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Hi everyone, welcome to the Hot Dish, comfort food for rural America.

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I'm Heidi Heitkamp.

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And I'm Joel Heitkamp.

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Today we're joined by Cynthia Cox from the Kaiser Family Foundation.

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Cynthia is a vice president and director of the program on the Affordable Care Act for KFF.

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She conducts economic and policy research on the ACA.

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Cynthia is here today to talk about all the things the ACA has that we're lucky to have -
and we're lucky to have her.

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Cynthia, welcome to the Hot Dish and thanks for joining us.

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Thanks for having me.

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It's great to be here.

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We found out another factoid about you that my husband once upon a time installed your
doorknobs on your condo because you lived in the same condo as my daughter.

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DC's just such a small world.

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Yeah, yeah.

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Well, I mean, not just DC, but you know, it's amazing.

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You can sit down at an airport and find out -

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Yeah, what an interesting area of study, especially right now, Cynthia.

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You know, obviously we're paying really close attention to what's going on in Congress,
really close attention to all of these increases in healthcare.

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But one of the sources, and I will tell you this without trying to blow any smoke, that I
always tell everybody the most trusted source for data and information is KFF or Kaiser

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Family Foundation, now KFF.

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And so we're so grateful that you're able to join us and maybe shine some light on what's
going on with health care costs today.

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And Joel talks to farmers and to people in middle America every day.

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Joel, what are you hearing about health care costs and how concerned are people?

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Well, I think some of the people as they get closer, Heidi and Cynthia, I think they're
starting to come out of the woodwork.

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uh Here's kind of the weird thing in the beginning.

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I shouldn't say weird thing.

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I should have expected it.

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But a lot of people, Cynthia, who are on the exchange don't want to admit they're on the
exchange because, of course, they see it as welfare and they don't want to admit they're

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on welfare, even though it's an absolutely great program that makes sure that it benefits
the rest of us that aren't.

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on the exchange but I don't know if you're seeing that Cynthia but I'm seeing more and
more people now come out as though this is a problem that they have to address.

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Yeah, I I think uh there's I think also just the the way that the ACA has been called
Obamacare for a long time, people didn't want to be saying that they had an Obamacare plan

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or that they needed Obamacare.

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But I think uh over time, perspectives on that have evolved.

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And uh and also, I mean, this is private insurance, but private insurance is expensive.

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And most people in the United States, whether you're getting insurance through Obamacare
markets or through work or Medicaid or Medicare, are getting some sort of

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subsidy or financial assistance to do so.

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It's actually very few people in the US who actually get full priced health insurance.

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so the ACA or Obamacare markets help people who do not otherwise have health insurance
because they don't get it through their jobs.

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Maybe they work a job that's, you know, they're self-employed, small business owners,
farmers and ranchers.

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know, people who just don't get health insurance through work come to this market to get

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private health insurance and they get financial help to afford it because it is very
expensive.

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Well, when you step back and you take a look at it, one of the arguments that we've been
hearing over the last couple of weeks is that Obamacare has actually driven up the cost of

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healthcare.

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um How do you at Kaiser kind of, or KFF, sorry, I know, you prefer the initials, but how do you
respond to that?

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Because you've obviously been pretty aggressive on the Republican plan for

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high deductible, and we can talk a little bit about high deductible uh Health Savings
Accounts, but how do you respond to the basic argument that they're saying that Obamacare

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has driven up healthcare costs?

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So I think there's like a lot of different ways to look at healthcare costs.

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There's how much does an individual spend on their health insurance or their healthcare
out of pocket costs.

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There's how much does society spend, you know, as a whole.

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um And there's also how much does the federal government spend.

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ah So, you know, I think it depends on, you know, how you're looking at this.

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But if you're looking at it from a societal perspective, like how much we spend overall in
healthcare, we do spend more now than we did before the ACA, but

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actually the rate of growth has slowed.

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You know, we spent like the rate of growth of how much healthcare spending is growing each
year is a little bit slower than it used to be before the Affordable Care Act, despite the

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fact that many more people have health insurance coverage and can access that healthcare,
you know, in many cases better than they could before the Affordable Care Act.

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Then when you look at, uh you know, just the people who are getting health insurance
through the ACA or Obamacare markets,

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um That's where there's a little bit more nuance.

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So what people actually spend on their premiums has been pretty flat if not falling, you
know, because of these extra financial help like the enhanced screen and tax credits that

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people get.

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How much insurance companies charge has also been pretty flat for the last few years.

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um But when you compare how much insurance companies charged

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Individuals.

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So these are people again who do not get health insurance through work or Medicaid or
Medicare.

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It's just the people who are buying their own health insurance.

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uh Before the Affordable Care Act, on average, premiums were lower than they are today,
much lower.

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But a big part of that is because back then, people who had pre-existing conditions were
often excluded from having health insurance and the health insurers didn't have to pay for

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people's treatments.

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A lot of health care wasn't

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paid for in that market.

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Prescription drugs or mental health care or pregnancy care or that sort of thing might
have been excluded.

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So yes, premiums were lower and insurance companies were paying a lot less for care than
they are today.

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But today, care actually or the insurance coverage actually covers people with
pre-existing conditions and it covers the treatment that someone might need who gets sick.

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and you also have uh tests like colonoscopies and breast cancer that are mandated em with
no fee.

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And so we're just getting better healthcare.

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I mean, I will tell you that same guy who installed your doorknobs um is also a family
physician and he could, when Obamacare kicked in and people could come in and get

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screenings, he was convinced that um at least a dozen of his patients had their life
saved.

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with early detection as a result of the new healthcare law.

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Yeah, I mean, there's so many ways that you can measure how just improved access to care
has uh led to not only better health outcomes, but also better financial outcomes for

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people.

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think the other thing, even when someone has a relatively high deductible plan, they still
have that kind of protection from catastrophic health care costs that they wouldn't have

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had if they had no insurance or if their insurance had no limits on how much that.

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could charge someone for their out-of-pocket costs.

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So Cynthia, what are the providers saying?

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I mean, we talked a little bit about, you know, those individuals that are using, you
know, the market and coming in and seeking that help for affordability.

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mean, I've got a ton of farmers where this is what they do.

