Stuart Altman, Ph.D, Heller School of Public Policy, Brandeis University

Stuart Altman

(Music)

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

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret, we're ending the year on something of a somber note,
the number of mass shootings in the country continues to escalate with no signs of
abating.

Margaret Flinter: While the proliferation of gun violence continues to dominate the
headlines, Mark, little if anything is being done about it and especially at the
congressional level. Pretty alarming when you consider that an estimated 32,000
people a year die from gun related causes in this country.

Mark Masselli: And, you know, with any public health threat of this magnitude we need
to have good data to back up some policies. There's been a 20 - year ban in placing
congress so called Dickey Amendment which bans the use of federal funds to study the
impact of gun violence in this country. And there's a growing call to end that ban from
the medical professions in a growing number of members of congress.

Ma rgaret Flinter: Well, we're just missing something from this narrative, an estimated
89 people a day die from gun - related causes in this country and domestic violence
incidents, and suicides, accidental death and violent crimes. And those daily
occurrenc es don’t make the headlines. So we need to support sound federal policy on
gun violence, Mark, including studying the issue, and that's going to take some solid
data.

Mark Masselli: Our guest this week is something of an expert on data surrounding
Univer sal Health Coverage in the United States, Dr. Stuart Altman is a noted Health
Economist at the Heller School at Brandeis University and his long involved in the
issues of universal coverage going back many decades.

Margaret Flinter: And Dr. Altman is also the Chair of a National Academies Committee
which has been analyzing progress since the IOM or Institute of Medicine’s ground
breaking Future of Nursing report released in 2010 which seek to enhance all aspects of
the nursing profession. And his committe e has just issued their five - year progress
report.

Mark Masselli: Lori Robertson stops by the Managing Editor of FactCheck.org is always
on the hunt for misstatements spoken about health policy in the public domain.

Margaret Flinter: But whatever the top ic you can hear all of our shows by going to
chcradio.com.

Stuart Altman

Mark Masselli: 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 Dr. Stuart Altman 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'm Marianne O'Hare with these Health Care Headlines. H ealth care
cost on the rise, health care cost in the U.S. hit the $3 trillion mark for the first time in
2014, up about 5.3% in spending from the year before. When the spending growth rate
was at its lowest in 55 years, just 2.3%, what's behind the increa ses comes as more
notable. In 2014, the fastest growing line item in the national health expenditures was
prescription drug spending which grew dramatically 12.2%. Expanding coverage under
the Affordable Care Act was a driving factor behind the rise, all owing more people
access to medical care and prescriptions that might have previously been out of reach.
On that note, the majority of Americans now believe the government should be
responsible for ensuring all citizens have health coverage albeit a sligh t majority 51%
overall. Those under 50 were more likely to be in favor of government supported
coverage than those over 50 and a vast majority of democrats about 80% were in favor.

Fitness wearables were one of the hottest ticket items on Black Friday thi s year.
Apparently some 50 million Americans use some kind of health tracking device. After
this Christmas that number could go significantly higher.

And genetically engineer or not to, the international summit on human gene editing
convened debate anoth er conundrum how far should scientist go, when editing human
DNA. The main focus was whether scientist should be allowed to use powerful new
genetic engineering techniques to edit genes in human eggs, sperm or embryos an
extremely controversial step that raises a host of safety and ethical issues. The
committee recommends intensive basic researches clearly needed and should proceed
so they can explore the safety and potential benefits of editing that kind of DNA. I'm
Marianne O'Hare with these Health Car e Headlines.

(Music)

Mark Masselli: We're speaking today with Health Economist, Stuart Altman PhD, the
Sol C. Chaikin Professor of National Health Policy at Brandeis University, where he also
served as Dean of the Heller School of Social Policy and Manage ment. Dr. Altman
serves as chairs of both the Health Industry Forum and the Council on the Economic
Impact of Health System Change, also chair of the IOM committee on assessing

Stuart Altman

progress and implementing their recommendations of the Institute of Medicine’s report
on the Future of Nursing. He served on President Clinton's Bipartisan Commission on
the future of Medicare and he's a member of the National Academy of Sciences and
their committee on the future of emergency care in the United States. He earned i s MA
and PhD degree in Economics from UCLA. Dr. Altman, welcome back to Conversations
on Health Care.

Dr. Altman: My pleasure.

