[MUSIC]
Are you looking for another podcast?
Debating America's constitutional crisis? Then listen to the oath in the office. The politics law and democracy podcast hosted by constitutional scholar, co-redirection writer, and serious XM hosts John Pugelsign.
Each week, the oath in the office breaks down the biggest political stories through a constitutional lens and plain English for broad audience. The show consistently ranks an Apple's top five-ing government and features guests
like Senator Sheldon White House and Supreme Court journalist, Dalia Lithwig. Smart, accessible, and focused on how power actually works. Listen to the oath in the office wherever you get your podcast and on YouTube with full video episodes each week.
[MUSIC] If you enjoy the kind of conversations we have here on, you might be right about policies, civics, and how to make sense of the news. And there's another show you might appreciate.
It's called the gist. The gist is the longest-running, daily news podcast. What makes the show interesting is that it resist the usual partisan scripts. Mike brings on economists, historians, journalists,
politicians, and other thinkers to look at issues from multiple angles to unpack the dynamics of a major political story. Mike's a veteran journalist whose work has appeared in outlets like the Atlantic, the free press,
and the Washington Post. And his approach combines careful reporting with the sharp sense of humor and willingness to question assumptions wherever they come from. If you're someone who likes thoughtful inquiry
and conversations that challenge easy answers, give the gist a listen. Follow the gist every weekday on YouTube wherever you get your podcasts. Until then, you might be right, sin you.
We ought to take advantage of the wisdom and the local knowledge that exists all over this country in public servants of both parties and enable them to address our agreed upon goals but to do so in ways they think will be more effective.
The guardrails are always about measuring the losers
compared to the winners to make sure that there's balance. If you could make everybody better off you would,
“but sometimes you have to make trade-offs.”
Those trade-offs are what I'm so complicated. I think in this oversight world of federal dollars going to states. - Welcome to You Might Be Right, a place for civil conversations about tough topics.
Husted by former Tennessee governors, Phil Brettison, and Bill Haslam. I'm Marian Wandamaker, dean of the Baker School at the University of Tennessee, where members of our producer circle make this show possible.
To learn more about our work, visit You MightBeRight.org. - Welcome back to You Might Be Right. I'm Bill Haslam, and here with my friend and co-host Phil Brettison.
- How are you today? - I'm good. - Well, we have an interesting discussion here about federal funding and state budgets. You know, there's a basic transaction
that a huge amount of money flows through, which is states send tax dollars from income tax and other taxes to Washington. And then they get it back again, often with a lot of strings attached.
And how effective that is and whether it's working in the way that it's shown,
“I think is a very pertinent question today.”
- And we've built been governors, so we have a unique perspective on this. People in favor of it say, hey, that's insurers, there's equitable programs across the state that California
doesn't have one Medicaid program and Tennessee, well, it is different California is dramatically different in terms of who and how we fund it. Other people say, well, you're just taking away states rights
which for functions which aren't were never meant to be.
And I think the closer to home, the policy decisions are made, the better decisions will be. - Well, you know, we've built had the experiences governors of having lots of federal funding come through
and working within those constraints and how to spend that money properly and so on. - I'm curious, there's to start out with the, where do you stand on that issue, does that work? - Well, listen, I think I've been a mayor in a governor,
honestly believe the closer to home decisions are made, the better the decisions are like what I was mayor. I can still today tell you how many sworn police officers we had in Knoxville in 2006, okay? I can't tell you how many,
how we patrol officers we had when I was governor. I'm just saying the smaller things are, the closer to home, the more you watch it.
“So I think it both, it's more effective,”
it's more efficient and it reflects local values better. So that being said, I do think there's some roles that the federal government has to play in providing those services.
I would have it be a more limited role than it is today.
- Yeah, I think, you know, from my standpoint, it's a good concept.
“I mean, I like the idea of having one economy”
and one country, and if you live in a poorer state, that doesn't mean that all the services you have are diminished from what California has or Massachusetts has or something. But there's some reality checks,
I think I'm what's going on. And one of them is that the level of services that we have is driven in substantial part of these days by deficit financing of the part of the federal government, and without their involvement,
you'd have a much lower level of services and states don't have that option. And certainly, I found it's difficult to sometimes solve problems and be creative with all the strings that come attached with the federal money.
One of the big problems I was had was that the federal government would put strings on things and you think about education and Medicaid, but they don't assume any responsibility for it. If the schools are messed up,
even though if they put the strings on, it's not their promise, not the problem. Any Washington is our problem as governors and the legislature's legislature's problem.
The answer to me has always been that I like the idea
of the federal government spreading money around, but the states ought to have, I guess this consistent group, what you've said, more authority and more flexibility and how it's spent with some clear kind of definition in a guardrail.
“I think that means the Congress kind of doing its job”
about what those guardrails are and what's permitted and what's not. - The difference in when UNI served as governors and those folks who were 40, 50, 60 years before us would be the scope of federal programs, right?
