Dr. John McDonough, Harvard School of Public Health

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I ’ m Margaret Flinter.

Mark Masselli: Oh Margaret , I ’ m just back from a momentous weekend for the
P resident's inauguration . I t was a great time . P eople were respectful and
excited about the launching of the second term in office.

Margaret Flinter: Well with so much divisiveness and contention in Washington
over these past few years , it was really wonderful to take a moment to be
reminded of what binds us together and seeing that unfold this week I think
everybody had a common feeling of great pride and being a n America n we can
agree, we can argue , we can disagree but the constitution provides the
framework for moving forward. And as one of the co mmentator said notice there
are no tanks in the street, this is the America n way of changing the
administration.

Mark Masselli: And speaking on another American icon it was also Dr. Martin
Luther King Junior’s birthday and I was reminded of my favorite q uote from the
civil rights reader, “of all the forms of inequality, injustice in healthcare is the most
shocking and inhumane . ” I think the P resident's taking a big step towards
remediating that problem.

Margaret Flinter: Well that's the quote that driv es so much of the work that we do
and that so many do in this country . A nd I think it really speaks volumes to the
P resident's commitment not just the healthcare reform but to the eliminating of
the economic disparities between people and the guarantee th at every child has
the chance of same opportunities.

Mark Masselli: You are absolutely right . A nd the P resident reminded us several
times in his speech that , we , the people cannot let our most vulnerable citizens
suffer in their time of need. I think i t also draws a little battle line of the newly
conveying congress which begins to tackle the issues around the debt ceiling
over the next few weeks.

Margaret Flinter: The P resident ha s pledged to protect the nations most
vulnerable. We know that there a re going to be some real pushes and some
pressures for compromises in our entitlement programs like medicare and
Medicaid. And you know I can ’t help it wonder around other things like loans for
higher education and things that really make a difference .

M ark Masselli: But hopefully they will work out their differences. I do sense a
more sober mood in Washington then there was four years ago , but there was
some important work that lies ahead , The Affordable Care Act goes into full effect

at the end of thi s year and that's going to require cooperation and leadership
from both sides.

Margaret Flinter: And of course , well I do think aspects of the Affordable Care
Act will continue to morph into existence in some ways. We have not yet
predicted so we will c ontinue to use Conversations on Healthcare to educate
you, our audience , and inform you about all the many new ones the aspects of
this big piece of legislation.

Mark Masselli: And speaking of informing and educating our guest today is one
of the thought leaders in development of Affordable Care Act and its
predecessor, the Massachusetts health reform law.

Margaret Flinter: Dr. John McDonough was on the ground floor of the creation of
both pieces of legislation. He’s the D irector of the C enter for P ubl ic H ealth
L eadership at the H arv ard S chool of P ublic H ealth and he’ll share his insights
both on the Affordable Care Act and its strengths and maybe on some of the
weaknesses or things he would like to see different.

Mark Masselli: And we’ll get another update from FactCheck.org’s Managing
Editor, Lori Robertson, always on the hunt for mysteries spoken in the public
domain.

Margaret Flinter: And no matter what the topic , you can hear all of our shows by
G oogling C HC R adio and as always if you have comme nts please e - mail us at
www.chcradio.com or find us on Facebook or Twitter because we love hearing
from you .

Mark Masselli: Now, we wi ll get to our interviews with John McDonough in just a
moment but first here’s o ur producer, Marianne O'Hare with this week’s Headline
News.

(Music)

Marianne O'Hare: I am Marianne O'Hare with this H eadlines News . And
perhaps the most liberal speech of his presidency, President Obama’s inaugural
addressed focused on the need to mak e healthcare more affordable but and
those who rely on social programs for healthcare should not be penalize d in the
process. Calling for quote, hard choice s that have to be made and reduce the
cost of health care as well as the size of the deficit. Also saying the
commitments we make to each other through medicare, Medicaid and social
security, these things do not st e p or initiative , they strengthen us, that's h is quote.
Response from the GOP we got to be ready to meet to look at all programs
including those socials ones mentioned as a place to look for spending cuts as
the deficit reductions conversation resumes.

