Alan Weil, Editor-in-Chief of Health Affairs

( Music)

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

Margaret Flinter: A nd I am Margret Flinter .

Mark Masselli: Well Marg a ret , two and a half million and counting, the number of
Americans who signed up for coverage by mid December on the federal
marketplaces.

Margaret Flinter: It should be noted that about half of those who signed up
during the second enrollment are returning customers, and many of them
shopped around for plans that might better suit their budgets and th eir family
needs. But the important thing is it does show that there is a very robust
interaction beginning to happen with the online portals this time around, and
everything seems much smoother.

Mark Masselli: There are still some issues. The volume i s quite high in the
federal exchanges , which is handling the insurance needs of about 37 states . So
people seeking help from insurance navigators on the phone are being asked to
leave their names and numbers, and they must wait for counselors to call them
back with such high volume. Those callbacks are taking a few weeks to get back
in some cases.

Margaret Flinter: So about half a million people phoned in to HealthCare.gov to
th st
try and make the December 15 deadline for coverage to begin on January 1 .
Kevin Counihan who heads up the exchange says that e veryone who calls by
th st
midnight on December 15 will see their coverage begin January 1 even if the
counselors couldn’t get back to them right away. So I would say he is doing a
terrific job at the helm of HealthCare.gov , Mark.

Mark Masselli: These new insurance marketplaces are also bringing differently
structured health plans . The growing trend in high deductible plans require some
analysis for families who must calculat e a slew of out - of - pocket exp enses . It
really is important to shop around.

Margaret Flinter: And we ha d been watching another approach to the problem of
covering the uninsured in America and also of controlling cost. Vermont was on
track to become the first state to launch a singl e payer system by 2017.

Mark Masselli: Governor Shumlin made the recent announcement that after
crunching the numbers every which way the re simply was no way to pay for the
significant increases that would be in taxes.

Margaret Flinter: And proponents of single payer approaches were so
disappointed because Vermont presented the best hope, maybe the only hope

right now in the United States for success , b ut that payment piece simply prove d
to o challeng ing .

Mark Masselli: The i dea is simply going to take some time to take root which is
unlikely in the current political climate.

Margaret Flinter: Well, our gues t today is someone who has a pretty global view
of the current political climate and health care in this country and the importance
of looking at health reform from a non - partisan angle. Alan Weil is the Editor - in -
Chief of the peer - review ed publication Health Affairs .

Mark Masselli: Lori Robertson , Managing Editor of FactCheck.org looks at false
claims spoken about health policy in the public dom ain . But no matter what the
topic , you can hear all of our shows by g oing to www.chcradio.com .
Margaret Flinter: And if you have comments , don’t forget to e - mail us at CHC
Radio at www.chcradio1.com
or find us on Facebook, LinkedIn , Twitter or
Google + ; we love hear ing from you . Now we wi ll get to our interview with Alan
Weil in just a moment .
Mark Masselli: But first , here is our producer , Marianne O'Hare with this week ’s
Headline News.
(Music) Marianne O'Hare: I am Marianne O'Hare with these Health Care Headlines . And
the numbers keep rising . Numbers of Americans who have signed up for health
coverage on the federal and the state exchanges has risen dramatically in the
last couple of weeks of December. According to the Department of Health and Human Services , 6.4 million Americans were able to sign up for coverage on
both the federal and state exchanges up from 2.5 million just a couple of weeks
ago. HHS Secretary Sylvia Mathews Burwell is hoping for 9.1 million enrollees
by the end of the 2015. But what about the cost ? The survey of American s
shows more are grappling with health care costs than they were a year ago , a
combination of paying for insurance where th ey might not have before , higher
insurance rates due to some of the mandated coverage items under the
Affordable Care Act , and largely the increased out - of - pocket expenses from
plans with much higher deductibles.
Meantime, the date ’ s been set. The nation ’s High Court will hear arguments on
the tax subsidies for those buying insurance on the federal health exchange.
The case is based on language taken literally from the original bill. The FDA is
lifting a decade ’ s long ban on a homosexual men donating bl ood. It was put in
place in the earlier days of the AIDS epidemic. It is however continuing a ban on
blood donations if a gay person has had sex with another person in the past
year. 50,000 new AIDS cases per year are still happening in this country, an d

the numbers are highest among young gay men of color, many of whom don’t
know they are infected at that early age.

