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Coratti: My name is Kris Coratti. I am vice president of communications and events at The Washington Post. Thank you so much for joining us here this morning.
Today we're going to talk about the future of healthcare with three prominent industry leaders who have decades of experience both in the public sector and the private sector. We're very thrilled to have all of them here with us today. But before we begin, I'd really like to thank our presenting sponsor, America's Health Insurance Plans, and our supporting sponsor, the University of Virginia.
And now I'd like to welcome to the stage Matt Eyles. He is the incoming president and CEO of America's Health Insurance Plans. He's going to say few words. Thank you. [APPLAUSE]
Eyles: Well, good morning everyone. I'm Matt Eyles, incoming president and CEO of AHIP, the national advocacy association that represents health insurance providers and hundreds of millions of members they collectively serve nationwide. As a sponsor of this morning's event, it's my pleasure to welcome you. Thank you for joining us. And thank you to the speakers today who are joining our program. They are real leaders in healthcare who can help answer a critical question, one that is top of mind for millions of Americans: what does the future of healthcare look like for me?
Many of the debates and discussions inside the Beltway often illuminate differences of opinion. But improving healthcare so that it works for every American is a commitment that I'm confident we all share. Making coverage more affordable, simplifying the healthcare experience for consumers and patients, improving quality and outcomes, lowering the price of prescription drugs, solving the opioid crisis, ensuring access to care and coverage for everyone—these are commitments we all need to work together to achieve. That means building on what's working today.
Nearly 300 million Americans have insurance that covers critical benefits like doctor's visits, prescription drugs, and today, many preventative services, like screenings for cancer, cholesterol, and type 2 diabetes, are 100% covered by health insurance providers. More than 20 million Americans, seniors and those with disabilities, have chosen Medicare Advantage. Nearly 55 million Americans get their coverage through Medicaid managed care organizations. And 180 million Americans rely on their employer for coverage.
They know that if they had a medical emergency, if their child were diagnosed with a terrible disease, if they have an ongoing challenge, like managing diabetes or heart disease, their coverage will protect them from the vast majority of medical costs, and provide both health and financial security. That's a vital responsibility that AHIP's members work hard to deliver every day. And if we improve what's working today and fix what isn't, if all us—insurers, doctors, nurses, hospitals, and pharmaceutical companies—work together, we can ensure that every American has access to affordable coverage and high-quality care. And we can ensure that America's healthcare future is bright.
I greatly appreciate The Washington Post for hosting this event today, and I look forward to hearing the insights of our speakers. We also look forward to working with you and all our state and federal leaders to lower costs, to improve healthcare and coverage for all Americans. Thank you very much. [APPLAUSE]
Coratti: Thank you so much, Matt. I would now like to welcome to the stage Carolyn Johnson from The Washington Post. She's going to lead our first discussion. Thank you. [APPLAUSE]
The future of an evolving industry with Highmark Health CEO David Holmberg:
Johnson: Good morning. I'm Carolyn Johnson. I'm a business of health reporter here at The Post. And our first guest this morning is David Holmberg. He is the president and chief executive of Highmark Health, which has a really unique vantage point in the healthcare system. They're a major insurer, one of the largest Blue Cross plans in the country, and they also own a large hospital system based in western Pennsylvania. So David has a great perspective on both kind of sides of the healthcare debate.
Today we'll talk about the insurance industry, the rising cost of medical care, and how that will affect healthcare systems over the next decade. And before we begin I wanted to let you know if you have any questions you can tweet them to us using the hashtag #PostLive, and I'll ask them to David. So one of the biggest kind of ideas about the future of healthcare right now is the idea of unusual bedfellow companies coming together, whether it's CVS—which most of us know as a retail pharmacy—buying a big health insurer, whether it's insurers buying doctors' practices and hospitals.
So you have a really interesting point of view on that because you've done it and you've seen it in practice for years. And so can you tell us a little bit about how that works and what the challenges are?
Holmberg: Sure. First of all, we appreciate the opportunity to be here. You know, Highmark is the third largest Blue Cross Blue Shield plan in the country. We might be the craziest because we decided to preserve competition and invest in a hospital system. So in addition to being an insurer, we're responsible for the delivery of care. And that's really changed the game for us. I think all of these unusual combinations you're seeing are really driven by the fact that we're at a crossroads.
You know, the majority of our healthcare system was built for volume. It was built post-World War II to address accidents and infections. And today what's driving the cost of healthcare is chronic disease. And so what that's creating is a real opportunity for new companies, innovators, different kinds of partnerships than have ever existed before.
Johnson: What are the challenges about that kind of a partnership though? Because insurers traditionally are focused on driving great bargains, getting good prices on things. And hospitals traditionally make money off of trying to get as much payment as they can for their procedures. So how do you balance those tensions?
Holmberg: Well, first of all, you have to get all the crazy people in the room and figure out who's the craziest. You have to think about this in a little different context than maybe an insurer has before, or a hospital system would before. And what we mean by that is, you know, we're at a crossroads. The consumers are demanding improvements in the quality of care, and the outcomes, and the value of care. But they're asking for it to be affordable. And that's what's changed. And that's what's driving all of this.
And so when you get in a room, you know, what you and I have to do is to ask everybody to take their hats off that they wear in their day jobs, and now think about the family or the individual as a whole, and be consumer focused. You know, my background is retail. I ended up in healthcare because I truly believe that healthcare is the new retail for the next several decades. And there's going to be an important transformation that happens here.
Johnson: Do you think that these kind of closed-loop systems are necessary for the future of healthcare? Talk a little bit about value and kind of how that is a different equation once you're on both sides.
Holmberg: Well, I think "value" means different things to different individuals. But from our perspective, having an integrated delivery system, finance and delivery system—we're the second largest in country. I believe 18.3 billion. And what we've learned from that is when you have all the pieces, all the tools together, what you can do is change how you're delivering care. Because you're not looking to do more procedures if you're a hospital president, and instead, you know, what you're looking to do is to create better value and better outcomes. And if you're an insurer, you're not just doing the finance piece of it, you're concerned about how do you actually change the care.
That's the real opportunity for us. We're at a very transformational moment here. And I think as an organization, we believe having that integrated model gives us a competitive tool so that consumers will have more choice.
Johnson: But won't they be kind of stuck in their own healthcare universe, choosing one system or another?
Holmberg: Well, that can happen. But I mean, I'm a believer that—just like in any other consumer decision or a thing that people do—they'll do what's in their best interest. As we've said before, "value" means different things, but it certainly is about improving quality. It's maybe changing how outcomes are derived and doing it with the lens of affordability. And so what that'll do—you know, yes, you may have people that are willing to say, "I don't need to have every hospital or every provider in the system in my network. And I'm willing to trade that to get higher performing, better quality people in their network."
And so it gives them choice, and it gives them options, which historically hasn't existed.
Johnson: Yeah. Well, let's talk about another area of cost. Drug prices are a huge topic right now.
Holmberg: Uh-oh.
Johnson: President Trump, last week, gave a very much anticipated speech about his strategy on this matter, to lower drug prices for consumers and for the system. What were your initial responses?
Holmberg: I think our initial response was, "It's a step in the right direction." The challenge we all have is we're on the verge of miracle drugs. And the problem we all have is that those miracle drugs are going to have a miracle price, and how do you figure out how to pay for them. And I think what we saw this past week was a step in the right direction. But we really have to think about the whole healthcare system differently.
When I think about the 5 million people that we serve, 22% of the money that employers and individuals are spending on their healthcare is going to pharma. And that's not necessarily sustainable. What we have to do is to think about things differently. Highmark Health just partnered with a drug called Symbicort, which for the first time we'll pay for the drug, but it's all at risk, meaning they have to get the outcome that they promised in the TV ad and to the patient. And if we get that, then they should get the benefit of that, and they should deserve payment for that. So we think that's part of the model that has to happen.
Again, we've got to move away from volume, to value. So when people make decisions to invest in healthcare there's got to be returns on that investment that lead to better outcomes.
Johnson: How do those kinds of outcomes-based payments trickle back to the consumer at the pharmacy counter?
Holmberg: Well, I think there's a number of different ways that that can happen. You know, I think you can do that through—I mean, obviously, most people when they're in a medical concern, or have a medical condition, they number one thing they're concerned about is getting better. We can never forget that. That's why our whole strategy is patient centered, clinician led, as we think about how we're transforming.
But then what happens is they start to be concerned about the economics. And so there's a lot of different ways you can transfer the benefit to the patient through your insurance rates, through copays and deductibles, and how you design products. And so the one thing I would just suggest—you have to remember though—is you can't disassociate pharma from the medical side of it. One of our biggest challenges today in America is unfragmented care.
So what's happening is one physician may see somebody for a cardiac concern. They prescribe a prescription. And then somebody else sees them for a pulmonary concern, and they give them a prescription. And so that fragmentation leads to conflicts, and it leads to inefficiencies, as well as poor outcomes.
Johnson: Do you find that you have the toolset to be able to handle those kinds of situations better being both on the insurance and provider?
Holmberg: Absolutely. I mean, you know, there's a lot of people who believe that data is the answer. I believe that insights are the answer. So we have an incredible amount of data because we're both an insurer and a health system. And so we're able to see the clinical data. We've invested, in our case, over $500 million in Epic and in the electronic medical records, which is really designed to coordinate care and to provide information that can be used. Plus, we're balancing that with the claims data that we see with an insured individual.