Primarily Medicaid, TANF and SNAP, which most people know as food stamps and welfare, those programs have grown so much larger than they were in the past. And the money comes, like I said, paid by from folks,
sent to Washington, comes back with a lot of rules and regulations around them, which I think make them not as efficient or effective as they should be. - Yeah, it's a real issue and I hope we can explore where I guess today.
- Let's get going.
Phil, our first guest is an old friend
and the person who I personally think if my understand federal budgets and state budgets and how money flows better than anyone,
“he was the director of the office management”
and budget under President George W. Bush, then he was a very successful two-term governor of state of Indiana. And then after that he left to be the President of Purdue University where he kept tuition flat
for 10 years in a row. So he understands a little bit about budgets and making hard decisions. Mitch, thanks, we're really grateful for you spending time with us.
- Thanks, Remi. - And this great to see you again, we serve as governors together for a long time. And and enjoy it. Mitch, we have a lot of people who listen to this.
So I think perhaps don't understand or haven't been exposed to just kind of how this federal funding of state activities works. Could she just talk a little bit about what goes on there, about how money is collected,
and how it's to share it back to the states and what some of the parameters are there, where the money goes? - Oh, Governor, you each experienced it. It comes in many forms, but as a general rule,
the federal government, a century ago, provided a tiny percentage of the funds spent in states today. It's, I don't know, 40% or more.
And it, it's always, it comes with the promise
of either doing new things or helping to pay for existing services, it comes with strings, and usually, and, but it's very hard for states, I think, to turn down, chance for local politicians to spend more money,
look a little better, but they're consequences, and as the phenomenon's gotten bigger and bigger, I think those downsides have to. - And so walk through what those, in your opinion, what those downsides are.
- Well, let's take the biggest single, by far, the biggest single source of federal, as they call it, aid to states, is Medicaid. And it is, now, you know, in a state like ours, your state is not dissimilar.
Seven cents of every 10 spent on Medicaid comes from the federal government. And first of all, I think there's,
There are incentives to bad government in there.
When you think of the fraud that we've seen in many states,
when you think of the estimates that a third
or more of Medicaid recipients may not be eligible under the prevailing rules, and ask why that is, it's because there's very little incentive for states to police these things better. It's, it's, it's a little of the money is their own.
That's, so that's one thing. A second league, those who have been in charge of the federal government in most recent years have a different view, I would say, than some of us do about what makes
for smart health care policy. A good example is they have a complete,
“I think, theological commitment to zero.”
They don't believe in any contribution, let's say, from a recipient, either of dollars or of work, in order to, in, let's say, in repayment or to partially earn the assistance of their fellow taxpayers.
So you wind up with a program that is a wash and misspending sometimes outright fraudulent behavior. And by the way, poor medical outcomes. Image, obviously agree with the argument that you're making one of the reasons health care costs
have gone up and feel wrote a book about this, too, is that it's like going to the grocery store when you don't pay for it, you don't really care what all goes into your grocery buggy. But the flip side of the argument would be
it one that Barack Obama made to me at one of the National Governance Association meetings that they have at the White House, that we've all been to. And I asked him, I said, hey, we'd be, why won't you block grant Medicaid funds to us?
Give us the same amount of money for the next three years, if you don't have any increases, we'll run it more effectively, we'll serve more people, et cetera. And his answer to me was maybe the summation of the argument on the other side is we don't trust you to care
for the least of these was his argument back to me, which was a very blunt kind of point. But what would be your answer to folks at say, well, there are some states that just aren't going to make certain they care about vulnerable people enough?
I think it's an insult, frankly, through leaders of both parties across the state. I certainly never met.
I never met a governor at Tennessee,
and I don't think I met a governor of anywhere. Who wouldn't, acutely, interested in and protecting the vulnerable citizens of his or her state.
“Let me tell you a story that I think bears a little bit on this bill.”
In my term in office, I was concerned, very concerned, about the uninsured, those above the Medicaid line, just barely above, but still not people of very many means. And we decided we wanted to do something about it. But I laid down two specifications for our people,
and ultimately we crafted a plan that had them both. One was that I said, I want HSA accounts for poor people. Money they can manage, money they will make even a nominal contribution to, so-called skin in the game, very little, but something so that they feel a stake
in their own health care, and then that they have autonomy, ability to make decisions in a way that Medicaid makes it for them.
The second stipulation was, this is not going to be
an entitlement program. I have to tell you that one of the object lessons from which I, which led me to that conclusion was a thing called 10Care, I had seen in your state, and it was replicated, unfortunately, in other places,
where an entitlement program with a very best of intentions ran away with a state budget, or made it very, very hard
“to fund other things that are important.”
Phil still has the scars to prove from that level. Well, as I recall, Phil had to prepare the damage, and maybe put things in a better position. And so I'm not faulting anybody, but I thought those lessons had been learned anyway.
