Dr. Jonathan Oberlander, Professor of Health Policy & Management, University of North Carolina-Chapel Hill.

( Music )

Mark Masselli: This is a Conversation s on Health Care , I’m Mark Masselli.

Margaret Flinter: A nd I’m Margaret Flinter.

Mark Masselli: Well Margaret another budget deadline in congress and another
standoff.

st
Margaret Flinter: And another new w ord, sequester, the March 1 budget deadline
looms large with the sequester about to kick in and the two parties disappointingly
remaining true to form and trenched in their respective camps and this is a dangerous
game Mark.

st
Mark Masselli: If there is no deal by March 1 , hundreds of billions of dollars in
spending cuts go into effect immediately across multiple governmental agencies and
that will generate some negative consequences, with funding from many programs at
risk for being cut including healt h care.

Margaret Flinter: Well I saw the New York Times recently printed a very specific list of
the children who will lose their positions and head start, the women who won't get
mammograms and one area where that political recalcitrant does seem to be falling
away those with the Medicaid expansion to include more people living close to the
poverty line, called for under the Affordable Care Act but rendered optional by the
Supreme Court decision just last summer.

Mark Masselli: Florida’s governor has j oined the growing list of states who were
vehemently opposed to the health care law. Governor Rick Scott just announced that
he’s reversing his position and agreeing to expand Medicaid. Pressures from health
care industry and consumer advocate groups imp acted his decision.

Margaret Flinter: He joined states like Michigan, Arizona and Ohio who first opposed
and now have agreed to the Medicaid expansion which will be covered entirely by the
Federal Government for the first three years and I think a very p ragmatic decision on
their parts.

Mark Masselli: I think you are right, but the jury is still out, the legislatures of those
states must approve expanding the Medicaid roles in some states like Florida with a
republican majority in the legislature that m ay pose a challenge.

Margaret Flinter: Our guest today is an expert on the politics of health reform and in
particular the challenges that remain somewhat of a threat to aspects of the Affordable
Care Act.

Mark Masselli: Dr. Jonathan Oberlander is the professor of Social Medicine and Health
Policy at the University of North Carolina - Chapel Hill. He writes extensively on health

care politics, author of several books on health care including the ‘The Political Life of
Medicare”.

Margaret Flinter: And F actCheck.org ’s Lori Robertson uncovers yet another false claim
about health reform.

Mark Masselli: No matter what the topic you can see all of our shows by googling CHC
Radio .

Margaret Flinter: And as always if you have comments, email us at c hcradio.c om or
find us on Facebook or T witter because we love to hear from you.

Mark Masselli: We’ll be getting to our interview with Jonathan Oberlander in just a
moment but first here is our producer Marianne O'Hare with this week ’s headline news.

(Music)

Mar ianne O'Hare : I’m Marianne O'Hare with these the health care headlines . (2:32
inaudible) eleventh hour deal, it appears as though congress is unable or unwilling to
head off illuming reduction in across the board federal spending. The so called
st
sequeste r is s l ated to go into effect on March 1 and while there are some whispers
from certain camps about willingness to compromise on certain budget issues, the
leadership appears headed for a standoff . Conservative GOP leader is warning
speaker John Boehner if he caves on the President’s Call for Tax increases on the
wealthiest Americans to address some of the budget deficit , he might lose the support
needed to keep his job as speaker. Meanwhile other conservatives like Senator
Lindsey Graham say, they are willing to compromise on some revenue increases as
long as the president is flexible on spending on entitlement programs like Medicare and
Medicaid.

The nation’s governor state budget directors, hospital administrators and research
scientists are all br acing for the impending cuts which are arbitrary and across the board
and can seriously impact their ability to meet their obligation. Serve their patient
populations or keep their research going if sequestration is allowed to proceed . And
Russian Presid ent Vladimir Putin not often viewed as a pay of public health reform is
taking a (3:40 inaudible) step forward. He’s signed a measure into law this week
banning smoking in most public places. 40% of Russian s smoke costing the nation $50
billion a year in health cost. I’m Marian ne O’ Hare with these health care headlines.

