

Hearing: Health and Human Services Secretary Confirmation, Senate Health, Education, Labor and Pensions Committee, January 18, 2017 (Part 1) and January 24, 2017 (Part 2).

Timestamps & Transcripts Part 1

  • 47:45 Senator Patty Murray: I want to review the facts. You purchased stock in Innate Immunotherapeutics, a company working to develop new drugs, on four separate occasions between January 2015 and August 2016. You made the decision to purchase that stock, not a broker. Yes or no. Tom Price: That was a decision that I made, yes. Murray: You were offered an opportunity to purchase stock at a lower price than was available to the general public. Yes or no. Price: The initial purchase in January of 2015 was at the market price. The secondary purchase in June through August, September of 2016 was at a price that was available to individuals who were participating in a private-placement offering. Murray:It was lower than was available to the general public, correct? Price: I don’t know that it was. It was the same price that everybody paid for the private-placement offering. Murray: Well, Congressman Chris Collins, who sits on President-elect Trump’s transition team, is both an investor and a board member of the company. He was reportedly overheard just last week off the House floor, bragging about how he had made people millionaires from a stock tip. Congressman Price, in our meeting, you informed me that you made these purchases based on conversations with Representative Collins. Is that correct? Price: No. What I— Murray: Well, that is what you said to me in my office. Price: What I believe I said to you was that I learned of the company from Congressman Collins. Murray: What I recall our conversation was that you had a conversation with Collins and then decided to purchase the stock. Price: No, that’s not correct. Murray: Well, that is what I remember you hearing it—say—in my office. In that conversation, did Representative Collins tell you anything that could be considered “a stock tip?” Yes or no. Price: I don’t believe so, no. Murray: Well, if you’re telling me he gave you information about a company, you were offered shares in the company at prices not available to the public, you bought those shares, is that not a stock tip? Price: Well, that’s not what happened. What happened was that he mentioned—he talked about the company and the work that they were doing in trying to solve the challenge of progressive secondary multiple sclerosis which is a very debilitating disease and one that I— Murray: I’m well aware of that, but— Price: —had the opportunity to treat patients when I was in practice. Murray: I’m aware— Price: I studied the company for a period of time and felt that it had some significant merit and promise, and purchased the initial shares on the stock exchange itself. Murray: Congressman Price, I have very limited time. Let me go on. Your purchases occurred while the 21st Century Cures Act, which had several provisions that could impact drug developers like Innate Immunotherapeutics, was being negotiated, and, again, just days before you were notified to prepare for a final vote on the bill. Congressman, do you believe it is appropriate for a senior member of Congress actively involved in policymaking in the health sector to repeatedly personally invest in a drug company that could benefit from those actions? Yes or no. Price: Well, that's not what happened.
  • 1:06:50 Senator Bernie Sanders: The United States of America is the only major country on earth that does not guarantee healthcare to all people as a right. Canada does it; every major country in Europe does it. Do you believe that healthcare is a right of all Americans, whether they’re rich or they’re poor? Should people, because they are Americans, be able to go to the doctor when they need to, be able to go into a hospital, because they are Americans? Tom Price: Yes. We’re a compassionate society— Sanders: No, we are not a compassionate society. In terms of our relationship to poor and working people, our record is worse than virtually any other country on earth; we have the highest rate of childhood poverty of any other major country on earth; and half of our senior, older workers have nothing set aside for retirement. So I don’t think, compared to other countries, we are particularly compassionate. But my question is, in Canada, in other countries, all people have the right to get healthcare, do you believe we should move in that direction? Price: If you want to talk about other countries’ healthcare systems, there are consequences to the decisions that they’ve made just as there are consequences to the decision that we’ve made. I believe, and I look forward to working with you to make certain, that every single American has access to the highest-quality care and coverage that is possible. Sanders: “Has access to” does not mean that they are guaranteed healthcare. I have access to buying a ten-million-dollar home; I don’t have the money to do that. Price: And that’s why we believe it’s appropriate to put in place a system that gives every person the financial feasibility to be able to purchase the coverage that they want for themselves and for their family, again, not what the government forces them to buy. Sanders: Yeah, but if they don’t have any—well, it’s a long dissert. Thank you very much. Price: Thank you.
