An Insider’s View on the Future of U.S. Health Policy

This special episode of the Princeton Pulse Podcast features a conversation with Chiquita Brooks-LaSure, former Administrator of the Centers for Medicare & Medicaid Services, known as CMS. Host Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, recently sat down with the renowned Princeton alumna to discuss the future of U.S. health care policy. Their talk was held in front of a live audience to kick off the Dean’s Leadership Series, hosted by the Princeton School of Public and International Affairs.

Chiquita Brooks-LaSure is an inspiring changemaker in the realm of health and health care. She was the first Black woman to lead CMS, where she oversaw programs serving more than 150 million Americans. Under her leadership, from 2021-2025, CMS doubled health coverage under the Affordable Care Act marketplaces from 12 to 24 million enrollees, expanded and strengthened Medicaid, lowered prescription drug prices, and raised maternal health standards. 

This candid and rich discussion addresses the future of Medicare and Medicaid under the current administration, policy pathways to strengthen these programs, and opportunities for advancing equity, access, and innovation in U.S. health care. 

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Learn more about Brooks-LaSure’s views on Medicare and Medicaid: 

Medicare and Medicaid Turn Sixty

Medicare Check-Up With Former CMS Administrator Chiquita Brooks-LaSure

The Princeton Pulse Podcast is a production of Princeton University's Center for Health and Wellbeing (CHW). The show is hosted by Heather Howard, a professor at Princeton University and former New Jersey Commissioner of Health and Senior Services, produced by Aimee Bronfeld, and edited by Alex Brownstein. You can subscribe to The Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your favorite podcasts.

Transcript

Episode #21

SPEAKERS: Heather Howard, Student, Chiquita Brooks-LaSure 

Heather Howard  00:00

Hi, and welcome to the Princeton pulse Podcast. I'm Heather Howard, professor at Princeton University and former New Jersey Commissioner of Health and Senior Services. On campus and beyond, I've dedicated my career to advancing public health. That's why I'm excited to host this podcast and shine a light on the valuable connections between health research and policy. 

Heather Howard  00:23

Our show will bring together scholars, policymakers and other leaders to discuss today's most pressing health policy issues, domestically and globally. We'll highlight novel research at Princeton, along with partnerships aimed at improving public health and reducing health disparities. I hope you'll listen in as we put our fingers on the pulse and examine the power and possibilities of evidence-informed health policy. 

Heather Howard  00:51

This special episode of the Princeton Pulse Podcast features a conversation with Chiquita Brooks-LaSure, former Administrator of the Centers for Medicare and Medicaid Services, known as CMS. In early October, I sat down with Chiquita to discuss the future of U.S. health care policy. Our talk was held in front of a live audience to kick off the Dean's Leadership Series, hosted by the Princeton School of Public and International Affairs. 

Chiquita Brooks-LaSure is an inspiring changemaker in the realm of health and health care. This renowned Princeton alumna was the first black woman to lead CMS, where she oversaw programs serving more than 150 million Americans. Under her leadership, from 2021 to 2025, CMS doubled health coverage under the Affordable Care Act Marketplaces from 12 to 24 million enrollees, expanded and strengthened Medicaid, lowered prescription drug prices, and raised maternal health standards. In recognition of these achievements and many others, in 2023 Chiquita was named among the 100 most influential global health leaders by Time Magazine. 

During this candid and rich discussion, Chiquita addresses the future of Medicare and Medicaid and the Affordable Care Act under the current administration, policy pathways to strengthen those programs, and opportunities for advancing equity access and innovation in U.S. health care. The following conversation was recorded on October 1st at Princeton University. 

Heather Howard  02:20

I am so delighted to be here. But let me start by thanking Dean Amaney Jamal, Vice Dean David Wilcove, and SPIA, for this amazing series. Chiquita, you're the first this year in the Dean's Leadership Series. And I can't think of a better person to kick off the Dean's Leadership Series, somebody who has deep roots here in Princeton as a graduate of the Class of 1996 and who spent an amazing career in and out of government, and I think that's really important. Chiquita just comes from lecturing the global health class, GHP 350, and demonstrating to students that careers are not a straight line. And I think we want to explore that with you, but there is a through line in your career, which is helping Americans to thrive and live healthy lives. So let's jump in. Tell us about how you got to be running the largest federal organization that most people haven't heard of, right? You had a budget of $1.4 trillion, 6,000 employees, and 30,000 contractors. Tell us how you got there, and hopefully how that journey started at Princeton? 

