Potential Midterm Election Implications for Health Care

1:30 p.m. – 1:35 p.m.              Welcome and Introductions

• Sarah J. Dash, MPH, President and CEO, Alliance for Health Policy (@allhealthpolicy)

1:30 p.m. – 2:45 p.m.              Moderated Discussion with Q&A

• Joanne Kenen, Executive Health Care Editor, POLITICO (@JoanneKenen)

• Jeanne Lambrew, Ph.D., Senior Fellow, The Century Foundation (@TCFdotorg)

• Rodney Whitlock, A., Ph.D., Vice President of Health Policy, ML Strategies (@RodneyMLS)

Sarah Dash:                        Hello everyone, and welcome to The Alliance for Health Policy’s webinar on potential midterm election implications for health care. I am Sarah Dash, president and CEO of The Alliance for Health Policy and I will be facilitating today’s discussion. For those of you who are not familiar with The Alliance, we are a nonpartisan organization dedicated to advancing knowledge and understanding on health policy issues. Our mission is to educate the health policy community on the pressing issues, and we’re delighted to do that today. We’re excited to examine the role of health care in the upcoming elections, as well as the potential health policy implications for Congress, the administration, and state governments, and I’ll be introducing our speakers momentarily. Sarah Dash:                        The Alliance for Health Policy gratefully acknowledges the National Institute for Health Care Management Foundation for supporting today’s webinar, which is part of the Beyond the Beltway: Health Webinars for Journalists series. Sarah Dash:                        If you’re interested in joining the Twitter conversation today, please use the hashtag #allhealthlive and follow us @allhealthpolicy. Before we get started, I’d like to briefly orient you to the go to webinar platform, and read you some technical notes. First, we recommend increasing the volume on your speakers to get the best sound quality. Next, we’ve taken a screen shot of the attendee interface. You should see something that looks like this on your computer desktop in the upper right corner. You can click the orange arrow to minimize and maximize this menu. Sarah Dash:                        You will be muted throughout the presentation, but you can ask questions by using the question panel to chat with us about any technical issues you may be experiencing, as well as to send in questions that you have for the panelists. And, we will collect your questions and address them throughout the broadcast. Sarah Dash:                        Finally, all webinar materials are available to download in the handout section of your attendee interface. And you’ll find the materials that accompany this webinar on our website, allhealthpolicy.org, along with a recording of today’s webinar. Sarah Dash:                        I’d like to introduce our esteemed panel of experts who are going to shed light on this important topic. Joining us today we have Joanne Kenen. Joanne Kenen is POLITICO Pro’s executive healthcare editor. Since arriving in Washington in 1994, she has focused on health policy and health politics, but her career, we are told, has had her cover everything from Haitian Hoodoo Festivals to US presidential campaigns. She jokes that sometimes it’s hard to tell the difference. Sarah Dash:                        We will also have Jeanne Lambrew. Jeanne is a Senior Fellow at The Century Foundation. Her writing, research, and teaching focus on policies to improve health care access, affordability, and quality. Previously, Jeanne worked in the Obama administration, first as the Director of the Office of Health Reform at HHS, and then as Deputy Assistant to the President for Health Policy. Sarah Dash:                        We have our third panelist here, who is Rodney Whitlock. Rodney is the Vice President of Health Policy at ML Strategies. He’s a veteran health policy professional with more than 20 years of experience working within the US Congress where he served as Health Policy Advisor and Acting Health Policy Director for Finance Committee Chairman Chuck Grassley of Iowa as well as earlier on the staff of former US representative Charlie Norwood of Georgia. Sarah Dash:                        We are so grateful to have them here with us today to give their thoughts and best guesses on what is a very interesting election cycle. Sarah Dash:                        Next, I’ll turn to our agenda for today. For those who have joined us for our previous webinars this year, we have formatted this one a little bit differently to allow for more of a free-flowing conversation. We’re going to dive right into a moderated discussion, and you can see that we’ve created a five-part framework that will bring us through some of the major components of this issue. Will spend about 14 minutes on each section. And, if you have questions, I will weave those into each section. And, then, finally, we will have time during this final thoughts section to answer any remaining audience questions, so please feel free to submit that at any time. Sarah Dash:                        So with that, let’s go ahead and get started with today’s discussion. First, I want to focus on just an overview of the 2018 midterm elections, and what are some of the major trends. So let me turn to our panelists first and ask, how is this year different? Is it different? Is this a healthcare election and what are the trends that you’re