It's been 4 years since the passage of Roe v. Wade, the 1973 Supreme Court
decision legalizing the right to an abortion. In a recent Wall St reet J ournal NBC
poll , 70% of those pol l felt the law should be upheld. That's the highest number
in support of the measures since polls have been taken on the matter.

Flu season continues its strong hold o n the nation with significant outbreaks in at
le ast 48 S tates. Statistic show the numbers of infections are not slowing down.
So what to do when vaccines run short ? T he traditional method for producing flu
vaccine takes up to nine months with unpredictable results. There’s a potent
new virus factor waiting in the wings and plentiful supply. The Food & Drug
Administration just approved a flu vaccine made by cells taken from the Fall
Armyworm , an agricultural pest. The cells produce copies of a piece of the flu
and it takes about three weeks for the vaccine to be created. I ’ m Marianne
O'Hare with this Headline News .

(Music)

Margaret Flinter: We’re speaking today with Dr. John McDonough, Director of
the Center for Public Health L eadership at the Harvard School of Pub l ic Health
where he is also prof essor. He served as a Senior Advisor on the National
Health Reform to the United States Senate helping to craft the Affordable Care
Act. Before that Dr . McDonough was the executive director of healthcare for all
of Massachusetts where he played a key rol e in the passage and implementation
of the 2006, Massachusetts Health Reform Law. He’s author of three book s ,
including Inside National Health Reform published in 2011. Dr. McDonough,
welcome to Conversations on Healthcare.

Dr. John McDonough: Thank yo u , n ice to be here with you.

Mark Masselli: John , now , you are one of the chief architects of both the
healthcare law in Massachusetts as well as the Affordable Care Act. The later
you described as having to survive it ’ s third near to death experience w ith the
reelection of President Obama. Its future seems secure yet murky in some
respects as opponents continue to mount new challenges and various states are
responding differently to certain aspects of the health law. And in the year 2011
book, I nside N ational H ealth R eform you see that there would have been a much
better way to craft the healthcare law but that it was the best that could have
been achieved given the political realities, what would have made it more
meaningful and what were some major o bstacles?

Dr. John McDonough: Well it's the first comprehensive health reform law that's
ever been passed in the history of United States. It includes coverage, reform of
the delivery system, so many other key elements that touch and address nearly
ever y part of the system. And at the same time if you talk to the experts and the
people who know each of those parts of the system best, everyone of them can
point out a dozen ways that the law could have been stronger in the coverage

and access part , the su bsides for people purchasing health insurance could have
been more robust and provided greater income protection.

The reform o f medical care and the delivery system could have been so much
stronger in terms of compelling the system to reform prevention an d public health
could have been stronger workforce reform, it could have been much more
robust so whatever aspect you pick the people who understand those systems
are very aware of how it could have been stronger. And at the same time given
the political realities in 2009 and 2010 , I believe it's quite clear that there wasn’t a
stronger law that could have gotten through the House of Representatives and
the Senate and gotten to the President’s desk. It was probably the best that we
were able to get and ev en that was such a brief window of time. There was only
about seven months when they were 60 D emocratic votes in the Senate which
were essential to the final passage of the law.

Margaret Flinter: Well Dr. McDonough, you think we could probably summarize
the rest of it and many of us felt as it was working its way through the system,
don't let the perfect be the enemy of the good. You’ve also used the word ironies
to describe much of the Affordable Care Act and you’ve said that it's fraught with
ironies. Tell us what you mean by that.

Dr. John McDonough: Well , there are innumerable ironies but I’ll -- let me just
mention two. So D emocrats very much preferred in terms of the new insurance
mechanism that are called H ealth I nsurance E xchanges. Democrats mostly
wanted to have a single F ederal E xchange and some of them were moderate
conservative voices and the S enate said no, no, no we have to give the States
the right to do this and only have the F ederal G overnment step in when the
States refuse to act be cause every State s going to want to come in and do this.
And since the law passed what we’ve seen has been significant resistance to
setting up these exchanges by the conservative and moderate , mostly
R epublican G overnors who the law was set up to try to appeal to deliberately.

