Jonathan Gruber, PhD, MIT Economist

[Music]

Mark Masse ll i: This is Conversations o n Healthcare . I am Mark Masselli.

Margaret Flinter: And I am Marg a ret Flin ter .

Mark Masselli: Well Marg a ret , here we are in the dark days of summer.
Congress is off on their summer recess. It is also t ime that campaigns kicking to
high gear leading up to the mid - term elections.

Margaret Flinter: Well, it's kind of hard to imagine what platform some members
of Congress are campaigning on Mark. It’s been deemed by the (inaudible 0:24 )
Trust as the leas t productive Congress since 1948.

Mark Masselli: T rue to fore, Margaret. Instead of passing immigration legislation
or any other essential legislation, the h ouse only managed to agree on one thing
besides increasing funds to help the overall of the Vete rans Health
Administration and that is to sue the President for delaying small business
mandate in the healthcare law for one year.

Margaret Flinter: According to a number of political strategists, the Affordable
Care Act is kind of seizing to be the hot bud an issue for the American people
that it was in 2010. I think frankly it’s just working for so many millions of
Americans already, t he efforts to undermine a law could in fact backfire on those
who try to use opposition to the law as leveraging their campaigns.

Mark Masselli: But the law is running the gone let of the number of legal
challenges , Margaret , including a recent lower court ruling issued diametrically
opposed decisions on the legality of the tax structure to underwrite purchases of
healt h insurance on the exchange. It's a measure that will likely put the
healthcare law right back in front of the Supreme Court. The issue is something
our guest today knows quite intimately.

Margaret Flinter: Health Economist and MIT Professor Jonathan G ruber have
been analyzing health policy and modeling health performs strategies for
decades. He was the key architect of the Affordable Care Act. He has got some
unique insights into these recent court rulings , and he has a long view on where
he things h ealth r eform is headed into the future.

Mark Masselli: As we look at some of these congressional actions and court
rulings, it’s important to go back to understand the original intent of the law which
is to make health insurance accessible and affordable for all Americans and to
strive for what near universal coverage can mean for the nation’s health and
that’s improved population health overtime.

Margaret Flinter: And Lori Rober ts on checks in as she does every week. She is
the Managing Editor of FactC heck.org and always on the hunt for misstatements
spoken about health reform in the public domain.

Mark Masselli: Well no matter what the topic, you can hear all of our shows by
going to chcradio.com and if you have comments, please e - mail us a t
[email protected] or find us on Facebook or Twitter because we would love
hearing from you.
Margaret Flinter: We will get to our interview with Jonathan Gruber in just a
moment.
Mark Masselli: But first , here is our pr oducer , Maria n n e O’ Hare , with this week ’ s
Headlines News.
[Music] Maria n n e O’ Hare : I am Maria n n e O’ Hare with the se Healthcare Headlines. The
march of the Ebola Epidemic has brought awareness to the crisis closer to our backyard. Two Americans working in Sierra Leone and other areas where the epidemic has spread had been doing extremely poorly after contracting the disease until they were given an experimental drug and showed almost immediate dramatic improvement from the deadly virus already which has been Sub - S aharan Africa health workers on the ground are having an extremely
difficult time with containment of the illness because incubation is generally a week to ten days and health officials are not able to keep family members and communities adequate ly isolated. The experimental drug made from a tobacco
derivative hasn’t been tested for efficacy in humans until now. Health insurance
and the Affordable Care Act - Florida is one of the states that shows not to
expand Medica id Coverage for more of its uninsured population living near the
poverty line, about a million still uninsured in the Sunshine State, neither did the State set up a state based insurance exchange which would have facilitated state residents seeking insurance plans online under the Af fordable Care Act.
Proposed i nsurance r ates are coming up for 2015 for Floridians seeking to
purchase insurance on the open individual market and rates are predicted to go up, more that 13% next year while Floridians who purchased coverage through the Fed eral e xchange not only qualified for subsidies, their insurance rates aren’t
expected to increase more than three percent in the same year. In a world of
rising obesity, is it this loss or the gluttons leading to that increase. According to a recent find ing in the Global Burden of Disease, America leads the world in obesity rates with about 50% of the population either overweight or obese , but
are we fatter because we are eating more or because we are more sedentary. Well according to a recent study, it was noted Americans aren’t really eating that
much more but we are far more sedentary across all demographic groups. Back in the 1980s up to 90% of people reported doing at least some physical activity in their leisure time. Now up to half Americans say they are not active at all.