watching? Joanne, you want to kick us off? Joanne Kenen:                  2018 is definitely a healthcare election. Now, as everybody on this panel knows, and everybody in the audience knows, we have what I sometimes call the 24 second news cycle. We sort of lurch, as a country, from crisis to crisis and scandal to scandal, and I do not know what will be foremost on people’s minds when they actually go to vote in two weeks. Two weeks? Three weeks. But, we do know that there’s the consistent, that voters are coming back to is healthcare. That has shown up in all the polling for months, so whatever it is the other scandal of the day or concern of the day or outrage of the day or hysteria of the day, healthcare is sort of this rock on domestic policy. That’s what people are coming back to. Joanne Kenen:                  And it’s not just something they care about. We are seeing it as a motivating factor. It’s the reason that’s going to get people to the polls. Joanne Kenen:                  Now, a few months ago, if you asked me, what was the healthcare concern, I would’ve said costs, because we were seeing that. We were seeing that both in the polling data, and just as a human being if you had a conversation with anybody it would be about cost, specifically drug costs has come up in the poll, both Republicans and Democrats. But, one night last June a Texas courtroom, Attorney General Jeff Sessions filed the federal position on what had been a somewhat obscure and not-that-much-attention-getting lawsuit. And, when the government of the United States actually joined 20 Conservative states suing to overturn Obamacare yet again, it put pre-existing conditions squarely back in the spotlight. Joanne Kenen:                  The Justice Department is not trying to strike down the entire law, but they do want the court to strike down the most popular parts of it, which some might think is not a great strategy for Republicans a few months before an election. Pre-existing conditions and some other related consumer protections, patient protections, are now at risk in this Texas courtroom. It’s a federal court, but it’s in Texas. It may take a year or two to play out in the court system. But, in terms of for the Democrats, it was a gift, because they can say pre-existing conditions are at risk. And, as we all know, pre-existing conditions, concern about pre-existing conditions, that is one of two issues, the other one being Medicaid, that stopped the Republicans from repealing Obamacare last year. So, every campaign in the country people are talking about pre-existing conditions. Sarah Dash:                        Thanks, Joanne. Jeanne, you wanna jump in? Jeanne Lambrew:            Sure. So, I’d like to build on that and talk about why. Why is pre-existing conditions such a hot topic in this election? And, I do think it goes back to last year, which, as a reminder, last year we saw the Republicans pledge to repeal and replace the Affordable Care Act, go from a political slogan to an imminent reality. Jeanne Lambrew:            So, just looking at the House-passed bill, The Congressional Budget Office estimated that it will cause 23 million people to lose coverage by 2026. Results in destabilized markets in areas of the country where one-sixth of the population resides, and “overtime it will become more difficult for less healthy people, including people with pre-existing medical conditions, in those states to purchase insurance, because their premiums would continue to increase rapidly”. Jeanne Lambrew:            So, everybody thought that the debate ended last fall, but look at the tick-tock. In October, the president issued executive order to look for alternatives to the ACA’s insurance reforms the same day he stopped payments for cost-sharing reduction subsidies. In December, Congress zeroed out the penalty for not having health insurance, the so-called Individual Responsibility Provision. In February, as Joanne mentioned, we saw this lawsuit that took the zeroing out of individual mandate penalty, and said, ‘Aha, the law is now UN-Constitutional, it’s no longer a tax, it’s a requirement for people to have coverage, and there’s no severability clause, the whole law should be struck down’. Indeed, in June, Department of Justice made an unprecedented decision to not defend the Constitutionality of the Affordable Care Act and strike down some of the pre-existing condition protections. Jeanne Lambrew:            And, if that is all not proof enough, even the responses to the Department of Justice action from Republicans in Congress has been inadequate. There’s a non-binding Congressional resolution that got introduced in the House would basically have no effect. And, in the Senate, there’s a bill called the Tillis bill, which, in the words of the patient groups, would, in short, for people with pre-existing conditions not provide access to coverage. Jeanne Lambrew:            So, all that means that I think the resonance of pre-existing conditions in the field, right now, is they want checks and balances. They want a Congress that’s gonna come in and slow down if not stop, prevent, and protect the protections that people care about in current law, but I also think is gonna create a primacy on trying to find common ground, ’cause people who get elected wanna do something, and flip it around. There’s a whole lot of Republicans that are up, especially in the Senate, in 2020, who also will wanna