So ironically D emocrats who wanted a F ederal E xchange and conceded to have
state exchanges will probably end up with a robust F ederal E xchange because of
the conservative R epublican G overnors who were saying no we refuse to set up
our own state exchange (9:18 inaudible ) . We’re going to see big federal
presence in this in spite of what the law had envisioned. A second irony is that in
some ways the law is a massive transfer of wealth within the United States . It’s a
transfer from higher income, higher insurance coverage states like
Massachusetts, New York where the rate of uninsurance is low to many Sun
Belt, Red S tates where levels of uninsurance are extraordinarily high. So for
example in Texas , about one out of three adults in Texas ha s no health
insurance. The law , the ACA was designed to send massive amounts of
insurance coverage subsidies to these Southern Red States and the governors
of these states are now saying we don't want that money.

Mark Masselli: John , let's take a look at the strongest aspects of the healthcare
law and things that you saw implemented in Massachusetts that are working
there and -- working well by most accounts. So let's talk about the pillars of the
Affordable Care Act that stand poise to do what the law was intended to do to
help the nation achieve the triple aim of access to care and improved quality of
care and better outcomes.

Dr. John McDonough: The first pillar is improving coverage if the law is
implemented as designed beginning in 2014 we should see a massive reduction
in the percent of people in the United States who don't have health insurance and
i f the law is fully implemented as it was intended we should get that rate of
coverage up to between 94 and 95%. T he Supreme Court decision m ade the
medicaid expansions in the law an option for states. I am hopeful that at the end
of the day most states will in fact embrace and implement those medicaid
expansions. The second major piece is reforming the quality efficiency and
effectiveness of medical care. The ACA includes many mechanism s which we
can already see are having a significant effect in transforming the processes of
care and the attention of the medical system to being really focussed on
improving the patient experience and improvi ng the efficiency and effectiveness
in quality of medical care. The third major piece is prevention and well ness in
public health . A nd at the same time we’re seeing some significant steps forward
including the first ever in the history of the nation, Nat ional Prevention Strategy to
really move it the way from a healthcare system that focusses only on taking care
of people after they get sick and instead focussing on keeping people healthy
and preventing them from getting sick in the first place.

Margaret Flinter: Well John , I ’ m going to give you an opportunity because I don't
think it's been talked about enough to talk about that national preventive strategy.

Dr. John McDonough: So part of the Affordable Care Act is the direction to the
United States S urgeon G eneral to form a N ational P revention C ouncil and their
first major task s was to develop a national prevention strategy for the nation and
t hey did that. And what's interesting is not just the product itself but how it was
created because sitting a round the table with the Surgeon General to create the
strategy was not just the department of health and human services but also the
federal cabinet departments of education, housing and urban development,
transportation, homeland security, defense, 16 fe deral agents in agency and
developed a blueprint not just for the Obama Administration but also for
C ongress also for States. So a really robust path to focus on how to keep the
American public healthy, it's an embracing of a strategy that sometime is ref erred
to as Health in A ll P olicies where we figure out smart and creative cost effective
ways to building health prevention strategies , so a green and healthy homes
approach says when we weatherise a home , let's also get rid of the things inside
the home e nvironment that make people sick and then have a significant amount
of avoidable medical expenses down the line. I encourage people to take a look
at the national prevention strategy.

Mark Masselli: We’re speaking today with Dr. McDonough, Director of t he
Center for Public Health Leadership at the Harvard School of Public Health. Dr.
McDonough’s served as a Senior Advisor on National Health Reform. He’s
author of three books including Inside National Health Reform published in 2011.
John your book has been allotted be numerous reviews as the definit ive analysis,
not just of the Affordable Care Act itself but of the merit political and cultural
actions that brought us to this point in history. You know we had David Gergen
on the show recently and he wa s lamenting that fact that we weren't able to pass
this act with any R epublican support . Tell me where do you see the opportunity
now that it starts to move out to the states where we might see some of these
Red States if you will , s tand up and start to e mbrace this so that this can be a bill
of national consensus.