Mark Masselli: Yeah, you know, I really want to get to the question of how you rank the
ACA's success now that we've had five years. And you have such an interesting perch
[ph] and I think you go back to the early 70s in the Department of Health Education and
Welfare, you served in the Clinton Administration critical in the -- in Massachusetts’
Health Policy Commission and yet y ou've called the Affordable Care Act a complicated
override of a complicated health system. So tell our listeners about where we stand.

Dr. Altman: Well, there's no question that the implementation of the Affordable Care Act
has been complicated beyond w hat most of us expected. I think there are reasons for
the complication, and in general let me state from the beginning that I'm a big supporter
of the overarching outline of the Affordable Care Act. I think it's -- since I believe that all
American shou ld have a good financial protection against high cost health care and I
don’t -- and I think for the most part Americans are not ready for a more revolutionary
program like a single payer. I think this was the only kind of plan that we get past
neverthele ss it has turned out to be quite a rocky road.

Margaret Flinter: Well, professor maybe one of the places we could start is some of the
changes that we're actually seeing in the care delivery system. And you've noted in the
past that the system of reform that we enacted with the ACA is mostly one of payment
reform not care delivery reform. And yet we are seeing some transformation on the
ground and some of it is tied to payment reform such as in Medicare which you have
such a long history with. Maybe you could talk to us a little bit about how some of these
payment reforms like bundle payments for outcomes, how are these things impacting
care delivery systems and how do you think these changes might pave the way for
other sectors to follow?

Dr. Altman: W ell first, many of these changes are related to the Affordable Care Act but
independent of the Affordable Care Act. And there's no question that in the Affordable
Care Act they set up demonstrations to do both what I call accountable care
organizations an d bundle payment. But much of it was happening anyway. So if we're
going to make any significant inroads in terms of slowing the rate of growth and health
care cost, so spending, you know, we have to change the payment system. But fee - for -
service system is a great system for understanding what you buy and what you don’t

Stuart Altman

buy and rewarding people and provide more services which is the way we normally pay
for most things. When in the area of health care, it just turn out to be a way of
overpaying for servi ces and promoting too many services, and more importantly, too
many very expensive services when less expensive would do. So, we need to change
the payment system. And bundle payments and the accountable care organizations is
a way of doing that and allo wing the health care system to adjust itself rather than
having outside forces like government or the insurance companies dictate what services
are available.

Mark Masselli: Well, I do want to shift gears and illuminate the work that you've done as
chair of the committee of National Academies which was formed to assess progress on
implementing the recommendations of the IOM's groundbreaking report, the future of
nursing leading change in advancing health. And this was released back in 2010 it
called for m ajor overhaul of our approach to training and development of the nurse
workforce. You just came out with a five - year progress report, tell our listeners about
your key recommendations.

Dr. Altman: Just to refresh your listeners, the 2010 report really wa s a very path finding
report of the role of nurses in our health care system, how they should be trained. And
more importantly how they should be used. Just to summarize, the two or three most
important recommendations, one was that states should be legi slating allowing nurses
to practice up to the full scope of their training and allow them to provide care
independently, if necessary, and to do it in a way that's consistent with good quality
care. And a number of states have implemented that law.

A seco nd recommendation was that as nurses are being asked to do more in a more
complicated health system they need to be better educated and therefore the
recommendation was that by the year 2020, 80% of the nursing workforce should be
baccalaureate or more. W e've relied very heavily on what we call associate degree
trained nurses, these are individuals who have mostly gone to community colleges and
two - year institutions or three - year. And they have provided the bulk of nursing
graduates. So this report says over time we ought to be moving more and more to four -
year schools. It didn’t say that associate degree program should end, rather they
should continue but then there should be paths that allow individuals trained in this
associates degree programs to get advance training so they get a baccalaureate.

We've seen amazing progress. We've substantially increased the number of what are
called pathways from associate degree to baccalaureate. So, we are seeing a growing
proportion of new nurses who have a baccalaureate trained degree. And as a matter of
fa ct last year the number of baccalaureate trained new nurses has exceeded the
number that come from associate to the first time we've had that. There also was a
strong recommendation for a more diverse nursing workforce. And here too we've seen

Stuart Altman

substantia l progress, the proportion of new nurses who come from backgrounds of Asia,
Afro - American or Hispanic has really grown. And it is by far the highest percentage of
any health profession.

If we're going to have the nursing workforce better reflect the popul ation that it serves,
we need more Afro - American nurses and we particularly need more nurses who come
from Hispanic backgrounds. So, substantial progress has been made but more work
needs to be done.