find common ground to move things forward. Jeanne Lambrew:            I do think, should pre-existing conditions continue to play out the way we are thinking it would, we’ll see activity in the states. We already know there’s four states with ballot initiatives on the Medicaid expansion that we’ll know the outcome of in a couple weeks. We also see states like California that, with a Democratic governor, may be incented to act. Jeanne Lambrew:            And, last but not least, I think kind of focus on pre-existing conditions we’ll talk about later, tee up the 2020 Presidential Election. Sarah Dash:                        Thanks, Jeanne. Rodney? Rodney Whitlock:            So, Republicans are in an extremely difficult position, here, in talking about pre-existing conditions, ’cause they’re not good at it. They have struggled mightily when confronted with the issue. Let’s roll the clock back to Jimmy Kimmel, and him opening his show one night talking about his son, Billy, who will have a pre-existing condition for the rest of his life. And, we all know that, and we react viscerally to that, ‘Well, that’s not right, we should be able to address that’. Rodney Whitlock:            The problem is Republicans have struggled meeting a simple standard, the unfortunate standard for them has been if you’re not protecting pre-existing conditions the way that the Affordable Care Act does it, you are failing. And, so, talking about Senator Tillis’ bill, he says very openly on his website, “We’re not trying to replicate the ACA.” Therefore, he will necessarily fail. Rodney Whitlock:            The problem Republicans struggle with in this whole conversation is taking it beyond that simplistic notion, that there’s only one way to do it, which is, of course, not true. There are different ways to getting at this question. How do you protect people with pre-existing conditions? How do you make sure that they have access to services, those services are affordable? But, everything I just said there all come with shades of gray, and you have to define terms. And, Republicans have struggled engaging in conversations where they’re trying to show ‘this is how we’re trying to get to that point’, and this is why this is such an effective issue for Democrats running against Republicans, because of the inability to message where you’re going to be on these types of things. Joanne Kenen:                  I think that one of the ironies of polling over the last few years on the ACA is if you ask people, “Do you like the Affordable Care Act?”, Democrats say, “Yeah.”, and Republicans say, “Hell, no.” The intensity is much more on the Republican side. But, there was always a funny thing where if you asked people, and the Kaiser Family Foundation did tracking polls for months, many months, and can sort of see this quite consistently, if you ask people about provisions within the bill, not the bill anymore, the law, people who said they didn’t like the ACA actually liked a lot of what was in it. Joanne Kenen:                  And, on the unpopular side, even Democrats never really liked the individual mandate very much. That was never, there was always just a sympathy for, ‘Should my government make me buy this?’. The individual mandate was never particularly popular. Republicans hated it and Democrats weren’t that crazy about it. The Democrats, obviously those that had the sophistication, understood why you needed it and how the market worked and why you needed this incentive to keep people in. Joanne Kenen:                  Pre-ex is the opposite. Republicans really liked the pre-existing conditions, just that basic idea, without all the legal conditioning around it or circumstances. And, I think it’s basically just a basic sense of fairness that Americans feel if you’re a kid born with something, a heart defect like Jimmy Kimmel’s kid, or you get a disease and you’ve played by the rules and you’ve paid for your insurance, you should have protection. That’s why you have insurance. And, this has been a real sore point, as Rodney said, for the Republicans, ’cause there is sort of this basic gut sense of ‘there but for the grace of God, it could be me or my kid’ or ‘this just doesn’t feel right that if you’re sick you’re no longer protected’, and that’s why it has so much … Joanne Kenen:                  There’s so many ads across the country, there’s so many politicians talking about their own pre-existing conditions, breast cancer for some of the women candidates, their children, heart disease, and Republicans trying to come back with ‘Yeah, it’s in my family, too. And, I understand … ‘ But, saying ‘I understand’ when you don’t have a policy that supports it is not a good place to be in. I mean, if some of those Republicans win, and some of them will, it won’t necessarily because they have a great pre-existing condition answer. Sarah Dash:                        Let me spend just another minute on this, and try and tie a couple things together. Sarah Dash:                        Rodney, you mentioned that there are different ways to get at pre-existing conditions. And, Jeanne, you mentioned that, perhaps, there might be some drive to find some common ground, particularly on this very potent issue. Sarah Dash:                        Under the ACA, pre-existing conditions was part of kind of a three-legged stool that included the individual mandate and the subsidies. Sarah Dash:                        What are some of the different policy options, and do they stack up in terms of numbers of people covered and protected? Could we get into that for another minute or two? Rodney Whitlock:            Sure, I’ll jump in, and certainly my colleagues can correct me if they think I need to be corrected, here. But, effectively, pre-existing conditions and the way you structure protections for them is going to be a decision which basically says, ‘For people who do not have pre-existing conditions, how much and how will I ask them to cost subsidize the cost of people who have them?’ Because, an insurer will look at them and go, ‘I think that people with pre-existing conditions are going to be more expensive, I want to charge them more.’ Rodney Whitlock:            So, now, to stop that I’ve got to put a structure in place that in some way either subsidize or limit the ability to ferry. And, so, you start there. The ACA’s structure basically say, you cannot deny anyone who has pre-existing conditions, and then we limit the amount of variation between the healthiest to the sickest by I believe it’s three-to-one. Jeanne, correct me if I’m wrong. And, so, just note there’s a little extra something for you, there, but that’s about it. And, that’s structurally how it’s done. Rodney Whitlock:            If are not in the ACA, if you are in, say, private insurance that’s governed under HIPPA, arguably, it’s a little more restrictive in that your community rate is effectively everyone pays the same, once you are, again, in an insured situation. People have talked about the idea of high-risk pools or the invisible high-risk pools, where you pull people out, look at them separately, and do it that way. But, we’re talking about policy areas where we are looking at different ways to do it. In politics, it’s either you are for it or you are against it, and that is how so much is being cast right now. Jeanne Lambrew:            I may argue as much about being for or against than what you’re for, because, back up nearly a decade ago, the burden of proof for incoming president and the Democratic Congress was ‘How are you gonna do it?’, and ‘Is it enough? Is it too much?’. And, then, once regulation, I could argue that the challenge of making the law work and kind of getting up and going was because people were comparing it to an ideal. I still find my premiums expensive. I still get surprise bills. So, it’s not perfect with the old comparator. Jeanne Lambrew:            Fast forward, Republicans are in charge, they’re in charge of the White House, they’re in charge of Congress, and they need to say what they’re for. I think we learned last year that groups, even Republican governors, weren’t really for the solution that they came up with. So, I think that’s the new pressure point. It’s not for or against, it’s what you’re for compared to what people have now. So, sure, the Affordable Care Act is far from perfect, but it is what people have. And, if you’re going to take away what they have, you have to prove that what you’re providing instead works. And, that, has been, I think, the challenge. Joanne Kenen:                  I think lots of people are very confused. “Healthcare,” as the president has famously said, “is in fact complicated. It keeps us all employed.” But, people are blaming Obamacare for everything, right? That’s not how most people get their insurance. Most people get it through their job or a family member’s job, or, if you’re older, on Medicare. But, anything that went wrong in your healthcare, it became ‘blame it on Obamacare’. And, you still see it several years out. If you watch the Obamacare haters on Twitter, it’s ‘My drug went up, and it’s gotta be Obamacare’s fault.’ They have nothing to do with one another in many, many cases. But, because of this ongoing confusion about what it is and what it isn’t and what is it responsible and what is it not responsible for it has let people of both sides of the aisle keep irritating some of that. And, yet, it’s stabler than anyone thought it would be at this point. Jeanne Lambrew:            And, just to add to that, the people who have pre-existing conditions know what they got. So, the community of people that have been discriminated against in the insurance industry are aware of it. People who have family members who had that experience are aware of it. So, again, go back to the fact that even, again, . 20 million people gained coverage. Tens of millions more gained these protections, and that is a constituency that wasn’t there even in five years. Joanne Kenen:                  I mean, if you looked at the town halls last year, that’s what it was about. What slowed down, didn’t eventually prevent, eventually the House did pass its repeal bill, but it took a lot more political capital and a lot more months than they ever thought. And, those town halls last year were about pre-existing conditions, like 99% of what people were up there talking about was pre-existing conditions. And, people were frightened and angry that they were not going to get them. Joanne Kenen:                  In the Senate some other dynamics came in, a lot of it was the governors and Medicaid and the fact that the bill did more than repeal the ACA part of Medicaid, it did a lot more like which is not on the table, right now, but it will be again, someday. But, pre-existing conditions, really, is what set fire to what we quote quote, you can’t see me here, but