We did create such a program, had a dedicated funding source. We doubled it to back those taxes, was what we did, which was a health care measure too. And successfully enrolled between a third and 40% of the true chronically-uninsured people of our state.
We didn't pretend we were going to solve every aspect of the problem. We were just going to take a great, big bite out of it, but in a way that number one recognized the dignity and the ability to make decisions for themselves
Of people at all income levels.
And secondly, protected the taxpayers of the state against a runaway program. Well, that lasted and worked very well for a while, but in subsequent years, the federal government acting on the very instincts that President Obama
apparently expressed to you.
First of all, demanded and even it was like $5 a month
contributions from the recipient. And secondly, essentially converted the program into a Medicaid expansion with all the,
“I think, shortcomings that the current Medicaid program has.”
And so there was a big philosophical difference between the state and our federal counterparts. And I happen to think that again, that it's a complete misjudgment of people at the state level that they won't try to act in the very best interest of the people that are serving
the beneficiaries of these programs. And I completely disagree and have empirical evidence to prove that talk about trust. I would have said to President Obama, "The problem here is you don't trust low-income people
"to make decisions for themselves, whether it's about health care, "where their children go to school, "or what kind of light bulbs they buy." - You know, one of the, I've, I've lived that, that whole 10-care thing you were referring to,
for the, it was, it consumed probably my first, my first term is, I didn't mean bring up a sore point. - His therapist is working through it. - Well, I have some probing on the scars in my back, I go right ahead from just considering it again.
But, you know, I mean, I'm sympathetic to the notion of the federal government helping to support the programs
“because I think, you know, while I think all governors,”
I would agree with you. I mean, I probably genuinely do want to do the right thing for all the people in the state.
The reality is the different states have different abilities
to do that as well. I mean, there's an income and wealth smoothing kind of issue there. My problem with it was that, as we were trying to deal with this complex problem and, you know, find ways that the amount of bureaucracy
and, you know, general tendency to say no to anything that this was the way it was done before, really became a problem. And an example of that, I like to, like one, you just brought up for us was one of the largest
problem in 10-care was the drug program. And we wanted to put a couple of very simple things in. I mean, very small co-pays for drugs that had dollar. I mean, it was almost nothing because there were people who had that.
And we could not get that approved. And that was in a Republican administration. That wasn't under Obama. It was very difficult to get done. We put together for the unsure to program
that sounds like, maybe what you did, which was a more limited form of health insurance that they would pay premiums for. When Obama Care came in, those programs were no longer legal, because they didn't cover all of the items
that were required. I mean, there are two ways in which I think, you know, reasonable creative ways of trying to deal with the costs of health care in the state. We're just thwarted by people who had, you know,
you know, no interest really. There's nothing in it for them to save costs, to save costs in these programs. And that seems to me the, you know, the downside of the federal enrollment.
The basic problem of great contemporary thinkers, like Phil of Howard, keep pointing out, is bureaucracies by their inherent nature, are compliance oriented. Somebody hands them a rulebook, says,
here's how we do it. They think proper stewardship of their job,
“proper, and they think success is checking all the boxes,”
making sure that everything fits into what is usually a vastly over-prescribed approach, whether it's health care education, environmental protection, whatever. And, you know, those of us, and I suspect the three of us agree on this.
First of all, our skeptical of a centralized wisdom
and one size fits all solutions. We're also, I really, I guess you'd say a corollary of that, is that we believe in federalism. We think it's a great, it's a superior approach
to have 50 laboratory experiments on these things. Health care, issues are different state to state. Health care, resources are different state to state. So you made it important point, not every state has the capacity to address these problems
Fully, but that's why a block grant approach,
like Governor Hazel mentioned, has always been
a smarter answer.
“And my view is when, unfortunately, when,”
it's not if anymore, a serious fiscal crunch comes to the federal government, this will be part of the answer, out of necessity, not because they'll have a revelation about federalism, but as they go broke,
they will, I believe, decide finally to push down some of their fiscal problems to places where we do balance budgets and where we try to deal creatively and view of local circumstances with these issues.
- The new Trump regime is taking a brick bat to norms the constitution and the law, seemingly saying to the US justice system, make me. Will the courts hold?
- What you're seeing right now is
a fundamental disregard of basic constitutional principles. - Join me, Dalia Lethwick, on Amicus, Slates Podcast about the courts and the law
“to hear from the lawyers, judges, advocates and analysts”
who have the answers. Search Amicus, that's Am, I, C, U, S, wherever you listen to podcasts, because legal knowledge is power. If you're like me and you enjoy podcasts
at provide historical context to the day's news headlines, then check out the long standing podcast called, "My History can beat up your politics." Each episode hosts Bruce Carlson uses history to make sense of today's politics,
covering different areas of American history from the Reagan administration stance on foreign policy, to Grover Cleveland's warnings about tariffs, and how the fall of the Soviet Union set the stage for today's geopolitics.