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You know, they they don't have enough employees to organize a plan of their own.

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So but what are the providers, you know, those folks that they're going to see to get that
kind of help?

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What do they say?

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Well, hospitals in particular are pretty concerned about the enhanced tax credits
expiring.

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They're also concerned about other changes that were made earlier this year in the summer
with what was called the big, beautiful bill.

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Also included a lot of cuts to Medicaid.

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And when you add all of that together, we're looking at like in the future, there's
probably gonna be about 14 million more Americans who are uninsured uh than otherwise

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would have been the case.

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And what that means for hospitals is that if those folks show up in the emergency room, uh
the hospital has to stabilize them.

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They have to take on costs to pay for that person's treatment, even if that person cannot
afford to pay for it themselves.

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uh And so from a hospital's perspective, they're concerned about what we call
uncompensated care.

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So someone shows up in the ER, by law the hospital has to stabilize them.

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And uh so that could add

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know, lot of strain to, you know, hospitals budget, especially rural hospitals that might
already be struggling financially.

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It could be enough to tip them over the edge into either having to cut certain services,
you know, that might mean like, for example, we're seeing rural hospitals cutting like

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labor delivery services or things like that, or just having to close altogether.

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So when you go back and you take a look at m who is on the enhanced subsidies on
Obamacare, it's interesting to me, and you can tell me whether my observation is right or

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wrong, that those states that expanded Medicaid have fewer people who are using the
enhanced subsidies because those people, their income falls within the Medicaid

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guidelines.

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They're able to get Medicaid and a lot of them, and we can talk about how

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how these people are actually working, but still qualify for Medicaid benefits.

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But when you look at the states and usually red states that have not expanded into, uh
done the expansion of Medicaid, they're big users of these subsidies.

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And so how does that kind of shake out politically?

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I mean, when it's Texas and Florida and these red states that are really

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the ones that are gonna get hurt.

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We don't know yet what the outcome's gonna be on Medicaid.

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We assume that there's gonna be a lot of people driven off Medicaid who then would have to
go to the exchanges if they're gonna buy health insurance.

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um this folly that Congress is on that somehow this is gonna affect only blue states is
just crazy to me.

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Yeah, I mean, I think so when you look at the last few years when the ACA or Obamacare
enhanced tax credits have been in place, the number of people buying ACA or ACA

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marketplace plans has more than doubled in the last five years.

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But half of that doubling is concentrated in Texas, Florida, Georgia and North Carolina.

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like

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there are really a handful of Southern states, in particular Southern red states that
account for so much of this growth.

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And the reason for that is because these enhanced premium tax credits made health
insurance essentially free for very low income people.

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They have a $0 premium payment.

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They do have a deductible, but it's $80, like eight zero, which is incredibly small for
private health insurance.

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And so those are the folks who, if they lived in a different state, they would be on
Medicaid.

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They would have pretty comprehensive medical coverage through Medicaid.

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But because their state did not expand Medicaid, they're getting these Obamacare plans and
uh getting, frankly, a pretty good deal on them.

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And so that has uh been incredibly uh attractive for people to bring them into the market
and uh to get that health insurance.

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And you're seeing that that's having an effect on the uninsured rate too, where these are
states that started out with really high uninsured rates and now more and more people are

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getting covered.

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So Cynthia, here's what comes at me and hide you as well on my talk show.

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I get hit a lot with, look, this is only the COVID increase.

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This isn't the Affordable Care Act.

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This is just uh what Joe Biden did in adding to the Affordable Care Act during the COVID
crisis.

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uh I don't care which one of you take a run at that, but...

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You know, which one of you wants to answer the question that comes into my radio's show?

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dealer's choice.

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Okay.

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All right.

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So uh I would say that, you know, kind of looking at the long-term picture here when the
AC was first passed in 2010, um you know, they're, first of all, they were trying to pass

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it in a budget neutral way and also, you know, working with lot of uncertainty about how
much premiums would actually cost for someone who didn't get a subsidy.

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uh And it turned out that um

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While health insurance coverage in the original affordable care structure was pretty
affordable for many people, it did not work for other people.

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In particular, there were some people who did not get any tax credit at all, but they also
saw their premiums go up because suddenly that insurance coverage was much more

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comprehensive and it was covering people with pre-existing conditions.

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This is what was driving a lot of the criticism of the ACA was that there were arguably
some people who were harmed by it because they had high premiums that they maybe couldn't

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afford and they weren't getting any financial assistance to help them afford it.

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And so that's what drove a lot of the repeal and replace conversations in 2017.

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And of course, those measures failed.

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But then fast forward to 2019 when the Democrats were holding a primary election.

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A lot of the Democrats at the time were talking about Medicare for all or Medicare for
more or Medicare for those who want it.

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But Biden was talking about building on the Affordable Care Act.

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And what he proposed in 2019 was something that looked very much like what these enhanced
premium tax credits that ultimately got passed look like.

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But he was doing this before we knew COVID was going to come.

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And so the COVID relief package was the vehicle through which they got passed.

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But it's not like they were only first thought of as a response to COVID.

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It was justified as uh a response to COVID because so many people were potentially losing
their jobs or needed health insurance during a pandemic.

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But uh the idea was already there before COVID.

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Yeah, and I want to point out that the original Affordable Care Act mandated that all the
states expand Medicaid.

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And that is the piece of the Affordable Care Act that was struck down by John Roberts on
the Supreme Court, taking away those mandates.

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And so then states walked away.

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North Dakota, very red state, recognized very early on that Medicaid expansion at a 90-10
share, and only 10 % of it's paid for by the state government.

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is a pretty good deal for our healthcare providers.

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I'd like to say that they were really worried about poor people getting health insurance.

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I think they were more worried about hospital administrators who were knocking on their
door, lobbying this.

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you know, this is the gap filler for states that have not expanded Medicaid.

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And the irony is the states that haven't expanded Medicaid tend to be more conservative.

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more red states, Joel.

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And so, you you can spin that argument that this is just COVID relief and it should have
triggered off.

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You could make that same argument that uh the tax bill of 17, which Trump passed, was a
temporary stimulus package, but now we've expanded it.