And so the real superpower that we're focused on—particularly with our partnership with Carnegie Mellon, and Johns Hopkins, and Penn State—is what do you with that information, and how do you turn it into predictive data? Our goal is for our folks to be able to reach out to somebody and say, "You're on the verge of having diabetes," not see them after they have an emergency room visit and they have a crisis.
Johnson: That sounds great. [LAUGHS]
Holmberg: Stay tuned.
Johnson: So there are other costs of healthcare aside from drug prices, even though we talk about drugs a lot. A Health Affairs study last year found that the top 1% of spenders in the United States were responsible for something like the same amount of spending as the bottom 75 percentile. I'm just wondering, did these patterns hold up in your population? And also, what kind of solutions do you see when the problems of American healthcare being expensive are both prices, but also just the distribution of healthcare problems, and how do you see a solution there?
Holmberg: Sure. Again, I think that what we see, and the data certainly bears out, that you do have a small portion of the population, less than 5%, which drives the majority of the cost of healthcare. And we have to think about how we deal with that differently. In most cases, it's driven by chronic diseases. I mean, post-World War II, we built all these hospitals around the country, and we built a healthcare system based on infections and accidents driving the majority of our need. Today we look at it and it's about chronic disease: diabetes, COPD, congestive heart failure, those kinds of things.
And so what we're doing is wrapping these folks with a whole different model of healthcare. And you can only do that if you take the incentives away for transactional relationships. So what that means is we took the 2,000 most complex cases in Pittsburgh, for example, and we changed how we interacted with them. We changed, and partnered, and vetted with their primary care physicians. A different level of care. We call it "extended complex care." And that did was, over 12 months' time period, we reduced their emergency room visits by 15%, and we've reduced the cost by 20%.
So they're getting better quality of life, better outcomes, and we're starting to get our hands around the cost. You can't do that if there's a disconnect between who holds the risk and who's actually delivering the care. And so our partnership, you know, changes that.
Johnson: As a hospital system as well, talk about kind of the future you see there in terms of expansion and growing because there's always a lot of growth happening in healthcare. And how do you see efficient growth since you're also trying to think about containing costs?
Holmberg: Well, I think efficient growth is about having the right beds in the right places at the right times. I would tell you that I've never woken up any morning since I've been in this role, and questioned how many people we have in hospital beds. In fact, our objective is totally the opposite. We want to keep people out of the hospital. We want to keep them healthy, and we want to treat them closer to their community.
So we're investing now in four neighborhood hospitals. And think of it as "bricks and mortar light." The idea is that there's emergency room capability close to where you need to be in case you do have an accident. But also, there's a very strong team-based primary care component so that you can go see your primary care physician and be wrapped with somebody who understands PT or understands diabetes. And then the third component is we're embedding specialists for those folks where it makes sense. So that's one way we're tackling it.
The second thing we're doing is, in our case, we introduce same-day appointments. I don't know how many people in the audience would raise their hand to say, "I called the doctor and I got in to see him that same day." What's changed for us is, in the last year, we did 238,000 same-day appointments, not only for primary care, but for specialists. And that's about access because the consumer is tired of having to fit into our schedule. They want us to fit into theirs. And so when we create access, what that does is you start to see the patients earlier on in a cycle, and less likely to see them in the emergency room down the road.
Johnson: Yeah. What are the lessons you've learned about how this can be hard? Are there any negatives for patients—[OVERLAPPING]
Holmberg: Well, I mean—[LAUGHTER] I would say it's one thing to insure grandma. It's another thing when you're taking care of grandma, too. Healthcare is local. I mean, just like today's an election day, politics is very local. Well, healthcare is local as well. And when you have a family member that's in need, you know, what we've found is that it can be very emotional and traumatic time for people. And so we have to rise to the occasion every day. You don't get a second chance. And so we believe that you have to earn people's trust.
What we've found is you have a healthcare system in our country that people have invested many dollars in, and they've invested their personal equity into. And today, it needs to transform. And so what we've found is it's hard. We found that you can't just nip around the edges. You can't just go in and maybe do a better job of just one segment. We have to transform the whole. And the only way that's going to work is with organizations like ours, in a private-public partnership, that are willing to do the hard work, and make the tough decisions, and walk away from legacy bricks and mortar, invest in technology where it matters.
Johnson: What do you think the role of technology is going to be? Because definitely one of the things swirling around the whole vortex of change in healthcare is these big tech companies sitting on the sidelines, maybe going to jump in at any minute, and we're all kind of wondering when. Where do you see technology having a real potential?
Holmberg: Well, first of all, I'd say let's go. I mean, we've seen others who have stepped in before. There's a reason why healthcare has been such a tough nut to crack. I mean, I think where technology is going to really matter is, first of all, with data. So think about it today. There's so many devices out there. You can get so much information about what your health status is, what your pulse is. I mean, I wear one when I run. And all that data, you know, you've got to do something with it. And so it's all unstructured.
I think the superpower that we're working with, with Carnegie Mellon and Highmark Health, is we're going to take that data, plus your clinical data, plus your claims data, we're going to put it all together, and use that for insights. And that will be the real opportunity. I also believe that there are real innovations that are changing how care is delivered. Let me give you one example. In Pittsburgh, we're the largest health system with the most robotic surgery rooms. So our operating rooms. What that means is more precision for the surgeons, better outcomes from the patients.
But you need to make investments in technology that solve real problems. You can't have technology that's looking for a marketplace. Instead, we need to say, "What are the problems we're solving for as America," and then, "What can technology do to fix that?" And I think that's a little different perspective.
Johnson: Yeah. Do you think that these technologies are best developed in-house by people from the healthcare system, or do you see the real potential for disruption by people who may not be hidebound by the traditions?
Holmberg: I think it's going to take both. I think what it's going to take is leaders who are willing to step up, and who are willing to be open to partnerships, who aren't going to be territorial and try to protect the past. For Highmark and for the Alleghany Health Network, our objective is to build the future of healthcare. And that means we want the smart people in the room at the table and making decisions.
One of our strategies, and we believe very strongly that clinical transformation and how you take care of people needs to be physician and clinician led. So we want the clinicians in the board room with us when we're making decisions. And I'm spending time in the operating rooms with them so that I understand what exactly is happening, and what their needs and concerns are. But I think that's a critical part of it.
And so, again, you know, our strategy has been to invite other people under the tent and come along the journey with us.
Johnson: I had the pleasure of going to Pittsburgh and riding around with David to see a lot of the things he's talking about. So it is really kind of fun to get out of the office and see how you try and tackle these really complicated, chronic health issues, and change care using all these tools. On a different topic, we're at the beginning of the new cycle we have each year on the future of the individual market, and the Affordable Care Act with states beginning to report the rate requests the insurers have been making. Just how do you see the future of this market evolving? Tell us a little bit about the journey you've been through the last few years.
Holmberg: Wow. I mean, if you think about the Affordable Care Act, and the journey from 2010 to today, it's been a wild ride. In the early days, there was so much that was unknown. It was a costly learning experience for us. We make no bones about that. As we started to get to know the folks who had signed up, you know, we learned that there was a lot of unmet need. And along the way, what we've also learned is that there's a real opportunity to engage them differently with than what traditional commercial insurance did, or maybe Medicaid or Medicare had done in the past.
And so today we're cautiously optimistic. In 2017, we saw some stabilization of the marketplace. Now there's some new changes, and those changes are going to create more uncertainty. And the bottom line to it is, you know, the broader the pool of people you have involved, the more you can work within that pool to figure out how to make this sustainable for the long term. So we are seeing rate increases again for 2019. We're seeing new challenges develop as some people in and some people move out. But the good news is we have four years of history now on most individuals who have stayed in the exchanges. So it's a little bit more predictive and you can start to sort out how to be helpful.
Johnson: So you see a road to stability in your mind? You don't see further chaos—[OVERLAPPING]
Holmberg: I think the road to stability depends on certainty of what the rules are. Tell us what the rules are, tell us where the field is, and tell us who the referees are, and I think the marketplace will sort itself out. I would say the jury is still out. We do see some level of stabilization, but with the new developments that have happened, it's to be determined.
Johnson: All right. We'll wait and see. You haven't yet filed your rates?
Holmberg: No. I think in Pennsylvania—I mean, you know, obviously we're in Pennsylvania, West Virginia, and Delaware. Pennsylvania is actually next week, and then West Virginia and Delaware are in the next couple of months after that.
One of the things that we think is really important to understand is, you know, if you believe that value-versus-volume medicine is meaningful and that it can have an impact, then it's important to have an individual—if they're going to be in the ACA or any other kind of insurance—stay with you for multiple years. Because the work that needs to be done has to be done on the front end. You know, I mean, you have to change how you interact with them. You have to maybe catch up some of their care. And then over time you can shape their health outcomes through more interaction.
But if they're in the marketplace and then out, if they leave, they go somewhere else, it's really difficult to make those investments. And so we believe that stability in the marketplace is a good thing, and that there's nothing wrong with that. You know, the rest is to be determined.
Johnson: In Washington, we often talk about healthcare as a national problem. We talk about the national trends. And we talk about kind of the premiums rising. It's always very different though, state by state, even county by county. There can be different trends—
Holmberg: Absolutely.
Johnson: —and different things happening. Can you just, as a large regional player, what are the specific healthcare problems that you see are common with kind of the national trends, and where do you see any outliers?
Holmberg: Well, I mean, I agree with you. I think the financing of healthcare may be a national issue, but the delivery of healthcare is local. And having spent much of my adult career in Texas, I know that the differences between Texas and the issue in Pennsylvania are pretty significant. And so what that means is it's not going to be—a sort of one-size-fits-all answer is not a magic wand. And in fact, it may create new issues.