Bottom line well (inaudible 4:41) seem to be winning in this race across the
weight gain line. Experts estimate only 1 in 10 America n actually move during
their workday, sitting in cubicles for most of their time in front of a computer and
at time must be made either before or after work to get that 30 minutes a day
recommended by Federal Guidelines. I am Marianne O’Hare with these
Healthcare Headlines.

[Music]

Mark Masselli: We are speaking today with Dr. Jonathan Gruber, Professor of
Economics at the Massachusetts Institute of Technology. He is also Director of
Healthcare Programs at the National Bureau of Economic Research, one of the
key architects of the Massachusetts Health Reform Legislation. Dr. Gruber also
advised the Obama a dministration on the Creation of the Affordable Care Act.
He has published over a 140 research articles and he has written several books
on the Economics of Healthcare including the popular graphic novel ‘Healthcare
Reform’. Dr. Gruber is a m ember of the Institute of Medicine, a member of the
American Academy of Arts and Sciences and was voted one of the 25 most
innovative and practical thinkers of our time by Slate Magazine. Dr. Gruber
welcome back to Conversation on Healthcare .

Dr. Jonatha n Gruber: Good to be here.

Mark Masselli: Yup. Jonathan it’s been a number of years since you have been
on and we have watched the role out of the Affordable Care Act unfold overtime.
Numerous legal challenges also continue to be waged against it and you recently
found yourself at the Centre of one of th ese decisions the DC Circuit Court ruling
on a literal interpretation of the wording in the healthcare law that says residents
and states who don’t create their own exchanges and there are about 36 of
t hose, who purchase insurance on the federal exchange cannot take advantage
of the tax subsidy to offset purchase of health insurance. So illuminate our
audience of why this wording there was so important in the case and were you
quoted accurately in the f ilings ?

Dr. Jonathan Gruber: Yeah. I just remember when the healthcare law passed,
the plan was always to go to conference to resolve the differences between the
house, that want the National Exchange and the Senate that want the State
Exchanges. So th ey essentially had to sort of patch together a version of the
Senate Bill that could be acceptable to both houses , and since that was a sort of
a rough process though, there ended up being some essentially typos in the bill,
things just weren’t cleaned up and one of those things was despite the fact the
bill said that exchanges could be running by the State or F ederal g overnment,
one piece of the bill says that subsidies shall be available on state exchanges.
Now that same piece references other piece of t he bill which says but there is
also a federal backstop to state exchanges and unfortunately, it wasn’t spelt that
explicitly that sort of typo has become the basis for a law suit against the law.

Now , no one who worked on the law and wrote the law has ev er said they
intended the law to work this way. That was never the intention of the law to
(inaudible 7:31 ) available to the state exchanges. In fact it would be stupid to
write a law to set up these federal exchange backstops and not have subsidies
avai lable. Nonetheless because this typo in the law exists, this lawsuit has gone
forward.

Margaret Flinter: So I would like to talk a little more about the potential threat
that the ruling poses to the healthcare law given how many states did not opt to
do a state exchange. Some analysts have called it the most serious legal
challenge yet to the integrity of the Affordable Care Act and the US district court
of Virginia deliver ed the diametrically opposed ruling to the DC Circuit Court
decision. So still f luid and unresolved . T his is clearly an example of language
that could be constituted as contradictory to the intent of the law s you have just
described. What do you anticipate will happen next in regards to this latest
(inaudible 8:14 )?

Dr. Jonathan Gr uber: Well I mean in terms of the seriousness , on one hand it is
less serious in a mandate case because it is sillier. It really sort of makes no
sense to the lawsuit. There is really no coherent legal theory here in my view.
On the other hand, (inaudi ble 8:27 ) make the way to Supreme Court and
Supreme Court decided to centrally ignore the intent of the law and interpret this
little language that would be a serious threat basically in the roughly 35 states
that have F ederal exc hanges, you would end up w ith essentially health insurance
being unaffordable for , on the order of 85% of the people who are buying through
the exchanges now, that would mean they wouldn’t buy, that would mean the
exchanges would collapse and the c entral Affordable Care Act would n ot work in
the states that did not have state run exchanges. Now what’s true is a number of
those states would quick ly figure out a way around that. Those states would do
things like have the Federal Government administer something they call the
State Ru n Exchange. So for the blue states, I think it would just be a hassle, not
deadly but the red states the ones that have already refused to expand Medica id
presumably would agree with me and presumably deny even more of the citizens
right to health insura nce .

Mark Masselli: You know when I get back to the issue of the exchanges, the
whole people started as the program matured, they got a little better at it. What’s
your assessment of current state of online on insurance exchanges nationwide
as well as t he Federal e xchange and do you expect any improvements to be
rolled out as we get near the open enrollment?

