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Sen. Bill Cassidy.
Republican Sen. Bill Cassidy of Louisiana has been around healthcare for a long time, but he hadn't made it to a late-night show to talk about it until now.Cassidy's suggestion that any new GOP healthcare bill pass the "Jimmy Kimmel test" - named after the late-night host, who gave an impassioned speech about his newborn son's open-heart surgery and US healthcare policy - led to an appearance on "Jimmy Kimmel Live!" on May 8.
While Cassidy is not a member of the Senate working committee devising a new healthcare bill, the appearance on Kimmel's show has helped shine a light on a proposal from Cassidy and Sen. Susan Collins.
Cassidy is a medical doctor specializing in treating liver diseases, and he has helped to open a free clinic for the working poor in Louisiana.
Cassidy spoke with Business Insider about the appearance, healthcare policy, and President Donald Trump's recent firing of FBI Director James Comey.
This interview has been edited for length and clarity.
Bob Bryan: You've been involved in healthcare reform for a long time, but you've never been on a late-night show for it. I was wondering how it came to be that you went from proposing the "Jimmy Kimmel test" to being on air with Jimmy?
Bill Cassidy: I think it started on a Sunday morning show when I was asked by [CNN's] John Berman - I think it was a Sunday morning show, or maybe Saturday, I forgot which - but asked, "How would you know the adequacy of coverage?" which is clearly one of Trump's contract points with the American voter, that he wanted to lower premiums.
You can lower premiums in a variety of ways, but one way to lower premiums is to just give people lousy coverage. So the thought occurred to me in that moment, just kind of spontaneously, "Well, there's Jimmy Kimmel - his son had all the coverage he needed."
Now, in that circumstance, perhaps anybody's son would, because there is Children's Hospital Los Angeles nearby. But we know there are other conditions where that's not the case. So the question in the Jimmy Kimmel test - the coverage does not have to have bells and whistles - but does the coverage cover a tragedy that could occur in someone's health or to a loved one? So I coined the Jimmy Kimmel test. For whatever reason, it went viral, and that led to a conversation with the "Jimmy Kimmel" show folks.
Bryan: The Jimmy Kimmel test in part focuses on preexisting conditions, and right now House Republicans that passed the American Health Care Act have talked about "layers of protection" for those people. They say the MacArthur Amendment says no one can be denied. They say there are layers of coverage. Do you believe there are enough protections for preexisting conditions in the AHCA? And if there are gaps in those layers, how would you fill those in?
Cassidy: Ultimately, to address the issue of preexisting conditions and conditions that suddenly occur - for example, you develop a preexisting condition when something terrible happens, imagine you get hepatitis, your liver fails, and you get a liver transplant. You went from being healthy to having a liver transplant to now having a preexisting condition.
The way to most effectively do that, the only way you can control expense, is to have a larger risk pool, that person who is sick is in the midst of a lot of other people that tend to be healthy.
Now within that group, you can do reinsurance of some sort that would mitigate the cost of an individual patient. But ultimately, you need a big risk pool.
I use the example of ExxonMobil. They have 50,000 employees, give or take, and if one person gets sick - say, the liver transplant I just mentioned - it hardly affects premiums at all, if at all, because you're spreading that expense over so many people. Spreading over so many people is the way insurance always works.
Now you can have a different layer here or a different layer there, but ultimately, if you don't have a big enough risk pool, it is going to be very expensive care highly concentrated among those that are really expensive, and that's not the way to go.
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Cassidy came up with the "Jimmy Kimmel test" for healthcare reform.
Bryan: You talk about widening the risk pool. How would you open up the risk pool? One way the Affordable Care Act tried to do it was to use the individual mandate to penalize people. You are not a supporter of the individual mandate, so how would you incentivize people to come into that risk pool?
Cassidy: One thing I've talked about, and it's in the Cassidy-Collins plan ... we suggest using what we use in Medicare. When I turn 55, I'm going to be on Medicare. I can call up and tell them I don't want to be on Medicare, but otherwise, I'll be on Medicare. So they use this kind of automatic enrollment. We give states the option of automatically enrolling those who are eligible.
We do it for other things like 401(k)s. Research shows that if a business automatically enrolls somebody with an opt out, they get 95% enrollment. If it's an opt in, they start out with 54% enrollment. And this is when a business is doing a match. So we just think that sort of opt-out provision from the business community works well.
Bryan: More conservative voices have criticized auto-enrollment because auto-enrollment is forcing people onto insurance and government shouldn't force people to have something they don't want. What would your response be to that?
