Bill Hoagland, Sr. VP of the Bipartisan Policy Center

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Mark Masselli: This is Conversations on Health Care, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret another do or die vote on the Affordable Care Act at the
Supreme Court and it was another victory for the Obama Administration. The high court
upheld the legality of the tax subsidies in all 50 states under the Affordable Care Act a
decisive win for health reform in this country.

Margaret Flinter: Conservative opponents of the law argued that the tax subsidies were
only authorized in states that had setup their own insurance exchanges. But Chief
Justice Roberts issued the majority opinion siding with the Obama Administration's view
that the intent of the law was to make subsidies available to all Ame ricans who qualified.

Mark Masselli: Well Margaret it seem like a heavyweight ten round battle that we've
been in. There have been high court rulings, lower court rulings and so the ten rounds
are over but it looks like people think it's a 15 round fight .

Margaret Flinter: The conservative opponents may have been blocked in the nation's
highest court, we'll let those legislative challenges continue. And our guest today is
somebody who knows quite a bit about this process.

Mark Masselli: Bill Hoagland w as a long time policy operative in congress he's now
Senior Vice President at the Bipartisan Policy Center in Washington. He's focus is on
economics and health policy. He'll give us an analysis of the Supreme Court decision.

Margaret Flinter: And Lori R obertson will be stopping by the Managing Editor of
FactCheck.org is being kept pretty busy vetting the claims of the numerous presidential
hopefuls entering the fray.

Mark Masselli: But no matter what the topic you can hear all of our shows by going to
c hcradio.com and as always if you have comments please email us at
[email protected] or find us on Facebook or Twitter we love hearing from you.

Margaret Flinter: We'll get to our interview with Bill Hoagland in jus t a moment.

Mark Masselli: But first here is our producer Marianne O'Hare with this week's headline news.

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Marianne O'Hare: I'm Marianne O'Hare with these Health Care Headlines. More
Americans like it than don’t Obama Care that is, according to a CBS New York Times

poll an overwhelming majority of Americans poll felt the tax subsidies just recently
upheld by the Supreme Court were a good thing a full 70% of those polled. And now a
majority of American some 47% versus 43% say they like Obama Care, 55% of
Americans feel the law has good things to recommend it and should not be repealed by
just improved upon.

There are still some challenges ahead, a number of GOP leaders are vowing more
repeal efforts in congress. And there are still coverage challe nges in states where
Medicaid was not expanded. Still more than 16 million Americans have gained
coverage since the launch of the Affordable Care Act bringing the uninsured rate to the
lowest it's been in years.

California has move forward with a plan to ban personal objections for childhood
vaccines. The measure will require all children entering kindergarten to have been
vaccinated, that information to be compiled at the governor's office. California was a
scene of a number of childhood disease outbrea ks like Measles and Whooping Cough
the measure is stipulating the public good was more important than personal choice.

And kids and ADHD one of the leading cause of childhood persecutions in this country,
now a new study out shows maybe it's best to let th e kids fidget. The study in child
neuropsychology looked at kids with and without ADHD both groups were fitted with a
motion monitor and were given cognitive task to complete. The kids with ADHD who
fidgeted the most during their cognitive test actually scored the highest. Conversely
fidgeting had no effect on the test results on the kids not diagnosed with ADHD, study
suggest that hyper activity may actually prove to be a benefit for those kids struggling to
pay attention. I'm Marianne O'Hare with thes e Health Care Headlines.

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Mark Masselli: We're speaking today with Bill Hoagland Senior Vice President of the
Bipartisan Policy Center where he directs and manages health and economic policy.
Mr. Hoagland spent 25 years working in the United State Senath serving as D irector of
B udget and A ppropriations under the majority leader Senator Bill Frist. He served as
staff director of the Senath Budget Committee from 1986 to 2003, the National Journal
listed Mr. Hoagland as one of the top 100 decision ma kers on Capitol Hill. He
coordinated the BBC's 2013 report a bipartisan RX for patient centered care and system
wide cost containment. Mr. Hoagland is a fellow of the National Academy of Public
Administration, earned his degree from Purdue in Penn State. Mr. Hoagland welcome
to Conversations on Health Care.

Bill Hoagland: Goof afternoon welcome.

Mark Masselli: Well it looks like it was a vindication and victory for the Obama
Administration as the Supreme Court ruled six to three to uphold the legality of the tax
subsidies used to offset cost to purchasing health insurance for all Americans. And this
is the second major high court decision addressing the challenges to the Affordable
Care Act, could you tell our listeners what specifically was the disput e in the King versus
Burwell and why it pose such a threat to the Affordable Care Act.