If we're going to get this right, what we have to do is understand who are we serving. We have to have a strategy that's customer-based or patient-based, meaning that you understand what the needs are in south Texas versus what they are in northwestern Pennsylvania. And so what I see in the same sort of macro trends, you know, chronic disease, heart conditions, diabetes is running rampant across the country, and certainly is a challenge for us in Pennsylvania, and West Virginia, and Delaware. Mental health continues to be a concern, and how that relates to pain management, those kinds of things.
And at the same time, you know, what I see is hope. I see that there is a path forward if we're willing to make the tough decisions, if we're willing to do the right things, and break maybe from where we've been, and think about this differently than what we've done in the past. And I would say, in our case, we're starting to see the early days of that impact. And that's why our performance has improved, and that's why our outcomes are improving.
Johnson: A lot of insurers are very interested in a lot of the sort of social and environmental context around people's lives. And there's a lot of interest in the social determinants of health, that's what they call it.
Holmberg: Absolutely.
Johnson: Basically, do you have transportation? Do you have food? Do you have housing? Economically secure? What are you doing in that area, if anything?
Holmberg: Wow. That's a great question because there's a whole bunch of environmental reasons why people can become unhealthy. Some of it's personal choice. Some of it's the environment they're in. We're partnering with the Blue Cross Blue Shield Association, for example, just one example, and providing transportation for people. So using Lyft in a pilot that we're actually doing in Pittsburgh, to make sure that individuals are making it to their doctor's appointment; finding ways to get them to, you know, when they need a treatment or get them to the pharmacy. That's an important part of it.
We have a pilot that we're doing on the north side of Pittsburgh, where we're working with some nongovernmental agencies, some foundations. And we're looking to take a whole neighborhood and see if we can apply a different model to it, where we address not only safety, but social issues, transportation. Because you can't disconnect the cost of healthcare and the condition of healthcare from jobs and education. If you have jobs, education, and a good healthcare system it becomes a little bit of a flywheel effect. It starts to take care of itself.
And so we think that we've got to figure out how to address these issues. At the same time, we have to understand whatever we do has to be scalable. I mean, in our case, we have 5 million people that we insure. We want to make sure that it's scalable for all.
Johnson: Yeah. Well, if you had to diagnose, I guess, the biggest problem facing American healthcare, what would you say?
Holmberg: Wow. That's a tough one. [LAUGHTER] You know, I think we don't like to exercise. No, I would say the biggest challenge is the healthcare system was built in a model that was based on past need. And the world has changed. I think the biggest challenge in healthcare is recognizing that we can—it's no longer about us, it's got to be about them. It's got to be about the people that we serve. And meaning, you know, we need to have a retail mindset where we understand what motivates that individual, how do we connect with them, and then how do we provide them the services and capabilities that fit their lifestyle and their choices?
You can't force somebody to do something. But what we can do is be in a position where we move from the healthcare system we've had in the past. We use technology, innovation, and a lighter version to engage people earlier on in their lifecycle, rather than waiting till they have a chronic disease to try to maintain it. You know, but instead to work on avoiding it.
Johnson: And if there was one policy lever that you could pull to make your job easier or care better, what would that be?
Holmberg: Oh, I think I'd have to think about that one for a while. [LAUGHTER] I mean, I'm not a politician or a policy person in that sense. Much of what I do is play the hand I've been dealt. The one thing I would say from a policy standpoint is, let's have that ferocious debate. Let's talk through what really has to happen here. Let's not address the fringe, but instead let's talk about what really is necessary in order for the next 10 to 20 years to make healthcare sustainable and make it affordable. And then let's make the decision and let's go and do it.
And if we do that, and we keep the rules the same—we don't keep changing the rules as we go—what that'll do is allow the marketplace to make investments, to make investments in individuals up front, and not hold back and try to be transactional.
Johnson: Great. Well, thank you so much for your time. That's all the time we have for this segment.
Holmberg: Thank you.
Johnson: Thank you, David Holmberg, for joining us. And I will be handing this off to Lenny Bernstein.
Holmberg: Thank you very much. [APPLAUSE]
An examination of public health with former U.S. Surgeon General Vivek H. Murthy:
Bernstein: Good morning. I'm Lenny Bernstein. I'm a health and medicine reporter for The Washington Post. Today our second guest is Dr. Vivek Murthy who was the 19th Surgeon General of The United States from 2014 to 2017. During his tenure Dr. Murthy grappled with the Ebola epidemic. He put out in 2016 a comprehensive look at addiction in the United States, a document that was sort of a call to action as previous surgeon generals have done with HIV and obesity. And, most famously, Dr. Murthy spoke with Elmo from Sesame Street about vaccinations. And is probably his most widely seen moment. [LAUGHTER]
Today we're going to sort of take the temperature of the United States on public health, on some issues that you may have thought of and some others that you may not be thinking about. I am told to ask you to please tweet us some questions on the hashtag #PostLive. And, really, please do, because it's a rare opportunity to ask questions to someone who really, really understands and gets it. There's lots of public health issues. We usually talk about opioids at these sessions. But I'd like to start with one that's really not gotten the same kind of attention. You have been speaking and writing about loneliness as a public health issue. And I'd like to understand how you came to that issue and also why that is a public health issue.
Murthy: Well, it's so nice to be here with you, Lenny. And Lenny is a reporter I have great respect for, and I believe the work that you do as a journalist is especially important now compared to any other time that we have lived in. You know, the loneliness is an issue that I began thinking about actually quite some time ago, before I was even in office. When I was practicing medicine up in Boston I was practicing as an internal medicine doctor, taking care of people with diabetes, high blood pressure, different types of cancer. But what I quickly came to see was that the most common illness that I was dealing with was in fact not heart disease or diabetes; it was loneliness, and loneliness that stemmed from a lack of meaning, a lack of self-worth, and a lack of social connection.
And so I became intrigued by this and started to see more of this when I was surgeon general when I would visit communities around the country. Very few people would come out and just say, "I'm lonely." That's not who people would talk about the issue. But when given the right opportunity, when asked the right questions, people would start opening up about the fact that they were in fact experiencing loneliness. Just a few months ago, for example, I was doing a radio interview, and there were several people who called in at the end. And one gentleman in his 40s called in, and he said, "My best friend died a few years ago, and I've been profoundly lonely ever since then. And I just don't know what to do about it. And, as a guy, I feel like I can't really talk about that. It's not a very masculine thing to do to say that you're alone."
Another woman called in and she said, "You know, my daughter just came back from her first semester in college, and I sent her to college thinking she's going to be with a community of people that she is connecting to, who she has fun with, who appreciate her for who she is. But instead she came back and she said, 'Mom, I'm connected to people all the time. You know, we're texting each other; we're messaging all the time, but nobody ever asks me about me. No one understands who I am. I feel so alone.'" So I've realized that loneliness is far more prevalent than I thought. In fact, if you look at the data, the numbers are in the 20s to 30% depending on the numbers you look at. AARP, for example, did a study looking at people over 45 and found that nearly a third of them are in fact experiencing loneliness. So this is a profound issue. It turns out it also has public health implications.
Bernstein: Yeah, you've written some pretty startling statistics about the impact of loneliness.
Murthy: Yeah. So if you look at health, what you see is that people who are lonely live shorter lives. In fact, the reduction in lifespan associated with loneliness is similar to the reduction associated with smoking 15 cigarettes a day. It's also greater than the association with obesity. So just image for a moment how much attention we spend talking about, thinking about, and addressing obesity and smoking compared to how much we think about loneliness as a public health threat. But folks who are lonely also have an increased risk of heart disease, of dementia, of trouble fighting infections, so they have a weakened immune system. And they also have a greater risk of depression and anxiety.
But the consequences of loneliness actually go far outside of health too. It impacts your productivity in the workplace. It impacts how our children do in schools. And what I've begun to see increasingly is that it also impacts our ability to dialogue as a community. And so if you imagine the times that we're in now, when we are struggling with major challenges, whether it's the opioid crisis or climate change or other chronic illnesses, these require us to be able to talk to each other, to dialogue as a community. But we can't do that if we are in the chronic stress state that is triggered by loneliness.
Bernstein: So why would loneliness have the same impact as 15 cigarettes a day, just physiologically?
Murthy: So it turns out there are probably at least two explanations for this. One is that it looks like people who experience loneliness actually have a difference in the health-related behaviors that they engage in. So they may be less likely, for example, to make the right choices when it comes to nutrition and physical activity. But there's another explanation as well which is rooted in evolution which has to do with the fact that loneliness triggers a chronic stress state in our body.
So if you imagine thousands of years ago when we were hunters and gatherers, being a part of a group was actually very beneficial because it ensured greater protection and a more stable food supply. In fact, when you were separated from the group is when you were more likely to get eaten by a predator or die from starvation. Now, think about the fact that that has been baked into our nervous system over thousands of years so that in the modern day and age when you are lonely, which is the equivalent of being separated from your group, having inadequate social connection, it triggers a similar stress response. And included in that stress response is hypervigilance. Right?
And so I mention this because in a situation where you are surrounded by predators, you want to be hyper-vigilant; you want to think that the rock that just moved over there might be an animal that's trying to jump out and come to get you, even if it's not. But in the modern day, if you are hypervigilance leaves you to suspect that people with good intentions have bad intentions, to suspect that people who perhaps aren't even interacting with you are trying to point at you or trying to threaten you in some way, you can imagine how this impairs our ability to actually dialogue and to interact with each other.
