Dr. Bruce Siegel [00:00:02]:

If I look at the magnitude of some of these cuts, the hospital’s gonna have to make some really tough decisions. You know, they’re not gonna be able to keep that trauma center open. They’re not gonna be able to keep that community hospital open. Maybe they have to cut back on clinics and programs. I think you’ll see a dramatic drop in access to care in this country.

Narrator [00:00:26]:

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

Chip Kahn [00:00:35]:

Several trade associations are dedicated to representing the hospitals and patients they serve. These associations are distinguished by the types of hospitals we represent. And the heart of our collective efforts is a shared commitment to advancing policies that improve and sustain 24. 7 patient care. America’s Essential Hospitals works on behalf of hospitals focused on care for the uninsured, low income and most vulnerable patients. This organization has been ably run for 15 years by my friend, Dr. Bruce Siegel. Bruce joins me today as he marks his last year as president and CEO of America’s Essential Hospitals to discuss a monumental health policy debate currently taking place here in Washington that could have significant consequences on patient care.

Chip Kahn [00:01:29]:

As the House and Senate work on a budget reconciliation bill, all eyes are on how these decisions will affect Medicaid, a program that covers over 70 million Americans, including children, veterans, seniors and people with disabilities. While GOP congressional leadership and the White House have pledged to protect Medicaid, potential cuts in the hundreds of billions loom. On today’s episode, Bruce and I will examine the mission critical role of Medicaid in American health care and discuss how sweeping Medicaid cuts would impact patients and the providers who serve those patients. Bruce, so great to have you here today.

Dr. Bruce Siegel [00:02:12]:

It’s great to be here with you, Chip.

Chip Kahn [00:02:14]:

Bruce, before we get into the meat of our discussion around Medicaid and the importance of this program, let’s take a look back. And could you look back over your 15 years at the helm of America’s Essential Hospitals and give some description of how you think the landscape has changed in terms of health policy?

Dr. Bruce Siegel [00:02:34]:

Yeah, I think, and this is a good thing that over the time I’ve had here, the idea that healthcare coverage is an expectation or almost a right, has certainly advanced. I think the Affordable Care act had a lot to do with that. I also think there’s a greater demand, appropriately to show value, to show that you are producing a good product. I think we have a better idea now of how to measure that, and that’s been very important. I’ll also say some things haven’t changed. So as we talk about the debate we’re going to talk about now. I can go back more than 15 years. I can go back to when I was working in a hospital 30 years ago.

Dr. Bruce Siegel [00:03:13]:

Some of those bad ideas from 30 years ago are back again today. So that’s part of the landscape that seems to be kind of fixed right now. And we’re sort of reliving some old debates.

Chip Kahn [00:03:22]:

So do you think the challenges of facing those of us who are advocating for hospitals that serve these, the indigent, the uninsured, that those threats are greater or lesser right now?

Dr. Bruce Siegel [00:03:35]:

You know, I think right now they’re greater. I think clearly we have proposals on the table to take over $800 billion out of Medicaid over a decade and a change of control in Washington that is going to be very, very challenging for us. I also think that not just for our essential hospitals or all hospitals, you know, there’s a lot of energy and money on other side of these issues. Saying bad things about hospitals and, you know, trying to knock hospitals for things that they do, I think that they do very well. And I think that’s something we’ve all got to fight together. So I think those challenges are definitely there. At the same time, I think we have deep wells of goodwill in our communities that are gonna serve us well. In the debates coming up over the next few months.

Chip Kahn [00:04:24]:

Let’s take a deeper dive into Medicaid and you sort of opened up the discussion on that topic. What do you see currently as the developing role of Medicaid? Obviously it serves many different people and a range from nursing homes to babies in neonatal intensive care units. But how has that evolved over time? And what do you sort of characterize as its current role in terms of making up this payer mix that makes healthcare work for Americans?

Dr. Bruce Siegel [00:04:56]:

Sure. In many ways, Medicaid is now the glue that keeps this whole system together. It has become the place where we’ve turned to, to rightfully address a lot of needs in our society. It’s the largest single provider of healthcare coverage in America. You know, we’re talking hospitals today. But to be clear, Medicaid is providing most of the nursing home care in America. Many Americans don’t realize that it’s about Medicaid, not Medicare. It is providing, you know, vast array of services to people who are disabled, often low income, outside the workforce, vast amounts of community based care that often keeps many people, such as people with intellectual disabilities out of institutions better not being a part of and doing things like covering half the births in the country.