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So, you know, they always pick and choose uh what they're going to basically look at for
uh continuation of public policy.

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but this is public policy and that has worked in terms of getting more people through the
door, probably saved a lot of lives in those states and actually took a lot of economic

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pressure off.

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And this is at a time that affordability now is the buzzword, the political buzzword.

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And when you look at healthcare, and Joel can attest to this, a lot of farm families, it's
their largest cash outlay behind the inputs that they put in the farm is their health

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insurance and their healthcare.

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this hasn't escaped uh Bill Cassidy, Senator Cassidy's notice, Physician actually a pretty
good guy.

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worked more in poverty medicine, so good on him, in Louisiana, and he's still fighting the
fight.

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So, Cynthia, I know you're watching really closely.

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What's the chances in the next week that Congress will pass a package that m will, in
fact, uh stopgap this loss of coverage for so many Americans?

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So there's a lot of proposals out there.

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There's everything, the Democrats have mostly unified around trying to extend the tax
credits as they are, uh at least temporarily until maybe buying some time to renegotiate

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them.

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uh Some moderate Democrats have been willing to cross over the aisle to talk to more
moderate Republicans about maybe some compromise, maybe making some changes to how the tax

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credits work.

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uh

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And then on the Republican side of things, there's a lot of different ideas out there.

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uh Like I mentioned, some of the moderate Republicans are willing to maybe do a temporary
extension of the current tax credits.

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And in fact, some of them actually voted with the Democrats on that last week.

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uh

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And whereas others like Cassidy, like you mentioned, is coming up with a different idea,
which is maybe instead of offering this as premium support, you offer it as help for

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deductibles and co-insurance through this HSA or Health Savings Account idea.

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And then you have others who would really just rather see the tax credits expire um or who
want to do something that's not really adding any new money or new financial assistance in

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to offset the premium tax credits.

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um

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You know, there's even some ideas out there that would effectively repeal and replace the
ACA marketplaces as we know them.

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So it's, you know, there's just so many different options out there that like, I think the
Republican party is having a really hard time unifying around one of those, or at least

195
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not getting enough votes to pass it or to bring enough Democrats over to pass it.

196
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um I do think what's really interesting just watching this play out is that I think there
probably is a proposal out there.

197
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that could get enough support of moderate Democrats and moderate Republicans to bring this
forward.

198
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uh But it just hasn't had a pathway, uh a political pathway to get there.

199
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I think there's like an idea out there of how this could be changed to make it palatable
to enough Republicans and enough Democrats, but politically it just hasn't gotten through.

200
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So, Heidi, I'm going to direct this one at you.

201
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uh If you look at your caucus, you know, they got blamed for the shutdown by many people.

202
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Anybody with an eye towards it might disagree.

203
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But the truth is, think poll wise showed it was about 50-50.

204
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uh Their whole focus was dealing with this, you know, making sure this got dealt with.

205
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uh Now that it hasn't been dealt with, uh should the Democrats still be helping?

206
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Oh, you know, that's a that's an excellent question.

207
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And, you know, Democrats want people to have health insurance.

208
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They want to see solutions and but they aren't willing to buy off on some crazy notion.

209
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And I think, Cynthia, you'd agree that they have been against Obamacare or the Affordable
Care Act for so many years, they just can't shift.

210
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And you know what it reminds me of?

211
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Everybody forgets this when when President Johnson.

212
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Heidi, when you say they, you mean the Republicans have been -

213
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Ah okay right.

214
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The Republicans, I mean, you know, John McCain and I always say, and Lisa and Susan Collins,
you know, were all in and saved the ASA, right?

215
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That last minute vote, everybody gives John credit for it, you know, and I do too, but I
always say Lisa and Susan played a big role.

216
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They just came in first.

217
00:20:52,938 --> 00:20:55,830
But when you look at kind of,

218
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how ugly the feeling is against the ACA and against Obamacare, against a backdrop where
now it's 60, 65 % of the people in this country think that it's working for them.

219
00:21:09,430 --> 00:21:18,650
And so, you know, the polling has shifted, but I wanna take you back to another example,
which was when Lyndon Johnson passed Medicaid.

220
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I mean, in fact, Ronald Reagan was one of the people who was and the AMA were out there.

221
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They were trying to get it repealed for years and years and years and years.

222
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And it took what, 50 years from the passage of Medicaid for the Republican Party to say,
don't touch Medicaid.

223
00:21:35,167 --> 00:21:43,931
And so I think that, you know, they've been wrong on by they the Republicans have been
wrong on health care policy for a lot of years.

224
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They they passed Part D, which was medic- medical,

225
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you know, medicine, but they never paid for it.

226
00:21:51,424 --> 00:21:59,986
And that was a budget buster because that was a huge component of health care costs and a
huge growth component of health care costs.

227
00:21:59,986 --> 00:22:03,747
And so I'm going to throw it back to you, Cynthia.

228
00:22:03,747 --> 00:22:05,827
We pay too much for health care.

229
00:22:06,087 --> 00:22:07,858
I don't think there's any doubt about it.

230
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And people are frustrated.

231
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People, you know, it's not like you can go, you go to Target and say, I'm going to buy a
vacuum uh cleaner.

232
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You know what the price is.

233
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You go to the hospital, well, what kind of insurance do you have?

234
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What have, who's negotiated for you?

235
00:22:22,650 --> 00:22:29,155
I mean, it just is overwhelming to try and figure out how, number one, what are we paying
for?

236
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And number two, how do we fix it?

237
00:22:31,697 --> 00:22:41,925
And that really builds on a lot of people saying, for all, single payer, however you're
going to say it, that we are moving in that direction anyway.

238
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And I know Kaiser's done a lot of study.

239
00:22:44,726 --> 00:22:47,230
So there's two things I want you to respond to.

240
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One,

241
00:22:47,956 --> 00:22:58,308
the work that you've been doing on the high deductible plans that I think has been really
significant because it is a warning that this is a formula for disaster for low income

242
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families.

243
00:22:59,179 --> 00:23:05,706
But also, how do we, are we moving towards single payer and does that make more sense?

244
00:23:06,065 --> 00:23:09,477
Okay, a lot to unpack there, but yeah, I will do my best.