Dr. John McDonough: The Affordable Care Act was designed on the assumption
that the only way that it could pass would be on a bipartisan basis . A nd for a
long period of time starting in 2007, 2008, there were a number of R epublicans
who were very clearly working very hard to get to a place where it would be
bipartisan . A nd in the intense political environment of 2009 with the im mergence
of the T ea P arty, it became politically dangerous. The person who exemplifies
this contradiction as much as anyone was Senator Chuck Grassley who was the
M inority L eader on the Senate F inance C ommittee and Senator Grassley was
quoted in June of ’09 and saying , “L isten , we’ve all got to be grown ups and
underst and there’s no way to get help reform done , unless we have some kind of
an individual mandate as a part of it. ” That was in June of ’09. In September of
’09 he was on Fox News again and he said the reason he opposed health reform
was because of the indiv idual mandate . A nd what happened in between June
and S ept ember was the famous T ea P arty , T own M eeting then really I think put a
major scare into many of the R epub li cans who were looking to be supportive and
I have a lot of respect for Senator Grassley . B u t I think you know his response
really reflects the intensely partisan and difficult political environment that existed
in 2009 over this law that ultimately mad e it impossible for it to be bipartisan.

Margaret Flinter: One of the issues that certainly h as moved mode of front and
center as some of the politics have been resolved is the issue of cost
containment in the delivery system. Tell us about where you see the most
meaningful cost containment results in Massachusetts and how they might
provide some in putting a framework for containing cost nationally as we go
forward.

Dr. John McDonough: After the Health Reform Law otherwise known as
RomneyCare passed in 2006. There was an immediate shift to conversing about
what can we do to provide greater eff iciency, effectiveness on lowered cost and
there have been a series of initiatives and lies that have been approved by the
legislature and the law that was passed this past July signed by Governor Patrick
in August is probably the most ambitious.

Mark Mas selli: John , let's talk a little bit about the recent talk that you gave at
Harvard School of Public Health that might be coming through the use of
technology. So help our listeners understand why these aspects of the health
reform law are going to be th e fundamental change agents in redesigning the
healthcare system.

Dr. John McDonough: Having effective and useful data and analysis of that data
on the performance of medical care and the medical care system is essential in
terms of moving forward in the directions that we want or if we don't have the
numbers to measure and understand what's most important , then we’re just
going to be stuck in neutral and we’re nor going to move forward. So creating a
robust health information technology system , focusing on comparative
effectiveness research through the Patient - Centered Outcomes Research
Institute so that we have the mechanism to provide physicians , hospitals , and
other folks in the healthcare delivery system with reliable and useful information
about wha t works and what doesn't work. There were other things as well that
are particularly important.

I’ll just mention just one example , beginning this fall hospitals that participate in
the medicare program which is just about every hospital in United States are no w
facing today signif ic a nt in growing financial penalties if they have rates of
medicare patient readmissions within 30 days that are excessively high and if
they have excessively high rates of hospital acquired infections. So we are
actually seein g embedded in the ACA the beginnings of the movement away
from a trend over the past decade called Paying for Performance . And we are
instead moving to a new platform that some people refer to as Paying for
Outcomes , a nd there’s significant work going on all around the country right now
in a very, very positive way to get control of those measures so that hospitals
don't face these new penalties.

Margaret Flinter: We’ve bene speaking today with Dr. John McDonough,
Director of the Center for Public Health Leadership at the Harvard School of
Public Health and co - architect of the health reform law in Massachusetts as well
as the Affordable Care Act. You can learn more about his work in health reform
by G oogling I nside N ational H ealth R eform or by going to h sph.edu. John , thank
you so much for joining us today on Conversations on Healthcare.

Dr. John McDonough: Thank you.

(Music)

Mark Masselli: At Conversation on Healthcare, we want our audience to be truly
in the know when it comes to the facts about h ealth care reform and policy . Lori
Robertson is an award - winning journalist and m anaging e ditor of FactCheck.org,

a nonpartisan, nonprofit consumer advocate for voters that aim to reduce the
level of deception in US politics. Lori , what have you got for us this week?