Margaret Flinter: I wonder, if we could ask you to com ment on another domain and that
was the recommendation for residency programs for both new nurses after the
baccalaureate degree but also for new advance practice nurses when they're
transitioning to a new specialty area. How has the progress been on that ? And what's
the assessment of five years?

Dr. Altman: Another important area of the commission was the value of having one
nurse residency program. We have a number of programs around the country and they
are growing, but there's no one model and while there is good evidence to substantiate
the value of residency training to have a kind of a transitional year while they're
providing care but also in a semi - learning experience is good for the new entrants into
the field. And it's also shown to improve q uality of care. So, these are valuable
programs, the problem is there are not enough of them and there is no clear model. So
we really encourage more evaluation of what model works best. You need better
funding, we think it adds value to the health care system.

Mark Masselli: We're speaking today with Health Economist Stuart Altman, the Sol C.
Chaikin Professor of National Health Policy at Brandeis University, Heller School of
Social Policy and Management. Dr. Altman chairs the IOMs Committee and asses sing
progress on implementing the recommendations of the Institute of Medicines report on
the Future of Nursing. Dr. Altman, you know, we're less than a year out from electing a
new president and I wanted to sort of get back to some of your thoughts about the
Affordable Care Act. We had David Gergen on a little while ago who was supportive of
the ACA but felt -- where it felt short was it just could not garner bipartisan support.
What are your thoughts about how we get there?

Dr. Altman: One of the reas ons for this rocky road is the unwillingness. When I was
really involved in governmental at the real legislative level in the early 70s you had
much more cooperation of cross party lines. You know, the democrats and the
republicans will much more likely to work together. They didn’t know would [ph] agree,
but once there was laws out there they worked to implement them whether it was
Medicare or attempts to slow the growth of health care cost. Now you have this I think
unfortunate split between the democ rats and the republicans. Congressman Ryan, the

Stuart Altman

new speaker is talking about changing every word and -- and, you know, this is just bad
policy.

The Affordable Care Act was compromised legislation to begin with, it built very much
on a republican model in the Nixon Administration and the one that was created in
Massachusetts by republican Governor Romney. It is not an advocacy position only
from the left side, and yet you would think listening to the right wing republicans that it's,
you know, the devil re incarnate. I'm really looking forward to what Congressman Ryan
wants to propose and, you know, he's a smart guy. And, you know, there may be a
number of proposals that he's coming up with that really would make the Affordable
Care Act better. So I don’t want to be the only critical about changes and I do think the
democrats need to listen to him. But if he's just going to throw the whole thing out and
really not accept the idea of universal coverage then, you know, we're in for a very
stormy period.

Mar garet Flinter: But Dr. Altman, two things that certainly strengthen the Affordable
Care Act were the support for the expansion of community health centers now serve 23
million people but also the expansion of Medicaid. What's your sense of the impact on
the investment both in expanding community health centers but also in perhaps more
importantly an expanding Medicaid coverage in the states where that's happened?

Dr. Altman: This is the largest ambulatory delivery system in the world and it's been
very i mportant for the health care system particularly for serving low income
populations. I chaired in 2000 an Institute of Medicine study on the future of the safety
net. And here's a case where this has been a bipartisan plan, it's an important program
that needs to continue, Medicaid itself is sort of designed to give individuals who are on
the program a kind of a card that allows them to go anyplace. And so some people say
well, if we have Medicaid we really don’t need these community health centers, but
that's just not correct.

I think that they work together, for many people these community health centers,
neighborhood health centers are really the best place for them to get care. So the
expansion is working in many parts of the country. So on one side we need to expand it
in the states that haven't expanded. On the other, I do think that the administration
needs to be as flexible as possible in allowing individuals state to tailor their programs.
We shouldn’t acknowledge that all states are not the s ame.

Mark Masselli: You've noted in the past that we've made a mistake by not including
physicians and surgeons in health reform in your futures of nursing recommendation
suggest as well that the nursing profession should be part of their care delivery sy stem.
And I was thinking about all of those in the context of the redesign of the health care
system. In the context of, you know, professional collaboration, right, how do you really

Stuart Altman

get at this sort of paradigm shift where you sort of need all of the k ey players talking to
each other? Talk to our listeners about the larger concept of -- we need to put these
professional groups together, working together, so we can get good outcomes for our
patients.