But the chronic stress that stems from loneliness, we know that that stress is connected with inflammation, which in turn is connected with higher rates of heart disease and many other chronic illnesses. So there are biological mechanisms through which loneliness may have its effect. That said, there are probably mechanisms through which we don't understand. But the bottom line is when you look at all the data on loneliness, the statistics, the biology of it, you're left with this inescapable conclusion that we need each other; we are fundamentally social creatures. It doesn't mean we're all introverts or extroverts. But both introverts and extroverts need some degree of human connection, even if we differ in how much that is. We haven't prioritized that really as much as a society. In fact, it's not that we have said connection is not important; we've just allowed our self to think that many other things are far more important, and we've taken our eye off the ball in investing in human relationships. And that has had its consequences in terms of our health.
Bernstein: Well, my kids tell me that they are connecting and hanging out with their friends, they're just doing it on phones and tablets and computers. Not the same?
Murthy: Not the same. And the bottom line is not that technology is bad. In fact, I think, you know, as somebody who spent years building a technology company and has used technology a lot, I believe in tech, and I think it can be helpful to us. But technology ultimately is a tool, and how it's used is what makes a difference between whether it's helpful or harmful. And what you see with social media is that when you use social media as a way station, meaning if you use it as a tool for in-person interaction, as a bridge to in-person interaction, it can be quite helpful in helping build social connection, as it has been to me.
So when I go from one city to another, I might look up friends on social media just to see like, you know, "Hey, which of my friends actually lives in Philadelphia now," or, "Has somebody moved to Anchorage, or has somebody moved to Topeka?" But if I'm primarily using social media as a substitute for in-person interaction, if I'm feeling lonely, for example, on a Friday or Saturday night and I say, "You know, I don't have anyone to hang out with, but let me go on my social media feed and just scroll through people's posts and then I'll feel connected to them," that actually tends not to work. In fact, in that case you see that passive use of social media is associated with greater rates of anxiety and depression.
Bernstein: We can't just say, "Okay, I'm not going to be lonely any longer." What do we do?
Murthy: So I think that there are a number of things that we have to do, like at an individual level and at a societal level. I think as a society, as organizations, whether you're workplaces or schools we have to think about how we create environments that foster authentic human relationship. And I say authentic human relationships because this is about more than just hosting happy hours and throwing people together in a room. It's about very intentionally trying to create opportunities for people to get to know each other on a deeper level. You know, people want to be understood for who they are. That doesn't mean that everyone wants to divulge their deepest and darkest secrets at work. But what it does mean is that they want to be appreciated for more than the person who knows how to do Excel spreadsheets and the person who is good at pricing strategy. People want to be known and appreciated as human beings, as moms and dads, as community members, as concerned citizens. And some of these exercises to enable that kind of interaction we actually created and built when I was in office, when I was serving as surgeon general, to help our own office foster stronger connections.
But on an individual level I think that there are also strategies that we can use. And I'll tell you this on a very personal note, because I myself am working on implementing these strategies in my own life because I too have experienced loneliness in my life. That's part of what brought me to this issue. When I was a child I was actually quite lonely in elementary school. I was very shy. It wasn't that I didn't want to interact with people, but I was lonely. And I had a wonderful family at home but lonely at school. And I never felt comfortable telling my parents that I was in fact lonely because saying I was lonely felt like saying I was not worthy of being loved. And that's what it feels like for many people to express their loneliness, which is why they don't. But this is why it was very personal to me. So coming out of office I looked at my life and I realized that I had allowed work to edge out a lot of my close personal relationships, and that had led me to be lonelier than I thought I would be.
And so the things that I'm doing now, which I think in general can be helpful, is, one, draw boundaries around technology so that you don't bring technology into your in-person relationships with other people. So specifically if I'm having dinner with my family, I try to leave my phone or my computer aside. If I'm catching up with a close friend, I try not to leave my phone open-faced so that I'm constantly looking at text messages or being distracted by alerts. But the other thing that I think is important to do is to also ensure that each day we have at least some authentic interaction with someone that we love. It could be one minute. It could be five minutes. It could be a text message you send to a close friend. It could be a quick call you make to someone you love. It could be picking up a call when you get it.
And I won't ask by a show of hands, but I know that many of us, myself included, have been guilty of seeing a phone call come from a loved one and then just not picking it up because we're worried that it will lead to a much longer conversation. [LAUGHTER] And we don't want to take that risk, right? But, you know, what I have found is sometimes just picking up and saying, "I can't talk to you right now, but, you know, it's so good just to hear your voice for 30 seconds," that makes a difference. So prioritizing relationships, protecting those relationships from the insidious invasion of technology, I think that these are both very important strategies to help us rebuild our connections in our life.
Bernstein: That's great. That's great advice. That's why the surgeon general is America's doctor. A couple of quick questions about other public health issues that seem to have faded, possibly because we have made some progress, possibly because we're ignoring. Hypertension; are we moving forward, are we making progress on the amount of salt in our diet and the level of hypertension in the United States and all the problems it causes?
Murthy: It's a good question. You know, high blood pressure is certainly something everyone has heard about, but you're not reading about it in the headlines every day. You're reading about the opioid epidemic; you're reading about violence from time to time. This is unfortunate because high blood pressure and cardiovascular disease more broadly is one of the leading causes of disease and death in the United States. And so one of the things that I think we have realized over time is that we have made advances in how to treat high blood pressure, in understanding what gives rise to high blood pressure. Where we have not made as much of an advance is in actually reducing rates of hypertension, of high blood pressure in the United States.
And I think that that is in part because I think we have not succeeded yet in taking a population-based approach to addressing high blood pressure. A population-based approach is not the same as an individual approach. An individual approach would be to say, "Okay, when patients come to clinic then we'll talk to them about their diet and exercise and put them on the right medicines, and hopefully that will address hypertension." But a population-based approach says, "Can we do things like reducing the overall sodium content in the foods that we eat by working, for example, with packaged food manufacturers, by working with restaurants and others to reduce that sodium content knowing that there is a connection between sodium content and high blood pressure?"
It also involves thinking about strategies for increasing physical activity. Can we create more green spaces, more walkable spaces that will allow people to be more physically active so that it cannot only reduce rates of hypertension down the line but also have other benefits? When I was in office, for example, I had released a call to action around walking and walkable communities. And the reason I had done that is because it turns out that if you walk an average 22 minutes a day and you do so at a brisk pace, you can reduce your risk of diabetes by 30%, your risk of heart disease by 20%. But we're not really seeing a big investment in creating walkable spaces.
I guarantee you though, if I told you that I had a pharma company that had a pill that if taken once a day could reduce the risk of diabetes by 30%, I think I would do quite well. Right? Because people would say, "Hey, that's a solution that we should invest in." But we have solutions like that sitting right in front of us. They're called sidewalks; they're called parks; they're called walkable spaces. [LAUGHTER] But, you know, we need more people to make the case to congress and to other legislators that sidewalks are actually powerful public-health interventions. They may not look like a medicine that fits in a bottle, but they can have quite an impact on our health.
Bernstein: If I am manufacturer X, I am not about to reduce the sodium in my product, risk the taste, the loss of the profits, the loss of sales unless I know that all the rest of the manufacturers are going to do it. So how do we get that done?
Murthy: This is where, I think, government has an important role that it can play. I'm not somebody who believes that everything has to be done by government or that the private sector necessarily has to be overregulated, but I do think where the government can step in is to play a leadership role in bringing people together to make decisions that ultimately benefit all of us. And this is one example of that.
Very few companies are willing to take a risk on changing the sodium content in their products on their own for the exactly reasons you mentioned; they're worried if their products don't taste as good or if they taste differently, that people will shift their consumption to other companies, to competitors. But there are a couple of things that we know. One is that even if you were to reduce the sodium content in your food by, let's say, 10% or 20%, you might notice a difference, but over time and over, in fact, an order of weeks or a few months, your palate will change, and it will acclimate to the new level of sodium content that you have.
This is actually not just true with sodium. It's true with sugar as well. And we could do a similar thing with sugar as we need to do with sodium, which is to bring manufacturers together to reduce the sodium as well as the sugar content in their foods. Because right now it turns out that close to 75% of packaged foods actually have sugar in them as well, things that you may not think of like pasta sauce and bread and crackers. But it is very powerful. And I know this in part not just from the science but from some practical experience. So when I was in office, a group of us on my team decided that we were going to do a quote unquote "sugar detox." So we gave up sugar for a period of 30 days.
Bernstein: Just cold turkey?
Murthy: Cold turkey; we just gave it up. And giving it up meant that we didn't take added sugar in anything; we didn't buy or consume products that had sugar added to them that were unnatural. We could eat an orange, for example, but we wouldn't drink juices that had sugar added to them. What we found, which was really interesting, is our palate changed within the order of a couple of weeks. In fact, one of the men who was in our group who was participating in this, he came back from lunch with half an orange. And I said, "Why didn't you eat your whole orange?" He was like, "I just couldn't eat it. It was too sweet." Everything suddenly tasted too sweet.
So the bottom line is, as human beings, we don't have to be worried that if we change the sodium and sugar content in our food that it's permanently going to change the quality of the food that we consume. Our palates will adapt. But the long-term benefits will remain. Government though I think can and needs to play an important role in bringing manufacturers to the table so that they can collectively make these decisions. And if they do reduce sodium and sugar content even by an incremental amount, it can have a profound effect on the lives of millions of people.
Bernstein: And sort of convince them that everybody is going to go along if they—they will acclimate to the same amounts of sugar across all these products?
Murthy: That's right. Yeah.