245
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just to put some numbers on it, in the United States, whether you're looking at it on a
per person basis or as a share of our economy, as a share of our gross domestic product,

246
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we spend about twice as much on healthcare than similarly large and wealthy countries like
in Europe or Canada or Japan or Australia spend.

247
00:23:30,946 --> 00:23:33,697
We spend a lot more on healthcare.

248
00:23:33,697 --> 00:23:35,380
And it's not because we're getting

249
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more healthcare.

250
00:23:36,520 --> 00:23:39,321
We actually get a little bit less healthcare by some measures.

251
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We have fewer doctors visits and shorter hospital stays than people in those countries do.

252
00:23:44,583 --> 00:23:50,284
But we pay higher prices for each hospital stay, for each prescription drug, for each
doctor's visit.

253
00:23:50,284 --> 00:23:53,565
It costs more than it does in other countries.

254
00:23:53,565 --> 00:23:59,287
Now, yes, single payer uh countries do spend a lot less.

255
00:23:59,287 --> 00:24:03,268
There's pros and cons of that, which I can obviously discuss, but like...

256
00:24:03,488 --> 00:24:05,148
It doesn't have to be single payer.

257
00:24:05,148 --> 00:24:10,328
There are other countries that have private health insurance systems that still spend a
lot less than we do.

258
00:24:10,328 --> 00:24:14,848
And the reason for that is, I mean, there's a lot of potential explanations.

259
00:24:14,848 --> 00:24:27,408
I don't want to oversimplify this, but one thing that is unique about the United States is
how little regulation there is or how little involvement there is of the government,

260
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whether it's a state or federal government, in the negotiations that happen between

261
00:24:32,724 --> 00:24:36,525
hospitals or other providers and insurance companies.

262
00:24:36,525 --> 00:24:45,368
So, you know, in the United States, there's like very little regulation of how much uh
insurance companies pay providers.

263
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In other countries, there are, you know, reference prices or, you know, direct regulations
or that sort of thing that limit how much the payers or the insurance companies uh spend.

264
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uh

265
00:24:56,856 --> 00:25:05,461
on those services and then that can lead to lower prices overall for, know, whether it's
taxpayers or people paying insurance premiums.

266
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uh Now, like you were saying before, when we go to the hospital, we don't know how much
it's going to cost us.

267
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And so there have been some efforts, even the first Trump administration used authority
under the Affordable Care Act to create more price transparency so that hopefully people

268
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would be able to

269
00:25:25,256 --> 00:25:28,427
at least get an idea of how much it's gonna cost them before they actually get there.

270
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But the reality is, is it's really hard to do that.

271
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It's really like just with the way that our system works, uh even creating more
transparent pricing is very difficult to implement.

272
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um so you often don't know.

273
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And when you have a high deductible plan, uh the reality is that many Americans do not
have in their checking or savings account enough money to cover.

274
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a typical deductible is a couple thousand dollars.

275
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For many people, it's even more than that.

276
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And a lot of Americans are just living paycheck to paycheck.

277
00:26:02,012 --> 00:26:03,312
They don't have that kind of savings.

278
00:26:03,312 --> 00:26:08,452
They don't have that kind of liquid assets to be able to meet their deductible or to meet
their out-of-pocket maximum.

279
00:26:10,032 --> 00:26:18,572
And so as deductibles go up, that can lead to cost barriers to getting the care that
people need.

280
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It can also lead to medical debt.

281
00:26:20,973 --> 00:26:25,181
And so we're seeing that a lot of Americans are struggling with medical debt right now.

282
00:26:25,181 --> 00:26:30,642
um And that can lead to other financial problems for them too.

283
00:26:31,022 --> 00:26:34,065
Cynthia, you got your last 10 bucks in your pocket.

284
00:26:34,566 --> 00:26:38,590
It's between this and getting this right and having milk.

285
00:26:38,590 --> 00:26:39,000
Okay.

286
00:26:39,000 --> 00:26:41,733
How are you going to bet on this thing?

287
00:26:41,733 --> 00:26:42,944
What happens?

288
00:26:43,456 --> 00:26:50,353
uh I think that most likely what's going to happen is that the enhanced premium tax
credits ultimately are expiring.

289
00:26:50,353 --> 00:26:58,690
mean, basically, if Congress didn't pass something by now, then at least in January,
people are going to be paying more money for their premiums.

290
00:26:58,951 --> 00:27:08,308
I'd say maybe there's a one to two percent chance that something comes together in the
last minute or maybe even in January.

291
00:27:08,308 --> 00:27:09,930
I'd say it's a very small chance.

292
00:27:09,930 --> 00:27:16,077
I think most likely what we're gonna see is that a lot of people are just gonna be paying a
lot more for their health insurance next year.

293
00:27:16,118 --> 00:27:21,684
And uh that's ultimately gonna mean that some people just go without health insurance too.

294
00:27:22,356 --> 00:27:23,369
Yeah, that,

295
00:27:23,369 --> 00:27:26,154
you got to wonder if that's the goal, Heidi, right?

296
00:27:26,154 --> 00:27:28,325
Well, I don't think it's the goal.

297
00:27:28,325 --> 00:27:40,122
I think the goal is to kill the Affordable Care Act and then create a crisis in healthcare
once again, so fewer people, so we have more uninsured and then there's an opportunity to

298
00:27:40,122 --> 00:27:41,383
have a discussion.

299
00:27:41,383 --> 00:27:46,305
The frustration that we should all have is show us the damn plan.

300
00:27:46,305 --> 00:27:54,581
You've been talking about this for, well, Trump talked about he was gonna repeal and
replace when he ran in 16.

301
00:27:54,581 --> 00:28:01,596
We have not seen a plan and we haven't seen a plan because Obamacare is a Republican plan.

302
00:28:01,596 --> 00:28:03,258
And people forget that.

303
00:28:03,258 --> 00:28:05,960
You know, Bernie Sanders doesn't like Obamacare.

304
00:28:05,960 --> 00:28:07,241
He wanted single payer.

305
00:28:07,241 --> 00:28:08,606
He wanted Medicare for all.

306
00:28:08,606 --> 00:28:16,828
A lot of Democrats wanted, um you know, basically allow people to buy into a federal
program, just like federal employees.