The show's been called the perfect antidote to talking heads by the Columbia Journalism Review, so you know it's worth a listen. Find my history can beat up your politics on all podcast platforms.
- I'm curious, this is kind of a personal question. I mean, you've been on both sizes issue and from the time you were at OMB, so the time you were governor, I mean, have your opinions changed at all
at the nature of this relationship? - No, I expected before, I suspected before,
well, it was my second sentence in the federal government,
I'd had to look at it as a younger person in the 80s, and, you know, I arrived deeply skeptical of federal, no-it-allism, and served in administration, which generally thought the same, you know, that was a former governor after all,
that I went there to serve, and as much as possible, we tried to be flexible in accommodating of state requests, for instance, of waivers of this or that rule. Absolutely, try what you think will work best for you.
But my conviction about that only got fortified when I wound up responsible for the affairs of one state and frequently had to work even in a Republican administration around the kind of inflexibility that you talked about, Phil.
“- Mitch, one of the, I can't remember his very goal”
or some concern of the past said, the federal government should deliver the mail to fin the country and get out of the way. Are there other things that besides delivering the mail and defending the country,
you think the federal government should do? - Yes, yes, you know, even someone is skeptical of the federal capacity or abilities as I am. Believes, we long since decided as a society that we will do more than that.
And so even today's, and I count myself as a strong believer in limited government, it accepts that there is a broader rule. And yet, that doesn't imply that the federal government should decide how
these other goals are approached and achieved. And we ought to take advantage of the wisdom and the local knowledge that exists all over this country in public servants of both parties and enable them to address our agreed upon goals
but to do so in ways they think will be more effective. - You know, if you look at the, I mean, over a period of time, the general structure of how the federal government handles these programs with the states, you know,
is remained relatively constant. I mean, obviously there's obviously differences in different administrations. Are there over time, are there reforms or changes
That you think would make a lot of sense to happen today
if you're kind of taking a fresh look at this relationship?
“- I think it's the same general direction”
we've been discussing here. And that is that, at the federal level in the world I would like to see is returned to,
first of all, Congress would,
the legislative branch would reassert itself in ways that it is, I think, wanted away from over recent decades. It would set priorities for the country and abortion are scarce resources against those priorities
but it would emphasize results in not compliance and it would entrust to states in some cases localities, having just defined the what and the how much it would delegate the how to those of us out the actually where the problems are.
So I think that day is coming as I said before at an necessity, not because greater wisdom or humility will suddenly show itself in Washington. - Mitch, the last question we ask everybody on the show we take from Howard Baker,
I'm assuming you bumped into a little bit in the Reagan administration who had a saying,
you know, always remember the other fellow,
the other side might be right. Can you think of a good example? Particularly on some of the topics we're talking to and regards to federal, money versus state budgets et cetera, where you think, you know,
I didn't quite have that right, you know, I learned a little something in the process. - Oh gosh, so many.
“I think any, anybody who's dealt with these issues”
at any level has to acknowledge mistakes they made. I made plenty of them as an elected official. And I think that the administration I served, you know, made some, looking back in the foreign policy area for sure, but the, you know, on the domestic front,
both sides have, I think, failed to reckon with the need to square ends and means. And that's our fundamental failing, I think. The over promising that has led us into a fiscal corner, we're not, not now easily going to get out of.
And so there were mistakes made there, certainly by the administration, I served that more of a spent on things that really were, even then could have been identified as, of marginal utility.
You know, I've made the half facetious comment in the past that you'd be amazed how much government you'd never miss. And we're gonna find out the answer to that question
“increasingly, I think, is interest costs,”
absorb more and more of the available dollars. And eventually, as the world gets tired of loneliness, money, and infinite quantities. - Mitch, it's been helpful, I said, you didn't disappoint, you have a unique background
to talk about this and we appreciate you sharing your insight in your time with us. - Well, if you don't mind my saying, it's joy to see each of y'all. Tennessee's a such an interest in state.
Y'all have produced a string of outstanding public servants, you know, punching above your weight as they say, of both parties and I, and I just was grateful for the chance to talk to two of the best. - Well, your gracious and nice, thank you.
I think we both could say we enjoyed serving from you and I'd tell people a time when I was a baby governor and I was confused about how something worked.
You were my first call and I'll always appreciate that.
- Wait a minute, you told me I was your first call. (laughing) He was my first long distance call. - Okay. - Thanks, Mitch, thank you.
(upbeat music) ♪ I'm just a bill, yes I only a bill ♪ - We all remember the song, it made it all seem so simple and turns out it's not who writes influences and kills bills, it gets messy.