Bill Hoagland: Yes specifically the challenge came from the plaintiff King versus the
administration. And Mr. King alleged that he was in a state that was not part of the -- a
state exchange and therefore it was being run by the federal government. There are
about 34 states that decided not to set up state exchange but looked at federal
government run. And there are some language within the law basically said that
sub sidies for purchasing health insurance on these exchanges would be available
through lay at red if the state had an exchange.

And so the argument was well if the state didn’t set up the exchange and the federal
government was running exchange, the federal government is not a state. Then the
subsidies should be not be available to those individuals in those 34 states, that was the
challenge it was straight forward, it was an interpretation of the language that was in the
law. And the most important fact he re being and of course the law had been
implemented, it was operational and in those 34 states nearly 6.4 million Americans
were receiving health insurance and were receiving subsidies.

And King won then those 6.4 million individuals would have lost the su bsides
necessarily that they felt that, that was necessary for them to continue to purchase
health insurance and probably would have had to drop health insurance immediately
had King won. So the decision by the court was no, this law was set up to provide
health insurance to Americas and therefore current law stood subsidies continued and
those 6.4 million people that might have lost their subsidies and therefore lost their
insurance continues on a status quo no change in the law.

Mar garet Flinter : So Bill in the majority opinion, Chief Justice Roberts noted that the
intent of the law was to also to improve health insurance markets not to destroy them
and, you know, really the security Affordable Care Act does an important social safety
net for as yo u noted 6.4 million individuals who might have lost the subsides. So now
that the high court has concluded that the subsides are illegal, what has this done to not
only secure coverage for those individuals but how has this really secured the
Affordable C are Act into the foreseeable future and improved health insurance markets,
could you comment on that a bit?

Bill Hoagland: So this is of course the difficulty and the challenges associated with
insurance. If you want as many people to participate and pur chase insurance and have

insurance in order to spread the risk across the entire body of population out there. So
you want both the individuals that are healthy and those who are potentially could be
sick or not so healthy, you want everybody in the pool so to speak to spread the risk
and lower the cost. Had this 6.4 million as an example drop out of the health insurance
market then there was a likelihood that this would have driven up at the premiums for
those who remained purchasing health insurance.

So the combination of this law was first as the justices has indicated was to preserve
and protect and extent health insurance to all Americans. And therefore that's one of
the reasons why I believe the justice has ruled in favor of keeping this 6.4 million people
in the pool. I think this indicates that the law remains in effect, I will be straight about
this as I can that does not necessarily mean that there won't contained it to be
challenges to the law. And particularly now the challenges had shift fro m the judicial
system to the legislative system and the republican controlled congress has indicated
that this does not mean the end of the battle with the Affordable Care Act that now the
battle moves back into the legislative process if you like.

And I w ould not be surprised in the least if later here you'll start to hear about a budget
process that has been set up at the end of July the congress is likely to pass a law that
repeals a major elements of the Affordable Care Act. And pass a law because they can
do that now with a control of the both chambers and under this thing we called budget
reconciliation. And this law will likely be put on the President's desk, now he will veto it,
and the veto will not be overwritten. But would not hurt the end of t his battle I am afraid
the hope would be that even the president and democratic members admit they're all
provisions in this law that probably could be improved. The law could be modified in
certain areas, there are questions about whether or not the empl oyer mandate is really
functioning.

There are other questions that need to be addressed, there are other ways of being
more efficient and there's liberty of the premiums out there. And so as a consequence
my hope would be that we'll get through this what I called kabuki dance one more time
then maybe we can get back to some serious discussion about reforms. And law is
perfect and nobody says that this law is perfect and it would be nice to get back to some
what I -- obviously working for the bipartisan po licy center, let's sit down and have some
serious negotiations back and forth on those areas that can be improved in the law.

Mark Masselli: We're speaking today with Bill Hoagland a Senior Vice President of the
Bipartisan Policy Center where he directs a nd manages health and economic policy
analysis. Prior to that the spend 25 years working in the United State Senath serving as
the Director of the Budget Impropriations. Bill you don’t want to get back to the, you
know, the bipartisan nature of congress right now, you spent your career really reaching
across the aisles trying to craft economic policy, trying to build consents. And yet there

seems to be little of that type of cooperation here particularly in this Bill I know Margaret
we had David Gergen o n the show. And David he really lamented that the bill didn’t
have bipartisan support and it sort of -- that's the root of the struggle, the American
people I think are getting a little weary of this. Do you really think after the summer
kabuki dance tha t we're going to get through to this, is there any end in sight?