Cassidy: They must not have heard me say that you can call up if you don't want to be. How is it forcing if all I have to do is call up and say I don't want to be? How is it forcing if all I have to do is make a phone call and tell them to take me off? I think it'd be incredibly stupid on something that is most obviously not an issue.
Bryan: Another concern with the AHCA, especially the MacArthur Amendment, was the possible repeal of essential health benefits. Some advocates for it say plans with lower actuarial values will bring down costs. What are your thoughts about removing some of those essential health benefits?
Cassidy: I think the better alternative is what we do in the Cassidy-Collins plan, in which those who are eligible for a credit would get a credit sufficient for an annual premium. They would get a pre-funded health savings account, so money would be deposited into the HSA and they would get a high-deductible health plan on top of it.
Now, if you look at current law, current law says a high-deductible health plan has to cover significant benefits, which is taken to mean, for example, hospitalization.
One thing that has not been established is whether HSAs or high-deductible health plans are to cover mental illness and addiction, so that was the only essential health benefits that we included. But aside from that, we think you could end up with the same sort of coverage.
I will point out that once you pre-fund health savings accounts, someone can pay for their colonoscopy, or for their Pap smear, or for their cholesterol check with the HSA. That's what it's there for. So we think we cover that, but we do it in a cost-effective way.
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Sen. Bill Cassidy
Bryan: In terms of costs-sharing-reduction payments - something that the insurers have said they need to see going forward to offer plans in 2018 - are you in favor of the Trump administration continuing to offer these CSR payments? In addition, would you be in favor of a congressional appropriation to remove the uncertainty surrounding the lawsuit regarding those payments?
Cassidy: Legally, I agree with the lawsuit, so I think whatever the president does he should do with Congress to make sure it passes constitutional law, that it passes constitutional muster.
No. 2, remember President Trump's contract with voters, the four points he said over and over: He said we're going to care for those with preexisting conditions, we're going to eliminate mandates, and we're going to lower costs. Which I think most voters took to mean we're going to lower premiums, not a better Congressional Budget Office score.
At least in the interim, Obamacare is such a mess - the only way you're going to keep premiums from totally exploding next year is to continue the CSR payments. If we decide we don't care about premiums next year because we can blame it on Obamacare, that's fine, but we're going to recognize that premiums are going to increase by 40% or more.
So maybe that's what it takes to get Democrats to the table. This process has become much more difficult because they don't seem to care about people paying $20,000, $30,000, $40,000 in premiums. As a negotiating ploy, I can't say anything about it.
Legally speaking, we've got to work to get a replacement, and that's what we have to keep families from being damaged.
Bryan: In terms of those two elements, though, President Trump has said the most easy political path is to let Obamacare collapse, but then you also talk about his contract with the American voter. Does using skyrocketing premiums by removing CSR payments as a negotiating tactic jibe with President Trump's contract with the voters to lower their costs?
Cassidy: At some point, you've got to react to the circumstances you're in. I think the president is not the czar. The Constitution says certain things, and frankly, I think constitutionally, Congress has to appropriate. So far, Democrats have not done anything to help on this issue, so if they refuse to help, then the president has to deal with a very difficult process in the House. So there is a political reality. So I cut the president slack in that regard.
Bryan: The Senate is working on its own version of a healthcare bill. Is there a sense of a deadline that the Senate wants to meet? Especially considering insurers are facing deadlines to submit their plans for 2018.
Cassidy: All due haste, we want to not live forever on this issue, but we want to fully consider it. I know that's not a definite, like saying by September 8, for example. But with all due haste - I mean, how long does it take to understand this issue and make a decision going forward and then have it scored by the CBO and passed? That's obviously going to take some time, but I can't tell you how long.
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Trump with Paul Ryan and Mark Meadows, the head of the House Freedom Caucus.
Bryan: You mentioned the CBO. The House moved toward with the AHCA despite not having a CBO score for the Upton and MacArthur amendments. Do you feel that every step of the process in the Senate needs a CBO score, or do you feel there are times you could go without it?
Cassidy: By law, I'm told we have to have a CBO score before we vote.
Bryan: Looking at the process in the Senate right now, there is the working group of 13 Republican senators. There has been some criticism of the group. Yourself and Senator Collins, who produced your own bill, were not in that working group. Do you feel like the working group as it is constructed now is a fair way to go about the process? Is it an open enough process?
Cassidy: I think anytime you bypass regular order in the Senate, the committees of jurisdiction, it's a little bit problematic. On the other hand, I say that if we're going to fulfill President Trump's contract with the American voter, those four points I listed earlier, then the only way you're going to get there is something like the Cassidy-Collins plan. Now, if you decide you're not going to fulfill those and you're not going to fulfill that contract, you could get something far different.