Lori Robertson : Well Mark and Margaret , we’ve received emails from readers
asking if the Affordable Care Act requires doctors to ask patients whether they
own a gun and recently a R epresentative John Fleming, he’s a family doctor as
well cl aimed that President Obama was pushing doctors to ask i f patients had
guns in their homes but neither of those claims was true. The Affordable Care
Act doesn't require doctors to ask about guns instead it includes language
designed to protect the rights o f gun owners. The law says that wellness
programs can't require that information about gun ownership or possession be
disclosed or collected , and it says that the Department of Health and Human
Services can't collect data on gun use and insurance companie s can't raise
premiums if somebody owns a fire arm.

So the law doesn't requires physicians to ask about guns about it doesn't prohibit
it either and some health professionals were concerned that doctors might avoid
the topic altogether. Obama recently an nounced 23 executive actions he would
take related to guns and one was to quote “ clarify that the Affordable Care Act
does not prohibit doctors asking their patients about guns in their homes ” . It's a
safety concern that's helped professionals report thre ats of violence to
authorities. And that’s my FactCheck for this week. I a m Lori Robertson,
Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players and is a project o f the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact, that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org’s Lori
Robertson check it out for yo u here on Conversations on Health Care.

(Music)

Margaret Flinter: Each week , C onversations highlight a bright idea about how to
make wellness a part of our communities and everyday lives. In one of the most
popular TED T alks of all time, g ame developer Dr. Jane McGonigal made a
pretty bold prediction.

Jane McGonigal : If we want to solve problems like hunger, poverty, climate
change, global conflict obesity, I believe that we need to aspire to play games
online for at least 21 billion hours a week by the end of the next decade.

Margaret Flinter: McGonigal is a thought leader in the growing trend of the
gamification of improving health and social well - being through interactive video
games. But she didn’t realize that her prediction would come home to roost on
her own doorstep after suffer ing a severe concussion in 2009. She has come to

the classic symptoms of traumatic brain injury, chronic headaches, fog ,
depression, even suicidal ideation.

Jane McGonigal : Suicidal ideation is quite common with tr aumatic brain injuries.
It happens to one and three and it happened to me. My brain started telling me ,
“ Jane , you want to die ? ” It said you are never going to get better and these
voices became so persistent and so persuasive that I started to legitima tely fear
for my life.

Margaret Flinter: So she created the game SuperBetter . McGonigal ’s research
shows that when people engage in gaming they are more likely to reach out for
help to empower themselves through their game Avatar and to use the Avatar t o
slay the symptoms they are battling. So McGonigal ’s Avatar became Jane the
Concussion Slayer.

Jane McGonigal : Now the game was that simple. Adapt a secret identity, recruit
your allies, battle the bad guys, activate the power u ps . But even with the game
so simple within just a couple days of staring to play that fog of depression and
anxiety went away , it’s just vanished. It felt like a miracle.

Margaret Flinter: Within a year the other symptoms , the headache and the fog
dissipated and went away. She decided to p ut the game online for anyone to
access and the feedback totally unexpected.

Jane McGonigal : Not everybody has a concussion obviously , so I rename the
game SuperBetter and soon I started hearing from people all over the world who
were ad apting their own secret identity, recruiting their own allies and they were
getting s uper b etter that facing challenges like cancer and chronic pain,
depression and Crohn's disease .

Mark Masselli: Now McGonigal is working with US military to assist the h undreds
of thousands of GI ’ s dealing with traumatic brain injury and PTSD . She says that
the game revealed a phenomena that scientist called posttraumatic growth, the
game just seems to get people to that place more quickly. SuperBetter, a simple
online game that allows players grappling with all kinds of conditions to battle
their symptoms in order to better manage and hopefully defeat their condition,
now that's a bright idea.

(Music)

Margaret Flinter: This is Conversation on Health Care. I am Marga ret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Health Care, broadcast from the campus of WESU at
Wesleyan University, streaming live at www.wesufm.org and brought to you by
t he Community Health Center .