Dr. Jonathan Gruber: I think the front end of the Federal Exchange that is the
consumer piece is working great. They solve those problems pretty quickly
a ctually , and its working fine. I think there still are some backend issues about
interacting with insurers. They still need to be worked out. So I think round two
will go better than round 1 but I imagined there will still be some glitches and like

the big issue is, even if situation reports of the law gives no way to the victory
and play up all the glitches. So yes there will be glitches. Things will go wrong
but what’s important for your listeners, the people who (inaudible 10:18 ) is look at
the big picture and so on average how it’s working. The difficulty for supporting
the law is what opponents do is immediately when one of arguments is proven
wrong , they just (inaudible 10:29 ) to another one without admitting the argument
was wrong, you know, we heard all through the fall and exchanged the (inaudible
10:34 ) well they didn’t they worked fine. So I think it’s just a matter of really
setting a tone and explaining to people that you know, overall its doing well even
if there are some remaini ng glitches.

Margaret Flinter: I think a recent common wealth report showed 81% of
Americans who gained coverage under the A ffordable Care Act are optimistic
that their coverage will be satisfactory moving forward and of course the
subsidies are a big p art of that because they helped to fray the cost of
purchasing insurance and the other happy group seems to be the insurance
companies, which I know early on you were making the point that the insurance
companies should benefit from this so if you were see ing the law, worked pretty
much the way it was intended so far. When you look back now on that first open
enrollment period, what were the big successes of that first open enrollment and
where did it fall short in their estimation?

Jonathan Gruber : Fund amentally it is working the way we have supposed to.
The basic three legged stool of fixing insurance markets and mandating
coverage and subsidizing coverage are working we ll. I think what I really miss ; I
think our analyst missed is how central the actu al administration exchange was
to making this law work well. I think we all just have to pay attention to policy
details and didn’t pay enough attention making the trains run on time and I think
we learned our lesson. We got burned in the fall and (inaud ible 11:44 ) law.
What’s good is that problem got fixed pretty quickly at the F ederal level and little
morning slowly but still being fixed at the state level and I think that’s the main
lesson we have learned. Going forward, I think there is going to be a lot more
focus on understanding that the administration of this stuff really matters and it is
not the policy that matters.

Mark Masselli: We are speaking today with Dr. Jonathan Gruber, Professor of
Economics at the Massachusetts Institute of Technolo gy. He is one of the key
architects of the 2006 Massachusetts Health Reform Legislation. Jonathan let ’ s
take a look at Massachusetts. The first goal of the law was to gain coverage for
the citizens to help eliminate health disparities in Massachusetts. How has that
reform impacted population health in Massachusetts and then also maybe pull
the threa t a little on their next phase as they start to think about payment reform.

Jonathan Gruber: Really fundamentally there are two problems of our health
care system. The first is an access problem and the second is cost problem.
You know, you have (inaudible 12:40 ) problem. You know, where outcomes are

terrible, but actually if you look at the data, our outcomes are people who were in
the system are quite g ood. The outcomes problem is really just a manifestation
of the access problem , and we saw that in Massachusetts there was a terrific
study, that was done which showed that mortality rate fell considerably among
the groups that benefit from the Massachuse tts Healthcare Reform . Indeed it
looks like we saved about 320 lives a year for expanding healthcare and that is
because of expanding health insurance coverage. So I think the population
health affects have been positive and that reflects the fact that r emember this law
is not about ripping up to some starting over , it’s about fixing the cracks in the
existing system and basically what that says is we did administer that. With
those populations that were really most subject to medical risk, we went into
health films and now it’s at that stage for now moving on to the next stage which
is actual thing about cost control. Now in one sense we have already started, in
fact cost growth over the last four years has been this lowest has been since we
started rec ording healthcare cost first. Was that the last I think it is still an open
question but I think we need to move on and take on that next battle but we can’t
do it until you get everyone into the system and I think we have done that?

Margaret Flinter: M aybe you can assure this more about the cost contained
issue. I know that it has been illusive in Massachusetts and everyone was very
clear, you know, the first goal was to get the plan up and running and then think
about the cost. Contained a little bit down the line but you may be tell us how
that is growing because I think we did like the Massachusetts a little bit as the
first state down the path of this universal healthcare.