I'm Scott Greenstone and I'm Libby Denkman on sound politics. We tell that story, the inside track on how policy gets made in this Washington and the other one and how it impacts you. - With now on the KUW app or wherever you get your podcasts. - There is a lot and I mean a lot going on
in the news around our government and our laws. And there's one question that we all hear or think about all the time. Is this constitutional? If you don't remember all the civics classes
you may have taken in school, you can get the answer to that question and many others by listening to civics 101. The critically acclaimed podcast
From New Hampshire Public Radio.
civics 101 is an entertaining way to learn about how our government works or at least how it's supposed to work. And you'll hear a lot of surprising stories along the way. Like, how to landmark Supreme Court decisions
affect our lives and what does the second amendment really say
and even why does the Senate have so much power? Civics 101 is a great companion to you might be right. As it'll help you understand a bit more about what's going on and it will make you a smarter citizen in the process.
So listen to civics 101 wherever you get your podcasts and tell them you might be right to send you. - Well, Bill, our next guest is Eleanor Patel who has an impressive resume. She's the co-director of the Urban Brookings Tax Policy Center.
She's a senior fellow of Brookings with that. It does a lot of research on how does tax policy and health policy and social safety nets, how do that shape economic behavior and important issue as well.
She's held positions with the White House Council of Economic Advisors of the U.S. Treasury Office of Tax Analysis and the Congressional Budget Office. So we have somebody that knows a lot more about these things than we do.
Which is pretty getting pretty common. - That's great. - I bet Sam, I'm actually used to that story. Now, thanks so much for joining us. Let me start with kind of the question around this episode.
And that's that, you know, individuals that live in states, pay taxes that goes to Washington. There's some sort of administrative overhead taken out of it and it's sit back to states frequently and with programs like met, not with all dollars,
but programs like Medicaid or SNAP or TANF, usually then with some strings attached. And so the question is, is that the right way to run this railroad? Should we be sending money out of states to Washington
and then it comes back with strings attached for various reasons?
“- Yeah, I think it's a really important question.”
And I would kind of imagine why individual taxpayers and states might wonder what the benefit is of sending dollars to DC just to have them boomerang back, but maybe in a way that's hard to use. I think the federal government serves an important role
across all states and ensuring that everybody everywhere has access to a minimum amount of services. And so all states contribute to federal revenues and then the federal government re-apportions that back to the states to make sure that some of these dollars
are going to, again, essential services like healthcare
and education, but also maintenance of roads, which everybody benefits from. All of these categories that we want there to be even an equal access to these programs across states. I think that the strings that get attached
to these programs are Washington's way of making sure that the state is doing with the dollars, what Washington DC says is supposed to be done with the dollars, providing healthcare and education and these sort of safety net benefits.
Some of those strings can be burdensome.
“And I think it's a really important debate to have”
to make sure that the guardrails around these programs are appropriately set and sized so that they're not overly burdensome for states to comply with. - So let me, maybe I'll kind of point to maybe with the crux of the argument.
As you said, it comes back to Washington, so they can make certain it's distributed fairly and equitably, et cetera. And I guess so the underlying question there is, well, why should Washington do that?
Why don't we trust our states to do the same thing? And I asked, then President Obama, something we were at a national governor's meeting, why don't you, why don't you block grant Medicaid to us? And in us, we're in a somewhat friendly responsibility,
but he basically said, we don't trust you
to take care of the least of these, which is a Republican guy that I was a tad offended by. I got the argument, it was like, we want to make certain this is happening the right way. So why should that be so?
- I think that some of what's happening,
“which I think is an important part of the debate,”
is not, I don't see it as a lack of trust, but just the recognition that sort of, where people are located across the country, just means that certain states have richer populations in other states, certain states have older demographics,
Utah, a state of mind right now, benefits for my young and healthy population. And so what the federal government is trying to do is make sure that certain states, with less wealthy individuals,
are not having their social safety net services sort of curtailed by the state's ability to raise revenue on a very different population base, than a state that might be younger, or healthier, slightly wealthier.
So I don't see it as a lack of trust. I do think that when money is set aside for health care, it's reasonable to expect a little bit just like a, you know, in any household budget, for example, if you budget a dollars for health care
to make sure that the dollars are spent on health care, but what you want to avoid is any kind of administrative oversight that results in sort of less health care being provided
Because one has to comply with the administrative oversight
and burden that comes with a dollar.
So there's a tension there that is not always dialed
appropriately, and I would hope that there's always an open mind
“to be flexible of, is there a better way to do this?”
'Cause I think the goal is to provide health care, and that's a goal everybody supports. - Yeah, you know, I mean, I'm the democratic governor in this combination, and the idea of moving money around so that states that have that are richer
than more ability to pay or in some ways, you make one economy out of the country and try to make it truly good one country. I think that's important. In my experience as governor, we dealt with an issue
of a huge issue with Medicaid, and what I found was that the system of administrative oversight at Medicaid works fine as long as everything is going perfectly smooth, but it's a very difficult environment to try to deal with challenges and make changes and so on.