307
00:28:16,828 --> 00:28:19,590
Those were the two big Democratic ideas.

308
00:28:19,862 --> 00:28:26,535
And uh John McCain, when he was running against Obama, basically rolled out the Affordable
Care Act.

309
00:28:26,535 --> 00:28:29,467
Mitt Romney did this in Massachusetts.

310
00:28:29,467 --> 00:28:31,107
It's the same plan.

311
00:28:31,107 --> 00:28:39,051
And so they can't stand it because it has a name on it they don't like, "Obamacare."

312
00:28:39,051 --> 00:28:45,736
So their problem is that their plan got implemented and now they don't have a second plan.

313
00:28:45,736 --> 00:28:58,412
And these high deductible plans, I think if you're interested, any of our listeners go out
on uh KFF's website and read some of the warnings about what could happen with high

314
00:28:58,412 --> 00:29:00,783
deductible plans.

315
00:29:00,783 --> 00:29:07,666
Before we let you go, I want to just talk a little bit about Medicare Advantage because a
lot of people are making that decision.

316
00:29:07,666 --> 00:29:10,265
Is today the last day to, yeah.

317
00:29:10,265 --> 00:29:11,338
right, yeah.

318
00:29:11,752 --> 00:29:21,765
I mean, we're probably a little late because this will air tomorrow, that, that Medicare
Advantage has been this kind of, okay, let's offer an alternative.

319
00:29:21,765 --> 00:29:23,495
Let's make the drug companies happy.

320
00:29:23,495 --> 00:29:24,906
Let's get them in.

321
00:29:24,906 --> 00:29:33,028
And, and now we're seeing a lot of these plans that were priced to basically get people to
buy Medicare Advantage.

322
00:29:33,028 --> 00:29:41,620
They're ratcheting back, they're lowering their benefits and people are trying to decide,
do I go back on regular Medicare with a

323
00:29:41,620 --> 00:29:44,476
with a supplement, know, what do I do?

324
00:29:44,476 --> 00:29:52,318
And so tell us a little bit about the work that uh you all have been doing at KFF on
Medicare Advantage.

325
00:29:52,318 --> 00:30:02,112
Yeah, so for those who are less familiar, so Medicare Advantage is meant to be the kind of
private alternative to traditional Medicare, where you get your Medicare through a private

326
00:30:02,112 --> 00:30:03,193
insurance company.

327
00:30:03,193 --> 00:30:09,816
One of the benefits of it is that it has prescription drug coverage and everything kind of
built into it.

328
00:30:09,816 --> 00:30:12,617
uh Some of the, yeah.

329
00:30:12,617 --> 00:30:14,068
But like, so that can make it attractive.

330
00:30:14,068 --> 00:30:19,412
The other thing that makes it really attractive is that they often offer like gym
memberships or other kinds of benefits that

331
00:30:19,412 --> 00:30:26,567
can be really appealing to someone who's turning 65 and is still wanting to stay active or
that sort of thing.

332
00:30:26,567 --> 00:30:33,882
So it draws a lot of folks in because of those benefits and because of the low costs
associated with it.

333
00:30:33,882 --> 00:30:43,869
But then what can happen is that when people actually get sick, they find out that maybe
what they need isn't covered enough or maybe they need to see a certain specialist and the

334
00:30:43,869 --> 00:30:48,416
network is really narrow and they can't find a doctor who would see them.

335
00:30:48,416 --> 00:30:53,596
Whereas with traditional Medicare, you can go to pretty much any doctor you want to go to.

336
00:30:53,616 --> 00:31:04,336
And then if people, when they get sick, when you're no longer 65, maybe now you're 70 or
75 and you might want to switch to traditional Medicare, you might not be able to get the

337
00:31:04,336 --> 00:31:08,996
supplemental plan that you need to get because you have new pre-existing conditions.

338
00:31:09,696 --> 00:31:14,756
And so I think people need to, when they're making this decision, just think about it in
the long run.

339
00:31:14,756 --> 00:31:16,808
What is going to benefit you?

340
00:31:16,808 --> 00:31:22,676
now, but also what is going to benefit you in 10, 15 years when you start uh needing a lot
of healthcare.

341
00:31:22,676 --> 00:31:26,147
Yeah, it's a real important decision.

342
00:31:26,147 --> 00:31:37,630
um And I think you'll see all the advertising, which I think is a waste of money, trying
to get people to sign on to Medicare Advantage.

343
00:31:37,790 --> 00:31:50,524
But people need to be very cautious about whether you stay on one of those plans or
whether you transition back to Medicare, traditional Medicare with a traditional

344
00:31:50,524 --> 00:31:51,954
supplement plan.

345
00:31:51,998 --> 00:32:06,425
because you could get trapped with much higher uh G plans or much higher supplement costs
because you have pre-existing conditions and they don't have to take you, unlike other

346
00:32:06,425 --> 00:32:08,106
kinds of insurances.

347
00:32:08,414 --> 00:32:11,084
Yeah, that's something that maybe a lot of people don't realize.

348
00:32:11,084 --> 00:32:15,519
Yeah, Cynthia, I want to thank you for joining us on the Hot Dish today.

349
00:32:16,280 --> 00:32:17,832
Yeah, we really appreciate it.

350
00:32:17,832 --> 00:32:19,564
I hope those doorknobs are working.

351
00:32:19,564 --> 00:32:23,058
If I know, if I know Doc, they're still turning.

352
00:32:23,058 --> 00:32:24,269
They're still getting in.

353
00:32:24,269 --> 00:32:26,271
So I do.

354
00:32:28,955 --> 00:32:31,098
He tightened them up to beat heck.

355
00:32:31,098 --> 00:32:31,978
I know.

356
00:32:32,660 --> 00:32:34,203
He's an overbuilder.

357
00:32:34,203 --> 00:32:35,618
He's an overbuilder.

358
00:32:35,618 --> 00:32:39,658
He and I beat you in Pinochle all the time, Heidi, but that's another thing.

359
00:32:39,938 --> 00:32:41,912
Cynthia, good to visit with you.

360
00:32:41,912 --> 00:32:42,574
Yeah, you too.

