U.S. Rep. Ami Bera has spent most of his career as one of the Capital Region’s leading voices on health care, first as a doctor and later as Sacramento County’s chief medical officer and a dean of admissions for the UC Davis medical school. But since being elected to Congress in 2010 to represent the 7th Congressional District, which includes Folsom, Elk Grove, Rancho Cordova and Fair Oaks, Bera’s focus has broadened considerably. Catching him on this coast can be tricky these days, but in July we were able to sit down with him in his Rancho Cordova offices to talk about the Affordable Care Act, immigration and a host of other hot topics.
Comstock’s: This conversation will appear in print in
October, the same month we’ll be registering Californians for the
health benefits exchange, Covered California. You’ve had your
issues with the Affordable Care Act over the past couple years.
Where are you with where the law is now?
Bera: I’ve pretty consistently said that I would have started approaching health care reform in a different manner. There are two major issues when it comes to health care. One is the cost. Individuals, small business and large employers are paying more and more every year, and their benefits get to be less and less. And then there’s the access issue: 30 million to maybe 50 million Americans with inadequate or no health insurance. You’ve got to address both issues, but the president chose to address the access issue without fundamentally changing the cost structure. My worry there has always been that if you bring these folks into a system where costs are constantly going up, you just accelerate that. But now we’re seeing something slightly different. It could be the recession or it could be that there’s a tipping point where costs can’t go up that much, but we’ve seen a deceleration in the cost increases. But since we’re still bringing all these folks in, we’ve got to address the cost issue. That’s where I think the focus should be.
Comstock’s: What are some realistic ways that can be
Bera: There are a couple of ways. There’s a cost to everyone who has health insurance for the number of folks without it. It’s just like auto insurance. It’s built into the cost of your policy, and some academics say it is anywhere from $1,000 to $1,500 dollars per policy, which is not insignificant. So just by bringing folks into the system, there will be a marginal cost drop. But real cost savings in health care come from preventing disease or from diagnosing and managing disease at an earlier stage. So it makes much more sense to prevent a heart attack than it does to wait until the person has a heart attack, shows up in the emergency room and the system kicks in. One reason why we spend more on health care than any other nation on this planet is because so much of our health care costs come on the back end. If we shift it to the front end, we can start to lower costs. Talking specifically about the health insurance exchange, we know the sicker, more chronically ill and older patients are going to come into the exchange. I think most of us agree on that. The challenge for Covered California and for exchanges across the country will be whether they can get young, healthy folks to engage. Because this really is an insurance pool that needs young, healthy lives offsetting the costs of the older, sicker lives. That’s the big issue we’ll all be watching.
Comstock’s: California was the first state to say it
would have an exchange, and we are also expanding our Medicaid
rolls. Several states have followed suit, but quite a few have
not. Is it even possible that this is going to work out the way
that the president and the administration originally hoped
Bera: California has been very proactive, and other states have not. I think part of our job in Congress is to look at these two models as they get implemented. If health care costs are coming down in California, if we’ve got a vibrant marketplace in the exchange the way we think we will, then you’ll be able to say to the residents of Texas, for example, “If your state is willing to work with us, we can start to control health care costs.” There’s a lot of opinion on the Affordable Care Act, but the Supreme Court has already ruled. It is law now, so let’s move this forward. Let’s identify what’s working and then let’s start to share those lessons of what’s working throughout the country. Let’s also identify what’s not working and then go back and re-jigger the system and fix those things.
Comstock’s: The president recently decided to delay
by a year the requirement that large employers provide health
insurance or potentially face fines if they have employees that
are going through the exchanges. Opponents see that as proof that
the whole system is in chaos. What do you think of the
Bera: I think it’s a symptom of the complexity of this situation. I’ve talked to a lot of small–and large–business owners and their biggest fear right now is uncertainty because, as we sit here in [July 2013], Covered California is still writing a lot of the rules and trying to get the systems in place. There are a lot of questions that remain unanswered. We’re still in a tenuous recovery. I think it’s very reasonable to say, ‘Let’s hold things off for a year, get rid of that uncertainty.’ A year from now, we’ll have a year’s worth of experience with the exchanges and a much more robust Affordable Care Act. At that junction, hopefully the economy has recovered and is stronger and it makes more sense. Right now, our main focus should be on our economic recovery and continuing to move the economy forward.
Comstock’s: Beyond health care reform, another source
of uncertainty in recent years has been partisan dysfunction in
Congress, particularly in the House. You’re very new there, but
you’re part of a group of colleagues trying to work together to
break some of these log jams. How is that effort going, and how
is that helpful in moving the economy forward?