You have a kind of risk that sort of,
I think punks say a lot of the fundamental decisions off to a real-making process, either because they don't want to make those decisions, or it's too much work or something, and then, you know, when you're trying to make changes and things, you're stuck into a kind of a bureaucratic process
where the natural inclination is the same now, and it makes it difficult to move, and we'll let you know, you know, your thoughts about, you know, if you agree that these are burdens and thoughts you might have about, you know, what things might need
to change as we look toward the future?
“- Yeah, I think that's like the question here,”
and I would just highlight that I think what you said is really correct, which is legislation is often quite vague, and, you know, legislators are relying on rulemaking processes to set the administrative guardrails in place, and a one-size-fits-all kind of mechanically means that,
when things are going exactly according to plan,
those goals are going to work really great, but if a state experiences a particular downturn or some labor market upheaval that other states don't, then suddenly the system becomes a little bit out of whack and very burdensome, and so one-size-fits-all mandates are hard,
and the rulemaking process is not right now set up to be able to allow 50 different sets of rules for 50 different situations, and so at a minimum, rulemaking processes can be revised, and I would hope that when states run into
overly complex administrative burdens, that there's a good way to communicate back to Washington, D.C., or for the Centers for Medicaid and Medicare Services, or whatever the agency is, that's overseeing the funds to revisit the rulemaking process,
and say, "Hey, you didn't quite realize this particular situation in the future. Can we adjust the guardrails to make sure that the burden is not, again, taking away from the amount of time and money and effort we have to spend
in health care and education and roads,
“and all of these really important pieces of the puzzle?"”
- Yeah, it's not so much the administrative burden. I mean, we both work in government, and we understand that, you know, in government there's sets of processes in place, it just administratively complex.
It more is an issue of, you know, trying to find ways to make changes to the programs that, you know, maybe a little outside of what people are used to seeing in some cases. We had huge problems with drug costs, for example,
in what we were doing, and just having, just having too much of the effort in Washington being about, you know, nobody else is doing that. You can't do it that way.
- Yeah. - And, you know, so the idea of some firm guardrails and some freedom to operate within those is a very attractive process, right? That's kind of not what it is now, though.
It's pretty much where you've got to, if you want to move left a little bit, it's not a matter of guardrails, you just got to ask if it's okay to move left a little bit. - Yep, I will say that my experience
with the lifting up of the Affordable Care Act, that was at Treasury at the time, and all those regulations were being written. In principle, the legislation was written to allow the state to the freedom
to experiment a little bit and introduce new systems, as long as they met a set of guardrails. My experience was that states like Vermont tried to interact with this process,
and then found that the guardrails that had been put in place, I don't want to put words in Vermont's mouth, but those guardrails made it very difficult for Vermont to experiment with providing, you know, Medicaid in the environment under the ACA,
which was supposed to provide states the freedom to experiment. And that's some of the beauty of having 50 states is that we can allow states to experiment and meet the needs of their populations. And I think just think some of these
grant formulas and processes continue to need to add flexibility to allow that targeting that states really can do in a much more effective way than Washington DC can do. - So, it sounds like in this conversation,
you're taking a viewpoint of, "Hey, it makes sense for these things
"to be kind of washed through the federal government.
Almost as a giant insurance program, that's gonna make up for the ups and downs of revenue flows and changes in demographics, et cetera, which is a Val argument. But you also are very sensitive
of the fact that different states have different needs and they should be able to consider their programs. That way. But you've been in government, you've had roles, and we have to, it's nice to say that in theory,
but it gets broken down in practice. So if, well, let's just say Phil got elected president tomorrow and you went to work for him and he said, "How really want you to figure out "how to break down those barriers."
So we can't allow the states to flexibility you just talked about. But keep the role that the federal government's gonna do in terms of being the big insurance company. How would you do that?
You've been there. - Yeah, I mean, I think it goes back to the really sort of boring topic of conversation, which is the rulemaking process. There is actually quite a lot of flexibility
in terms of what agencies in the federal government can do to take legislation and turn it into, for example, the internal revenue code. And depending on the set of priorities, that, for example, the Department of the Treasury
is currently facing, right now they are trying to lift up an enormous tax bill, so to ask them to do other rulemaking processes is challenging, but not impossible. But depending on the new president's priorities for revisiting this rulemaking process,
there is actually a process by which agencies can revisit to try to work within the confines of the law to introduce additional flexibility.
“It just is a matter of, I think, a political priority.”
And so I do think the president that comes in that is more laser-focused on working within what's there, 'cause sometimes going through Congress can be quite slow.
And the thing that you get out is not always the thing
you intended when you could start the process, that the rulemaking process is a place to start for this. And I think most people, you said back what I said, which is I think that there's a role for the federal government to provide insurance,
but also that states know their populations better than the federal government. And so there needs to be some room within these programs to achieve the top line goals with some flexibility to meet states needs.