  • 1:46:34 Senator Michael Bennet: So, I ask you, sir, are you aware that behind closed doors Republican leadership wrote into this bill that any replacement to the Affordable Care Act would be exempt from Senate rules that prohibit large increases to the deficit? Tom Price: As you may know, Senator, I stepped aside as chairman of the budget committee at the beginning of this year, and so I wasn’t involved in the writing of— Bennet: You have been the budget committee chairman during the rise of the Tea Party; you are a member of the Tea Party Caucus; you have said over and over again, as other people have, that the reason you’ve come to Washington is to reduce our deficit and reduce our debt. I assume you’re very well aware of the vehicle that is being used to repeal the Affordable Care Act. This is not— Price: Yes. Bennet: —some small piece of legislation. This is the Republican budget. Price: Yes, I'm aware of the bill. Yes. Bennet: But do you support a budget that increases the debt by $10 trillion? Price: No. What I support is an opportunity to use reconciliation to address the real challenges in the Affordable Care Act and to make certain that we put in place at the same time a provision that allows us to move the healthcare system in a much better direction— Bennet: Do you support the budget that was passed by the Senate Republicans— Price: I support— Bennet:—to repeal the Affordable Care Act that adds $10 trillion of debt to the budget deficit? Price: Well, the reconciliation bill is yet to come. I support the process that allows for and provides for the fiscal year ’17 reconciliation bill to come forward.
  • 2:38:37 Senator Chris Murphy: But do you direct your broker around ethical guidelines? Do you tell him, for instance, not to invest in companies that are directly connected to your advocacy? Because it seems like a great deal: as a broker, he can just sit back, take a look— Tom Price: She. Murphy: —at the positions that you’re taking— Price: She. She can sit back. Murphy: She can—she can sit back— Price: Yeah. Murphy: —in this case—look at the legislative positions you’re taking, and invest in companies that she thinks are going to increase in value based on your legislative activities, and you can claim separation from that because you didn’t have a conversation. Price:Well, that’s a nefarious arrangement that I’m really astounded by. The fact of the matter is that I have had no conversations with my broker about any political activity at all, other than her— Murphy: Then why wouldn’t you tell her— Price: —other than her congratulating— Murphy: Why— Price: —me on my election. Murphy: But why wouldn’t you at least tell her, “Hey, listen; stay clear of any companies that are directly affected by my legislative work”? Price: Because the agreement that we have is that she provide a diversified portfolio, which is exactly what virtually every one of you have in your investment opportunities, and make certain that in order to protect one’s assets that there’s a diversified arrangement for purchase of stocks. I knew nothing about— Murphy: But you couldn’t have— Price: —those purchases. Murphy: But you couldn’t have a diversified portfolio while staying clear of the six companies that were directly affected by your work on an issue? Price: Well, as I said, I didn’t have any knowledge of those purchases. Murphy: Okay.