361
00:32:42,574 --> 00:32:43,144
uh

362
00:32:43,144 --> 00:32:49,337
And I hope as this goes on, we'll know more probably by the end of the year, you'll come
back.

363
00:32:49,337 --> 00:33:03,284
And I just think this is something that there just cannot be enough oh dialogue in the
public sphere from professionals like you who know the facts, who obviously aren't out

364
00:33:03,284 --> 00:33:03,914
there.

365
00:33:03,914 --> 00:33:10,386
You know, not playing a partisan role, but are out there, you know, trying to make sure that
everybody in America has affordable health insurance.

366
00:33:10,624 --> 00:33:11,650
Well, thank you for having me.

367
00:33:11,650 --> 00:33:13,078
I'd be glad to come back.

368
00:33:13,078 --> 00:33:14,000
Great.

369
00:33:14,000 --> 00:33:15,046
Thanks.

370
00:33:21,690 --> 00:33:35,739
Joel, you know, the long awaited uh response from the Administration to uh the mess that
they made with tariffs and angering some of our best customers in rural America,

371
00:33:35,739 --> 00:33:42,144
especially soybean customers, $12 billion, 30% of what they're sending Argentina.

372
00:33:42,144 --> 00:33:42,776
Whoa.

373
00:33:42,776 --> 00:33:47,269
You, if that was $40 billion or $12 billion, because you know what my guys notice.

374
00:33:47,269 --> 00:33:49,141
There's no question about that.

375
00:33:49,141 --> 00:33:55,286
But I think the Administration must have got some pushback on that, Heidi, because they're
already talking about another one.

376
00:33:55,286 --> 00:34:02,412
But I'll tell you what, my audience, the people that don't farm, if they do another one
right away, they're going to go nuts.

377
00:34:02,412 --> 00:34:04,234
They didn't like this one, Heidi.

378
00:34:04,234 --> 00:34:10,086
Well, and soybeans, didn't soybeans go down about 50 cents a bushel right after it was
announced?

379
00:34:10,086 --> 00:34:15,339
And so, you know, this all has market implications and farmers are smarter than this.

380
00:34:15,339 --> 00:34:22,572
They know that they can't sustain on government, you know, on some kind of hand to mouth
government assistance.

381
00:34:22,572 --> 00:34:23,862
They've got to have their markets.

382
00:34:23,862 --> 00:34:25,613
They've got to sell their soybeans.

383
00:34:25,613 --> 00:34:33,791
And so what are you hearing from, are they moving soybeans, anything going to the west out
the ports on the west coast?

384
00:34:33,791 --> 00:34:35,562
Yeah, no, little bit.

385
00:34:35,562 --> 00:34:39,365
But I mean, really, they're still not they're still not selling soybeans.

386
00:34:39,365 --> 00:34:42,567
uh You know, I mean, here's the thing.

387
00:34:42,567 --> 00:34:45,209
There are less farmers out there.

388
00:34:45,209 --> 00:34:46,640
Farms have gotten bigger.

389
00:34:46,640 --> 00:34:50,632
There's farm employees like we just talked about with the Affordable Care Act.

390
00:34:50,632 --> 00:34:54,075
But, you know, there's less farmers out there.

391
00:34:54,075 --> 00:34:57,927
So if you're going to give subsidies out like you are this 12

392
00:34:57,927 --> 00:35:05,702
billion dollars, what you're going to do is tick more people because not everybody farms
and there's more people that don't farm in these rural areas.

393
00:35:05,702 --> 00:35:08,720
So I don't know, I don't think it trickles down.

394
00:35:08,720 --> 00:35:16,549
I can tell you as somebody who works in a rural area who's reliant upon, you know, farmers
having money.

395
00:35:16,610 --> 00:35:18,832
I don't see farmers out there having money.

396
00:35:18,832 --> 00:35:20,010
That's the answer.

397
00:35:20,010 --> 00:35:30,133
Well, and you know, we're hearing rumors at now is the time of the year that all the farm
groups after harvest that they all get together and they all talk and we're hearing rumors

398
00:35:30,133 --> 00:35:32,384
farmers not getting operating loans.

399
00:35:32,544 --> 00:35:44,128
The sugar beet farmers had devastating news, you know, and it's going to have huge
ramifications for a lot of people who plant sugar beets, which is an expensive crop to put

400
00:35:44,128 --> 00:35:45,148
in the ground.

401
00:35:45,382 --> 00:35:54,921
And you can blame sugar dumping or whatever that looks like, or you can blame the
administration because they think cane sugar is better than beet sugar, which is stupid

402
00:35:54,921 --> 00:35:56,492
because sugar is sugar.

403
00:35:56,492 --> 00:36:07,528
Last time I looked, but every time you turn around, you're hearing another story and the
stories coming from bankers is not good, even with the $12 billion.

404
00:36:07,528 --> 00:36:08,770
Now, let me ask you this.

405
00:36:08,770 --> 00:36:13,540
uh Was the Indiana state legislature a sign?

406
00:36:13,540 --> 00:36:20,092
Was it a sign that uh Republicans don't get up in the morning and fear this guy anymore?

407
00:36:21,196 --> 00:36:33,376
I think the Indiana folks are just stubborn, probably, you know, people like us who just
don't like being pushed around, who know right and wrong.

408
00:36:33,376 --> 00:36:38,676
It's kind of like the speaker of the house down in Arizona, Rusty, who stood up to Trump.

409
00:36:38,676 --> 00:36:41,716
There still are people out there who have principles.

410
00:36:41,776 --> 00:36:44,272
The more interesting thing is,

411
00:36:44,272 --> 00:36:52,116
Marjorie Taylor Greene, basically what she's been talking about is she said, you know, I'm
always about six months ahead of the curve.

412
00:36:52,116 --> 00:36:55,978
She said, I'll say things and then six months later, everybody's saying them.

413
00:36:55,978 --> 00:37:06,622
She's saying there is a lot of dissatisfaction and Trump was furious about that 60 minutes
interview because it basically showed the underbelly of the MAGA movement.

414
00:37:06,622 --> 00:37:10,377
Huge story today in the Washington Post about how MAGA

415
00:37:10,377 --> 00:37:15,620
is furious with Trump for focusing on foreign policy, which you and I have talked about
before.