Dr. Bruce Siegel [00:05:50]:

So, you know, Medicaid has a much broader, I think, reach and touches many more Americans than we really realize and beginning to tinker with. That could have some pretty negative consequences. And that’s what I’m most worried about, you know, in the coming battle over Medicaid.

Chip Kahn [00:06:08]:

You know, at this stage, there are a lot of different ideas on the table. And in terms of the cuts you referenced a few moments ago, some of the big numbers that potentially could be reached in budget reconciliation and we could talk about specific policies. But just generally, how do you relate the idea of these big cuts and the patients? What will be different for patients if some of these cuts come down? And also assuming, I think that states are not able to just pick up the slack because remember, our audience needs to remember that this Medicaid program is a federal state matching program, but the federal government is the larger player.

Dr. Bruce Siegel [00:06:51]:

Sure. So I think you’ll see vast damage to individuals healthcare if these things happen. So give you an example. One idea is work requirements. And we’ve seen that play out in Georgia where people are forced to sign up and attest or certify that they’re working or volunteering a certain number of hours per work. And mind you, 2/3 of adults on Medicaid are working and the rest, most of them are taking care of people. Georgia did this as part of a pilot program. They had 240,000 eligible people for the program in Georgia.

Dr. Bruce Siegel [00:07:26]:

They enrolled 5,000 just creating that paperwork barrier. And the bureaucracy that comes with that has basically just built a barrier to coverage in that program in Georgia. Now they’re spending maybe a third of their dollars on healthcare and 2/3 on administration. I mean, just imagine having 56 state and territorial bureaucracies to do work requirements for Medicaid, which is what you’d be asking for. I think the other implications though, you know, they may be a little more subtle. But let’s think about it. I spend my time as you do with hospitals. If I look at the magnitude of some of these cuts, hospitals are going to have to make some really tough decisions.

Dr. Bruce Siegel [00:08:07]:

You know, they’re not going to be able to keep that trauma center open. They’re not going to be able to keep that community hospital open. Maybe they had to cut back on clinics and programs. I think you’ll see a dramatic drop in access to care in this country, probably starting first in rural areas who are already the most marginal in terms of funding in pretty low income communities across our country and places where we’ve seen a lot of hospital closures already. And then in Other places, I think that the barriers we create to coverage, as well as, you know, basically shutting down access points where people can get care, would have dramatic impacts, devastating in some places.

Chip Kahn [00:08:51]:

You know, it’s interesting you talk about these effects in terms of access to care because, you know, one particular think tank has produced work where they argue that health insurance and Medicaid specifically as well, in general, you know, doesn’t affect or improve better healthcare outcomes. I personally don’t know whether or not this is credible work from an academic standpoint, but from a practical standpoint, if I was to suffer personally from cancer or from heart disease, actually I’ve experienced both. I can’t imagine from a medical care standpoint not having insurance. What’s your response to these claims? That there’s sort of no connection between health coverage and health.

Dr. Bruce Siegel [00:09:38]:

I read those claims and they just don’t hold water. I mean, anybody can, you know, if you have 20 studies that show that coverage helps and one that doesn’t, well, sometimes people just pick that one study to talk about. And I think that’s happened a little bit of cherry picking, perhaps in some of this. I think it’s complicated, but I think there’s pretty good evidence, and you actually measured two good ones, that for cancer and heart disease, for liver disease, having coverage makes a difference in terms of whether you live or die. Big outcome. We also have good evidence that people who have chronic illnesses are more likely to stay on their medications, be able to see providers get managed appropriately when they have coverage. I mean, why should that be a surprise, not having health insurance? Excuse myself here. It kind of sucks if you don’t have health insurance.

Dr. Bruce Siegel [00:10:34]:

You can’t afford to do these things very often if you’re a low income individual. So why are we surprised that giving somebody the ability to see a doctor or nurse practitioner or whatever allows them to do things they couldn’t do otherwise is kind of obvious. But there’s people who have other perspectives and I respect that. But you’ve got to be honest about what some of the data says. Other big impact is on maternal mortality and birth outcomes. Half the births in this country are covered by Medicaid. And so your ability to touch the, those expectant mothers and those babies is huge. And the numbers show that, you know.