Bernstein: A quick question about smoking. It's down to about 15% of the population, yet it is still probably the single greatest risk factor, cause of death in the United States. What needs to be done? What's left to be done on smoking?
Murthy: Well, we've made a lot of progress, but we do have a lot of work to do. In 1964 when my predecessor Surgeon General Luther Terry published the first surgeon general's report on tobacco, smoking rates in the United States were around 42%. Dropping all the way down to 15% is a major, major public health victory that didn't come easily. It came because of the hard work of people in communities across the country who build education campaigns, who came together to change policy like increasing taxes on cigarettes and creating smoke and tobacco-free places. But it was an important victory.
That said, we still lose about half a million people every year in the United States due to tobacco related disease. And the more we learn about tobacco, the more we realize that there are more illnesses associated with than we originally thought. So in 2014, in fact, when the 50th anniversary of the Surgeon General's Report on Tobacco was published, it was recognized that unlike '64 when there was one cancer that was seen to be associated with smoking, and that was lung cancer, now there were over 13 cancers. There is also an increased risk of diabetes seen with people who smoke. Like that, more and more we see added risks of smoking.
What do we need to do? Well, I think for sure we have to double down on public health strategies that we have seen work when it comes to smoking. That means continuing to increase taxes on cigarettes. That has a profound effect particularly on youth utilization. So if we want to protect our kids, taxing cigarettes are actually a very important strategy. But the second thing that we have to do is we have to work on better cessation tools. We already have a number of FDA approved cessation tools that are on the market. They work well for some patients; they don't work well for all patients. And so we need better cessation tools.
Now, people have asked about e-cigarettes in this context. "Are they the cessation tool that we've been waiting for?" And I don't think we have enough science to say clearly that they are. But I do think that they are interesting enough that they merit strong scientific inquiry to see if they are in fact safe and effective tools for smoking cessation. What we don't want with e-cigarettes is for people to start using the e-cigarettes and then end up using both e-cigarettes and traditional cigarettes, a situation we call a dual use. That has happened in some populations. But the only way to know if this works or not is to study it rigorously. And I think that's something that we should do.
Bernstein: I'm going to back you up back to nutrition because we have a Twitter question. "Why do doctors receive so little training in diet and nutrition when plant-based diets are scientifically shown to prevent and improve heart disease and diabetes?"
Murthy: So that's a great question. And, in fact, I will tell you what my nutrition education was in medical school. My nutrition education consisted of an eight-week class that was offered once a week in the evening, and it was optional. [LAUGHTER] So how many people do you think went to that class? There were about six of us, I think, in the class. One of them was the instructor, so not a whole lot of people. So traditionally this has been a huge gap in medicine that we have—there are actually several gaps in traditional medical training. One is around nutrition. Another is actually around emotional health and well-being, which has a profound impact on our health but which we don't really talk about very much in medical school. In fact, I'll say this parenthetically, that the power and impact of emotional health and well-being is so profound on our health—and something I saw so clearly again and again when I was in office—that I decided coming out of office that what we needed to do was to really shift our culture and understanding around emotions so that we could understand the role it played in health, but also invest in cultivating positive emotions and teaching children how to regulate their emotions.
And what we see when you do that is that not only can you actually reduce rates of addiction, a major problem right now, but you can also reduce rates of violence; you can reduce incarceration rates; you can improve graduation rates and grades; you can reduce teen pregnancies. So the power of investing in emotional well-being is actually quite extraordinary but has been barely tapped. And that's why coming out of office I am working now with some colleagues to build an institute on emotional health and well-being that will help make that journey for us from a place where we largely ignore emotions to one where we harness them to improve our health.
But part of what we need to change in medicine around nutrition is education. And that's slowly happening. But I don't think we can wait for medicine to get fully on board with training its clinicians to understand how best to deal with nutrition in the clinic. I do think what we need in addition to training doctors is we need public health strategies around nutrition. We talked about a couple of them, working, for example, with manufacturers to reduce sodium and sugar content. But what we also need to do is think about the availability of healthy foods and beverages in our communities. We know, for example, that accessibility, whether in terms of both affordability but also in terms of location, is paramount to people's choices.
If you work in an office building that doesn't have restaurants around it but that has an office cafeteria, the food that's in that office cafeteria is going to have an impact on the choices that you make. And if there are healthy options, then you are more likely to make them. The Department of Defense—I had the chance to work with them when I was in office as part of the National Prevention Council of which I chaired, which was the council set up by the Affordable Care Act which brings together the secretaries of all the major federal agencies to think about how their policies impact prevention. And one of the things the Department of Defense was doing was actually experimenting with looking at their own cafeterias on bases. And what they found is we needed simple things like change the location of the grill and the salad bar to bring the salad bar closer to the front of the cafeteria. You could have a significant increase, in fact, on people's choice of healthier foods.
So these types of population-based strategies, I think, are essential for us to take now if we want to affect as large a number of people as quickly as possible. Working with physicians and training nurses to have conversations with patients in clinics and hospitals is important, but I don't think it's going to happen quickly enough for us to ultimately get to where we need to be, which is a place where people can make healthy choices at affordable rates and ultimately live healthier lives.
Bernstein: Gotcha. I've left us about five minutes for the opioid epidemic. I see some glimmers of hope after covering this for three years. Prescriptions are down. Members of congress are introducing dozens of bills to finally address the kinds of things that you have been speaking about and others have been speaking about. That has absolutely nothing to do with the upcoming midterm elections, of course. But overdoses will probably rise again in 2017 when we get the data, particularly from fentanyl. So can you tell us where are we right now in the opioid epidemic, and what do you see going forward?
Murthy: Well, you know, the opioid epidemic is on so many levels heart breaking. I first started to see the impact of it when I was practicing medicine up in Boston and realizing that more and more patients were coming in struggling with addiction to opioids. And realizing that as doctors we had not been well trained in how to think about pain, how to address pain, and how to address addiction, save for addiction-medicine specialists who are too few in number.
But the tragedy of opioids also is that it's revealing something deeper that we are dealing with, which is not just a problem with prescribing but, as I came to see in communities all across the country, there is a deeper pain that people are experiencing, a deeper despair in their lives that is often being fed or temporarily assuaged by not just opioids but by alcohol and by other substances that can easily be misused. And so if we ultimately want to address the opioid epidemic, we do need to change prescribing practices; we do need to expand the access to treatment; we do need to get naloxone in the hands of not just first responders but family members; but we also need to think more deeply about the root causes of addiction.
You know, addiction in many ways is as much a social disease as it is a biological disease. And what I mean by that is that while addiction impacts us on a biological level affecting our prefrontal cortex, affecting our extended amygdala, affecting our basal ganglia, all areas which are related to our ability to deal with stress and rewards and to control decisions and such, while all of that is true, we also are increasingly realizing that the social context of our lives, whether we are fulfilled, whether we have meaning, whether we have social connection with others, also plays a role in our experience of and our likelihood of developing addiction. So I think that we have to really understand this in order to build a comprehensive strategy.
I think where we are now is in a place where overdose deaths are still not decreasing, so we have a lot of reason to worry. But that does not mean that we are not making progress. So we are, for example, reducing prescriptions of opioids, which is important. We, in fact, have seen a near 25% reduction from the peak of opioid prescribing. It's still far above where it was in 1999, so we have a ways to go. Where we're also seeing progress is in extending medication-assisted treatment, which is evidence-based treatment with methadone, buprenorphine, naltrexone, extending that to people who actually need it. There are still far too many people who need treatment and can't get it, held back in part not just by funding but also by a terrible stigma around medication-assisted treatment. But in places like Rhode Island, for example, we are seeing that the state has now moved to make medication assisted treatment available in the prison system. And what that has allowed is for more people who need treatment to get it and a reduction in overdose deaths by nearly 12% statewide in Rhode Island in just a year's time. We're also seeing in cities like Baltimore and others where naloxone is made readily available to first responders and to the public that overdose deaths, in fact—or the people have been able to save a growing number of lives with the use of naloxone. And so I think there is reason to be hopeful that some of these strategies are working.
But here are a couple of things I think we have to do if we really want to accelerate this movement. Number one is we have to invest in these upstream prevention programs. By upstream prevention, what do I mean? I don't mean just changing prescribing; I don't' mean just patient education about opioids. I mean investing in the many programs that we wrote about in chapter three of "The Surgeon General's Report on Alcohol, Drugs, and Health," programs which are often school- and community-based, which are relatively inexpensive to administer, but which can have a dramatic impact on drug use among children, adolescents, and among adults. Some of these programs like the good behavior games program, for example, for every $1 you invest in it, you see a $64 reduction in healthcare cost, criminal justice cost, and loss of economic productivity.
There are other programs like that too; the life skills program; the Nurse-Family Partnership. But we have invested so little in those programs, despite how much they can return. And I think part of the reason we've done that is partly not enough people know about them in terms of policy makers, but there is also a mentality that we want to invest in something today that's going to have a result tomorrow. But we need to play both the short and the long game when it comes to opioids, and that means investing up front.
But the last thing I'll say on this in terms of what we have to do is that we also need to think about what's the appropriate role that each of us has to play here. This is not a problem—opioids—that the government is going to solve on its own. We need people in the private sector, individuals, and communities to help step up and help us shift the culture around addiction, which still tells us that this is a disease entirely of choice, that this is evidence of a character flaw or a moral failing. And that is not the case. You know, addiction is a disease of the brain. It's a social disease as well that many of us could be a victim to and may already be a victim to. And it's really often just dependent on the circumstances in which we live.
