Announcer (00:06):

Welcome to Hospitals in Focus, from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:16):

Welcome to a special edition of Hospitals in Focus. I recently had the opportunity to sit down for a fireside chat with one of the few lawmakers to ever hold leadership positions in both the United States’ Senate and House, Senator Roy Blunt. It was a wide-ranging, informative discussion where we talked about everything from Medicaid expansion to the growing partisan divide in Washington, DC.

After serving more than 25 years in Congress and nearly 50 years in public service, Senator Blunt has a unique perspective on where we are today and where health policy is headed in the future. This was recorded last month during the Federation’s Board of Governor’s Meeting. I hope you enjoy the conversation as much as our audience did. We have a real treat this afternoon with our special guest, Senator Roy Blunt from Missouri. I’ve known the Senator for many, many years, and he always has been…

Actually in this position I have today and in other positions previously, he’s always been very open and willing to listen and really just a good friend over the years. To give you a little background, he’s almost in his 50th year of public service, going back to 1973 when he was appointed county clerk in Green County in Missouri. He was a Secretary of State. He was a Congressman for many years and was elected to the Senate in 2010.

There aren’t many senior members of either party, I think, who have served in the kind of roles that he served in in both chambers and frankly had the length of service that he has. I hope this afternoon we can glean some lessons. I thought. Senator, to start off and set some context, I might ask you, you’ve seen a lot in the House and Senate over the years, and you’ve spent much of your time as a leader in both. How has the process changed, I’m going to say from better to worse, but how has it changed in your view?

Senator Roy Blunt (02:33):

Chip, I think better to worse, though we have moments of inspiration where we still can respond and get things done. I was elected to the Congress 25 years ago next month. Two of my current colleagues in the Senate, Jerry Moran and John Thune, were elected at the same time, and we were all together at another event this weekend. We’ve spent 25 years of this together in both the House and the Senate. I do think 25 years ago, and even 15 years ago, maybe 12 years ago, the Congress still had a predisposition to get things done.

And frankly, the people we worked for had a much greater appreciation if you could get things done. Sometimes I think at home anymore that you get something major done and the people you work for wonder, “Well, what did you have to do to get that done?” It’s like somehow you’ve all sold out to the deep state if you’re able to get something done. When I was elected Secretary of State in Missouri, I was the first Republican to win that job in 52 years, and you very much did not run as a partisan in that environment because you weren’t going to win if you did.

You ran as somebody. If you let me, I’ll do this job. And after I get a chance to do this job, I’m going to constantly let you know how I did it and how I did it better for you than somebody else might have. And that was a pretty significant coin of the realm at that moment. That would’ve been 35 years ago. I think it was still the coin of the realm 25 years ago and 20 years ago.

But we’ve sort of fallen into this place to where so many people run for office and serve in office and one of their major themes is, if I don’t get exactly what I want, I’m not going to settle for anything less, which in a democracy is a sure formula not to ever get anything. In a democracy or in your family or it’s your church or wherever, if you’re getting everything you want all the time, there is something wrong with you.

We have a lot of people now who not only do they run on that basis, but they go home and explain to everybody that, I didn’t go along with any of it. I think that’s probably the biggest single change. At the same time, last year when we dealt with the COVID crisis in ’19 and ’20, mostly in ’20, we passed five big bipartisan bills that were pretty innovative and didn’t hit the target every time, but we didn’t have time to hit the target every time.

We were seeing if we could get things out there like the Paycheck Protection Plan, a totally new concept, some other things we may talk about later. But even when we did that, you would still have… Even reporters ask you after you passed five bipartisan bills, “When are you guys going to start working together?” These are reporters in the capitol building every day who kind of miss it when you do step up and do the things that you have to do in a democracy.

But I think the biggest change is limited appreciation for how government functions or when it functions and lots of willingness to talk about what an imperfect result it was. And because of that, somehow unsatisfactory.

Chip Kahn (06:13):

You sort of prompted a question. What do you think changed between the work in 2020 the American Rescue Act, and then what we see developing now? I’ll sort of leave the infrastructure out for the moment. What’s the contrast? Because in some ways, the American Rescue Act had some new things in it, but in some ways was building on what was done in the previous year. Why did they choose, because it was their choice, to go partisan with that rather than stay in this mode that you experienced in 2020?