  • 2:54:20 Senator Elizabeth Warren: One of the companies—it’s the company raised by Mr. Franken, Senator Franken—and that is Zimmer Biomet. They’re one of the world’s leading manufacturers of hip and knees, and they make more money if they can charge higher prices and sell more of their products. The company knows this, and so do the stock analysts. So on March 17, 2016 you purchased stock in Zimmer Biomet. Exactly six days after you bought the stock, on March 23, 2016, you introduced a bill in the House called the Hip Act that would require HHS secretary to suspend regulations affecting the payment for hip and knee replacements. Is that correct? Tom Price: I think the BPCI program to which I think you referred I’m a strong supporter of because it keeps the decision making in the— Warren: I’m not asking you about why you support it. I’m just asking, did you buy the stock, and then did you introduce a bill that would be helpful to the companies you just bought stock in? Price: The stock was bought by a direct—by a broker who was making those decisions. I wasn’t making those decisions. Warren: Okay, so you said you weren’t making those decisions. Let me just make sure that I understand. These are your stock trades, though. They are listed under your name, right? Price: They’re made on my behalf, yes. Warren:Okay. Was the stock purchased through an index fund? Price: I don't believe so. Warren: Through a passively managed mutual fund? Price: No. It’s a broker— Warren: Through an actively managed mutual fund? Price: It’s a broker-directed account. Warren: Through a blind trust? So, let’s just be clear. This is not just a stockbroker, someone you pay to handle the paperwork. This is someone who buys stock at your direction. This is someone who buys and sells the stock you want them to buy and sell. Price: Not true. Warren: So when you found out that— Price: That’s not true, Senator. Warren: Well, because you decide not to tell them—wink, wink, nod, nod—and we’re all just supposed to believe that? Price: It’s what members of this committee, it’s the manner of which— Warren: Well, I’m not one of them. Price: —members of this committee—Well, I understand that— Warren: So, let me just keep asking about this. Price: —but it’s important to appreciate that that’s the case. Warren:Then, I want to understand. When you found out that your broker had made this trade without your knowledge, did you reprimand her? Price: What—what I did was comply— Warren: Well, you found out that she made it. Price: What I did was comply— Warren: Did you fire her? Did you sell the stock? Price: What I did was comply with the rules of the House in an ethical and legal and— Warren: I didn’t ask whether or not the rules of the House— Price: —above-board manner— Warren: —let you do this. Price: —and in a transparent way. Warren: You know, all right. So, your periodic transaction report notes that you were notified of this trade on April 4, 2016. Did you take additional actions after that date to advance[audio cuts out] the company that you now own stock in? Price: I’m offended by the insinuation, Senator. Warren: Well, let me just read what you did. You may be offended, but here’s what you did. Congressional records show that after you were personally notified of this trade, which you said you didn’t know about in advance, that you added 23 out of your bill’s 24 co-sponsors; that also after you were notified of this stock transaction, you sent a letter to CMS, calling on them to cease all current and future planned mandatory initiatives under the Center for Medicare and Medicaid Innovation; and just so there was no misunderstanding about who you were trying to help, you specifically mentioned— Unknown Speaker: Your two minutes are up, Senator Warren. Thank you. Warren: —hip and knee replacement.
  • 2:58:20 Senator Johnny Isakson: This is very important for us to all understand under the disclosure rules that we have and the way it operates, any of us could make the mistakes that are being alleged. I’m sure Senator Franken had no idea that he owned part of Philip Morris when he made the statement he made about tobacco companies, but he has a WisdomTree Equity Income Fund investment, as disclosed in his disclosure, which owns Philip Morris. So, it’s entirely possible for any of us to have somebody make an investment on our behalf and us not know where that money is invested because of the very way it works. I don’t say that to, in any way, embarrass Mr. Franken but to make a point that any one of us who have mutual funds or investment managers or people who do that, it’s entirely possible for us not to know, and to try and imply that somebody’s being obfuscating something or in otherwise denying something that’s a fact, it’s just not the fair thing to do, and I just wanted to make that point. Senator Al Franken: This is different than mutual funds. Isakson: It’s an investment in Philip Morris. Unknown Speaker: Alright. Unknown Speaker: Thank you. Warren: And my question was about what do you do after he had notice. Unknown Speaker: Senator Warren, your time has been generously… Senator Kaine.