Chiquita Brooks-LaSure  03:46

I will do my best, although sometimes I look back and think, how did this happen? What a fortunate person I have been to have been a part of so many amazing things. It is truly wonderful to be here. This institution is full of some of my happiest memories in my life, and for all of you who are students here, Princeton is an amazing place. I sat there in a class on public policy, and I think it really started to change my thinking about what I wanted to do. I had come to Princeton very focused on the sciences. I started out as a chem major and thought about being pre-med. Wasn't quite sure that's where I wanted to go. And sitting in some of the public policy classes, I really became very drawn to start focusing on policy. I was a politics major. I left Princeton... you know what, I didn't even think about this, but my first year out of college I worked at a law firm, and I got to know a bunch of students who were at the policy school, who were in grad school, and they asked me what I was interested in. They said, "You should not go to law school. You should go to policy school." And that really changed my trajectory. I went to policy school and met a professor who said, "You must go into health care," and it really did influence my interest in health policy. I had started out, I would say, probably more interested in social policy, like education, and I would say that somewhere along the way, I came to really understand that if you don't have health, you really can't have life, liberty and the pursuit of happiness. It really was a fundamental part of actually trying to achieve any of the other things that I thought were incredibly important.  

And so I started my career at the Office of Management and Budget, which is an agency within the White House. There are political officials in charge of it, but it is the largest agency within the White House that is career civil servants. I worked during the end of the Clinton administration and the first couple of years of the Bush Administration on CHIP. It just started the Children's Health Insurance Program, and during that time, I started traveling the country. And I can still remember, to this day, meeting this mom who was so excited that her children were going to be enrolled in the CHIP program. She was so proud that her children were going to have coverage, and that she was paying for it through the private CHIP program. And it really helped me to understand how important it was for so many people to have health insurance, what a difference it made. I think throughout my career, the arc has been wanting to get the people of this country health insurance coverage.

Heather Howard  07:29

So I started by saying that you ran the largest government organization that people haven't heard of, but people have heard of the programs you ran at the Center for Medicare and Medicaid Services. Tell us about the different programs you ran and who they served, and what role they play. 

Chiquita Brooks-LaSure   07:48

CMS now has a great deal of authority. It did at the beginning, but it has grown in breadth over the decades. CMS runs the three big programs. It runs Medicare, which is for people who are over the age of 65 or who have disabilities. The vast majority of people who fit those categories are covered by Medicare. It is the largest single payer in the sense of one entity by the federal government, and it is now both a combination of what we call traditional or original Medicare fee per service, where CMS pays doctors and hospitals directly, as well as Medicare Advantage, which is run by private plans. 

There's Medicaid, which, at the beginning of this year, was the largest in terms of the number of people covered. We'll get to why that may change. But the Medicaid program covers across our country, most low-income people and a lot of middle class people who fit certain categories. So 50% of the children who have high needs in this country, like if you need an organ transplant, for example, get covered by the Medicaid program. It also is incredibly important for long-term care. A lot of the services that are covered when you go to a nursing home or in your home or community are often paid by Medicaid. 

The Affordable Care Act created [health insurance] coverage, and we call it Marketplace coverage. We reached 24 million people covered at the beginning of this year. CMS runs that. It also oversees a lot of the insurance rules for individual market insurance and small businesses. But a couple of things that CMS does that are lesser known are things along the lines of the health and safety of facilities. Most of the facilities in this country, if they accept Medicare payments, must meet standards that CMS sets, and so things like surveys to make sure the nursing home is safe. Those are funded out of the CMS budget. A lot of the rules, the conditions of participation, or things that you have to do in order to receive funds from the federal government are also things that CMS oversees. When we went through COVID, you wouldn't think of CMS as being on the forefront of those issues. You think of NIH, you think of CDC, you think of FDA. But CMS had a lot of responsibility for COVID because of that level of authority over the health and safety of facilities. 

Heather Howard  11:01

It's interesting. So you're directly providing health insurance to about 160 million people through those programs, but you're really touching everybody, because you go to a health care facility, the safe care you're getting traces back, right? And also, Medicare is a really interesting lever for the federal government. Do you want to tell them if there's some interesting history from the early years of Medicare, and how some important social progress was made using Medicare as a lever? 