And then the caveat on the lowering premium aspect is what I said as, well, the Jimmy Kimmel test: If we take the primary goal to lower premiums, is the coverage adequate if something terrible happens to someone's loved one? There's only one way to get there, to fulfill his goals and pass the Jimmy Kimmel test, and that's going to look like the Cassidy-Collins plan. That is if we're serious about that goal.
Bryan: If the Senate working group comes out with a bill that fails to live up to that goal or the Jimmy Kimmel test, or does not provide enough protections for people with preexisting conditions, would you vote against it? Even if there's pressure from leadership?
Cassidy: If you don't mind, I'll avoid answering hypotheticals. Not to dodge your question, but I've learned in life it's best not to do so.
Bryan: You know, I had to ask the question.
Cassidy: Oh, I know, but I'm a physician, and my training for however many decades has been patients would ask me questions that were almost existential, then I would have to say, "Why don't we wait and see what happens?"
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Bryan: You've talked about working with Democrats. Is there serious consideration about bringing Democrats into the process? Are you currently having discussions with Democrats in the Senate about a bipartisan solution?
Cassidy: Yes, I'm serious. Yes, I've spoken to Democrats. So far, there has been no one seriously interested. They're under incredible political pressure not to cooperate, but some of the parts of Cassidy-Collins require 60 votes [to avoid a filibuster]. For example, allowing price transparency so that someone would know the price of a blood test before they get it as opposed to getting a bill for $200 six months later - we need Democrats to pass because of the 60-vote threshold on such a bill.
As long as they decide to be passive, stay on the sidelines, there's nothing that can be done. I'm just amazed. You become a senator not by being passive, but by being active, and all of a sudden, we've got a whole group just deciding to sit on their palms.
Bryan: You talk about political pressure - is there any sense from Democrats that there are concessions that would bring them on to actually support the bill?
Cassidy: I don't know. If you look at the Cassidy-Collins bill, we return power to the states. We give power to a blue state to do a blue thing. Then we give power to a red state to do a red thing. It's federalism, a conservative principle I grant, but a conservative principle that totally works to the advantage of a blue state and, oh, by the way, to a red state that happens to be represented by a Democratic senator.
So I think it's frustrating because not only do I think it's a good thing for our country and our people, but in the interest of politics. That's my take on it. I think we should put patients before party.
Bryan: You're in favor of protections for preexisting conditions, the elimination of caps on lifetime limits - these were all things that were part of the Affordable Care Act. Obviously, there are issues with the ACA, but overall, do you think the ACA represented a step in the right direction for the US healthcare system? Obviously, you are not a fan, but were there any positives in that bill?
Cassidy: You could've accomplished the positive things in the Affordable Care Act for a fraction of the cost, in terms of tax dollars, and in terms of disruption of institutions, and in terms of economic growth. There are businesses after businesses and municipalities after municipalities that have taken full-time workers and made them part-time workers to avoid paying mandatory benefits or penalties. There's been, by some estimates, 1% per year loss to our GDP growth.
The opportunity cost of Washington, DC, taking all the power from patients and states and bringing it to Washington, DC, far outweighs the benefit. You could've have done it for far less with far less disruption. So sure, you throw 3,000 pages against the wall, some of it is good. But that said, there is a tremendous cost for our economy and out people.
Bryan: What are your thoughts on the firing of FBI Director James Comey by President Trump?
Cassidy: Obviously, the timing looks bad, but I'm not sure there ever is good timing. Mr. Comey had become an issue, criticized both from the right and the left. At some point when you're director - I think he's a great American, by the way, who cares deeply about our country, who's passionate about our country, who tried to do a good job in an exceptionally tough situation - but when the director himself becomes the issue, that is probably a distraction from the mission of the institution.
Bryan: A number of your colleagues on either side of the aisle have said that an outside investigator should take over the FBI's investigation into possible ties between the Trump campaign and the Russian government. What are your thoughts on that?
Cassidy: That's absurd. One, the bipartisan Senate Intelligence Committee is doing a great job - no one has criticized the work they've done.
Secondly, Comey had just testified saying there had been no evidence of everything that people are alleging.
Thirdly, the idea that Comey goes away and, if there is an investigation, the investigation goes away? Comey's first meeting of the day is about his budget. The second meeting is with his HR department. The third meeting is, you know, fill in the blank. Then he's got a chief lieutenant who's doing everything, who is the point. And then on Friday afternoon, that's when Comey gets his briefing from that chief lieutenant. That chief lieutenant is still there. That chief lieutenant will still be driving that investigation.