Meanwhile, when do you think is the best time to enter the ER if you have got a
critical cardiac event? If you answered when all the top cardiologists are away at
a medical convention you would be right. A recent Harvard study looked at
outcomes from patients who enter ed the ER with cardiac arrest or an incident
related to congestive heart failure when the top docs we re all away, patients did
about 10% better with a 70% survival rate after 30 days rather than a 60%
survival rate when the top docs were in town. The study finds that fill - in docs are
less likely to do invasive intervention s th at could yield more deadly side effects.

I am Mar ianne O'Hare with these Health Care Headlines .

(Music)

Mark Masselli: We are speaking today with Alan Weil, newly installed Editor - in -
Chief of Health Affairs, a leading peer - review ed journal on health, health care
and policy. Before that Mr. Weil was t he Executive Director of the National
Academy for State Health Policy. Mr. Weil, an a ttorney , was d irector of the New
Federalism Project at the Urban Institute . A frequent speaker and author on
health reform policy, Mr. Weil co - authored several books inc luding Federalism
and Health Policy, and served on President Clinton’s Consumer Commission on
the Quality in Health Care Industry, co - authoring the Patients ’ Bill of Rights. He
earned his Master ’ s in Public Policy and his law degree from Harvard. Alan,
w elcome back to Conversations on Health Care.

Alan Weil: It's nice to be back, thank you.

Mark Masselli: Yeah. And it's been since 2011 when we discussed the
Affordable Care Act , and lots has happened since then. Eight billion Americans
enrolled on an d received coverage on the exchange, and five million access ed
coverage to Medicaid expansion, only about half of the states choosing to
expand Medicaid. What’s your assessment of the outcomes from state to state
and is that what you envision would happen ?

Alan Weil: I don’t think anyone anticipated the country splitting quite the way it
has, and two elements were certainly not foreseeable by me. The first I think I
have a lot of company on which is the Supreme Court after all is responsible for
having ma de the Medicaid expansion something that states could choose to
participate in or not as the law was written. All states were to expand Medicaid ,
and we we re going to have a uniform national platform of coverage . Now with
the court’s rewriting of the s tatute they said the federal government cannot tell
states that if they fail to expand Medicaid they will lose their base funding for the
program, and we have what you just described. I truly don’t know a single
person who thought that was where we were g oing to be at this point.

What I didn’t foresee was how much states would become a place where even
after the law was enacted and signed that there would be such a division about
whether or not implementing the law was something states were will ing to
par ticipate in at all, and so you have the significant element within the Republican
Party that basically said, “ Anything you do that is involved in implementation of
the law is an (inaudible 07:50) . ” That is a big factor I think in the division today
and ce rtainly not one that I expected.

Margaret Flinter: Well certainly, Alan, you obviously are a long time health policy
advocate and expert, you have contributed frequently to Health Affairs, and now
you are the Editor - in - Chief of what we think of a s the pe er - review ed journal for
Health Policy. For our listeners, maybe tell us a little more about the journal’s
history, who the major participants and contributors are, and if there is any new
directions that you are planning for the publication.

Alan Weil: So we started with the luminaries in the field, and I would say we still
have them. We call upon a broad cross section of health services, researchers,
physicians and economists and sociologists and statisticians. We cover the
range of issues in health c are as they relate to the policy e nvironment in which
we operate in . As for new directions, you know, mostly I will say I take the helm
of this terrific journal that is so strong , I don’t need to layout a big plan of
transformation . But I do think we are in an era of faster information where the
traditional peer - review ed journal is coming under fire both from the time that it
takes and the resources it takes as well as the many distribution channels that
are available to those who don’t want to subject th eir work to peer - review and
want to get the message out much more quickly , a nd I think navigating that
changing e nvironment really is my top priority.