Chip Kahn [00:11:09]:

We are at a high watermark in terms of the aspirations of 2010 and ACA, and that coverage has been arrived at both because of Medicaid. And I would also argue in the exchanges, the marketplaces by the enhanced tax credits that have enabled us to get Almost up to 25 million people covered in the individual market. And a lot of those people are in states that didn’t expand Medicaid. I think half of them are in those states. So coverage is so important. Having been engaged as you were back in 2010, what’s your view of where we are with coverage and your concerns about the threat even with Medicaid and then beyond Medicaid?

Dr. Bruce Siegel [00:11:54]:

Oh, yeah, I think the threat goes beyond Medicaid. It goes to the exchanges. And the exchanges have been a huge boon to health and healthcare. One great example is Florida, which didn’t expand Medicaid, but it does have the exchanges and it’s covered millions in that one state alone. Very much at risk. I think the, you know, exchange subsidies were enhanced under the prior president’s administration. So that makes it something of a political target. There’s a lot of money involved there, you know, so it’s a big pot to go looking for if you got other priorities.

Dr. Bruce Siegel [00:12:27]:

But the fact of the matter is, most of the people on the exchanges, if you take those subsidies away, they just will not be able to afford health insurance at what the prices will default to, and you will see millions more without coverage and without the benefits that we’re talking about right here. One thing I also want to mention, Chip, is we’re talking about healthcare, and that’s important, and health outcomes, that’s important. But as we’re also looking at what’s probably a slowing economy for a lot of reasons right now, we also got to start to worry about the economic impacts of what all this is going to mean if some of these things come to pass.

Chip Kahn [00:13:04]:

One thing about Medicaid that I think even some on the right are beginning to discuss is that the profile of the Medicaid recipient, at least on the health coverage side, is changing and that it really reflects a broad swath obviously of low income, but of Americans. How can we communicate that so that there’s more realization of the span? You know, sort of, you know, it really may reflect based on income, but sort of all of us in some way.

Dr. Bruce Siegel [00:13:40]:

Yeah, the groups who are on Medicaid are really broad. The largest single group is low income whites in America, often in rural communities, then Latinos, then blacks. But it’s really sort of a broad swath of America. It’s people of various ages. You’ve got elderly people who are low income, who are often dual eligibles. And mind you, Medicaid helps those people on Medicare cover those out of pocket costs. You know, that cost sharing that’s embedded in the Medicare program, but not in Medicaid, which basically pays everything. That’s a huge boon to elder Americans.

Dr. Bruce Siegel [00:14:23]:

And Medicaid picks that up for those who really can’t afford it. It’s also dealing with the young, you know, the expectant mothers, the babies they have, dealing with those who are working adults, you know, which is what the Affordable Care act did, who have very low incomes. I think the good news here, Chip, is that Americans have begun to realize that. I remember back before the ACA when you’d look at polling and you’d see Medicare, Social Security, we love it for most Americans. Medicaid, not so sure that’s changed. And if you look at some of the credible polling in the last year or so around Medicaid, you are seeing the support for Medicaid, the realization of how important it is, approaching getting very close to what you see for Social Security and Medicare. And I think that’s really important. And I think the reason you’re seeing that is one, because we’ve had huge debates about Medicaid since, you know, ACA and the run at repeal and replace.

Dr. Bruce Siegel [00:15:27]:

So people got tuned in and that stuck. But the other thing is most people, you know, now know somebody on Medicaid, somebody in their family. They may have been on it. They realize that unfortunately, they may be one or two paychecks away from having to be on Medicaid. And also I should mention that’s not partisan. Yeah, the approval rates are higher for Democrats and independents, but there’s still a majority of Republicans, over 60% have favorable views of Medicaid. They want to protect it. That’s powerful.

Dr. Bruce Siegel [00:16:01]:

And I think that’s a message that will help protect the program and one which as good stewards that we need to make sure people are aware of and our policymakers understand that Americans really care about this program and be careful with it. Tread lightly.

Chip Kahn [00:16:17]:

I’m gonna go big picture for a moment. Since I have this opportunity to have you here in your last nine or ten months or so of your tenure at the essential hospitals. What kind of advice do you have for the next generation of leaders of hospital associations? The kind of jobs that you and I have now.