416
00:37:15,620 --> 00:37:19,332
People forget that, that they want to, it's America first.

417
00:37:19,332 --> 00:37:22,204
Why are we doing anything with Venezuela?

418
00:37:22,204 --> 00:37:26,626
And so I think, and people can see a war brewing and they don't like it.

419
00:37:26,626 --> 00:37:33,310
And so, you know, and Trump has stubbornly refused to pivot on affordability.

420
00:37:33,310 --> 00:37:37,382
He went to Pennsylvania, gave an asinine speech,

421
00:37:37,382 --> 00:37:40,894
rambled on about nothing and said it was a hoax.

422
00:37:40,894 --> 00:37:50,509
And he's talking to people who can't afford their health insurance, who can't afford their
car insurance, who can't afford to have a tire blow on their car because they couldn't

423
00:37:50,509 --> 00:37:52,020
take it to the tire shop.

424
00:37:52,020 --> 00:37:54,001
And so he's he's tone deaf.

425
00:37:54,001 --> 00:38:06,008
And I think I think the mega movement, along with traditional Republicans, are getting
very concerned and and I but but not so concerned that they're going to take care of this

426
00:38:06,008 --> 00:38:06,928
health care.

427
00:38:07,218 --> 00:38:08,979
Well, but here's the thing.

428
00:38:08,979 --> 00:38:12,652
And I said this on my radio show, gotten some trouble for doing it.

429
00:38:12,652 --> 00:38:15,973
Quite frankly, yeah, I don't care.

430
00:38:16,254 --> 00:38:20,556
I said this when Joe Biden and Donald Trump were running against each other.

431
00:38:20,556 --> 00:38:25,710
And for our people who love the hot dish, 1-800- mad at me if you want.

432
00:38:25,710 --> 00:38:32,023
But 80 year old men, 80 year old women should not be president of the United States.

433
00:38:32,124 --> 00:38:33,000
Period.

434
00:38:33,000 --> 00:38:41,515
When I saw him in Pennsylvania giving that speech, giving that talk, and then when I see
him doing other talks, he looks like a really old man.

435
00:38:41,515 --> 00:38:45,487
Now, he always struggled keeping his concentration when speaking.

436
00:38:45,487 --> 00:38:46,427
I get that.

437
00:38:46,427 --> 00:38:48,268
And he always rambled on.

438
00:38:48,268 --> 00:38:49,889
But it's gotten worse, Heidi.

439
00:38:49,889 --> 00:38:53,711
His physical uh ability has gotten worse.

440
00:38:53,711 --> 00:38:56,053
The way he talks has gotten worse.

441
00:38:56,053 --> 00:38:58,194
What he says has gotten worse.

442
00:38:58,194 --> 00:39:02,886
And this is only it's not even a year into his second term.

443
00:39:03,014 --> 00:39:07,791
And so, you know, he's an old man, Hyde.

444
00:39:07,937 --> 00:39:21,128
Yeah, and you know, everybody who's hitched their star to him, and I include an old friend
of mine, Lindsey Graham, you know, when you start seeing the machetes come out and cutting

445
00:39:21,128 --> 00:39:26,082
the umbilical cord from Donald Trump, that's when you're going to see.

446
00:39:26,082 --> 00:39:28,063
And Lindsey's up for reelection.

447
00:39:28,063 --> 00:39:31,737
South Carolina is a state that's going to get hit by a lot of healthcare costs.

448
00:39:31,737 --> 00:39:32,917
He's got some baggage.

449
00:39:32,917 --> 00:39:36,202
I think there's some interesting candidates running in South Carolina.

450
00:39:36,202 --> 00:39:49,348
not saying that he's gonna lose, but I don't, I I think that the Democrats and the Senate
are feeling a lot more optimistic today because Trump hasn't pivoted, because Trump

451
00:39:49,348 --> 00:39:55,876
continues to stick with the line that all of this is a hoax and it's not his fault.

452
00:39:56,228 --> 00:39:58,930
This reminds me a lot of you in high school.

453
00:39:58,930 --> 00:40:01,592
uh You had bad friends there too.

454
00:40:01,592 --> 00:40:10,018
uh know, I mean, yeah, well, OK, you know, let's let's talk about Harlan Mueller.

455
00:40:10,018 --> 00:40:11,418
That's a whole other issue.

456
00:40:11,418 --> 00:40:20,625
uh I mean, yeah, he was actually was a deputy then he grew into his share, but but he's
good family friend.

457
00:40:20,625 --> 00:40:21,565
We're just joking.

458
00:40:21,565 --> 00:40:25,778
uh Yeah, but I mean, here's the deal Heid.

459
00:40:26,420 --> 00:40:29,241
This was all done because they feared him.

460
00:40:29,341 --> 00:40:35,963
I'm not convinced that when they get little groups of people anymore that they fear him as
much.

461
00:40:35,963 --> 00:40:37,543
I'm just not.

462
00:40:38,084 --> 00:40:40,384
I don't know if it's the people around him.

463
00:40:40,384 --> 00:40:49,667
got a fear or what now I might be Marjorie Taylor Green and be six months ahead in this
conversation, but the hot dish will save it.

464
00:40:50,267 --> 00:40:51,347
But I'm.

465
00:40:51,868 --> 00:40:52,948
He's looking old.

466
00:40:52,948 --> 00:40:57,251
He's looking like he's about one step away from being feeble.

467
00:40:57,712 --> 00:41:03,576
I'm sorry, but we know what that feels like and ah they're not going to like how it feels
like.

468
00:41:03,981 --> 00:41:07,741
Yeah, and Joel, he hasn't had a lot of wins.

469
00:41:07,781 --> 00:41:11,881
I mean, you can say the one Big Beautiful Bill, you know, okay.

470
00:41:11,881 --> 00:41:20,761
And if I hear one more, I mean, Besset basically saying, oh, it's gonna be on average
$2,000 more in people's pockets.

471
00:41:20,761 --> 00:41:24,001
That's not true for the lower half of this country.

472
00:41:24,021 --> 00:41:26,761
I mean, they don't pay $2,000 in taxes.