(Music)

Mark Masselli: We’re speaking today with Dr. Jonathan Oberlander , professor of Social
Medicine and Health Policy & Management at the University of North Carolina - Chapel
Hill. Dr. Oberlander is a leading expert on health care politics with the specific focus on
the cost of health care and is author of several books including the ‘The Political Life of
Medicare” and ‘The Social Medicine Reader”. He’s a contributor to the New Eng land

Journal of Medicine and the Journal of Health Politics, Policy and Law. Dr. Oberlander
is the Russell’s Sage Foundation scholar and earned his PhD in Political Science at
Yale University. Dr. Oberlander welcome to Conversations on Health Care.

Dr. Jonathan Oberlander : Thanks so much for having me on.

Mark Masselli: You know , you’ve been analyzing the politics of health care reform in
this country dating back to the start of the last century, in your recent article in the New
England Journal of Me dicine, the future of Obama Care , you state that the passage of
the Affordable Care Act was a landmark a chievement for President Obama and his
reelection sealed its fate but you say that frets the law far from over in the opponent s of
health care law are d eploying tactics to delay and to fund this law. Tell us what you see
as some of the most vulnerable aspects of the Affordable Care Act.

Dr. Jonathan Oberlander : Well I think it’s important to emphasize that the a lot really
has crossed a threshold since 2010 but the threat of (5:17 repeal ) really has receded
given the ruling by the Supreme Court up holding the constitution ality. S o at this point , if
we’re looking for vulnerable parts of the law maybe some that have escaped de tention
we might start first with the IPAB that would not be the iPad which is not vulnerable. But
the IPABM the Independent Payment Advisory Board which is a commission of 15
experts that if Medicare spending exceeds a specified threshold, they would have the
power to make recommend ations to slow down Medicare spending that would go to
congress and if congress didn’t do anything, those recommendations would go in the
law. It’s been very controversial from the beginning and actually no t one person has
been confirmed to the panel yet and it’s not clear to me if anybody is going to be
confirmed if they can get the necessary votes and the senate. S o I think we’ll expect
we’ll hear a lot about that because I think that institution is in some ways overrated and
not essential to containing cost as we’ve been led to believe.

Another area that I think is vulnerable that we ha ve not heard about is the employer
mandate, the requirements in the Affordable Care Act that firms with 50 or more
employees that don’t provide health insurance that a re workers and the workers wind up
getting subsidized coverage from the government that they have to pay a penalty. I
think that’s actually a substantial political (6:41 Inaudible) feel, we haven't heard more
about it but if the American economy is still struggling ne xt year and I hope it’s not but if
it is I think you’ll see republicans really target the employer mandate and say we can't
afford to impose any call center employers when we’re trying to climb out of this
economic hole. I don't know if they’ ll be able to do anything about it given that they
don’t control the senate but I do think you will hear a lot of debate about the employer
requirements.

Margaret Flinter: Jonathan there’s been some interesting shifts and changes in
innovation already fo r one thing that’s going forward that just as it seems to be on the
radar of most Americans is this co - op plan option. I understand that a number of the co -
op health plans have now been approved which should really be member owned and

governed. Can you m aybe sure with us a little bit about your thoughts on the status of
those plans and what impact they are likely to have ?