  • 3:21:09 Senator Tim Kaine: Do you agree with the president-elect that the replacement for the Affordable Care Act must ensure that there is insurance for everybody? Tom Price: I have stated it here and— Kaine: Right. Price: —always that it’s incredibly important that we have a system that allows for every single American to have access to the kind of coverage that they need and desire. Kaine: And he’s—
  • 3:31:52 Senator Patty Murray: You admitted to me in our meeting that you, in your own words, talked with Congressman Collins about Innate Immuno. This inspired you to you, in your own words, study the company and then purchase its stock, and you did so without a broker. Yes or no. Tom Price: No. Murray: Without a broker. Price: I did not. Murray: You told me that you did this one on your own without the broker. Yes? Price: No, I did it through a broker. I directed the broker to purchase the stock, but I did it through a broker. Murray: You directed the broker to purchase particularly that stock. Price: That's correct. Murray: Yeah.
  • 3:34:42 Senator Patty Murray: Will you commit to ensuring all 18 FDA-approved methods of contraception continue to be covered so that women do not have to go back to paying extra costs for birth control? Tom Price: What I will commit to and assure is that women and all Americans need to know that we believe strongly that every single American ought to have access to the kind of coverage and care that they desire and want.
  • 3:36:38 Senator Patty Murray: The Office of Minority Health was reauthorized as part of the ACA. So will you commit to maintaining and supporting this office and its work? Tom Price: I will commit to be certain that minorities in this country are treated in a way that makes certain—makes absolutely certain—that they have access to the highest-quality care. Murray: So you will not commit to the Office of Minority Health being maintained. Price: I think it’s important that we think about the patient at the center of all this. Our commitment, my commitment, to you is to make certain that minority patients and all patients in this country have access to the highest-quality care. Murray: But in particular—so you won’t commit to the Office of Minority— Price: We—Look, there are different ways to handle things. I can’t commit to you to do something in a department that one, I’m not in—I haven’t gotten it yet— Murray: But you will be. Price: —and— Murray: You will be, and— Price: Let me put forward a possible position that I might find myself in. The individuals within the department come to me and they say, we’ve got a great idea for being able to find greater efficiencies within the department itself, and it results in merging this agency and that agency— Murray: I think—I think that— Price: —and we’ll call it something else. Murray: Yeah. I—okay. Price: And we will address the issues of minority health— Murray: I just have a minute left, and I hear your answer. Price: —in a big, big way— Murray: You’re not committed, okay. Price: —and make certain that it is responsive to patients.

Part 2

  • 14:50 Senator Ron Wyden: Congressman Price owns stock in an Australian biomedical firm called Innate Immunotherapeutics. His first stock purchase came in 2015 after consulting Representative Chris Collins, the company’s top shareholder and a member of its board. In 2016 the congressman was invited to participate in a special stock sale called a private placement. The company offered the private placement to raise funds for testing on an experimental treatment it intends to put up for FDA approval. Through this private placement, the congressman increased his stake in the company more than 500 percent. He has said he was unaware he paid a price below market value. It is hard to see how this claim passes the smell test. Company filings with the Australia’s stock exchange clearly state that this specific private placement would be made at below-market prices. The treasury department handbook on private placement states, and I will quote, they “are offered only to sophisticated investors in a nonpublic manner.” The congressman also said last week he directed the stock purchase himself, departing from what he said was typical practice. Then, there’s the matter of what was omitted from the congressman’s notarized disclosures. The congressman’s stake in Innate is more than five times larger than the figure he reported to ethic’s officials when he became a nominee. He disclosed owning less than $50,000 of Innate stock. At the time the disclosure was filed, by my calculation, his shares had a value of more than $250,000. Today his stake is valued at more than a half million dollars. Based on the math, it appears that the private placement was excluded entirely from the congressman’s financial disclosure. This company’s fortunes could be affected directly by legislation and treaties that come before the Congress.
  • 30:49 Senator Orrin Hatch: First, is there anything that you are aware of in your background that might present a conflict of interest with the duties of the office to which you have been nominated? Tom Price: I do not.