So we have to remember that we each have the power to change culture when it comes to addiction. And if we can change culture, then we can change a lot of other things. We can make it easier for communities to accept medication-assisted treatment facilities. We can increase the pressure on elected leaders to invest in expanding treatment for the opioid epidemic. But this is what we have to do. And government, the role that they need to—the federal government, I think, can and needs to play now is a role in setting a clear vision and benchmark of where we need to go on opioids. How much, for example, are we trying to reduce opioid overdose deaths in the next one year or five years? I don't think that that has been stated clearly. How are we holding states and the federal government accountable also for doing the work that needs to be done on opioids, not just for passing bills but responsible for changing outcomes? You know, I care less about a bill that's passed; I care more about an outcome that's achieved. And we might say that the bill is a way to, the method to achieving the outcome, but that's only a possibility; it doesn't mean it's going to happen unless we hold our elected leaders accountable to those outcomes.
So this is a place where I think government has a unique role to play. There is not private company that can set up and set a goal for the United States in terms of how much we should be reducing opioid overdose deaths in the next five years or 10 years; that is a place where I think the government has to step up. So, yeah. So I was really privileged to work on this issue though when I was in office, because I do think that at the root of the opioid epidemic are deeper questions that we have to ask about society. What kind of society do we want to live in? Do we want to live in a society where we believe every life truly matters? Do we want to live in a society where we all chip in, recognizing that we are vulnerable in some way, whether it's to addiction or loneliness or other conditions, and that we are stronger when we come together, when we recognize our interdependence, and when we help each other? As tragic as the opioid epidemic is, if it can move us in a direction of shared understanding about our interdependence, if it can help us address these deeper social roots of disease, then I believe that we will have used it ultimately to improve ourselves to become stronger as a country.
Bernstein: Thank you so much, Dr. Murthy. You gave us a lot to think about in just a half an hour. Thank you.
Murthy: Thank you. [APPLAUSE]
Bernstein: We're going to turn it over now to my colleague Paige Winfield Cunningham for the final discussion today with CMS administrator Seema Verma. Thanks. [APPLAUSE]
One-on-One with Seema Verma, Administrator of the U.S. Centers for Medicare and Medicaid Services:
Cunningham: Good morning. I'm Paige Winfield Cunningham, health policy reporter and author of the Health 202 newsletter here at The Washington Post. And I'm pleased to welcome my guest, Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, and she's here to outline her vision for the Medicaid program, which covers around 70 million Americans and of course, is a very integral part in America's healthcare future. So let's welcome the administrator. [APPLAUSE]
I want to remind our audience in the room and those watching online that you can tweet us your questions using the #PostLive and I will pose some of them to the administrator later on in our discussion. Before we get started, I actually wanted to ask you a mom-to-mom question, if that's okay? [LAUGHS]
Verma: Okay.
Cunningham: So I understand you have two kids, a daughter and a son, and one of them is graduating from high school this week?
Verma: Yes. Yes, this week, so it's been a big week for all of us at HHS. It's not only drug pricing, but it's graduation for my daughter and for Secretary Azar. They both go to the same school and so we're excited. Big week.
Cunningham: That's great. I have two little ones of my own and one on the way. So here's what I wanted to know: Do you give your kids waivers to get them to help with work around the house? [LAUGHTER]
Verma: Everybody's working and there are no waivers. You just do your job. [LAUGHS]
Cunningham: Good to know. All right, so speaking of work requirements, let's start with that because as you know, it's probably the buzziest topic around Medicaid these days. You so far have approved the community engagement requirements in four states and a half-dozen others have applied as well. I want to know what metrics are you going to use to determine whether these new requirements are a success or a failure.
Verma: Let me talk about community engagement at large. So these efforts really were borne out of some of the changes to the Affordable Care Act. The Medicaid program traditionally has been one that has served the aged, blind, people living with disabilities, pregnant women, and children. And with the Affordable Care Act, we added all of these new able-bodied individuals to the Medicaid program and so I think states were looking at this saying, "We don't want to just give people a card or just health insurance," but we want to try to help the needs of this population. These are individuals that are living at the poverty level—at or near the poverty level and so what can we do to help them? Not just getting healthcare coverage, but finding a pathway out of poverty, a bridge to independence.
And so our efforts were really as a response to where the states were in terms of wanting to do more for this population. And so what we did earlier this year is we put out guidance for states about how they could structure what we call "community engagement". And Community engagement isn't necessarily just about work. It could be volunteer work, it could be job search activities. It could be job training. Anything to sort of help that individual seek independence and a pathway out of poverty. And the other thing we did in the guidance is we also put some guidelines around what may or may not work. We know that a community engagement requirement may not apply to all populations. So this is focused on able-bodied individuals. It does not apply to people living with disabilities or pregnant moms or kids, obviously. It's just focused on those groups of individuals.
And within that, we also asked states to think about what types of exemption would be appropriate. So there are some individuals that are facing acute medical conditions, they're medically frail and community engagement might not be appropriate for them. Or there's individuals that are dealing with substance abuse disorder, opioid addiction. So creating exemptions for those individuals as well or they may be living in areas where they may not be jobs available. There may be problems with the economy in that particular area. So to think about how could they create exemptions. So we put these guardrails around the program.
The response we've received has been very positive and when you look at community engagement from a polling perspective, there's a lot of public support for these types of programs. There was also a survey of physicians that was also done that showed high support for this as well. One of the things that we're doing with all of our programs that Medicaid is—we're trying to give states as much flexibility as possible. And with that flexibility also comes some accountability. So we're going to have very strong evaluations of these programs. And really, the purpose of them is to improve health outcomes and so as part of the evaluation and your question, which is, "How are we going to look at these programs and what types of indicators?" We're going to look at health outcomes. The research shows that there is a strong link between people that are working and better health outcomes. So that's one of the things we're going to look at and we're going to look at individuals who are on the program and how many of them actually participate in the requirement, how many of them actually go on to getting a job and being independent of the program. So there's a lot of different parameters that we're going to be looking at. But it's all centered around improving health outcomes.
Cunningham: There have been some concerns expressed about sort of a difficulty in implementing these kinds of requirements and that's something I know that the Medicaid plans themselves have expressed to me. Are there ways that you can help them to put these new requirements in place?
Verma: So I think anytime you start something new, there's going to be some challenges, just understanding the best way to do this, but as I've toured the country and talked to a lot of states—I was actually in Arkansas when their waiver was granted, and we heard some remarkable ideas that they have going on, on the state level. For example, they had been working on a partnership with some of the nursing homes that said, "We need individuals to help the certified nurse assistants or we need aides." And they actually had a lack of these types of employees. So they were going to run free training programs and they were really kind of building that partnership with the state. They were also working with their community colleges and granting scholarships to some of the individuals that are on Medicaid that were participating in the community engagement requirement. So I think every state is going to approach this differently, but I think it's exciting to see the type of discussion and collaboration on the community level.
Cunningham: I want to ask you about some of the other kinds of Medicaid flexibility states have been requesting, but first, let me step back for a minute with a broader question, and that is: How do you want the Medicaid program to look different overall when you eventually leave CMS compared to when you started last year?
Verma: I think the Medicaid program, like I said, is a promise to the most vulnerable populations in our society. So I want to make sure that our programs are delivering high-quality, accessible healthcare. That we are improving health outcomes, that we are helping each and every individual that's on the program achieve the best quality of life and that we are helping each of those individuals attain their highest level of potential. And while doing that, we also want to make sure we're improving health outcomes and finally, making sure that the program is sustainable—sustainable over the long term.
If we look at the Medicaid program, this is the number one or number two budget item in most states and it's starting to crowd out other priorities for the states. It's education, it's infrastructure, it's job creation. And so there's been a lot of discussion about the Medicaid program and its financing. And just a little bit of history: If we look back at the program, in 1985, states were spending about 10% of their budget on the Medicaid program. And if you fast forward just a few years ago, it's almost a third of their budgets. And so the program originally started as a federal-state partnership where the federal government and the state were contributing towards the costs. Well, what's happened over time is that states have increased their spending more and more, and with that increased spending came more federal oversight. So more oversight, more regulation. And what we have now, in the end, is what I would say is more of a one-size-fits-all approach, where the federal government is basically dictating to states how they run their programs. And obviously, that's understandable because of the spending. But I hope to get us to a place where we can agree to what we're going to spend on the program and then provide a new era of flexibility for states.
In my personal experience, I worked with the Medicaid program for many years, and before I came to CMS, my job was to work with states, help them design innovative programs and then work with CMS. And one of the biggest barriers to creating flexible programs, innovative programs to help achieve better health outcomes was quite frankly, CMS. CMS was the biggest barrier towards delivering innovation. And so I hope to get to a new era where states are driving their programs and they're deciding what's going to work best in their communities because they're closer to the people that they serve and that we can hold states accountable. So we're going to give them flexibility but hold them accountable for shaping outcomes and so we can actually measure what they're doing.
Cunningham: What's your vision, though, for enrollment overall on Medicaid? And I've just been curious about this because your critics like to say, "Well, they just want to rollback enrollment, reduce enrollment." Conservatives often would argue, "Well, that's a good thing because ultimately, you want to get people off of these kinds of programs." So as I had mentioned earlier, it covers around 70 million Americans now, which is a lot of people. Where would you like to see that number go?