Senator Roy Blunt (06:48):

A couple of things. One is I think that Democrats in Washington right now somehow have convinced themselves and did after the election that they had a mandate. There’s clearly no reason to believe that. I mean, the Senate couldn’t possibly be closer than 50/50. The House has the smallest Democrat margin in 170 years, and the only thing that Joe Biden and Donald Trump agreed on in the presidential election was they both wanted it to all be about Donald Trump.

And how you take that and create this idea, we have a mandate for great change, I don’t know, though I do think they believe the lesson learned from the Obama administration was you may not be in control for very long, and so you should do everything you possibly can while you’re in control. I actually think what’s going to happen is it’s going to be a self-fulfilling prophecy. If you do everything you possibly can, you won’t be in control for very long, because I don’t think there’s a mood in America for the extreme way they’re going.

And on the American Rescue Plan, what a lost opportunity for President Biden, who I think has certainly a bipartisan inclination, if not a bipartisan voting record, what a great opportunity for him to step up and say, “Okay, we’re going to just now do whatever we need to do to finish that bipartisan work from last year, as opposed to we’re going to build on this in a way that establishes a foundation of this becoming all permanent,” like the tax credit for everybody with kids. I think that number is around every family that less than $150,000.

That’s almost everybody with kids suddenly starts getting a check. And even though it was a check for a year. Where Immediately six months later into it, well, we ought to make that check for a year, a check for the next five years, with a sense that if you can ever get that done, year seven it’s almost impossible to imagine that that Congress wouldn’t extend it by another year. One, I think they’ve misread their mandate, such as whatever it might have been. And two, I think they’ve misread the desire in the country to actually see some people work together.

Chip Kahn (09:27):

Well, in the Bipartisan Infrastructure Bill, clearly in the Senate, many work together, but that’s sort of sitting out there now with all this other work they’re doing around it. How do you see this playing out? Do you think they have a formula to make it successful? Because as you say, they have a razor thin vote margin, despite the fact that they have this notion of mandate.

Senator Roy Blunt (09:53):

Well, you would think it gets hard all the time for them to get anything done. Clearly the president’s not nearly in the position he was in six months ago and maybe not in the position he was in six weeks ago. It does seem to me… I know the Speaker Pelosi on one of the Sunday shows a month ago was talking about how we need to rally around the president’s vision.

I’m not sure if you’re a moderate Democrat in a district that President Trump carried, and I think they’re about 19 of them, that this would be exactly the time that that rally around the president’s vision is where you want to be. I think they’re maybe six months late or six weeks late at least on that. I hope we can salvage the regular Infrastructure Bill. Four years of Trump, we were always going to big infrastructure spending next. It was kind of the great white whale of the Trump administration.

And frankly, eight years of Obama, we didn’t do anything extraordinary in infrastructure. We just sort of done the minimal in a country that is incredibly benefited by our ability to trade all over the world and be interconnected to each other. Location really matters to us, but it doesn’t matter if you don’t do what it takes for that location to work, highways, roads, bridges, ports, airports, all those things. Anybody that travels knows we’re behind on.

And here’s a real opportunity to not get way ahead, but at least do substantially more than we’d be doing otherwise.

Chip Kahn (11:42):

One of the things that, I guess, was rumored a few days ago, because you had the controversy of the debt ceiling and then you’ve got the democratic voter rights initiatives. There was sort of this threat that they would pull the plug on the filibuster.

Senator Roy Blunt (12:00):

Correct.

Chip Kahn (12:01):

From your view… I guess, let me ask a dual question. In this day and age, what role and what’s the importance of the filibuster? And then two, do you think it is seriously threatened at this time?

Senator Roy Blunt (12:14):

Well, I think that Leader McConnell thought it was threatened last week. He his view, which I’m not sure I share, but there’s no way to know if it’s right or not, is that this maybe was the one moment where our two stalwarts on the other side, Manchin and Sinema, would decide, okay, if the Republicans aren’t going to help us to see that the government pays its bills, maybe we’re going to have to change the rules for this one thing. You can’t change the rules for one thing. Two reasons for it.