  • 51:36 Senator Ron Wyden: Will you commit to not implementing the order until the replacement plan is in place? Tom Price: As I mentioned, Senator, what I commit to you and what I commit to the American people is to keep patients the center of healthcare, and what that means to me is making certain that every single American has access to affordable health coverage that will provide the highest-quality healthcare that the world can provide.
  • 1:24:34 Senator Richard Burr: Are you covered by the STOCK Act, legislation passed by Congress that requires you and every other member to publicly disclose all sales and purchases of assets within 30 days? Tom Price: Yes, sir. Burr: Now, you’ve been accused of not providing the committee of information related to your tax and financial records that were required of you. Are there any records you have been asked to provide that you have refused to provide? Price: None whatsoever. Burr: So all of your records are in. Price: Absolutely. Burr: Now, I’ve got to ask you, does it trouble you at all that as a nominee to serve in this administration that some want to hold you to a different standard than you as a member of Congress, and I might say the same standard that they currently buy and sell and trade assets on? Does it burn you that they want to hold you to a different standard now that you’re a nominee than they are as a member? Price: Well, I—we know what’s going on here. Burr: Oh, we do. Price: I mean— Burr: We do. Price: It’s—and I understand. And as my wife tells me, I volunteered for this, so…
  • 1:26:49 Senator Richard Burr: As the nominee and hopefully—and I think you will be—the secretary of HHS, what are the main goals of an Obamacare replacement plan? Tom Price: Main goals, as I mentioned, are outlined in those principles, that is imperative that we have a system that’s accessible for every single American; that’s affordable for every single American; that is incentivizes and provides the highest-quality healthcare that the world knows; and provides choices to patients so that they’re the ones selecting who’s treating them, when, where, and the like. So it’s complicated to do, but it’s pretty simple stuff.
  • 1:34:58 Senator Johnny Isakson: Any one of us can take a financial disclosure—and there’s something called desperate impact, where you take two facts—one over here and one over there—to make a wrong. Any one of us could do it to disrupt or misdirect people’s thoughts on somebody. It’s been happening to you a lot because people have taken things that you have disclosed and tried to extrapolate some evil that would keep you from being secretary of HHS when, in fact, it shouldn’t be true. For example, if you go to Senator Wyden’s annual report, he owns an interest in BlackRock Floating Rate Income Fund. The major holding of that fund is Valeant Pharmaceuticals. They’re the people we jumped all over for 2700 percent increases last year in pharmaceutical products. But we’re not accusing the ranking member of being for raising pharmaceutical prices, but you could take that extrapolation out of that and then indict somebody and accuse them. Is that not true?
  • 1:51:30 Senator Michael Bennet: I wonder whether you also believe that it’s essential that there be a floor for insurance providers. You know, some of the things that the Affordable Care Act require for coverage include outpatient care; emergency services; hospitalization; maternity and newborn care; prescription drugs; rehab services; lab services; preventative care, such as birth control and mammograms; pediatric services, like vaccines; routine dental exams for children younger than 19. I’m not going to ask you to go through each one of those, but directionally, are we headed to a world where people in rural America have to settle for coverage for catastrophic care; are we headed to a place where there is regulation of insurance providers that say if you are going to be an insurance market, you need—particularly if we’re in a world where your son had crossed state lines —there has to be a floor of the services you’re willing to pay for? Tom Price: I think there has to be absolutely credible coverage, and I think that it’s important that the coverage—that individuals ought to be able to purchase this coverage that they want.