Chiquita Brooks-LaSure   11:29

Medicare is the driver of so much of how our health care system works in this country. It has 70 plus million people who are covered by it. And when President Johnson signed Medicare and Medicaid into law, one of the things that he required when the law was implemented is that hospitals be desegregated. And I bring this up because this is not ancient history. I gave birth in Virginia about 11 years ago, and when we were in the hospital, my husband was talking to women who were there, who were older, who said they were born in DC because Virginia had not desegregated. And even though they had always lived within five minutes of the hospital, they were not able to give birth there. But within a year, most of the hospitals in this country had desegregated because Medicare was so important. They wanted to get funds from the federal government, and so they changed their rules.

Heather Howard  12:44

That's an early accomplishment of Medicare. When you think back on your four years as head of CMS, what accomplishments do you look to? 

Chiquita Brooks-LaSure   12:53

I am incredibly proud of what we were able to accomplish during the four years. We were able to achieve the lowest uninsured rate in our nation's history, which I personally believe is so important. I think it is so important for not just the people that are covered, but for our health care system. It's one of the reasons why our health outcomes are where they are -- not the only reason, but it is, I would say, necessary, not sufficient. And by getting states to continue to expand Medicaid, covering women 12 months postpartum, and a lot of work done on the Affordable Care Act, we were really able get us into a good place in terms of coverage. There was still more to be done, but that is something I'm incredibly proud of. 

I'm also very proud of CMS, for the first time, negotiating Medicare prescription drug costs. It's hard to say how important prescription drugs have become to health care in general, and specifically for seniors in our country. I spent a lot of time just talking with so many people who truly were making decisions between putting food on the table and filling their prescriptions. Being able to negotiate the prescription drugs not only affected the drugs that we negotiated better prices for, but the law changed the rules so that the benefit is more affordable for everybody. This year, for the first time, there's a $2,000 out of pocket cap. So once seniors who are enrolled in Medicare prescription drug coverage hit $2,000, they no longer pay out of pocket. For so many people, this is a game changer, and one of the really tangible effects that we were able to do.

Heather Howard  15:07

You also ushered in a new way of thinking about the medical system's role in addressing the non-medical drivers of health. In class, we talk a lot about the social determinants of health. Can you talk about how you grappled with controlling budgets for health care, but recognizing that health outcomes are not always determined by health care?

Chiquita Brooks-LaSure  15:32

I would say that medicine continues to evolve, and in some ways, we're getting back to, I almost want to say, first principles... when you had a local doctor who really knew a lot about what was going on in your situation. Now, we all go to more specialists, and sometimes we have lost the understanding that so much of our health is connected to so many other things. I would say this is where the medical community has really started to say, hey, food insecurity makes a huge difference in someone's health, how they're eating, what they're putting in their bodies, what they have access to. This is making a huge difference, things like whether your housing is insecure, if you have mold in your house that leads to asthma that ends up costing us a hospital stay. There is more and more acceptance and awareness that these other conditions really are affecting our nation's health.  

A lot of this actually was driven by the private sector. Some of the private plans in Medicare started to cover things like air conditioners for seniors who were in communities where heat waves would cause them to end up being hospitalized. It's cheaper to put in an air conditioner than it is to pay for the hospital stay. So as a result, a lot of states started to come to us and say, we want to cover some of these additional services. And the frame that we looked at was saying, okay, what are our health care-adjacent close connections, and saying we will pay for those things in really limited areas... short-term housing, so that we don't send you from the hospital onto the street, because it is a waste of federal dollars for you to then end up back in the ER three days later. So paying for a short-term set of services around food and services like those. And this, I think, is going to continue to be something that health care grapples with. What is the appropriate line for health to pay for, and what should be paid for out of another set of services? But the way that we looked at it was, again, the language I always used is "one degree health care-adjacent." Not quite there with the two degrees, but one degree is something that the federal government will cover. 

Heather Howard  18:22

Did you find yourself fielding a lot of requests? You know, we talked about this in class, that even if you don't care about health care, you ought to care about health care because it's where the money is, right? And people coming to you because you had the checkbook and saying, "Can you pay for this?" 