One is probably just you can’t reverse the parliamentarian and do that in a targeted way. And even if you could, if you ever change the cloture rule in the Senate, and I’ll talk more about that in the second, if you ever change the cloture rule in the Senate for say paying the bills the government owes money to, why would you then not change it to protect our democracy? Why would you not change it to do whatever is the next thing to save the planet? Was it more important to pay people money that the government owed money to than it is to save the planet?

It won’t work that way. Used to have a rule when I was the whip in the house and only two people… You mentioned there’s only two people in the history of the country have been elected leaders in both the House and Senate, and I’m one of them. It must not be a very smart thing to have been willing to do. When I was the whip in the house, we had in the house there was a rule called the motion to recommit. And on every bill, you have a chance that goes through the regular process to send it back to committee to do X.

And X usually sounded pretty good. Send it back to committee to add this to it. My rule as the whip and generally the rule in the house has been if you never vote for one of these, it’s fine, because you say, no, that was just a procedural thing to kill the bill. But if you ever voted for one of them, what about the next thing that comes along? Is it less important than you vote for Second Amendment issue one day and the next day, the motion to recommit about the value of motherhood.

You’re for the Second Amendment, but you’re not for the value of motherhood. You can’t go down that line. I don’t think you can ever selectively eliminate the super majority in the Senate that shouldn’t be overused, but it’s there. Why does it define the Senate? The cloture rule, where it takes 60 votes to begin a debate and 60 votes to end a debate, the cloture rule really requires you to find friends on the other side. The Democrats two or three times in the history of the country have had more than two-thirds of the Senate.

Republicans have never had more than 56 popularly elected Republican senators. That’s our all-time high. The Democrats haven’t had many more than that very many times. What that rule does is it makes you seek out people on the other side that you don’t agree with on everything, but you do agree with on at least one thing. I could go down Senator Stabenow and I, Debbie Stabenow from Michigan, have done a lot of work on mental health, treating mental health like all other health.

Chris Coons and I every year reauthorize the Victims of Child Abuse Act, even though oddly the Obama administration tried to eliminate it two times. But we do that. Sherrod Brown, who I’ve known for 35 years, we’ve agreed on exactly five things in 35 years, and they’re all federal law. Everything from a bill we did on advanced manufacturing to all women who have breast cancer surgery have to be told all their options. We have to have a pretty strong, wide expanse to find five things we agree, but it makes you better friends.

We’ve been friends for 35 years. But once you pass that first bill together, you think, well, let’s find something else we can do together. There’s a much longer list of those members than I just went through. I think it does define the Senate. It also means if you to have a super majority in the Senate, the country really has to feel pretty strongly about something for quite a while.

If you look at the House, often these things don’t become law because of the Senate, but there’d be election and the House majority changes and three or four major bills passed that would hedge you in a really de different direction. And they die in the Senate because the Senate wasn’t impacted by the very last election like the House was. And by the time you get through two or three Senate cycles, countries usually change its mind. We’re not radically going this way and then radically coming back the other way.

I think the cloture rule, the filibuster rule in the Senate has developed, not sure it’s what exactly what the founders thought would happen, but it developed in a way that it almost requires the country to think a little bit about what it believes it wants to do before you actually wind up doing it.

Chip Kahn (18:00):

From the standpoint of outsiders and, I guess, things like the filibuster is sort of inside game. The filibuster really is important, I think, to the business community, to groups like ours, because I think we’re all better off if legislation takes time and has deliberation. Is there anything we can do or do you think this is such a high political issue that it’s… If it goes one way or the other, the outside can’t affect it. It’s just the internal politics that rule the Senate that’ll determine what happens.