I’m making air quotes, “resistance” really sort of grew up around the fight over ACA. Sarah Dash:                        So, this is a great discussion around pre-existing conditions, and before we kind of move off of the key topics that we’re looking at, in terms of the election three weeks from now, I just want to turn to Medicaid. As Jeanne mentioned, there are several states that have Medicaid ballot initiatives. What are you watching in terms of those Medicaid ballot initiatives? Are they the same across those states? And, what do you foresee, if anything, as far as what an incoming Congress might do around Medicaid? Joanne Kenen:                  So, there are three Conservative states, Idaho, Utah, and Nebraska, that have not expanded the Medicaid under the ACA, and have ballot initiatives. And, right now, there’s not great polling on this. Right now, most people think they will pass. Now, it passed last year in Maine and Governor LaPage, he’s gonna go out fighting. Maine approved Medicaid in the first of these kinds of ballot initiatives by almost 60% and the governor had kept fighting, and that’s now in the courts and part of the governor’s race going forward. It’s on the ballot in Maine, they already won. I would expect, I think it’s quite likely that it passes in all these three states. How the next legislators and governors respond, we will see. I’m not sure they’ll fight it as, what’s the word for how fighting, I don’t know what word you would use for how Governor LaPage of Maine, it’s like his reason for living seems to be fighting Medicaid expansion. It may not be that. Joanne Kenen:                  I mean, Idaho is a really, really interesting state, ’cause here’s this really Conservative, rock-solid, red state, and they’ve implemented the ACA. They run their own exchange, and they run it reasonably well. At the same time, they’re trying to tear it down. They had a proposal to basically get rid of it, which went too far, even for the HHS under President Trump. So, Idaho’s gonna be sort of fun to watch. We just had a reporter out there last week, in fact. Joanne Kenen:                  So, I think that they’ll probably pass. I mean, we could be proven wrong. My gut feeling is they’ll pass. I’ve said things that are wrong, before. Montana’s a little different because they have expansion, and the ballot initiative, there, has to do with tobacco taxes in order to pay for ongoing Medicaid bills. And, I’m not sure if there’s any polling on that. You know that one? Rodney Whitlock:            I do not. Joanne Kenen:                  I think it’ll pass. I’m not that familiar with it. Rodney Whitlock:            So, I think one of the things you are seeing, particularly in some of the more red states that did not expand, is perhaps a growing recognition that there’s all this money they could have been taking to this point, and, eventually, they may have to consider taking it. Joanne Kenen:                  The rural hospitals sure want it. Rodney Whitlock:            And the community health centers. I mean, there’s an argument to be made that you are turning down this money. Now, state legislatures where they have ballot initiatives have two choices: do it themselves and own the decision and responsibility for it or put it on the ballot and let the community at large make the decision for them. If you see it pass in three states on November 6th, I think you might see a bit of a wave, there, start to develop. Jeanne Lambrew:            And, I would just add, beyond those three states this is a hot topic in the state of Georgia with the governor’s race. It’s come up in Kansas a fair amount. So, it is not just a ballot initiativecy, but it does cut on more traditional lines in those states. Joanne Kenen:                  So, has close, and that was a totally Republican state, it was a Moderate Republican versus a more Conservative Republican fight. The Moderates did favor expansion and lost, so we’ll see what happens next year. Sarah Dash:                        In terms of federal policy and the question of states leaving a lot of money on the table, the original Medicaid expansion, I believe, was due to … 100% has been phasing out over the last number of years, so what do you foresee, if anything, about a push at the federal level to get some of those latecomers to the game, you know, additional federal resources or is that completely off the table? Jeanne Lambrew:            Sure, I mean, there has been a bill introduced by Senators Kaine and Warner, for obvious reasons, because Virginia was a late expansion state, that would, instead of having that 100% match attach to years like 2014/2015/2016, it would attach to the first year of expansion. That bill could potentially have more bipartisan support, because, at this moment in time, most of the states out there would be red states who would benefit from it. And, I do think there’s been a renewed thought about what the poor states could be getting from Congress that might be more amenable to it, so I think there could be some action there. Sarah Dash:                        So, let’s turn now to our second kind of main topic, which is the post-election, or immediate post-election, or lame duck scenarios, and, understanding that there may be a number of different scenarios that might play out. We have a question from the audience, here, which is, “How concerned should we or how much concern should there be about