473
00:41:26,761 --> 00:41:33,692
I mean, he just, I mean, so they're creating expectations from the Big Beautiful Bill that
will never materialize,

474
00:41:33,692 --> 00:41:42,969
and they are not addressing healthcare costs, they're not addressing home ownership costs,
they're not addressing credit card debt, they're not addressing the things that they could

475
00:41:42,969 --> 00:41:46,241
actually address and show some sympathy for.

476
00:41:46,241 --> 00:41:56,392
And eventually when um you start seeing Republicans holding affordability hearings, that's
when you know that the worm has turned.

477
00:41:56,392 --> 00:42:00,514
Well, and the one thing that hasn't been talked about a lot is credit card debt.

478
00:42:00,514 --> 00:42:05,707
uh You know, I know, but a couple K isn't going to solve credit card debt.

479
00:42:05,707 --> 00:42:07,898
You know that and I know that.

480
00:42:07,898 --> 00:42:10,400
So this has got to turn around.

481
00:42:10,400 --> 00:42:11,240
uh

482
00:42:11,240 --> 00:42:18,443
This, the last time I checked, and you know, I have just absolutely told my kids, you
have a credit card, you pay it off every month.

483
00:42:18,443 --> 00:42:20,444
Do not carry a balance.

484
00:42:20,444 --> 00:42:22,580
That is the stupidest waste of your money.

485
00:42:22,580 --> 00:42:25,706
Of course, that's what the United States of America is doing, right?

486
00:42:25,706 --> 00:42:27,407
Putting everything on credit.

487
00:42:27,407 --> 00:42:34,410
But you know, last time I checked, my son's credit card uh interest rate was 28%.

488
00:42:34,410 --> 00:42:39,622
That's almost 30% of the principal, and you aren't paying any principal.

489
00:42:39,980 --> 00:42:41,220
Think about that.

490
00:42:41,220 --> 00:42:46,400
I mean, and that's something Trump promised to fix and so did Elizabeth Warren.

491
00:42:46,400 --> 00:42:47,940
Get on it, get on it.

492
00:42:47,940 --> 00:42:50,040
They don't need 28%.

493
00:42:50,040 --> 00:42:57,880
Swipe fees, the companies that have credit cards, and Josh Hawley did this, which I
thought was really fascinating.

494
00:42:57,880 --> 00:43:00,200
He asked them, what is your margin?

495
00:43:00,200 --> 00:43:01,780
How much profit do you make?

496
00:43:01,780 --> 00:43:05,281
50% profit on the backs of small business.

497
00:43:05,281 --> 00:43:08,444
Think about it, and now you see what small businesses are doing.

498
00:43:08,444 --> 00:43:14,127
They're basically giving discounts for people who don't pay with credit cards, because
they can't afford the swipe fees.

499
00:43:14,348 --> 00:43:18,051
And so, you know, there's so much that you can point to.

500
00:43:18,051 --> 00:43:29,770
And at the same time that they're doing that, they're ratcheting back some of the good
work that was done on fees, like airline fees, like, you know, fees for concerts that the

501
00:43:29,770 --> 00:43:31,542
Biden Administration took on.

502
00:43:31,542 --> 00:43:35,038
And now they've uh kind of reversed course.

503
00:43:35,038 --> 00:43:37,642
And when you talk to Republicans, you say, what's going to save you?

504
00:43:37,642 --> 00:43:39,771
They say, mergers and acquisitions.

505
00:43:39,771 --> 00:43:41,317
And I go, oh, trickle down.

506
00:43:41,317 --> 00:43:45,383
That's worked so well for you when you're dealing with macaroni and cheese issues.

507
00:43:45,383 --> 00:43:46,529
You're just not.

508
00:43:46,529 --> 00:43:54,178
I'm just going to tell you this, folks, that shouldn't stop you from having a very Merry
Christmas going out there, buying a gift or two.

509
00:43:54,178 --> 00:43:56,860
And uh just because it's got.

510
00:43:58,742 --> 00:44:08,333
Or dolls, but but to be reasonable about this, I'm going to tell you right now, Heidi, I got you
a couple of rings of deer sausage for Christmas again, so.

511
00:44:08,333 --> 00:44:18,098
I just want to say that in our family, we usually exchange gifts, but there was threats
about not buying presents.

512
00:44:18,279 --> 00:44:20,174
Threats, yeah.

513
00:44:20,174 --> 00:44:24,500
We got enough things that plug into, enough things with chords on them.

514
00:44:24,500 --> 00:44:37,444
And it is, if you have to put a present on a credit card and you can't afford to pay the
monthly amount, the best thing that you can do for your kids is keep your family

515
00:44:37,444 --> 00:44:38,534
financially solvent.

516
00:44:38,534 --> 00:44:48,827
And I hate to sound like Scrooge, but you know, being able to afford the groceries is more
important than getting the latest oh toy that some kid would want.

517
00:44:48,827 --> 00:44:52,468
I mean, we got coloring books, but you know.

518
00:44:53,342 --> 00:44:54,643
We shared a toy.

519
00:44:54,643 --> 00:44:58,954
We got a dog once for Christmas for three of us kids, and I never got to pet it.

520
00:44:58,954 --> 00:45:01,966
And I was the one that owned a third of it.

521
00:45:01,966 --> 00:45:05,467
So, yeah, folks, Merry Christmas, everybody.

522
00:45:05,467 --> 00:45:07,648
Thanks for joining us for the hot dish.

523
00:45:07,648 --> 00:45:08,131
You bet.

524
00:45:08,131 --> 00:45:08,931
Take care.

525
00:45:12,046 --> 00:45:23,052
Thanks for joining us today on The Hot Dish, brought to you by One Country Project, making
sure the voices of the rest of us are heard in Washington.

526
00:45:23,052 --> 00:45:25,968
Learn more at onecountryproject.org.

527
00:45:25,968 --> 00:45:28,262
That's onecountryproject.org.

528
00:45:28,850 --> 00:45:31,840
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529
00:45:31,840 --> 00:45:39,049
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530
00:45:39,049 --> 00:45:43,733
We'll be back next week with more Hot Dish, comfort food for rural America.