Senator Roy Blunt (18:38):

Well, no, I think there surely is a way that you can encourage people in the Senate to not want to see that rule change. One is it does give every center a little more power than you would have otherwise. It protects the rights of the minority. That may be the one genius of our system is that we have figured out how you…

Unlike a parliamentary system where you just run over the other side, when you’re in control, we have figured out how we have this non-parliamentary system where the minority continues to have a right to be heard and even a right to be involved. The truth is, Chip, it really doesn’t take very much to get 10 of our side. If you want to work with us just a little bit, I don’t think it’s that hard to do.

But when you start out like we have this year with we’re going to do whatever we want to do and we’re going to do it all by ourself, because there are 50 that we could possibly do within the rules that relate to spending or raising money, which is the only way you can use reconciliation, we’re going to do that. Like last week or two weeks ago on the debt ceiling, the press knowing I’ve done this for a while and I’ve been involved in the debt ceiling fights before, “Well, what would it take for you to vote, to raise the debt ceiling?”

And I said, “If you could find a reconciliation bill that 10 of my side would be for and I wouldn’t have to be one of them, I’d be willing to raise the debt ceiling. If you could moderate the way forward in a way that there’s some bipartisan buy-in, I don’t have to be one of the 10 people that would be buying in for me to think that was enough of a progress that, well, maybe we can now talk about the debt.”

And on that issue, the debt ceiling until 2011, and we’re the only country that has a debt ceiling, you could argue there’s not much virtue of the debt ceiling, but until 2011, we always raised the debt ceiling to an amount. You didn’t have a date. You just kind of guessed how long that might take you. And at some point, the Secretary of the Treasury would say, “We’re within six months of getting to the debt ceiling.” And that, that in and of itself held spending down some.

And then in 2011, the decision was made by the Obama administration and Democrats in the Senate, we’re going to just suspend the debt ceiling to a date certain. And of course, in that world, anything you can spend between then and the date certain becomes the new debt ceiling. We at least last week got for the first time in 10 years to vote on an amount of money that would be the debt ceiling, instead of some date out there somewhere that would be the debt ceiling.

President Biden, who, by the way, twice and the Bush’s voted against the debt ceiling, and so did Schumer. The debt ceiling increased. If the debt ceiling doesn’t generate a discussion about future spending, I don’t know what purpose it possibly serves. You can say all you want to about, well, the debt ceiling’s about the money we’ve already spent. The debt ceiling debate has never been about the money we’ve already spent. It’s always about what we’re going to… Now let’s talk about what we’re going to spend in the future.

Nancy Pelosi in 2019, the Speaker of the House, Speaker Pelosi said, “I’m not going to help raise the debt ceiling.” Remember, she controls one of the things that would do this. “I’m not going to help raise the debt unless the Trump administration agrees to spend more money.” And Secretary Mnuchin began to come down every couple of weeks for about six weeks until they finally agreed to spend $19 billion more dollars than we were going to spend otherwise.

The debt ceiling is always about future spending, as opposed to, well, you helped figure out to spend the money. Now you have to join us in raising the debt ceiling. If the debt ceiling serves any purpose at all, it’s to talk about future spending. Under Obama, when we had some say in it, we got budget caps for 10 years. And the budget caps sometimes we had to raise them just like the time I just mentioned when the Democrats could and did insist we raise them, but they were there to have to be raised.

They clearly held down spending in that 10 years, just like Speaker Pelosi’s insistence that we spend $19 billion more dollars domestically than we would’ve spent the last time we raised the debt ceiling, talked about future spending, not how much money we’d spent in the past.

Chip Kahn (24:07):

Talking about the evolution of the body, maybe it’s mythological, but my sense was decorum was important in the past. I was a little surprised that the leader on the democratic side didn’t just say thank you and move on the other day, instead seemed to have to make a big deal out of what happened. How does that affect the chemistry of the body from your view?

Senator Roy Blunt (24:37):

Not helpful. Not helpful. I’ve served in both the House and Senate, and I think relationships matter a lot more in the Senate. Now, I was the whip almost the whole time I was in the House. We had little margins, so I was constantly working to figure out which Democrats could help us on which issues. I had pretty good bipartisan relationships there. But I think generally people that come to the Senate from the House and find out you do have some dependency on each other because of the rules.