I would hope that's not a very controversial point to take. It's just as you said, it's hard to get the rubber to the road and make this happen. But let me ask you a specific question. I talked earlier about block grants.
Tennessee now has what I'd call a modified Medicaid block. - Yep. - Block grant. What's wrong with that? Well, it's wrong with that. To me, it feels like a really good approach.
“Now, you have to have the expertise in state to pull it off,”
which we do, 'cause we've been in managed care for a while for 30 years now. But given that, what's wrong with that approach? I don't think there's anything wrong with that approach. I actually would go back to where we started,
which is for Tennessee that might actually be the exact right approach, and it might not be the right approach in other states that don't have the longstanding experience to be able to manage such modified block grant appropriately. And so I think that's again recognizing
and meeting states where they are, which some states have administrative capacity built in some lanes and not others. And so allowing more prescriptive funding to come in if that is not where you have the administrative capacity
can make a lot of sense. But allowing states that have developed their own Medicaid systems like in Tennessee to flexibly provide care is important. On the back side of that, I would say,
some of the guard real process that can feel really, I think, contentious and onerous is that any change that Tennessee were to make to their Medicaid program, for example,
is always gonna have winners and losers.
It's not possible to shuffle the dollars to get everybody better. And so the guard reals are always about, you know, measuring the losers compared to the winners to make sure that there's balance.
And that's just not a black and white question, right? That could be values that come from DC or values developed with in Tennessee and recognizing that if you could make everybody
“better off you would, but sometimes you have to make trade-offs.”
And those traders are sort of so complicated. I think in this oversight world of federal dollars going to states. - That last comment you made is something we should teach in civic courses all
between the government and involves trade-offs, that you're not usually deciding between good and bad. - That was one of the first things I found when I got in government, I always thought it was picking the good from the bad, it's usually not.
- I always think you wanted a good versus.
- Yeah, you want to pay school teachers more and pay police officers more, yes, you know. So, of course, if we could, we would. - But who do you want to pay less? - Right, exactly.
- That's right, that's right. - So you've got a chance to serve in the Greshal Budget office in Treasury, White House Council, Economic Advisors. If you're with a really good friends for dinner
and they're saying, what you learned in that whole process that would help us as citizens to know, and, like said, it's obviously a broad question, but what if you learned in serving in that context that would help people better understand
How government works?
- I think what I have learned and continued to learn,
that's a really good question, is that even though right now things can feel incredibly polarized that all of the jobs I've ever had in the federal government don't feel like that, that everybody who is working in those,
it doesn't matter under which administration you're working, everybody who is working at the Treasury Department, at the IRS, at CMS, that all of these agencies, they're all there with very, you know, different backgrounds and different expertise
to sort of do the work of federal government in a civil service role. And I think it still feels good to me that that is what these citizens do.
“And I think we have this incredible human capital”
and operation in DC and in state government. I have worked with the Utah State government and at all levels of government,
I just think that even though this environment feels
like you can't have a conversation about things that are controversial, my experience is that I've worked with people left and right in center and federal government and everybody is trying to come together
to make sure that we have the evidence in front of the politicians and the decision makers so that they can make the decisions that they think is in their political best interest, which is very different than sort of the economic answer.
And sort of recognizing that those conversations can and should continue to happen and of like civil and polite and productive way, I try to say that as often as I can. - Yeah, well said.
- That's obviously what we're trying to do here with a couple of government governments in different parties to explore these issues. And I have to say I've found out that once you take out this sort of political weaponization
of things, you frequently have the same things. I mentioned earlier that we had four governors during the time of the ACA was governor then, two D's and two hours and a couple of them are now up in the Senate and there are lots of things
that the four of us could easily agree on to do. - Yes. - And, you know, something's not, but I mean, a huge area of compromise there. But of course, what happens is once they get weaponized,
people have to go to their respective parties and towed to the line. You know, there have been some recent examples of states actually rejecting federal funding and actually because we're an example here
in terms of the Medicaid expansion. And more recent of course, you know, federal government withholding, you know, dollars. Does that, do either of those trouble you or about putting something fundamentally dangerous
into the system? - I mean, I think that you can think of examples that might feel uncomfortable, but it doesn't make me uncomfortable on the whole that states might decide for example to not expand Medicaid.
It's not my personal opinion, but I think again, that's the notion of states might know better than Washington, DC, how to budget and provide these services. And if they feel like they can do that without the federal dollars and also like we've talked about,
the federal strings that come with those dollars, that is the system we put in place. And all the federal government can ever do is use carrots and sticks to try to nudge the states to do things that they think are right,
but they can't tell the states to do that. And I wouldn't ever want the federal government
“to be in a position that says you must do X.”