Dr. Jonathan Oberlander : Yeah I don't it’s going to have much impact actually . So the
co - op was sort of a consolation price to liber als who didn’t get the Medicare like public
option that they wanted so badly out of healthcare reform, didn’t get a national health
insurance exchange which was another consolation price and didn’t get a Medicare
buying and expansion in Medicare for folks who are age 62 to 65. So this you know if
you are scoring at how may Olympics, they don’t give medals for fourth place and that
was sort of fourth place and so the co - ops are supposed to be nonprofit ways of
delivering health care, structuring and so fort h. So that they sound good and in fact we
have funded some co - ops but actually much of the money that was left has been
resented already. And you know a lot of changes have happened to the Affordable
Care Act and that already it is very much a living law n and one of the change s i s they
actually have resented the funding, that would have expanded the co - op program and
so I think in most parts of the country it’s going to be a very negligible impact and I don't
think it’s realistic to believe that new nonpr ofit organizations are going to be able to
compete with the behemoth of American health insurance.

Mark Masselli: Jonathan, I want to pull the thread a little more on some of those
vulnerable areas of the health care law that are soon about to take cente r stage and
one of them that we’ve been following is the development of the online insurance
exchanges. What do you think in terms of the significant savings that we’ll see from and
what troubles you as you think about the execution on this very important element of the
Affordable Care Act?

Dr. Jonathan Oberlander : I think the key is to understand the exchanges are up front in
a broader war over Obama Care that has not ended. Another thing over republic and
congress voted for the Affordable Care Act and there was and is a tremendous partisan
divide . Exchanges actually were an idea that had originally a lot of conservative and
republican support because if you think about what they are they are really clearing
houses for a private health insurance and one of the basic theories behind an exchange
is we should have more competition and so republicans of all different stripes including
Paul Ryan have endorsed different forms of an exchange in their own health plans and
if you look back at the public opinion d ata the exchange idea was the most popular idea
of an y in the Affordable Care Act and so you are quite right and about half the states so
far had said no thanks we’re not going to do it and not all of them but most of them
would map onto states that John M cCain and Mitt Romney won red states. And then I
think at this point there are couple of questions of the exchanges. One question is how
ready is the federal government going to be to run exchanges in a couple of dozen
state s which is a much bigger task and I think people anticipate it.

In the long run having more of a federal exchange might actually be simpler and more
efficient but in the short run how ready are they going to be. Second question is how
ready are the states going to be and a lot of s tates were simply hoping that the law
would be overturned by the Supreme Court and they are not prepared, so there’s a real

question and even in the states that are gung - ho about this, this is you know a difficult
task and not an easy thing to set up. And I think a question that sort of is above all of
that is how many of the eligible folks are we going to enroll, the people who are eligible
for subsidies in the health insurance exchange were eligible for Medicaid, how many of
them are we actually going to get. You know Massachusetts has done a great job in
enrolling people in their health plan which was the model for the Affordable Care Act but
this was a Bipartisan Law in Massachusetts with governor Romney supporting it , it
passed almost unanimously in t he state legislature and a real question I have is how
this is going to play out in states where there is not bipartisan support and we know
already that there’s tremendous state variation and signing up eligible people from
Medicaid . Now , it’ll be intere sting to see how that plays out both in Medicaid and the
exchanges in the coming years.

Margaret Flinter: Well Jonathan you just at the end of your comment there, we’re
speaking to Medicaid expansion which certainly seems to be one of the vulnerable
aspe cts of the healthcare law and not just finding people but actually figuring out how
across the country are we going to resolve this sort of patchwork quilt of Medicaid
expansion. How do you see this planning out politically at the state level and the fede ral
level , will there ultimately be about practicality and the reality that their health care of
hospitals and institutions can do much better by taking advantage of the federal support
for the increased expansion ?