Jonathan Gruber: Now the original Massachusetts law did nothing for cost
c ontrol. Cost grew at exactly the same rate as the nation. But the original law ct
wasn’t trying to do cost control. I mean, I sort of say criticizing the
Massachusetts law for not controlling cost , is like criticizing the Red Sox for not
winning the the Super Bowl . It’s not the thing we are trying to do. They have
won the World Series. That was great. Now if we think about cost control that’s
a much, to be honest, that’s a much much harder goal. We have struggled for a
longer time. Massachusetts di d pass somewhat aggressive cost control law.
Cost s have grown slowly in the state although once again and I think not
appreciably slow in the nation as a whole. I think it’s really going to be a question
and it’s going to be a much longer run question to evaluate. We would be
humble and recognized that we do not quite know exactly what to do to control
off care cost. I am patient in saying that we are going to learn but it’s going to
take time. You know, unfortunately, humble and patience not two words you
would use to describe politicians, so it’s going to be much more difficult process
politically.

Mark Masselli: Yeah, trying to describe the public’s mood we see at least the
polls and that I would suggest as opinion people who have got insurance thro ugh
either exchange or happy the national view seems to be a little less rosy. We
have the Supreme Court’s hobby lobby decision allowing corporations to avoid

certain birth controls. The y have thrown quite a bit of confusion in the (inaudible
15:29 ) of c ourse that has Republicans voted to sue their President who voted to
obviously overrule the ACA numerous ti mes. How do you see the health care law
surviving intact?

Jonathan Gruber: Well I think the battle is already won. The healthcare law is
going to survive. Now, let’s look at what survive means. There is a worst case
scenario. The worst case scenario is that it survives intact in only the blue
states. The worst case scenario is that this law suits somehow despite any logic
persuades the Supreme C ourt and in the (inaudible 16:04 ) States decide they
only want to be a part of the healthcare law but that’s a worst case scenario. You
know, I think the expected scenario is this law to get seen for the sham that it is
and that basically the law survives and that slowly over the time, as people
benefit from it, and the national attention pivots to other topics, it slowly gains
acceptance, but I think you know, what’s striking is even if the law has been
successful , the public opinion has gotten worse abou t it. I think what that reflects
is the fact that as I said the most Americans are not affected by this law and so
we would becomes what most Americans read and see and as we go into a
typical hotel lobby in America (inaudible 16:42 ) is on. It is just a question of as
people to get know mo re and more people who benefitted from it and as you say
(inaudible 16:48 ) will benefit from it, love it. Hopefully, those opinions will swing.

Mark Masselli: Weren’t you surprised that given the healthcare lobby even in the
red states that we haven’t had more traction you know, maybe not Texas but
Pennsylvania or some other of these states where the healthcare industrial
complex if you will hasn’t really squeezed out the state g overnment to move into
the M edicaid prog ram.

Jonathan Gruber: You know I am really surprised. I am surprised as someone
who sells public policy and I mean you know, as a healthcare expert I am quite
frankly surprised to speak on political economy. Yeah, I mean when the
supreme court decision happened, you know, basically the reaction of (inaudible
17:33 ) like don’t worry about it the states will extend M edicaid, why wouldn’t they,
right, I think the fact that so many states have managed to essentially fool their
citizens into not understandin g what a good deal this is for the state. It is sort of
amazing and frustrating.

Margaret Flinter: Yeah I though one of rules of behavior, which you don’t vote
against your own economic (inaudible 17:42 ).

Jonathan Gruber: You think about, you take the state of Florida there are 1
million uninsured people below poverty line. So by turning down to expansion
what the state of Florida is saying we are going to turn down the opportunity for
the Federal g overnment to pay to help a million citizens and at the same time
injection billions of dollars into our state economy. I mean literally no one is work
off in Florida, no one. The lowest income people get free health insurance the

higher income people get the benefits of stimulus of the state. It sort o f like you
said it rejects any model I (inaudible 18:27 ) is how people should vote. It’s really
frustrating as an academic as it is as a public policy advocate.

Margaret Flinter: We have been speaking today Dr. Jonathan Gruber, Economist
and Professor a t MIT and Co - Architect of the Massachusetts Health Reform as
well as The Affordable Care Act. You can learn more about his work by going to
economics.mit.edu/faculty/gruber. Jonathan thanks you so much for coming
back on Conversation on Healthcare today.

Jonathan Gruber: My pleasure.