Dr. Bruce Siegel [00:16:37]:

Wow, that’s a tall order. I had to think about that for a little bit. I spent time in health departments before and running public hospitals where I had to do a lot of advocacy work. Cause we were so government dependent in various places. And I still think it’s still about the relationships in many ways, and it’s still about the message and the integrity of that message. So, yeah, the technology has changed. Congress is a very different place from what it was in some unfortunate ways 30 or 40 years ago in terms of the partisanship and the rancor. But I still think having a compelling message and communicating that again and again and again, regardless of the technology platform or whatever, is still central to success and helping people to understand that this isn’t an abstract story or narrative about dollars or paying for tax cuts or whatever.

Dr. Bruce Siegel [00:17:37]:

It’s a story about people with a face. And still telling that story is the most powerful thing, and I think it continues to serve us well.

Chip Kahn [00:17:45]:

That’s so helpful. Let’s get personal for a moment. And you’ve had such an impact on health policy and your career, but at least at the essential hospitals, you’ve chosen to leave and move on. What’s next for you?

Dr. Bruce Siegel [00:18:01]:

I don’t know, Chip. Sleeping in. Somebody asked me the other day, what’s on your bucket list? And I said, I don’t want any more lists. I got too many lists driving my life right now.

Chip Kahn [00:18:15]:

Wow, that’s. That’s. That. That’s quite an answer. I. I think I’m with you. I. I’ll tear up all my lists.

Dr. Bruce Siegel [00:18:22]:

Tear up your list. Too many lists. You know, I think I get closer to the date. People have told me, hey, you need to retire. Don’t make a lot of decisions before you, before you walk out. Get closer to the date, then decide what you want to do. I mean, could I see doing some things as an advisor or, or part of a governing board? Sure. Do I want to be an employer or employee? Not so much.

Dr. Bruce Siegel [00:18:41]:

I’ve been doing that for a while. I think I’ll sleep a little later. I’ll be happy.

Chip Kahn [00:18:46]:

Well, Bruce, it’s been a pleasure talking with you today, having you on the podcast, and I really wish you luck in what comes next. Your leadership at the Americas Essential Hospitals has had a lasting impact, ensuring that so many vulnerable patients can maintain access to the care they need. I just wish you well. And again, you know, thanks for being with us today. I think this is a very helpful conversation and particularly as we, you know, drill down on that sort of topic of the day in terms of health policy, Medicaid.

Dr. Bruce Siegel [00:19:20]:

Absolutely. Thank you, Chip. And grateful for the partnership.

Narrator [00:19:29]:

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

With an extensive background in health care management, policy, and public health, Bruce Siegel, MD, MPH, has the blend of experience necessary to lead America’s Essential Hospitals and its members through the changing health care landscape and into a sustainable future. With more than 350 members, America’s Essential Hospitals is the only national organization representing hospitals committed to serving those who face financial and social barriers to care.  

Since joining America’s Essential Hospitals in 2010, Siegel has dramatically grown the association as it strengthened its advocacy, research, and education efforts. His intimate knowledge of member needs comes in part from his direct experience as president and CEO of two member systems: New York City Health and Hospitals Corporation and Tampa General Healthcare. Just before joining America’s Essential Hospitals, Siegel served as director of the Center for Health Care Quality and professor of health policy at The George Washington University School of Public Health and Health Services. He also served as New Jersey’s commissioner of health.  

Among his many accomplishments, Siegel led groundbreaking work on quality and equity, with funding from the Robert Wood Johnson Foundation. He is a past chair of the National Quality Forum board and the National Advisory Council for Healthcare Research and Quality. Modern Healthcare recognized him as one of the “100 Most Influential People in Healthcare” from 2011 to 2019 and 2022 to 2024; among the “50 Most Influential Clinical Executives” in 2022, 2023, and 2024; among the “Top 25 Diversity Leaders in Healthcare” in 2021; one of the “50 Most Influential Physician Executives” from 2012 to 2018; and among the “Top 25 Minority Executives in Healthcare” in 2014 and 2016. He also was named one of the “50 Most Powerful People in Healthcare” by Becker’s Hospital Review in 2013 and 2014.  

Siegel earned a bachelor’s degree from Princeton University, a doctor of medicine from Cornell University Medical College, and a master’s degree in public health from The Johns Hopkins University School of Hygiene and Public Health.