Chiquita Brooks-LaSure  18:38

Yes, one of the former CMS administrators said to me, when I was doing my rounds of getting advice, it's the best job in health care and the worst in the federal government. I think I probably talked to more members of Congress and more stakeholders than many of my counterparts, because when there's a problem, people come looking for CMS. And part of the reason is CMS has the most, I would say, the most direct impact on people's lives, because money is flowing more directly. And so things like lead poisoning and the drinking water, there aren't all of these places to easily put money into place. I'll use a more recent example. Last year, there was a big cyber attack, and it wasn't specific to the federal government, it was to a private entity that, lo and behold, no one knew, controlled 1/3 of the claims in this country. And so across the board, it just depended whether you use this particular system or not, and immediately people look to us like, "Well, can you front money to the providers? Because they now are dealing with a cyber attack, and we can't pay them." That's just an example of even if something isn't your fault, or CMS's core responsibility, because so many dollars flow, policymakers often see this CMS as an easy way to try to fix problems. So you're often called in to address problems in the other sectors.

Heather Howard  20:40

Let's talk about some of those. Health care is one sixth of the GDP, right? And we keep anticipating that soon it'll be one fifth. So, in many ways, that just raised incredible stakes for all of your decisions, right? How did you approach some of those? The decisions you're making are affecting markets. How did you approach those kind of decisions when you were realizing and recognizing that you're regulating such a significant portion of the economy, more than any other high-income country in the world?  

Chiquita Brooks-LaSure  21:14

I would say a couple of things. I credit a lot of my time in different experiences. I really tried to make sure that I got a 360 view of an issue. When I was CMS administrator, I had the opportunity to work on almost all of the programs that I oversaw. So I would have some perspective. I would really try to make sure that I engaged the other entities that had dependencies. To give a more specific example of my own experience in the private sector... When I was in the private sector, I was on the receiving end when the Medicare drug benefit passed the first time. It was 2003, and I was working at a consulting firm, and we were reading all of the regulations. I remember this one meeting I had with a very senior executive. I was 27 years old. He was asking me all of these questions, and I realized I understood so much more than he did, because I had worked in the federal government, and it helped me to understand how little the private sector understands about how the government works. And I think the same is true on the other end, that sometimes the government doesn't appreciate what the private sector needs to do when they put out the rules. And so I tried to approach these very big ticket issues by making sure I had engaged, and not even me, per se, certainly me, but really the team coming up with whatever the recommendation. I know sometimes they'd be very scared when I would ask them questions, but we really needed to make sure that we knew what the implications were going to be for our decisions. Nine times out of 10, I would say to the staff, if everyone's unhappy, we probably got it right. It's okay if people are mad at us, but we need to make sure that we have listened and engaged and considered their perspectives. 

Heather Howard  23:30

Well, that raises an interesting question, Chiquita. There's been a lot in the news recently about the role of evidence in policymaking and deference to expertise.  And we teach our students here the importance of understanding, designing studies, interpreting studies. When you were Administrator, how did you think about expertise, internally and externally? And are you worried about that... whether we're relying on expertise sufficiently? 

Chiquita Brooks-LaSure  24:00

I am incredibly worried about just the erosion of really wanting to rely on evidence. I think that broader than science, we in our country are experiencing an erosion in trust in so many of our organizations. And that is hard and difficult. Science is not perfect at all. And I'll get to what I think science needs to do in a minute. But I think that we have to have confidence in our scientific institutions. It's so important that work is done. And just to put ourselves in the shoes of someone trying to absorb information... If you're a pregnant woman in this country and you wanted to be pregnant, you are working so hard. Everybody in our society now tells you what you're supposed to do. Why are you drinking that cup of coffee? Should you really be doing this? You're working so hard to keep that baby alive. You need to know that you can trust what your doctor is telling you. It is a real challenging moment where people feel uncertain about what they're hearing and what they can trust. I think the scientific community, as we think about how to rebuild trust, has to continue to work on really explaining. I think so much of our life, not all of it, but much of it really comes down to making sure we're talking in ways that other people can understand, to making sure that people are aware. Like with COVID, with the rules changing, and just the frustration that came as a result of that, I think continuing to figure out how can we break things down so that they are practical for people.