  • 1:56:45 Senator Pat Toomey: When we talk about repeal, sometimes I hear people say, well, we’ve got to keep coverage of pre-existing conditions because, you know, we’ve got to keep that. And when I hear that, I think that we’re missing something here, and here’s what I’m getting at. There’s obviously a number of Americans who suffer from chronic, expensive healthcare needs. They’ve had these conditions sometimes all their lives, sometimes for some other period of time. And for many of them the proper care for those conditions is unaffordable. I think we agree that we want to make sure those people get the healthcare they need. Now, one way to force it is to force insurance companies to provide health-insurance coverage for someone as soon as they show up, regardless of what condition they have, which is kind of like asking the property casualty company to rebuild the house after it’s burned down. But that’s only one way to deal with this, and so am I correct: is it your view that there are other perhaps more effective ways—since, after all, Obamacare’s in a collapse—to make sure that people with these pre-existing chronic conditions get the healthcare that they need at an affordable price without necessarily having the guaranteed-issue mandate in the general population? Tom Price: I think there are other options, and I think it’s important, again, to appreciate that the position that we currently find ourselves in, with policy in this nation, is that those folks, in a very short period of time, are going to have nothing because of the collapse of the market.
  • 2:18:05 Tom Price: Every single individual ought to be able to have access to coverage.
  • 2:29:45 Senator Tim Scott: My last question has to do with the employer-sponsored healthcare system that we’re so accustomed to in this country, that provides about 175 million Americans with their insurance. In my home state of South Carolina, of course, we have about two and a half million people covered by their employer coverage. If confirmed as HHS secretary, how would you support American employers in their effort to provide effective family health coverage in a consistent and affordable manner? Said differently, there’s been some conversation about looking for ways to decouple having health insurance through your employer. Tom Price: I think the employer system has been absolutely a remarkable success in allowing individuals to gain coverage that they otherwise might not gain. I think that preserving the employer system is imperative. That being said, I think that there may be ways in which individual employers—I’ve heard from employers who say, if you just give me an opportunity to provide my employee the kind of resources so that he or she is able to select the coverage that they want, then that makes more sense to them. And if that works from a voluntary standpoint for employers and for employees, then it may be something to look at. Scott: That would be more like the HRA approach where— Price: Exactly. Scott: —employer funds an account, and the employee chooses the health insurance, not necessarily under the umbrella of the employer specifically. Price: Exactly. And gains the same tax benefit.
  • 2:58:00 Tom Price: What I’m for is making certain, again, that the Medicaid population has access to the highest-quality care possible, and we’ll do everything to improve that because right now so many in the Medicaid population don’t have access to the highest-quality care.
  • 3:20:50 Tom Price: Our goal is to make certain that seniors have access to the highest-quality healthcare possible at an affordable price. Senator Bob Menendez: Well, access without the ability to afford it, and I’ll end on this— Price: That's what I said, affordable price.
  • 3:28:45 Senator Sherrod Brown: If you and he are working together, are you going to suggest to him that we find a way in repeal and replace to make sure there is guaranteed healthcare for our nation’s veterans? Tom Price: Well, I think it’s vital, again, as I’ve mentioned before, that every single American have access to affordable coverage that’s of high quality, and that’s our goal, and that’s our commitment.
  • 3:30:52 [regarding a disabled child coverd by Medicaid] Tom Price: We are absolutely committed to making certain that that child and every other child and every other individual in this nation has access to the highest-quality care possible. Senator Bob Casey Jr.: Okay, so not an access—he will have the medical care that he has right now or better—if you can come up with a better level of care, that’s fine—but he will have at least the coverage of Medicaid and all that that entails that he has right now. And that’s either a yes or no; that’s not— Price: No, it’s not a yes or no because the fact of the matter is that in order for the current law to change, you all have to change it— Casey: No, but here’s— Price: —and if I’m given the privilege of leading at the Department of Health and Human Services— Casey: Here’s why it’s yes— Price: and I respond to— Casey: You should stop talking around this. You have led the fight in the House, backed up by Speaker Ryan, for years— Price: To improve Medicaid. Casey: —to block grant Medicaid, okay? Price: To improve Medicaid. Casey: To block grant Medicaid. What that means is, states will have to decide whether or not this child gets the Medicaid that he deserves. That’s what happens. So you push it back to the states and hope it works out…

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