Bill Hoagland: I do think there's a recognition that there are areas that could be
addressed in this law. I worked on the Hill and I work for republicans and in all those
years at there and we did strive to work across the aisle and find common ground
(inaudible 11:54 ) partisan issues from time to time that happened and there's nothing
you can say about that of the next partisan. But on this something a major pieces of
legislation whether i t's social security, whether it's Medicare, whether it's taxes. You
can't reform these particular policies in this country in a partisan way it has to be done in
a bipartisan way.

And the sad part about this particular piece of legislation as David has in dicated it was
put together in a partisan way, it was passed without any republican support in the
house or senath. And quite frankly the big problem from my perspective as an old
staffer was that it pass the senath and what pass the senath on that Christ mas morning
that particular law did not go to conferences. You might recall at the end of that 2009
there was a special it pass to 60 votes -- republicans not voting for it all democratic
votes. And that particular law basically went straight to the pres ident and had that bill
going through the normal process which would have been a conference between the
house and senath, there might have been some opportunity to address just as particular
issue the wording as it relates to state exchanges versus federal exchanges.

The way the law went together unfortunately is created a number of the problems and
the judicial challenges that have come to past. I remain hopeful that on those major
issues we can still come together and find common ground. I think there's a lot of thesis
of this law quite frankly republicans like, coverage up the age of 26, no preexisting
conditions. A number of these provisions are positive in fact we're republican proposals
many years ago. And so I think we have -- now we're unfortunat ely going to be moving
into presidential politics and I presume this will become another issue for the election, I
wish we could say this is the law, let's work together to improve it where we have
agreement that there are areas that need to be improve. T his is critical that we have a
system that provides a health insurance to as many Americans as needed. So I'm
hopeful I think we will unfortunately go through another process here in a couple of
months then we'll have to see whether people say okay that's it, let's now sit down or do
we have to wait for a presidential election to go through this again.

Margaret Flinter: There are many times when it feels like the Affordable Care Act is
entirely about coverage and insurance. But it's also about the care, it's about quality of

care, it's about patient centered care, it's about cost and you authored the bipartisan
policy centers 2013 for a bipartisan prescription for patient centered care and system
wide cost containment. So where do we pick up from here ki nd of post seeing the ACA
remaining largely intact at this point, where do we pick up to make this notions of patient
centered care which is in other word saying safe, quality satisfying cure and cost
containment (inaudible 14:56 )

Bill Hoagland: Well I t hink congress has started to even move in that direction that we
had outlined with the report that we put together. But the cornels of the improvement
process were embedded within the affordable care act and that is something they called
the Accountable C are Organizations ACOs. And these Accountable Care
Organizations have talk about restructuring essentially the payment system in such a
way that we move away from paying fee for service. So we move to paying for the
quality of the product that is deliver ed.

But the approach is to move it away from just paying for a service but paying for the
quality and changing our reimbursement system. So the key that came out of our
particular study and as I say is starting to be implemented around the country and in a
private sectors of this collaborative care organizations. It does talk about the restricting
of the delivery system in a way that includes the hierarchy from hospital to physician to
pharmacist to home health care delivery. It puts the whole system of health care into
one basket of it, it's a culture of health issue that we have to focus on. I think we're
moving in that direction, I think it's a system that's going to take some time but to me
that is the answers to change the payment system and to rewa rd quality as oppose to
just rewarding paying for the number of services of doctor a hospital might deliver.

Mark Masselli: You know, we had Governor Deval and he was also focusing on the first
element of the bill around health care in Massachusetts so it 's really about access,
really thinking about how to get good outcomes and how to control cost. You know, tell
us a little bit Bill about the bipartisan center, what's going on there and because this is a
very important group in the work you do is vital f or the country.

Bill Hoagland: The Bipartisan Policy Center as its name would imply is not nonpartisans
it is bipartisan it is republicans who feel strongly and democrats who feel strongly. It
was established eight years ago by four former majority leade rs of the United State
Senath Senator Bob Dole recently passed away, of course Senator (inaudible 17:07 )
Baker on the republican side. Senator Tom Daschle and Senator George Mitchell. And
the four leaders came together who had work though the congress wh en it was more
bipartisan and was more accommodating to understand the other person and to work
with the other person to come to solutions. Energy policy that's where it began is
focused on right now a number of areas in health care that I'm involved in. Obviously a
cost containment being one of them, we're also focusing on long term health care one of

the other major elements that was not addressed in Affordable Care Act, long term
institutional or non - institutional or home base care. We're focusing on prevention issues
we had a former Secretary of Agriculture Dan Glickman and Donna Shalala who are
involved with working with those on prevention issues, part of this health care issue is
really goes back to culture of life, what we eat how we exercise thos e are major
elements in terms of preventing cost going forward in health care. And so we're
focusing on those three health innovation big issue. The issues associated with health
information technology, the transfers of information, we're also focusing r ight now on
food and drug administration and we're talking about cost is and that are some of these
drugs that are coming on the market are extremely expensive. This gets very difficult
because then we're getting into some ethical issues as to whether the y should or should
not be charging prices for such large drugs. As an old budgeter I remain focused on the
long term debt of this country and other way to address that. So a number of factors
we're always busy and thank you for the call out for the Bipar tisan Policy Center.