Mark Masselli: So in this ever - changing world of how readers consume news,
sort of where that audi ence is not so much on the content side but on the deliver y
side, thoughts about that, even in the state position that Health Affairs i s , you
have others who are quite anxious about the transformation and what it might
necessitate for organizations like yoursel f?

Alan Weil: Well, we occupy a unique space, and one thing I think we all have to
remember is there is not one typical reader . Particularly for the policy work we
do, we are reaching CEOs of organizations, we are reaching young staff
members on Capitol Hill, we are reaching practicing clinicians around the country
and indeed around the world, and I think we all know with the pace of change in
how information is distributed and disseminated t hose different audiences are
looking to different sources. It' s making sure that as we think about our
audiences we have appropriate distribution channels for the range of
mechanisms that they are accustom ed to. Our core asset is credibility and non -
partisanship is a very important part of that. Our peer - review pro cess and as
long as we build from that core, some people will be Googling a topic and they

will find it, some people will read a blog entry, some people will read a tweet, and
as long as we retain the quality of our content I think we can reach people the
way they are used to gaining access to information.

Margaret Flinter: Let me take a quick look back if I can Alan, and you were in the
health policy trenches back in 1990 when the Clinton Administration took it s shot
at passing comprehensive health refor m , and you have noted that the
conventional thinking back then was that the three pillars of reform improving
access, improving quality and containing cost s were actually competing interest s
and couldn’t it be simultaneously achieved. But you have more re cently said that
the Affordable Care Act ha s shifted that landscape on these three goals , and
perhaps the ACA has made it possible to envision the three pillars of access,
quality and cost to actually reinforcing one another. What do you mean by that?
Exp and on that thought some for our listeners.

Alan Weil: I remember going to dozens of conferences a couple of decades ago
where people said you can't have high quality affordable system for everyone. I
really believe it's the practice of medicine and the evidence based behind that
practice that’s changed in these years along with some good thought leadership.
We now understand that when people get access to appropriate care they
actually stay healthier , and it cost s us less certainly in the long run , and
sometimes in the short run. We have also learned a lot about quality that was in
its infancy a couple of decades ago , and understanding the problem of overuse.
So there is now a framework in the Affordable Care Act . Obviously no t everyone
agrees with t he approach it takes , but most of the attention goes to the elements
of the Affordable Care Act design ed to expand access to care through more
health insurance. But there are major elements having to do with cost ,
particularly modifications to the Medicar e program which is the biggest leve r the
federal government has , and major initiatives to improve quality, a nd the hope of
course is that we can bring those together in a reinforcing way as opposed to a
competitive way. I do think our thinking about those three elements has shifted
fundamentally with a very positive sense of what’s possible as opposed to what I
remember which was sort of a resignation that well this is the best we can do.

Mark Masselli: We are speaking today with the Editor - in - Chief of H ealth Affairs,
a leading peer - review ed journal. Before that, Mr. Weil was Executive Director of
the National Academy for State Health Policy, a non - partisan organization
helping states achieve excellence in health policy and practice. You focus much
of y our efforts on improving population health on the state and local levels . You r
work at NA S HP and the Urban Institute centered on the importance of state
policy directors being essential to improve population health, and what do you
see in the states ; what ’s exciting about population health?

Alan Weil: When I think about the Affordable Care Act , it creates a number of
tools that states can use . The changes in Medicare payment are a catalyst for
thinking about accountability in the health care system . So between state and

local there are opportunities to think more holistically about the health of the
population , and so one of the most powerful efforts that I observe is when a
community looks at its own population health statistics , and they say “W e reall y
need to focus here on children with asthma who are ending up in the hospital
when with appropriate preventive services they wouldn’t have to do that ,” then
you cannot just generalize about population health you can har ness the
resources of the community to actually do something concrete.