Dr. Jonathan Oberlander : I hope so but I am worried that at least in the short run
ideology is going to trump pragmatism . Nobody envisioned that the Supreme Court was
going to rule that the Medicaid expansion was essentially optional for the states. That
came as a shock to a lot of legal scho lars and people who follow Medicaid, it certainly
came as a shock to the people who wrote the Affordable Care Act because the way the
act was written , people up to about $ 14,000 or so are eligible for Medicaid nationally
across the country regardless of th eir demographic category which is a breakthrough in
Medicaid policy. And above that up to about four times the federal poverty line, people
would get subsidies in the exchange. But there’s no provision in the law that says that if
you are in a state that doesn't do the Medicaid expansion , that you wi ll be eligible for
subsidies to go in the exchange, in other words , if you are living in a state like Texas or
a state like Louisiana or maybe a state like my own and North Carolina which may not
take the Medi caid expansion and you are very low income and your state does not do
the Medicaid expansion, you are not eligible for subsidies to go in the exchange, you
are going to remain uninsured. So there’s a terrible gap here because of the Supreme
Court decision that’s going to leave millions of low income Americans uninsured.

Let's be clear that the Medicaid expansion is a tremendous deal for the states. A 100%
paid for by the federal government at the beginning after a few years, 90% that’s a
much better de al than they get from the federal government . Now on Medicaid we
know that Medicaid expansion is good for state economies because if you insure low
income people they have more money left over to purchase other goods and services
which is good for economi c growth. We know that Medicaid expansion is good for
health outcomes, saves lives and we know that Medicaid expansion will be good for

hospitals and other medical providers . So there’s a compelling case for states to do the
Medicaid expansion but again this is even more politicized than the exchange issue and
given the ideological nature of debates over health reform and over Medicaid and given
that 25 states and nor do the exchanges. I think quite a few states are going to say no
at the beginning to Me dicaid. Now there are hospital lobbies, you are right are going to
pressure them to say yes but I think a lot of them at the beginning are going to say no
but in the short run, I think the real significance of this is a lot of low income Americans
are goi ng to be caught in a rather gaping hole in the Affordable Care Act safety net.

Mark Masselli: We’re speaking today with Dr. Jonathan Oberlander , professor of Social
Medicine and Health Policy & Management at the University of North Carolina - Chapel
Hill. Dr. Oberlander is the author of several books including the ‘The Political Life of
Medicare” and “The Social Medicine Reader”. Jonathan as I was listening to you, I was
sort of harking back to an interview we did recently with David Gergen who also share s
your concern that the Affordable Care Act was such a partisan divide in our country and
I wonder how do you envision this Affordable Care Act ever recovering from this . Do
you see any seam of opportunity to bring sides together that can slowly stitch th e nation
back together to understand the importan ce of this to individual constituents, what's the
pathway politically to bring the country together?

Dr. Jonathan Oberlander : Well I am going to say something that is going to sound a bit
morally obtuse bu t I think the main pathway is actually not to focus on what it does for
low income Americans but to focus on what it does to protect Americans you have
insurance, both private insurance and Medicare. This was the great feeling politically of
th
health reform ers in 2009 and 10 and actually stretching back from (15:49inaudible) 20
century as well. You know the uninsured are disproportionately low income, they don’t
get as much medical care as the rest of us. They die at a higher rate because they
don’t have health insurance but they are not politically powerful. They don’t vote at a
high level, they don’t have a lot of money and so on. And so if you want to win a health
reform debate, you have to persuade Americans who already have insurance which is
about 83 - 84% of us that health reform is in their interest and I think if there’s a path
forward for the Affordable Care Act, it is people experiencing it and understanding that
when you actually look at what it s doing for me and for my family and for my friend s, this
is not too bad, this is not as scary as we thought.

The second path forward is to persuade folks with Medicare and folks with private
insurance that this law is good for them and that it helps their children who are under
age 26 stay on their co verage, that it expands their access if they are on Medicare to
preventive services, that it has new rules on insurance plans that prohibit them from
annual and lifetime limits on coverage that protect American families from going
bankrupt. So I think tha t’s the case that has to be made and you know there’s a lot of
controversy when Medicare was enacted in 1965 as well and of course in Medicare very
quickly rose to become a popular program but the Affordable Care Act is different in at
least two respects. One, the political environment is much more divided on partisan
lines and it was in 1965 , and second , Medicare is an easier program to understand and
the Affordable Care Act is not a single program, it’s a series of policies and subsidies

and regulations and programs that affect different groups of Americans in different ways
at different times. And that makes it more difficult to explain to people and it makes
more difficult to explain to folks what the benefits are. I mean I don't think most insured
Am ericans understand what the Affordable Care Act will do for them.