Dr. Altman: That was the central focus of much of ou r recent report. The health care
delivery system is moving away from a fee - for - service individual practitioner model
towards a more collaborative team base system. And so some of, if not much of the
argument against the expanding scope of practice for nu rses, well, it's fair to say that
increasingly that argument is sort of unnecessary because our delivery system is
moving away from the fee - for - service individual practitioner any way. And so in these
team base chair models you do find physicians much mor e willing to allow nurses to
practice up to the level of their license and to do it in a more independent way. And you
have supervision in the sense that it's part of a team effort. So, as we expand these
accountable care organizations I think a lot of t his antagonism will just go away. And
that's what we found as we went through the literature in this recent report.

Margaret Flinter: We've been speaking today with Health Economist Dr. Stuart Altman,
he's the Sol C. Chaikin Professor of National Health Policy at Brandies University's
Heller School for Social Policy and Management. And he's also the chair of the Institute
of Medicine Committee assessing of the IOM report on the Future of Nursing. You can
access that report at NationalAcademies.org. Dr. Altman, thank you so much for joining
us on Conversations on Health Care today

Dr. Altman: Thank you very much for asking me.

(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the fact s about health care reform and policy. Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for voters that aim to red uce the level of
deception in U.S. politics. Lori, what have y ou got for us this week?

Lori Robertson: Hillary Clinton said at the democratic presidential debate in November
that nearly 3,000 people had been killed by guns including 200 children since the
democrats had last debated about a month before. Some of our readers asked us if
that was correct, comprehensive data on that specific timeframe isn't available instead
Clinton extrapolated the numbers based on figures on gun deaths from past years. In
2013, there were 33,636 gun deaths, according to the Centers f or Disease Control and
Prevention, that averages to about 2,800 gun deaths or nearly 3,000, as Clinton said,
each month of the year. These are the most recent numbers from the CDC, they
include suicides which made up 63% of gun deaths that year, homicide 33% of gun

Stuart Altman

deaths and unintentional discharges, legal interventions or war and undetermined
causes.

As for firearm deaths of children, the Clinton campaign relied on figures from 2010. The
2013 CDC figures for children 19 and younger back or up those gun deaths average
205 per month. But if we look only at those ages 17 and under the average killed by
month was 105. We won't know the number of gun deaths for 2015 for another year or
so and even then we won't be able to look at the number for a specific t ime period as
Clinton cited.

A group called the Gun Violence Archive seeks to provide near real - time tracking of gun
incidents through media government and other sources. For 2015, it counts 11,633 gun
deaths through November 18, but that number doesn’t y et include suicides which the
group says are not reported the same way as other incidents. The group executive
director told us Clinton's 3,000 figure would likely be right, once suicides are included.
And that's my fact check for this week, I'm Lori Rob ertson, 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 would like checked, email us at
www.chcradio.com . We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Health Care.

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. For all the people in the world
without limbs acquiring prosthetics can be costly and out of reach. It's especially
challenging to make prosthetics for chil dren since they are in constant state of growth.
Rochester Institute of Technology scientist Dr. Jon Schull stumbled upon a clever and
affordable solution, provided online open source templates to anyone, anywhere in the
world who has access to a 3D print er and provide prosthetic hands for next to nothing.

Dr. Jon Schull: I've made this Google Maps Mashup, if you have a 3D printer and you'd
like to help put yourself on this map. And if you know someone who needs a hand, put
yourself on this.

Mark Masselli : So he founded the e - NABLE Network which has massed thousands of
volunteer makers in upwards of 40 countries around the world, providing cheap but
functional prosthetics for children in need.

Dr. Jon Schull: We know that we've delivered about 800 hands devices. And we
suspect that is comparable number have been downloaded by people we can't track
because we put all of our design on the Internet.

Stuart Altman

Mark Masselli: The movement has grown so rapidly, the simple limb designs have
become more sophisticated as recipients of the prosthetic devices provide feedback for
designers to make more efficient devices.

Dr. Jon Schull: These things grip or ungrip that's all they do. So they are much less
functional than our biological hand and they are also less functiona l than a fancy
Myoelectric hand. But for kids it's huge, because those expensive devices are typically
out of reach for children who are now below them so it doesn’t make sense for those to
get a $5,000 or $10,000 hand. And, you know, our hands don’t eve n pretend to look
like regular hands they look like super hero, Iron Man hand and for that very reason
they're very popular with kids.

Mark Masselli: e - NABLE a global collaborative network of open source designs linking
to makers with 3D printers to provi de low cost prosthetic limbs to children and adults
around the world who might otherwise not be able to afford them, now that's a bright
idea.

(Music)

Margaret Flinter: This is Conversations on Health Care. I'm Margaret Flinter.

Mark Masselli: And I'm 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 the Community
Health Center.