Margaret Flinter: I think it ties to something that you have talked about this
federalism and health care , a nd there has been this fierce debate on states ’
rights that the Affordable Care Act precipitated. So maybe tal k just a little bit
about this new federalism , and also , do you see the possibility of increased
regionalism coming into play around health care in the future?

Alan Weil: Well, we are certainly seeing regional differences in the response to
the Affordabl e Care Act , and many of our largest cities s i t on state borders and
so certainly, the opportunity to work across state lines to try to solve problems is
a practical necessity. I think it would be naïve to deny that the Affordable Care
Act embraces an acti vist role for government in the health care sector. It says
we have a market failure , we have lot of people who can't afford coverage , and
we are going to solve that by giving resources to those who otherwise wouldn’t
be able to afford it. And that broad conception of the word that the state has a
primary role in addressing this social problem that not everyone agrees upon and
we have regional differences in the view of that. So actually , much of the tension
around the Affordable Care Act is just around public sector versus private sector
and the role of g overnment no matter what level.

Now what I have not seen is a serious effort to define an alternative pathway to
achieving the goals of the Affordable Care Act. On the one hand, the state roles
in impl ementing the law are many , and that’s been my focus for some time , b ut a
national division over the role of government is a somewhat different discussion
than division over whether it should be federal or state , and I actually think a lot
of the opposition to the Affordable Care Act is much more about role of
government than it is about federal versus state.

Mark Masselli: We want to spend a little time talking about payment reform .
Massachusetts started off its initial reform and they have had some good
outcomes in terms of their access issues , b ut talk a little bit about the landscape
around payment reform.

Alan Weil: The Affordable Care Act was a catalyst. It's happening in the private
sector as well as in the public sector. The term often used i s Accountable Care
Organizations , and the idea is to pay for the care of a population and to reward
those who deliver care to that population. They can keep depending on the
payment models some share of what they save by reallocating their resources so
ther e is no question that this is a real phenomenon. Payment reform is a tool ,

and then you can ask given the goal what kind of payment will support the goal
a nd to then reimburse them, pay them for each thing that they do on the
expectation and understanding that what they did was valuable. Well, we are
now starting to understand , and many physicians would agree that a lot of what
they do is not valuable . Interventions that help people live a healthier life tend
not to be paid nearly as well as cutting some one open and fixing something
inside their body or scanning them.

So payment reform for what , to enable those who deliver care to think differently
about the choices that they make. Our quality metrics are still fairly primitive
particularly when it come s to people with complex health care needs. So I would
say that the working out of the meaning of quality and the purpose of payment
reform is something that is much better done locally or at the state level than
nationally , that our efforts to change pay ment at the national level tend to be
pretty clunky. They are directionally appropriate , but the details are complex ,
and they need to be worked out by people sitting around the table with trust who
can say this is how we are going to measure quality, yes this is how patients view
quality, this is how clinicians view quality, this is a payment model that will
support that . From my perspective, that is by necessity a local discussion , and
it's what ties all of these topics together.

Margaret Flinter: We have been speaking today with Alan Weil, Health Policy
expert, and Editor - in - Chief of Health Affairs, the leading peer - review ed journal on
health policy. You can learn more about his work by going to
www.health affairs.org , and you can follow him on Twitter by going to
www.twitter.com/healthaffairs . Alan, thank you so much for joining us on
Conversations on Healthcare today.
Alan Weil: It's been a pleasure.
(Music) Mark Masselli: At Conversations on Health Care , we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award - winning journalist and managing editor of
FactCheck.org, a non - partisan, non - profit consumer advocate for voters that aim
to reduce the level of deception in U.S. politics. Lori, what have you got for us
this week?
Lori Robertson: Well, in a new twist a Democratic group is attacking a
Republican senate candidat e for supporting “government - run health care.” That
phrase has been a mantra for Republicans attacking the Affordable Care Act and
those who support it, but neither this new Democratic attack nor the old
Republican ones are true. The Democratic group sen ate majority pack is airing
the ad attacking Representative Bill Cassidy, Louisiana Senator Mary Landrieu ’s
main GOP opponent. It says Cassidy wrote a plan that’s been called Obamacare