Republicans trying to push through an ACA repeal, including Medicaid cuts or caps during a lame duck session, particularly if they lost the majority?” So, we’ll start off the next section with an audience question and go from there. Rodney Whitlock:            I think that is a bit of a stretch to imagine. The House of Representatives and who is left and who is … The House has already passed the bill, the American Healthcare Act, would they be convinced to come back in and try again? The Senate, remember that you have was 52-48, it is now 51-49, meaning that you have to find a way to convince two Senators to change their vote. I continue to find that to be rather outlandish, and some Republicans, and I think you even see this in certain Republican races out there, at some point Republicans missed an opportunity to say ‘mission accomplished’. They didn’t have an aircraft carrier and a banner to do so, but once they repealed the individual mandate and implemented AHPs and STLDIs, Short-term Limited Duration Insurance plans and Association Health Plans, and begin to make the changes they did administratively, at a certain level they could have done more to declare victory to take them out of the situation where you’d be asking that question. Joanne Kenen:                  Often, the reconciliation bills . They need 60, don’t they? Rodney Whitlock:            No, you’re right, ’cause they use them on taxes. Joanne Kenen:                  Right. Rodney Whitlock:            But, they could use, we’re in the new budget year, you could do . We’re talking really, really … Jeanne Lambrew:            I will remind you that the current Congress that we’re still in did reconciliation instruction during a lame duck while President Obama was still in office. So, it is not … Joanne Kenen:                  I mean, the two that would have to switch would be Susan Collins and Lisa Murkowski, and I don’t think any of us see either of them switching. I mean … Jeanne Lambrew:            Sure, although, going back and looking at lame ducks, I think it’s an interesting period of time. I was around during what will be the most comparable one which is 2010, right, after there was Democratic control of the White House, Democratic control of Congress, and, then, there was a mid-term election, and what happened in the lame duck? Jeanne Lambrew:            Interestingly, Pew Charitable Trust did an analysis of lame ducks and found that looking at 2010, 99 laws were passed and that represented nearly a third of the substantive output of the entire Congress. I mean, things happened, and can happen, especially if there’s a change, and there’s an outgoing Congress. Why would that be? Well, certainly the potential interest in some of the tax bills that we saw floating around the House on health savings accounts, poor mandate relief, maybe more extensions. I mean, that all adds up to $100 billion. But, that could be on the table. Jeanne Lambrew:            Flip it around, there may be Democrats who’d wanna, would go along with them and get out of the way, because next year is gonna be a year where they’re both gonna be willing to put forward a positive image should they gain one of the chambers, and they may be interested in, again, cutting deals, there. We hear that there may be a big wall fight, which means there’s opportunity for, again, negotiations, and there could be policy put into that negotiation. Jeanne Lambrew:            And, last but not least, this lame duck is gonna be full of announcements. So, this Texas case that we talked about, the judge is supposed to rule as soon as possible, the plaintiff’s asked for an injunction for January 1. Decision in that one. The short-term plan lawsuit decision sought by November 1. There’s a couple new rules that will come out probably next couple months which could also incent activity. Rodney Whitlock:            The term of art that I know we used on The Hill to refer to lame ducks, and I think what you described there is called ‘clearing the decks’, and there are going to be opportunities to do things that you do under this current configuration that you know will be more difficult in the next. And, so, that will motivate a lot of what we see during that period. And, for those of us who would like to be home for good by Thanksgiving, oh, no, we are likely to be working on eggnog or maybe all anxiety. Joanne Kenen:                  Right, but also they did finish, I mean unusually, they did finish the Labor-H, the health spending bill, and that’s done. So, the wall fight, they’re gonna fight over Trump’s border wall and other issues that are unresolved that I guess gets a December 7th deadline. It’s not that they can’t hang healthcare. If you want it, you can find a way on many things, but the main vehicle for putting a lot of the healthcare stuff is this Labor-H spending bill. And, that has, quite unusually, been addressed. Jeanne Lambrew:            and I will go back to another one of my fond lame duck memories was in the 2010 lame duck, as a reminder, we all stayed here and had a New Year’s Eve deal on doing continuing resolution on a whole bunch of policy. And, as a reminder, that was but we also had to repeal the CLASS Act and Appreciative Long-term Care Commission, and rescinding co-op funding in that particular round, so note that it doesn’t always match up. Joanne Kenen:                  The other issue that is gonna probably come up in the lame duc