Margaret Flinter: Great, we've been speaking today with Bill Hoagland Senior Vice
President of the Bipartisan Policy Center. You can learn more about their work by going
to bipartisanpolicy.org. And Bill thank you so much for joining us on Conversations on
Health Care today.

Bill Hoagland: It's been my pleasure, thank you very much.

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Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it comes to the facts about healthcare re form and policy. Lori Robertson is
an award winning journalist and managing editor of FactCheck.org a nonpartisan, non -
profit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

L ori Robertson: In his speech announcing that he was running for president Donald
Trump claims that under Obama Care, Health Care premiums were going up 29, 39, 49,
even 55% that's misleading. He's talking about proposed rate increases for 2016 for
some p lans on the individual market. But it's unclear whether such increases will be
approve by state insurance regulators. And other plans have proposed decreases in
rates or single digit increase.

The Affordable Care Act requires insurers to submit any propo sed rate increase above
10% for individual and small group market plans to state and federal regulators for
review. This plans will be sold on a state and federal exchanges as well as during
(inaudible 20:16 ) for individual buying their own plans. Most A mericans get their
insurance coverage through work and their premium have been rising at low rates
recently. The average family plan premium for employer policies went up 3% from 2013

to 2014. But the individual market is different insurers must now acce pt anyone who
wants insurance and they can't charge policy holders more based on health status like
they used to. Trump (inaudible 20:42 ) a 55% increase and in fact there are plans that
have requested increase that high and even above.

In New Mexico for i nstance where Blue Cross Blue Shield grants that reduced premium
for 2015 now want to increase them substantially. But the publish rate request only
include those that are above 10%. In Indiana four of the nine insurance company
selling plans on the exch ange are proposing to decrease premiums and the largest
insurers has proposed a 3.8% increase according to the Indianapolis star. And that’s
my fact check for this week, I'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 of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you'd like checked email us at
chcradio.com we'll have FactChe ck.org's Lori Robertson check it out for you here on
Conversations on Healthcare.

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Margaret Flinter: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday lives. Tens of millions of p eople
around the world have conditions that make it impossible for them to speak on their own
requiring them to adopt a computerize voice box for communicating. Perhaps the most
well know of thi s folks is the physicist Stephen Hawking.

Stephen Hawking: I would thought it was fairly obvious what I meant.

Margaret Flinter: The problem is that sound of Hawking speaking through his voice box
is the same voice sound say that a ten year old girl with a neurologic disorder might be
(inaudible 22:19 ) use as well .

Dr. Rupal Patel: In the US alone there are 2.5 million Americans who are unable to
speak, that's millions of people worldwide who are using generic voices.

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

Dr. Rupal Patel: There had to be a way to reverse engineer voice from whatever little is
left over. We set out to create custom crafted voices that captured their unique vocal
identities.

M argaret Flinter: Creating 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 melding a donated voice with a footprint of whatever natural sounds the
perso n is able to make.

Dr. Rupal Patel: Why don’t we take the source from the person we want the voice to
sound like and borrow the filter from someone about the same age and size, because
when we mix them we can get a voice that's as clear as our surrogate a nd is as similar
in identity to our target talker.

Margaret Flinter: 16,000 people have signed up to be voice donors at the Human Voice
Bank Initiative, volunteers like this little girl will read a serious of simple phrases over a
several hour period.

Female: Things happen in pairs, I love to sleep, the sky is blue the 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 v oice with my friends.

Margaret Flinter: Such speech synthesis will give that person the dignity of a speaking
voice that is as closely match to their own identity as possible.

Dr. Rupal Patel: They say that giving blood can save lives, giving your voice can
change lives.

Margaret Flinter: Dr. Patel who si a Professor of Computer Engineering at Northeastern
University has launched the website vocalid.com.

Dr. Rupal Patel: I imagine a whole world of surrogate donors coming together to give
people voices t hat 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 lugaric
disease or stroke will be giving the c hance to communicate and a voice may just for the
-- the human voice bank initiative matching vocal donors with millions of people who
seek to authentically communicate with friends and family and 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'm Margaret Flinter.

Mark Masselli: And I'm Mark Masselli, peace and health.

Female: Conversations on Healthcare broadcast from the campus of WESU at
Wesleyan University. Streaming live at WESUFM.org and brought to you by the
community health center.