Verma: I think as I said before, my goals are about delivering high-quality care and improving outcomes for the individuals on the program. When I look at the Medicaid program, I think of it almost in terms of two Medicaid programs. There's the program that serves the most fragile, vulnerable populations in our society. These could be people that are living on ventilators or quadriplegics. That's a very different program than looking at the program for the able-bodied individuals. So the Affordable Care Act, or Obamacare, expanded it to those individuals—to able-bodied individuals and so I think it's a different type of program and we need a different response. For those individuals, the goal should be helping them not only to provide healthcare coverage but helping them with a pathway out of poverty. It's much easier to just hand a card and say, "Good luck to you. Go get your healthcare." It's a much harder thing and a much higher goal that we have to actually help these individuals live independent lives.
And so it is success for us when somebody is able to rise out of poverty and no longer need the program for those able-bodied individuals. If they are able to get a job that provides health insurance and create that independence, I consider that a success.
Cunningham: So we've talked about the work requirements but a couple of other things that states have requested. I think the next thing we've all waiting on is Wisconsin's request for drug testing. How are you evaluating their request and thinking about that?
Verma: So we look at any state's proposal. It's kind of thinking about, "What is it that they want to achieve?" Obviously, our nation is in the middle of an opioid epidemic. The president has asked Health and Human Services to declare that a public health emergency so we're very focused on developing strategies to try to address the epidemic. So when we look at some of the things that states want to do, it's understanding where is it that you want to go and what goals do you want to achieve? For a lot of states, what they're looking at is they want to be able to identify individuals that need help and we've got to figure out what's the best way to identify those individuals and then help link them to the services that are going to be most appropriate. Because states are trying to do something about the opioid epidemic.
So as we're looking at what's the best way to accomplish that and there's many ways to address that. States could come up with ideas around doing a risk assessment and not only identifying issues around substance abuse, opioid use but also looking at a comprehensive health assessment to look at all of the types of health issues that a person may be facing.
Cunningham: And then recently you drew a line for how far you're willing to go with flexibility in Medicaid by rejecting Kansas's request for lifetime limits for three years, I believe. But do you see any scenarios under which you might approve less strict lifetime limits? I know there are a couple other states with similar requests. I think Arizona and Utah have asked for a five-year type of limit. How are you evaluating those requests?
Verma: So I think in the case of Kansas—let me just say that's a wonderful state where they've done terrific things with their Medicaid program. They're very innovative. When we put out the guidance around community engagement, what we talked about was making sure that states were aligning with their SNAP and TANF programs because those programs also have community engagement requirements and we didn't want individuals to have two sets of requirements. So if they were in SNAP or TANF, we didn't want them to have a different set of guidelines on Medicaid. I think that created a little bit of confusion for states. In the SNAP and TANF program, if an individual is in the program for about three years and after, depending on a certain amount of time. And afterward, they have to engage in community engagement to retain those benefits.
And we're comfortable with that approach. What we understand about the Medicaid program is you're dealing with a fragile population and their changes in their lives. So they may be able to go into a community engagement program, get a job, they're independent. But circumstances change, and we always want to make sure that the program serves as a safety net and there's a place for people to go when they need it. What we have approved or what we'd say temporary lapses in coverage. So an individual may not comply with a requirement around cost-sharing and they could potentially lose coverage. But we want to make sure that there's a pathway back into the program, that there's a way for them to come back in if they're compliant with the requirements.
Cunningham: So does that mean pretty much a no from you guys on lifetime limits?
Verma: Yeah, we've indicated that we would not approve lifetime limits and I think we've made that pretty clear to states.
Cunningham: So let's talk about Medicaid expansion for a minute. It's been eight years since the ACA was passed. Hard to believe sometimes. Nineteen states, I believe, have not expanded Medicaid, leaving about 2.4 million people in this coverage gap where they can't get Medicaid but then are ineligible for the marketplace subsidies. Do you feel like the remaining states should expand Medicaid, and if they don't, what should be done for these people in the coverage gap?
Verma: So a couple of things. Our whole philosophy has been supporting states in where they want to go and what they want to do. We're not trying to push states any which way on this particular issue. If a state comes to us with a state plan amendment request, under the law, we're required to process that application and we're going to do so accordingly. At the same time, we're not going to do the types of things that the previous administration did in trying to strong-arm and force states into expansion. We saw examples where they had existing programs, or they tried to reduce funding in other areas, trying to be coercive with states and try to push them into expansion and we're definitely not doing that.
Cunningham: One approach that has been raised is partial Medicaid expansion, like in Utah and I believe that's something the prior administration had rejected. So Utah wants to cover people up to 100% of federal poverty. Can you give us any insights into your thinking about that type of approach?
Verma: So we're continuing to look at that issue. I think we've had a few states and we're continuing to look at the policy issues around that and what the implications are. If they're doing partial expansion, that means they're coming to the exchanges and so we're trying to understand all of the implications and the scenarios and what the impact would be. One of the things that we do when we're looking at waivers, and usually the states are coming to us when they have a waiver request. And what that essentially means is they're asking us to waive regulations or waive laws and they're usually doing that because they want to create an innovative program. So when we look at the parameters around how we approve waivers, we're looking at that in terms of what's the impact going to be on the federal budget. That's a big issue, a big threshold question.
We're also looking at what we can waive under the law, what is actually permissible, and then the third area is it consistent with the objectives of the Medicaid program.
Cunningham: Yesterday, both you and Secretary Azar mentioned you'll be rolling out some updates to the Medicare and Medicaid drug pricing dashboards and the Health 202 had sort of a sneak peek this morning of that. Can you share some details about what new data you're adding and why you think that will make these more useful?
Verma: Sure. So one of the things that we've talked about at the agency from the time we got there is that we want this to be about patients first and so much of the decision-making and policy, we're always thinking about the patients. So from my perspective, we want to empower patients with the information that they need to make the decisions that are going to work best for them and their families. So we want to empower patients with information about costs, information about quality, and also, make sure that they have their health records at their disposal. So you kind of hear us talking about that and there's a variety of initiatives around those lines. And so we've had a drug pricing dashboard that's been at the agency for a little while, but we've made some updates to this dashboard. So in the past, which you could gather from this dashboard is you can see essentially what the Medicare program, Medicaid programs had been spending. But we've revised this dashboard and it's available for the first time today.
And this time, you'll actually be able to see the prices. You can see for every drug in Medicaid and Medicare what the prices are and you can also see for the first time, the year-over-year price increases. So you'll be able to see whether there's been a double-digit increase or a triple-digit increase. Or in some cases, a quadruple-digit increase. So all of that information is available as of today.
Cunningham: Who are you aiming at with this dashboard? Who do you want to use it? Just health policy folks mostly or more of consumers?
Verma: I think it can be everybody, but essentially, our philosophy has been around patients first and we want to make sure that patients have that information. So our goal is to focus on patients, but I think it could be used by a variety of different individuals.
Cunningham: So let's talk a little bit more about the president's drug proposal. There's been a lot of attention paid to the ideas around Medicare and there's a lot in there. But it also includes a few suggestions about Medicaid and a lot of this is quite cryptic so hopefully, you can help us kind of understand some of these ideas. But one that I noticed is allowing five states to experiment with behaving more like commercial health plans by letting them limit drug formularies and then negotiate prices with manufacturers. Can you talk a little bit about that idea and how promising you see it? I know that Massachusetts has also requested a waiver along these lines.
Verma: Concerning the issue with drug pricing, there's been a lot of attention, obviously, on Medicare. But for Medicaid and for states, it's a big issue there as well. And just a little bit of background on how the Medicaid program works with drug pricing. So there guarantees a certain level of discounts and that depends on whether it's a brand or generic. And then that level of discount changes depending on how the manufacturer has priced their products. So if they have increased that price beyond normal inflation, then they're going to be giving additional discounts. So what happened with the Affordable Care Act is they actually put a cap on that. So essentially, they put a cap on the penalties that these manufacturers would face. So essentially eliminating any incentive for manufacturers to keep prices lower and actually the reverse.
And what we've seen is over 2,300 drugs, actually, the prices had gone up when they made this change in the Affordable Care Act. So that's definitely been an issue for states. But one of the issues that states face is that they are able to get a lot of discounts and it works really well when there is a number of competitors because they're competing to have better placement on a state's formulary. But I think the issue for states that has been more problematic is that when there are new drugs available, new drugs that don't have competitors. And I think the best example of this when some of the new drugs around hepatitis came out. And we saw some very, very high price tags and for states, they're not prepared for this. They're on a one-year or a two-year budget cycle and so all of a sudden, they have these major costs to pay for and they're not prepared for it.
And so one of the things that we've been talking about with states is for drugs in this particular category—new, high-cost drugs with no competitors—is thinking about modernizing how we pay for medication. Not only in Medicare, but also in Medicaid. Thinking about tools like value-based pricing and this is something that we've seen some experimentation going on in the private market and bringing some of that innovation to our Medicare and Medicaid programs. And what this essentially means is thinking about paying for drugs on the basis of the outcomes that it achieves. So maybe paying for the drug over time, depending on whether it's actually delivering results. It could be based on, "Is this drug able to impact the total cost of care? Is it able to actually lower our spending overall?" So we're looking at some ways and working with states.
And we'll continue to look at the formulary issue. At this point, I can't comment on any particular state, but that's our overall strategy with states is kind of thinking about new ways of paying for high-cost drugs.
Cunningham: But you guys could go ahead with this five-state demonstration? Is that correct? Is that something you're actually pursuing?
Verma: That's exactly—we want to make sure that states have flexibility. I think the complicating factor is that right now, states do get these guaranteed discounts that I talked about and they get these guaranteed discounts because they're required to make available every drug that the FDA approves. And so we need to think about if we're giving them flexibility, are they also able to get these discounts?