Lite . True, it was called that by an opinion columnist but it's not a n accurate
description. And the 2007 b ill Cassidy wrote while a Louisiana State Senator
wouldn’t have created “government - run health care” add s claims with
government bureaucrats making medical decisions. There is nothing like that in
the bill which woul d have set up a state insurance exchange to serve as a
clearinghouse for individuals and businesses by an insurance.

The proposal also was a far cry from the Federal Affordable Care Act which
didn’t exist at the time. Cassidy ’s b ill didn’t include subsid ies for low income
people, a mandate to have insurance or pay a fine or a set of essential health
benefits that insurance had to cover like the ACA. The Louisiana b ill called for
state officials to come up with new health insurance proposal s design ed to r each
universal coverage in the state , but that never happened. The bill died quietly in
committee without even a public hearing. Cassidy meanwhile has aired an ad
attacking the ACA saying he voted against it because it would lead to cancel led
plans, expe nsive premiums, no guarantee that you could keep your doctor. But
that was all true before the federal law was passed. And that’s my fact check for
this week. I am Lori Robertson, managing editor of FactCheck.org.

Margaret Flinter: FactCheck.org is co mmitted to factual accuracy from the
country's major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact, that you would like
checked, e - mail us at www.chcradio.com . We will have FactCheck.org's Lori
Robertson check it out for you here on Conversations on Health Care .
(Music) Margaret Flinter: Each week Conversations highlights a bright idea about how to
make wellness a part of our commun ities and everyday lives. According to
Michigan Organic Farmer Michel l e Lutz, health care spends too much time and
money trying to fix the problems that are caused by a poor diet , (inaudible 22:39)
be at the Henry Ford West Bloomfield Hospital agree with her. For years , she
had offered organic food growing and cooking demonstrations at the health care
facility just outside of Detroit , b ut when officials drew up plans to renovate the
hospital three years ago, they decided to take it to the next level. A m illion dollar
certified organic hydroponic greenhouse and garden were built and Lutz was
hired away from her farm to run the operation.
Michel l e Lutz : We really wanted to change the way that food culture was done in
a health care setting. When you have the opportunity to heal someone it is very
important that what they are eating becomes part of that plan.
Margaret Flinter: The facility now provides most of the nutritional organic greens,
vegetables, fruits and herbs used in the food that is prepared t here not just for
patients who have come there to heal , but for their families and hospital staff as
well.

Miche l le Lutz : It's rather seasonal. In the wintertime and in the fall we change to
more of a cold - tolerant crop , and then in the summertime like this time we are
now transitioning to the point where we a re picking cherry tomatoes, and we
ha ve sweet peppers and things like that that we will be supplying for the kitchen.

Margaret Flinter: Lutz says there is an educational component to the program
t hat’s ongoing and multi - generational.

Miche l le Lutz : Right now, we are averaging 3,000 students per academic school
year that go through our Healthy Habit program. We have a demonstration
kitchen inside of our hospital , and then we have the greenhouse r ight behind the
hospital. So we utilize those components to make sure that we press upon
especially our youth and our community what does it take to have the foundation
of healthy habits .

Margaret Flinter: And hospital chefs work to incorporate more sup er greens and
medicinal herbs into their recipes , reducing the reliance on sugar and salt for
flavors. The nation’s first hospital - based year around certified organic
hydroponic greenhouse , one that provides fresh fruits and vegetables to patients
who are healing and the clinicians working to heal them, improving health and
well - being for the system community - wide and teaching the next generation
about the benefits of organic produce for a healthier diet.

Miche l le Lutz : The idea of being just a hospital doesn’t work anymore. You have
to be a community center for wellness.

Margaret Flinter: Now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Health Care . I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace an d health.

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