Every Senator can slow down things by not giving consent and relationships really matter. I think we were all hopeful that after the Reed-McConnell relationship that the McConnell-Schumer relationships would be better and they don’t seem to be.

Chip Kahn (25:32):

In some areas, I guess this has a disappointing result. In the area of policing, for example, there was negotiation, but it seems like an area that’s so sensitive and gets to some of the visions in the country that it would’ve been wonderful for some action. It just seems like they haven’t been able to come together. What can break the ice on…

Senator Roy Blunt (25:56):

Well, it does. But again, let’s go back to my earlier observation. COVID certainly broke the ice, and we had five big bipartisan bills with some really good ideas in them that led to things like more testing. Senator Alexander and I came up with this suggestion for that we called it the shark tank to where… We moved forward with the shark tank. And of the groups that went through the shark tank, some were already existing companies. Some were five people with a new idea.

Two million tests are being produced every day through the shark tank that have nothing to do with all the tests that are being produced otherwise by other companies who were already producing tests. 100% of all of the home tests came through the shark tank idea. What might be good about that, Chip, was that because of the way that worked the in healthcare, the federal government in this testing area became a more intertwined partner.

The shark tank group and that of the 31 companies or groups that finally came out of the shark tank and got a couple of billion dollars of direct investment, the sharks swimming with them through the whole thing. And that may be why if we move to advanced research for health, which the president wants to do and I want to help on, we’ve sort of set up a trial as to how that might work.

To where unlike NIH that I’m for and I’ve made a big commitment over the years to NIH, but unlike the National Institute of Health where you give people a grant and say, “We’ll check in with you every once in a while and see how you’re doing. And in five years, we hope you have a result,” this would be like a shark tank like environment to where you zero in on one or two things that have great imminent promise and importance and then move forward in a partnership. That was pretty good idea that came out of a bipartisan effort.

Some of the things we tried worked. Some didn’t. I think the government still moves forward when it has to, though it’s not as… Another thing I’ll say here while I’m thinking about this too, there’s so much diversification of media out there right now. Not only do people come with their own opinions to an argument, they come with their own facts. It’s a lot easier to come to a conclusion when you had different opinions and one set of facts than we had different opinions and different sets of facts.

I’m sure all of you have been in these discussions, either casual discussions after work or whenever, or at work where one side is absolutely convinced that your facts are not the real facts and their facts are because they just read them on the internet, or they were on MSNBC this morning or Fox News last night. I think that’s made a big difference generally in the way we deal with each of other on lots of levels and that’s reflected in the Congress.

Chip Kahn (29:31):

Let me talk a minute about just a Missouri issue. In 2020, the voters voted to expand Medicaid to the ACA groups. From a hospital standpoint, this kind of coverage is critically important, because for low income people, it removes the financing issue, which becomes important when they walk in the hospital. We want to care for them. I guess the state lawmakers in their wisdom chose to not move forward. I guess the circuit court now has said the state should. How do you see this evolving?

What do you hear from constituents on this? What do you think their attitude is about this sort of back and forth on this issue?

Senator Roy Blunt (30:15):

I don’t know that constituents have a strong view on this issue and it would depend totally on how you presented it. The federal government put out a huge inducement to states to cover more people, largely single adults. Many states did that and others didn’t. I didn’t get too involved and I try not to give a lot of advice to people in Jefferson City until we’ve solved all of our problems here. That probably means I won’t be in the advice giving business.

But I do think while there are some problems of an initiative process that determines how you’re going to spend state money, because that money has to come from somewhere that in this case, it is what people voted to do. Frankly, because of the over assistance to state governments that the Congress insisted on and got even worse in the Build Back Better or whatever, the American Rescue Plan, they’ve got enough money to do this. I think the problem frankly will be getting people to sign up. 150, 200,000 people that could sign up.

And even though the signup process has been going on for a long time, only 17,000 people have signed up. That’s probably a bigger challenge for both state governments and healthcare providers to get people qualified into the system, and particularly people qualified into the system that have some access to healthcare before they show up in your emergency room. I believe if voters have decided, I understand the legislative concern of where does this money come from, where does our 10% come from? It’s come from higher education.