Cunningham: Well, I also did want to ask you—I'm glad you brought up the best-price law. Because your colleague, FDA Commissioner Gottlieb has suggested that that actually could leave consumers worse off by encouraging drug makers to raise the list prices. And do you agree with that? Do you think that best prices discounts artificially drive list prices higher and is that something that should be explored for changes?
Verma: I think that the pharmaceutical industry has given us great innovation, not only to the United States, but to the entire world. But innovation really doesn't mean anything if you can't afford your medications. And I think what my colleague Scott is referring to is the whole system of pricing is based on rebates. And it's a convoluted system with the idea of a middleman that's negotiating rebates from the manufacturers. But the middleman, PBM is basically negotiating not only with the drug manufacturers but they're also getting money from plans. And it's just a convoluted system where the middle man is getting money from both sides. And so what we've started to think about is we want to create incentives for manufacturers to lower their list price. Essentially, what I think the blueprint talked about is thinking about whether our system should be based on list price instead of these rebates.
Cunningham: What excites you the most in the president's drug proposal? I know that Secretary Azar was asked this question yesterday and he said that this idea of bringing more Medicare Part B drugs under Part D—to him, that was one of the biggest things. But what do you see as like potentially the most significant in helping to reduce drug spending?
Verma: Well, first of all, I'm very proud and honored to serve with this team. I think the president's leadership on this issue has been tremendous. As long as I've known him, in every conversation that I've had with him, he always talks about drug pricing. It's a high priority for him and I think the steps that we're taking and what was outlined in the blueprint is quite frankly, very historic. No other president has put together a plan like this. There are a lot of different elements in that plan and they really are structured around a few different areas. The first one is increasing competition and on the issue that you brought up with the Part B plan and Part D is that a lot of times, we don't have competition. We've got some new high-cost drugs, which is why FDA is trying to increase the time to bring generics and other competitors. So that's one piece is increasing competition. And we know that within the Medicare program, there are some drugs that are in the Part B program, but the competitor is in Part D and so we're trying to figure out ways of bringing those programs together or looking at how we could create some of the things that we've done in Part D and Part B to create an environment of competition. Because we know when we have competition, that's going to lower prices.
And then we're also looking at the area of negotiation. If we create a more competitive environment, we want to give new tools to the PBMs, give them the types of innovative tools that are going on in the private market to negotiate better prices. And then the third area is what we talked about before is creating incentives for pharmaceutical companies to lower their list prices. And that has to do it looking at the entire rebate system. The whole way the rebate system works is around actually encouraging higher prices because the higher the list price is—because all of the rebates are based on a percentage of that list price. And so the higher the list price, that means the higher the rebates, there's a higher cut that all the middlemen get. And then, unfortunately for patients, that means that they're paying more out-of-pocket expenses because their out-of-pocket expenses are based on the list price.
There are so many different things that I think we have in the blueprint, but I'm excited because I think it provides a real opportunity to lower prices for all Americans.
Cunningham: One of the criticisms, though, that I've been hearing a lot over the last couple of days is this is a huge list of ideas and they would sort of tweak things around the edges, but that there's nothing that's going to directly get at the price of drugs. How do you respond to those criticisms?
Verma: Well, first of all, this has been a priority from day one and so we've already done some things to lower list prices. We made some changes in our hospital program, a 340B program, where we knew that hospitals were getting discounts, but they weren't passing those onto our seniors. Essentially, overcharging them. We already made that change this year. Seniors are going to save $320 million just this year. We also made some changes to the Part D program, so that when generics become available, that our seniors have immediate access to that. They don't have to wait a whole year and that means that they're going to pay lower prices. So we've already made some changes that seniors are starting to feel that are going to lower prices. And I think what we've outlined in a number of different steps, whether it's the changes to Part D, whether it's addressing the incentives, all of those things are going to work together. It's not going to be a one-shot and we're done. But we've been working on it over the past year and we're going to continue to do that.
Cunningham: This has been a great discussion about coverage for the low income, but for a minute, I did want to touch on coverage for the 10 million or so Americans that get their coverage through the marketplaces. And, of course, I've written a lot. My colleagues have written a lot about your pursuit of short-term and association health plans, which you say would provide people cheaper, leaner insurance options. But do you have any worries that this will end up drawing the healthier consumers out of the marketplaces and essentially leave behind a high-risk pool?
Verma: I think we look at the Affordable Care Act and the impact that it's had. At this point, we are at triple-digit increases. Prices have gone up over 100% since the Affordable Care Act started and with these higher prices, what we're seeing is higher deductibles. A lot of folks can't even afford the plans that they have. We have states that only have one choice of health plan and we've got 50% of our counties that only have one plan. So we're paying more and we're getting less choices.
We also, because the costs have gone up so much, there's a lot of individuals that can't afford any coverage. If they're not getting a subsidy, they have no way of getting coverage. And with these states where there's only one cover, one insurer, or counties where there's one insurer, those prices are going to continue to go up because we've created virtual monopolies. So what the short-term limited duration plans are about are giving people another choice, giving them an option. Because a lot of times, it's a choice between no coverage at all or a type of short-term limited duration plan that potentially, could be a lifeline for people that are facing having no coverage at all.
Cunningham: But then are people in the marketplaces left then with higher premiums than ever before?
Verma: And I think we're assessing the impact. I think some of the actuarial studies show that the impact is not that high. Our concern is for the millions of Americans that have no place because they cannot afford any coverage at all. Unfortunately, we're in a difficult situation because Congress has not addressed the issues with the Affordable Care Act. At the end of the day, we need a comprehensive solution and this administration has been about trying to address the problems, repeal and replace. Because we know that it's just not working.
Cunningham: To kind of end with a broad question here—we saw some pretty significant gains in lowering the uninsured rate in the years right after the ACA's provisions went into effect and lately, we've learned that the uninsured rate is creeping back up. In fact, it's back up to 12.2%, which is much higher than most other developed countries. Are you worried this trajectory is going to continue and how can it be prevented?
Verma: Well, I think that it is going to continue because as I said before, prices are going up with Obamacare. We've had some states that have had 200% increases. And so while many people are subsidized, you're now creating a new pool of individuals that they can't afford coverage. We've heard horror stories from folks where they were paying a couple hundred dollars a month for their healthcare coverage and then after the Affordable Care Act, they're now paying $900 or $1,000 and they've seen the prices go up dramatically. And at some point, people can't afford coverage.
And so that's why you're seeing the number of uninsured go up and I would anticipate if we do not have changes at the federal level—and Congress needs to make changes—we're going to see the number of uninsured go up. And that's why I think the president has acted. That's why you saw the executive around short-term limited duration plans and association plans because that's supposed to give at least an option for individuals that are facing being uninsured because the costs are so high.
Cunningham: Do you hold out any hope still that Congress is going to act on this? We all saw sort of the meltdown last year in effort after effort and it seems quite unlikely now. But how do you view that situation?
Verma: I'm always going to remain hopeful because we look at the damage that Obamacare is doing to so many Americans. We're seeing these price hikes. We're seeing lack of choices and so we're very hopeful. In the meantime, what we've tried to do is focus on what we can do from a regulatory level. We made changes with our payment notice that came out last year to give more flexibility for states so that they can regulate their markets, giving them new tools that we hope will lower prices and create more choices for states.
Cunningham: Can I ask you one last real wonky question? This practice of silver loading, you I believe referred to it in the big marketplace rule that you released in April, but is this something that you're going to continue allowing insurers to do next year? As our audience probably knows, this was a practice by insurers, which basically meant that consumers could get more generous subsidies in the marketplaces because the silver plan rates were increased. But can you give us any insight into that?
Verma: Yeah, we continue to look at this. I think generally, with the Affordable Care Act, it seems like any move that you make, it's a difficult issue because the underlying structure of Obamacare just isn't working. So you make one move in one area, try to help one group and it's going to have an impact. So we're continuing to look at the impact of silver loading as well as a lot of different things that are going on in the market.
Cunningham: Okay, and any final thoughts on kind of what you would like to look back on as sort of your biggest accomplishment when you end up leaving CMS in the future?
Verma: I think that's the problem. I have a long list of things because I think our healthcare system is moving in a concerning direction. From a broad perspective, we have a lot of exciting technology and innovation and new treatments and therapies and we want to make sure that we're delivering high-quality healthcare to our beneficiaries. But we also understand the large role we play and the footprint that we have in the entire industry. Recently, our actuaries released a report talked about where the cost of healthcare is going and that by 2026, it will be one in every $5. And that's something that keeps me up at night. We really need to do something about bending the cost curve, while at the same time, delivering on giving people innovative therapies. So building some efficiencies in the system. We also want to work into a new era of what I would say "patient empowerment".
We've had so much discussion over the years about how to lower prices and for everything that we've done—we've increased regulation, we've regulated everybody. Thousands of pages of regulations. We have a new healthcare law that was supposed to provide coverage to all of these individuals, but it didn't do anything about the underlying drivers of healthcare costs. And so after all of that, we haven't done anything to do lower the costs of healthcare or the rate of growth. And I think that's a goal, not only for CMS, but hopefully, for the entire nation. Because we're on an unsustainable trajectory.
Cunningham: Well, unfortunately, that's all the time we have for today. I'd like to thank Administrator Verma for joining us. [APPLAUSE]
Verma: Thank you.
Cunningham: And if you'd like to watch the full interviews and highlights from today's program or from any past Post Live programs, head over the WashingtonPostLive.com and thanks to everyone for being here and for tuning in. [APPLAUSE]