Heather Howard  26:15

So one area in which you dealt with evolving science was the development of these new blockbuster weight loss drugs. Can you talk about how you how you navigated questions about whether insurance would cover them and whether there would be equitable access?

Chiquita Brooks-LaSure  26:38

The way Medicare has evolved is things have been added to it over time. So Medicare doesn't look the way that it did when it was originally passed by Congress. It was in 2003 when the Medicare program added drug benefits. And the reason why it took so long was because drugs weren't really that important to health care. When it was first passed, they became more important. 2003 was when Fen-Phen had just come off the market because of side effects, and so Congress wanted nothing to do with weight loss drugs. There was a rule put in the law that said you will not cover weight loss drugs. States, in Medicaid. could cover them by choice if they wanted. Now, this had been revisited during the AIDS pandemic, or, I don't know we call that, but when AIDS first hit the scene because people with AIDS had what was called wastings disease. And so Medicare started to pay for HIV, AIDS drugs just related to that. 

Science has changed over the last 20 years. Increasingly, a lot of our scientists came to say that obesity is a disease. It is causing all of these diseases, or all of these effects. And it itself -- not just diabetes, not just heart disease, but obesity is leading to disease, leading to problems. And so we proposed -- and this was in what we call regulations -- reinterpreting that weight loss provision and saying that obesity is a separate disease. We're distinguishing between weight loss and obesity. We proposed to cover the drugs. That was pulled back by this Administration, but I will say something that is not known, too, about the way that CMS makes decisions. It is not supposed to make decisions based on price. Our authority is to cover or not cover. It is not to set the price, except for these very specific instances where now the agency has authority to negotiate based on the specific law, but Medicare is yay or nay. It doesn't take into account the cost of a drug when it's deciding about coverage. And we felt in the previous Administration that it was time to treat anti-obesity drugs just like we do every other drug. 

Heather Howard  29:51

This is a super interesting example of policymaking. So the statute says Medicare cannot cover weight loss drugs. But that doesn't mean you can't cover medication to treat the disease of obesity, and somehow you found a way to do that. Did that actually go into effect?

Chiquita Brooks-LaSure  30:11

It did not. We put together a proposal, and then the way the federal government works, nine times out of 10, is you propose something and then you finalize it in a final rule. The Administration turned over, and that provision was not finalized, so that didn't go into effect. 

Heather Howard  30:30

So we're not able to study the impact of it, but we'll see, as there's more clamoring for the medication, we'll see what happens. Can you anticipate what you think is going to happen, given intense interest? 

Chiquita Brooks-LaSure  30:43

Well, there was a lot of interest in Congress passing legislation to require Medicare to cover anti-obesity medications. I think there's been the issue of the price tag. I would expect that, over time, the price will come down as we see more and more competition entering the market. States have choices about whether they cover anti-obesity medications, and states are making different choices, as are insurance companies, but we're also seeing drug companies that are providing it directly to people, which is interesting because it is disrupting how drugs are paid for in this country. And I think it's a really interesting model that the drug companies are saying, well, we can actually give it to you directly and this works out for us. And so we'll see. I don't know that we could see that for all the drugs that we all need, but it is actually very interesting what's happening in the market.

Heather Howard  31:55

So you're highlighting what some would call a feature, others a bug, of our health care system, which is federalism. And the variation across states. Let's talk about H.R.1, the federal budget reconciliation legislation that passed this summer. There are significant cuts to health care in that legislation, about a trillion dollars, right? I mean, it's going to play out across the country, and we're going to see states have to implement it and grapple with many new restrictions that are included in the federal law. What do you anticipate the impact being on our health care safety net?

Chiquita Brooks-LaSure 32:36

So I think a couple of things. I think that the law, this nearly trillion dollars in cuts, was really hard for people to understand. 

Heather Howard  32:52

Why? Just the law of large numbers?

Chiquita Brooks-LaSure  32:54

No, I sort of say it as death by 1,000 cuts. We had a really big debate on health care. In the previous Trump Administration, it was called "repeal and replace," and the implications were really, really clear to people. They could see what was going to be taken away, and what it was going to mean. This bill was way more challenging to understand. The way I would describe it is there were a lot of provisions that added red tape for people and made it more difficult for them to receive coverage. And that is true on the Medicaid side, and it was true on the ACA side, the Affordable Care Act coverage. For most of us who are covered by our employers, once a year you're if you want to change your health plan. No, you don't, then you should just be automatically enrolled. There were a whole series of changes that were made. Auto-enrollment was taken out for people. So during this open enrollment period it's going to be more challenging. But how do you explain that one of the provisions takes out auto-enrollment? 