Bera: There are a large number of new members elected in my freshman class — 50 Democrats and 35 Republicans — who understand we were elected because the public wants to see us work together and find common ground. We entered the institution with that goal in mind. One of the first organizations I joined when I got there was a group called the Problem Solvers, which is under the umbrella of nolabels.org (a bipartisan citizens movement). It started with 23 Democrats and 17 Republicans coming together and agreeing that we have to have a commitment to working together, to getting to know each other and to trusting one another. The first major piece of legislation that I cosponsored was a “no budget, no pay” act. The Republican leadership introduced its own version the following week, which was slightly different, but it passed the House, passed the Senate and was signed into law. Now, that may be symbolic, but at my core I believe that we have to come up with a budget. If Congress does nothing else, the public should demand that Congress and the president have a budget that lays out our priorities. You never run a business without having a budget and laying out how you’re going to use resources. The whole idea behind the Problem Solvers is, if the leadership’s not going to do it, then change has to come from the grassroots members. I represent a group of individuals just like [House Speaker] John Boehner does. So I’ve got to be a voice for the 700,000 or so Sacramentans that I represent. If it’s not going to change at the top, we’re going to push it from the bottom.
Comstock’s: How can you do that? How does change come
from the bottom in Congress?
Bera: Well, the Problem Solvers group is now up to 77 members. We started with 40, and pretty evenly split, with a few more Democrats than Republicans. We think we have to get to about 100 members. We’re also now working on legislation together, not groundbreaking bills but pieces of legislation that we think could make government more efficient. And it’s building trust. It’s getting back into this mindset that we should be working together. For example, we introduced a bill on the doctor shortage with Republican Mark Meadows from North Carolina, who represents a rural area. The bill allows physicians that have done their residency here on a J1 immigration visa to stay here as long as they’re going to go into practice in these underserved communities. Based on my experience as the dean of admission at the UC Davis medical school, I know we have serious needs for rural health care providers. So we’ve got to address the doctor shortage. I look at this from the perspective of a physician. And that’s another area of health care reform — do we have enough doctors?
Comstock’s: Yes, that is a huge concern with the ACA,
even among its biggest supporters. We’re going to put millions of
people into the system at a time when we already have a massive
doctor shortage, and there’s not a lot in the bill that addresses
Bera: There’s not. The practice of medicine is going to change, which brings in the scope–of–practice question. I think we’re going to have to be practicing in a team-based approach. We should put patient safety as our foremost issue. But it might be the physician working with the nurse practitioner, working with the pharmacist, working with an optometrist, managing a team of patients. Because there’s no way we’re going to quickly train the number of physicians necessary. But there are all these areas where folks probably could practice at a slightly higher scope. Two decades ago, you’d go to your doctor to get your flu shot. Today, you’re probably getting it at a Walgreens. So there are safe ways for us to do this.
Comstock’s: But haven’t scope–of–practice turf wars
been going on long before the ACA ever came around?
Bera: Sure. There’s a turf war going on in the state of California between the optometrists and the ophthalmologists right now. I hear about it all the time. What I would say is, we don’t want an optometrist to go out there and hang up their shingle and present themselves as ophthalmologists. But what we certainly could do is have optometrists and ophthalmologists practicing in conjunction, managing a bigger population of patients. They just have to be able to figure out what that is, because there’s no way for us to care for everyone who is going to be coming into the health care system, to just hold on to one patient/one doctor. It’s not going to work. And there’s a lot that optometrists could do. But certainly we want them to practice within the scope of their training.
Comstock’s: Let’s shift gears a bit. You’re a
first–generation immigrant. Immigration is always one of the
nation’s hottest hot-button issues. The Senate has passed a
comprehensive immigration reform bill, but the House has not. A
lot of folks are speculating that with the demographic changes
the nation is experiencing, this could be a defining moment,
certainly for the Republicans but maybe for both parties. What
are your thoughts on our efforts at immigration reform as they
Bera: I think this is certainly a defining moment for Speaker Boehner and what he wants his legacy to be. The question to him is, do you want to see an immigration bill move forward, and are you going to be in charge and guide this process, or are you going to let the most conservative elements of your caucus guide this process? That’s a question he has to answer. I would hope that he rises to the occasion and says, “The public wants to see Congress work. Even if it means my speakership, let’s bring something to the floor to vote on.”