It comes from elementary and secondary education. Does it come from parents as teachers? Where does it come from? It’s a legitimate thing for them to be concerned about, but I think they’re moving forward now. And now the bigger concern for our providers will probably be how do we get people qualified to where they get services. And that leads me to another thought, which is telemedicine.

And another thing that COVID forces to do, and we did through legislation, was to do something we probably should have done five years ago, maybe even a little earlier than that, of telemedicine. But the fear at HHS and CMS was, well, if people can go to the doctor more easily, they’ll go to the doctor more often and that will cost us a lot of money. One, I think people decide that there’s a lot to be said for being able to go to the doctor more easily.

And two, I think there’s some development of the view that if people go to the doctor more often, it might cost you less money because they only go to the doctor when there’s a crisis that could have been prevented. And figuring out how to be sure we keep telemedicine in the system and also being sure that we adapt to it in a way that meets concerns about licensure and certification. Every one of you have hospitals on the border of some other state, and we really have hospitals in…

Seven states touch Missouri. No state but Tennessee has that many states that touch it. The drive from elevation centers are right on the edge of the state in most cases and people that drive from Illinois to St. Louis to get healthcare, that’s not a problem. But if suddenly the St. Louis, Missouri doctor is giving telehealth care to somebody in Illinois or Kentucky or Iowa, do we have a system that really accommodates that?

Senator Murphy, another Democrat that I’m finding one thing I can work with, and I have a bill, the TREAT Act, that I think is too short-term, and that it was largely designed to work during the pandemic, but we need to be thinking of how telemedicine creates maybe new liability that unnecessary if we’ll figure out how to deal with it. But I think telemedicine is definitely here to stay. I hope it is.

Telebehavioral health maybe even more, bring that behavioral health professional closer, who’s often further away from you than your primary health provider is, even closer to you than it has been before. I think people are going to look for new ways to make telehealth available to people it’s less available to now, but the healthcare disparities we saw during COVID are real as well. Telehealth, if we can eliminate the disparities of broadband, telehealth can be one of the things that can help eliminate some of those disparities.

I think particularly for rural health issues and for inner city health issues.

Chip Kahn (35:42):

Senator, I guess we’re getting to the end now. As we close out, and unfortunately for us, as you get closer to the end of your career in the Senate, what do you see as your legacy of the 25 years in Washington and the 50 years almost in public service?

Senator Roy Blunt (36:01):

Well, I would want to point out, I was 23 when I first became a county official, so 50 years of public service does sound like a lot, doesn’t it? Two or three things. One is when I became the chairman of the committee that funds health and education and labor, NIH, the National Institute of Health, hadn’t had an increase in over a decade. Not a penny. We’ve increased it 43% in the six years that I was chairman of that committee. I think we’ve got a pattern going where we’ll increase again this time maybe by a new record number, which would be fine with me.

And healthcare is changing so quickly. And with no increase, particularly young researchers were just deciding to do something else. But healthcare is changing so quickly. The opportunity to be part of immunotherapy and microbial research and all of those things that a decade ago nobody was talking about, really important. I do think working as we have to try to make behavioral health treated like all other health and we’re making real headway there.

I guess on the intel side, I’ve been on the intel committee House and Senate, this is the daily terrifying work of being on that committee in ways that you can never really share with anybody. But I would say trying now as quickly as we can to advance artificial intelligence, machine learning. Our adversaries, particularly China, are moving very rapidly there. I’m trying every week to be part of the butt-kicking operation that continues to talk about how important it is that we don’t lose our advantage that we’ve had since World War II in all of those areas.

And once we lose that advantage, our technical advantage has really been the asset we had that allowed us to be who we’ve been for the last 75 years.

Chip Kahn (38:14):

Well, Senator, thank you so much for spending so much time with us. This has been a great conversation. I’m sure the audience enjoyed it and really appreciate your perspective.

Senator Roy Blunt (38:24):

Thank you. Great to be with all of you.

Announcer (38:32):

Thanks for listening to Hospitals in Focus, from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media at @fahhospitals and follow Chip at @chipkahn. Please rate, review, and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.