(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly known when it comes to the facts about health care reform and policy. Lori
Robertson is an award winning journalist and managing 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 we continue to see democrats and republicans attack ea ch
other over the affordable care act and Medicare. For instance in the Montana,
(inaudible 19:27 ) an ad from the republican candidate Steve Dyane features a
67 - year - old breast cancer survivor who says the ACA puts her Medicare at risk.
Meanwhile an ad f rom the democratic candidate (inaudible 19:40 ) features senior
woman claiming that (inaudible 19:43 ). We are seeing similar misleading
Medicare claims and raises across the country. First the republican add. The
claim about the breast cancer survivors M edicare being at risk is based on the
tired attack that democrats cut more than 700 billion dollars from Medicare to pay
for Obama Care. The Affordable Care Act doesn’t slash 700 billion dollars from
the current Medicare budget. Instead this is a cut in the future growth of
spending over a decade and the slower rate of growth which applies to payments
made to hospitals and other non - physician providers extends the solvency of the
program. It remains to be seen whether this would translate into reduced
se rvices. In terms of breast cancer however, the ACA expanded benefits for
mammograms covering them fully without cost sharing from Medicare
beneficiaries on a yearly basis. Now the Democratic ads. It features three senior
women one of whom says that Repr esentative James voted to cut Medicare
benefits, a reference to James’s vote for Representative Paul Bryan’s Ryan’s
budget plan. Bryan’s proposal for Medicare with next ACA’s free preventive care
including cancer screenings and flu shots , and it would get rid of the laws closing
of the prescription drug Donnatal . The relatively few seniors have drug caused
high enough to put them in that coverage gap. So far roughly 16% of Medicare
beneficiaries have saved money on prescriptions thanks to the ACA’s expan ded
benefit. And that’s my Fact Check for this week. I am 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 of the Annenberg Pu blic Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at chcradio.com , w e will have FactCheck.org's Lori Robertson
check it out for you here on Conversations on Healthcare .

Each week , Conversations highlight s a bright idea about how to make wellness a
part of ou r communities and everyday lives. Tens and millions of people around
the world have conditions that make it impossible for them to speak on their own
requiring them to adopt a computerized v oice box for communicating. Perhaps
the most well known of these folks is the physicist , Stephen Hawking .

Stephen Hawking: I wouldn’t have seen that it was fairly obvious what I meant.

Margaret Flinter: The problem is that sound of Hawking speaking th rough his
voice box is the same voice sound say that a 10 - year old grow with a neurologic
disorder might be forced to use this well because there just haven’t been many
voice options on the market.

Dr. Rupa Patel: In the US alone, there are 2.5 million A mericans who are unable
to speak and many of them use computerized devices to communicate.

Margaret Flinter : At a recent Ted Talk, Speech Researcher and Innovator Dr.
Rupa Patel shared a program she has launched that can change that reality
vocal id.

Dr . Rupa Patel: I thought there had to be a way to reverse engineer a voice from
whatever little is left over. So we decided to do exactly that. We set out to create
custom crafted voices that captured the ir unique vocal identities.

Margaret Flinter: Cr eating a voice bank of donor voices that will allow voices to
be individualized for each unique patient seeking to communicate through an
electronic voice box.

Dr. Rupa Patel: Why don’t we take the source from the person we want the
voice to sound like a nd borrow the filter from someone above this image and size
because they can articulate speech and then mix them because when we mix
them, we can get voices as clear as our surrogate talker and is as similar in
identity to our target talker. It’s that sim ple.

Margaret Flinter: Since its popular to Ted Talk in February, 16,000 people have
signed up to be voice donors at the Human Voice Bank i nitiative. So volunteers
like this little girl will read a series of simple phrases over a several hour period.

F emale: Things happen in pairs. I love to sleep. The sky is blue without clouds.

Margaret Flinter: And then those phrases are matched with the voice footprint of
the patient being provided for.

Female: This voice is only for me. I can’t wait to use my new voice with my
friends.

Margaret Flinter: Such speech synthesis will give that person the dignity of a
speaking voice that is as close matched to your own identity as possible. To take
that dream from the lab and into the real world, Dr. Patel who is a Professor of
Computer Engineering at North Eastern University has launched the website
vocalid.com.

Dr. Rupa Patel: I imagine a whole world of surrogate donors from all walks of
life, different sizes, different ages, coming together to give people voices that are
as colorful as their personalities.

Margaret Flinter: And with the Bank of Voice Donors now building around the
world, Dr. Patel expects that patients with conditions ranging from muscular
dystrophy to Lou Gehrig's Disease or stroke will one day be given the chan c e to
communicate in a voice made just for them. The Human Voice Bank Initiative
matching vocal donors with millions of people who seek to authentically
communicate with friends and family in a voice that most closely matches what
would be their own. Now that’s a bright idea.

[Music]

Margaret Flinter: This is Conversations on Healthcare . I am Marg a ret Flin t er.

Mark Masselli: And I am Mark Masselli . Peace and health.

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