Comstock’s: What happens if this bill dies
Bera: I think the public throws their hands up and suggests that there needs to be a change in Washington. I would say the problem of dysfunction lies at the leadership level.
Comstock’s: Let’s talk about a couple things here
locally. Are we going to get a Water Resources Development Act
Bera: So we can actually take care of our land?
Comstock’s: Yes, and so we can finish all the
critical flood control issues that are of great importance to
Bera: I’ve stopped trying to make promises or predict what the House of Representatives is going to do. I think the ranking transportation and infrastructure chairman, Ray Hall from West Virginia, wants to see something moved forward. I’ve talked to some of my Republican colleagues along the Mississippi River, Congressman Rodney Davis (Illinois) being one who has a district that also faces flooding issues and wants to see something move. So we’ve looked at ways that we could support one another. Again, the bottom line is the leadership. Will they bring something to the floor? If they brought a Water Resources Development Bill bill to the floor, we would pass it. I have also co-sponsored a bill, the Partnership to Build America, which would fund an infrastructure bank, which could be another mechanism to potentially fund work on “chief-approved” projects like our levees. We’ve got around $1.7 trillion of corporate profits sitting overseas, so the question is, how can we incent those corporation to bring those dollars over in a smart way and at the same time fund an infrastructure bank?
Comstock’s: Let me stay on a local thing — the Bay
Delta Conservation Plan. The governor is still strongly behind
the plan and the building of these large tunnels in the Delta to
convey water north to south. There is, however, strong opposition
in Congress. What’s your sense of the chances for this bill
Bera: The governor is pretty firmly committed to moving forward. We’re pushing back. This is a $24 billion project, maybe even more. We can’t solve water just for today; we have to make sure we’re solving it for the next generation as well. My perspective is, let’s make sure we’ve come up with the right solution. Let’s be sure we looked at all the alternatives. I’m not saying we don’t have to address water conveyance. We really do. Agriculture is incredibly important to California’s economy. With global warming, water is increasingly becoming a more precious commodity. We’re losing our biggest reservoir in the snowcap. So we’re going to have to figure out how to capture and move water, but let’s do it in a way that solves this for the next 30 or 40 years. That’s probably the multipronged approach, not just diving headfirst into building these tunnels.
Comstock’s: You’ve been very vocal in your belief
that Sacramento needs to diversify its economy. How would you
like to see the Sacramento economy grow and diversify in the next
10 to 15 years?
Bera: A couple of areas. Certainly there is the renewable energy conversation that’s already taking place, and we also have a robust conversation taking place in the medical space in terms of bringing some venture dollars and creating some innovation labs. But our competitive advantage really is in the agricultural space. We have the top agricultural school in the world, UC Davis, and we sit at the heart of one of the richest agricultural regions in the world and we’re on the Pacific Coast. All we have to do is look across the ocean and see China and India and 2 billion potential consumers. They’re going to increasingly struggle with how to feed their population, so there’s huge market opportunities. I’d love to see Sacramento become the Silicon Valley of the agricultural sector, and those conversations are taking place. I think UC Davis Chancellor Linda Katehi recognizes the unique opportunity there. I think folks in the private sector do as well. So, as a United States Congressman, what can I do to advance those goals? I happen to be the only Indian American in Congress. I recognize everything I do here in the United States is amplified in India, so there’s real interest in how I’m moving forward. I’ll be going to India later this summer, mostly to look at those business opportunities, and part of my goal is to go out there and talk about the unique opportunities in the Sacramento region and try to bring some of that investment here.
Comstock’s: It is interesting that with Vivek
Ranadive buying the Kings, so much of our thoughts have turned to
India. I don’t know if that’s something we’ve thought a lot about
in this region in the past.
Bera: It is part of the next economy blueprint, which talks about creating these export markets. I think it’s a natural progression. I wouldn’t have guessed the Kings would have played into this conversation, but as we were watching it, I do think the whole sale turned on David Stern’s desire to open up the Indian marketplace. He’s about as shrewd a businessman as there is, so that certainly plays into that. It’s interesting that the only Indian American congressman happens to be a former season ticket holder for the Kings. The mayor and I have certainly talked about it.
Hospitals, law firms and state agencies involved in implementing the Affordable Care Act have seen a sizable bump in workload — and in some cases, staff sizes — as they prepare for the major overhaul mandated by the 2010 law and to adjust to other industry changes.
Think of your best friend, a friend that knows all your ticks, hobbies and vices. Now imagine this friend happens to be a doctor, and she’s your doctor.