There was a lot of discussion about fraud and abuse, and we're going to make sure people are really eligible. I don't agree, but say you agree that you should have certain kinds of requirements in place. The thing that I would say is, you add red tape, you add it for everybody, whether or not those people are eligible. So there are a whole series of provisions that fit into that category. 

Then there were a series of provisions that, really, at the end of the day, shifted cost to the states. So it said, we used to let you raise state dollars this way, and we're changing those rules. You could have a debate about state financing and whether or not we're doing it the right way. And I would say that is worthy of discussion. But the way it was set up, it's just going to cut states' ability to raise revenue. And at the end of the day, from a state perspective, implementing these changes, even though they're a couple years off, it happens really, really fast. So for a lot of states, they're rushing to figure out how to implement all of these things in a short period of time. And they know that they're going to have to make some hard choices... cut benefits, cut people, or lower provider rates. Separately, before H.R.1 passed, I would say that a lot of our providers were already on a knife's edge. A lot of my time as CMS administrator was spent hearing from rural hospitals and providers, states, governors, and members of Congress begging me to help with this hospital. And hospitals in a lot of communities, they're not just health care providers, which is incredibly important, but they're also the main employer. For those of us who live in more densely populated areas, it's hard to understand how some people in this country live. When I was CMS administrator, I was in Colorado and took this beautiful drive. We were going to drive to this rural hospital. And when we got to it, they said that one out of three days of the year, you cannot drive down that road. It's a major highway, and so your nearest hospital is way further away if you can't get through. There are parts of Alaska where you've got to get on a plane to get a mammogram. Who's going to get on a plane to get a mammogram? I mean, when somebody needs surgery, now they've got to pay for a week living in this major city. It is a very big deal, and that's how a lot of communities are operating. 

And so we were already there, and CMS did not have a ton of authority to help in these situations. But literally, a new road is created, and it's faster, and your payment as a hospital changes from the Medicare program, because now you're not 25 miles away from the nearest hospital. And so I say that we were already in a challenging place. COVID actually gave a bolus of money to a lot of hospitals, but that money ended. And so H.R.1 comes along, and estimates are that more than 300 rural hospitals were closed. We are already hearing across the country that hospitals are making changes, and some people have said, well these changes don't take effect for a couple of years. Well, if you know that you're already in the red, and that in a couple of years your funding is going to go down, what decisions are you going to make? They've heard from a hospital exec who said they stopped their planned expansion in Georgia. A labor and delivery wing was closed last week in Nebraska, in Virginia. I think we can expect to see more of that. A really sobering assessment.  

Heather Howard  38:58

On that note, we want to bring the audience into the conversation, and particularly want to hear from students, and hope you will come line up and ask questions. 

Student  39:07

Thank you for coming and giving your presentation to us today. I had two questions, and I'll try to make them quick. The first is what are the pros and cons that you see with the Trump RX program, the direct to consumer approach, and your thoughts on most favored nation pricing, making Pfizer invest in U.S. drug manufacturing, things like that? And the second is similar to the GLP1 discussion, and approving drugs for multiple comorbidities. What is the discussion around therapeutics that target aging? There was the TAME trial with metformin that aimed to delay the onset of multiple age-related diseases. What are some of the regulatory barriers there, and perhaps more relevant to CMS, what are the barriers to making drugs with multiple indications reimbursable?

Heather Howard  39:55

I'll summarize quickly for everybody to hear. So the first question is that the Trump administration announced a new initiative on drug pricing yesterday, Trump RX, and what do you think of that? And the second was about innovation in aging-related medication - something I have a great interest in, so I'm glad you've asked that! 