And so for me, when I see states turning money down,
again, it might not always go with my political views,
but the act of turning money down, I think is a very healthy part of the system we've set up. And if the voters in Tennessee don't like that Tennessee did not expand Medicaid, that's up to the voters to tell their local politicians and state politicians
we don't like this and something can change. That's the process. - Great, this has been an excellent conversation. I really, really appreciate it. This podcast is named, you might be right
after Howard Baker, who was certainly a part of an advocate for his points of view, but also very realistic about the need to compromise and understand other people's points of view and so on. I'm curious in your own, you've had such broad experience,
in your own experience. Are there some things you can think of where you had an opinion on some subject and listening to somebody who had a very different view caused you to say, wait, I may not be right about that.
Well, I think I need to change my mind. Is that ever happened? - Yeah, actually, it's funny that you can ask 'cause this might sound a little bit wonky, but quite recently, that's my job, actually,
my job is to be a wonky person, but the work opportunity to tax credit recently expired. And there's a debate right now about whether that tax credit which provides funding to employers to hire from disadvantaged sort of labor market groups,
whether that should be renewed.
“And I think that I came into that thinking”
that those programs are providing, again, important incentives and guardrails for these disadvantaged populations to be hired, to begin with. And then I saw a paper, actually, an economics paper that did a deep dive into the administrative data
In the state of Wisconsin and really found that
that credit wasn't helping anybody's employment.
It was being pocketed by employers. It was being claimed only by sort of the nine largest employers in the state and there was no effect on employment. And so that's an example of something where if I had read that paper, I probably would be somebody saying,
let's have a debate about whether we should reauthorize WATC. And now I'm somebody who says, that is not a good use of federal dollars. It's not helping the populations who think it's helping.
“And I think we should rethink whether this program”
should exist in some other form if at all. And so that happens to me kind of a lot with economic research where you have some intuition about what's going on. And then you let the data speak and you realize
this program maybe isn't doing the thing we thought it should do and we shouldn't be afraid to let it expire, which is the thing that's very hard in DC is letting programs expire. - Well, thank you.
That's a good answer and you've been a good guess. We really appreciate the insight. And like I said, the both the commitment to get to the right answer approach that you seem to be taking, we really appreciate that.
- And I'm so glad you had me on. Thanks for inviting me. - Thank you very much. - Yeah. Well, I feel like these two guests did just what we want
our guests to do to clearly describe somewhat different points of view. But both of them with the humility of mind and thought that let them be open to understanding where they haven't exactly gotten it right.
“- Yeah, I think it's a very kind of healthy set of differences”
because they're obviously both aiming toward the same thing, which is to provide the best possible services in these areas to the citizens of the states, have somewhat different views about how to go about doing that. I see the same thing in education a lot.
- Right. - So we have everyone's trying to get to the same place and people are different views about it. And that's a very healthy, very healthy thing. - You know, Mitch is obviously coming from
right of the Sinolein and Elinol, but we're left of the Sinolein. But again, I think if anybody listened to them, they'd say, hey, into the day of that person is running a major department of the government,
I bet we'll be just fine. Here's one thing it did remind me of is this.
In government, you never get in trouble
for leaving things the way they are. If you leave the budget to it as you leave a program, oh, it has nobody ever knows that it's wasting money. Nobody gets upset. You get, you catch black when you change something.
“And I think that's what happens with a lot of our programs”
is somewhere in the bureaucracy. So my says, well, yeah, Tennessee does look a little different than Illinois in this deal. We should treat it differently. But if I do, I might get my hand smacked.
And so I'm gonna say no, it's just easier to say no. - Well, you know, I mean, it's just a, I don't say this is a condemnation of bureaucracists. You have to have them to run a process of government. But there's no question that the, you know,
I mean, the jokes are all right, which is like being bureaucratic. You just sort of say no for your four time, before you even settled down to try to solve some of the problems.
You know, when I first got involved with government,
which was really after I ran for mayor the first time and then started to get involved with Medicaid, things just really struck me was, what's rewarded in government is very different from what's rewarded and say the private sector.
Like a Medicaid, what got rewarded for people was not improving the services to Medicaid. It was like not making this state Senator happy, unhappy, and not making the governor unhappy and things like that. And I don't know how to fix that change.
The change has been said to have as much. The incentives are clearly quite different when you're in one of these agencies than they are in a lot of other places. Great discussion, thanks for being a part of it.
It's great to be with you again. - Thanks for listening to You Might Be Right. Be sure to follow on Apple Podcasts, Spotify, YouTube, or wherever you listen to your favorite shows. And please help spread the word by sharing,
rating, and reviewing the show. Thank you, Governor's medicine and has them for hosting these conversations. You might be right is brought to you by the Baker School at the University of Tennessee,
with support from the Boyd Fund for Leadership and Civil Discourse. To learn more about the show in our work, go to you might be right.org and follow the show on social media
at YNBR Podcast. This episode was produced in partnership with Relationary Marketing and Stone's River Group.