Chiquita Brooks-LaSure  40:15

Maybe I'll start with the second question. Many of you probably know this, but just in case, what happens in our country when new therapeutics come to market is first you've got to get approved by FDA. And then CMS only gets involved if there's something unique about it, if we're talking about a new class or something. At first, in the Medicare program, if it's a physician administered drug, or it's delivered in the hospital, CMS will look to see, should Medicare be covering it. And that is a different question than what FDA is looking to see. They're looking at whether it is safe and effective. CMS is looking at whether this drug needs to be covered for people who are over the age of 65, if it needs to be covered for the people who are enrolled in Medicare. So increasingly, what CMS cares about is, does the clinical trial speak to some of these perspectives? Now you're saying for the aging population, is CMS going to cover it? For many of these things, they're going to be covered because Medicare automatically covers things that are within certain classes. But the overall issue of pricing, I think, is one of the biggest issues for our country. 

So back to your first question about what I think of the announcement. I think our drug policy is so broken in this country, and it is really a problem. And it's not the fault of one single actor. I think there are a whole host of reasons why it is not working, but we are going to have to unpack this. We have many people who are in the process. Nobody truly understands, and the incentives are wrong. So you've got pharmacists, you've got PBMs, you have health plans, you have drug companies, and sometimes the government, all of which have some level of frustration about how this is working. And so what I think of the announcement is the idea that you're going to make an arrangement with just one company is not going to solve this fundamental issue that we have. It's really problematic. And it's problematic because of drugs that are on the market that people can't get access to. They can go overseas and get them at more reasonable rates. But it's not just that. It's what kinds of innovative drugs come to market. So if you're a company, do you invest in something when you know we're operating in a world where nobody can afford it? Are you, as a venture capital company, going to give money to this startup to do something? I talked to this CEO earlier this year who has what I'd consider something amazing, and he was talking about the challenges of getting VC funding, because who's going to pay $2 million for this thing, right? I'd rather pay pennies for something else. And so to me, it is a public policy good that we figure out our pricing. And I think it's possible. Even employers, the commercial market is getting frustrated enough with drug costs. I am a believer that you have to get to a tipping point before people will be willing to upset the status quo, and that's probably coming.

Heather Howard  44:40

And so maybe you could talk about where we go from here. What happens next?

Chiquita Brooks-LaSure  44:44

You know, I think for a lot of states, this is just a really difficult moment. It's true that sometimes when you're in a moment of crisis, you've got to keep the trains running. And so I think for a lot of states, they have to absorb a lot of things, and they're going to have to make some incredibly tough choices. That said, I truly believe that in times of crisis, there are opportunities. And it is sometimes in these difficult times that people are willing to do things differently, to try new things, or look for additional options. Whether it's in this next year, probably not, but I think that states will continue to have to look to other models, to look to other ideas, because some of these things actually can reduce costs. But you know, it may not be the state that comes up with the idea. It could be that it's outside entities, so nonprofit organizations and think tanks. In my mind, when you're the state and you're trying to make sure you do x, it doesn't mean that state innovation can't happen. But it may not come from you. It might be from outside experts. And I would encourage all of you who are thinking about public policy, it doesn't mean that you work for the government. That's not the only way to serve your country. There are many ways that you can work in the private sector and the nonprofit sector, at the state level, at local level, where the mayors in this country do a lot of the work, and there are many places to try to be mission driven and do good things.

Heather Howard  46:52

Well, you know, we've said many times throughout this discussion that these are challenging moments, but you're ending us on a note of optimism that the folks here, the students here, are the future. And I think you're hopeful that they'll engage in health policy and can really chart a different future, right? Anything you want to say in closing? 

Chiquita Brooks-LaSure  47:16

I'm always impressed by every generation. You guys are going to solve some of these major problems. I mean, you really are. Let's hope -- and not to put pressure on you. I really didn't think about this until we walked into this room, but I do think sitting here was when I started to be interested in health policy for the first time, when we had this big discussion where health care was a right. And I was sort of like, is it? This is a place to learn, to test your ideas, and learn new things. And I have great hope seeing all of you. 

Heather Howard  48:02

Please join me in thanking Administrator LaSure. Thank you. 

Heather Howard  48:05

Thank you for listening to the Princeton Pulse Podcast, a production of Princeton University's Center for Health and Wellbeing. The show was hosted by me, Professor Heather Howard, produced by Aimee Bronfeld, and edited by Alex Brownstein. We invite you to subscribe to the Princeton Pulse Podcast on Apple Podcasts, Spotify, or wherever you enjoy your podcasts.