Margaret Flinter: Well Jonath a n, I’d like to ask you to speak to one of the areas of I
know your great expertise in and that’s the cost containment piece and you’ve written
extensively abo ut the inherent challenges of containing cost in a system that so many
derive their revenue, their income and their profits from . You’ve said that the law only
throws darts at cost containment, tell us what you mean by that and how would you like
to expan d those darts to a more comprehensive strategy.

Dr. Jonathan Oberlander : You know universal health coverage is a very difficult goal
and it’s something we’ve been fighting in this country about for a century and when
Massachusetts passe d their Health Ref orm Law in 2006, the national reformers had a
model but the sub - sensitive model and a political model. When Massachusetts enacted
their Health Reform Law, they said look , it’s so hard politically just to expand coverage
for the uninsured , we’re not going to do health care cost really at the beginning and to a
large extent that’s what the Affordable Care Act, it is well now that there’s n o question
that Affordable Care Act has more cost containment than in Massachusetts but
nonetheless I think most of it is what I would call throwing darts and that what I mean by
that is there are lots of ideas in the health policy research community, electronic medical
records and patient centered medical home. And basically what the Affordable Care
Act does in the theory behind in cost control is let’s just throw all those ideas at the
board at once like darts . A nd we don’t really know which one are going to stick and let's
just hope that one or two stick and so the proponents of this would say it’s you know its
stronger because it has a diverse strategy . A nd my response to that is I don't really
care how many cost containment tools there are, I care how many are effective. To me
it’s not about how many strategies we have, it’s about having effective strategies and
well I completely sympathize with the political calculation and don’t think that the
Affordable Care Act would have passed with stronger cost control, I do think over time
we’re going to have to move to strengthen it.

Mark Masselli: We’ve been speaking today with Dr. Jonathan Oberlander , professor of
Social Medicine and Health Policy & Management at the University of North Carolina -
Chapel Hill. Dr. Oberlander is the author of several books including the ‘The Political
Life of Medicare” and “The Social Medicin e Reader”. Thank you so much for your time
today.

Dr. Jonathan Oberlander : Oh thanks for having me on , I really enjoyed it

(Music)

Mark Masselli: At Conversation s on Health Care we want our audience to be truly in the
know when it comes to the facts about healthcare 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 reduce the level of deception in U.S.
politics. Lori , what have you got for us this week?

Lori Robertson: Well , Mark and Margaret we found some misleading tweets from house
republicans including Speaker John Boehner who claim that the Obama administration
was spending $1.2 million “paying people to play videogames ” but t he 1.2 million went
to university research that studie d how videogames can stimulate the cognitive abilities
of seniors. This Twitter campaign started with House Majority Leader Eric Cantor who
tweeted that “ President Obama wants to raise your taxes so he can pay people $1.2
million to play World o f War c raft ” and more G O P tweets were launched the following
day. None mentioned that the videogames were part of a cognitive study of seniors.
The project in question, doesn’t even use the World of Warcraft gam e that Cantor and
others mentioned but it does use the Wii game Boom Blox . The $1.2 million was grant
money awarded by the National Science Foundation to a project at North Carolina State
University's games through gaming lab . The research that how video games can
improve everyday abilities such as memory a n d reasoning and seniors can broadly
sought together knowledge on how cognitive training can reduce the client as people
age. We take no position on whether the government should have funded the projec t
but the GRP tweet s twist what the grants are all about. And that’s my fact check for this
week. I’m Lori Robertson Managing Editor of Factcheck.org.

Margaret Flinter: F actcheck.org is committed to factual accuracy from the country’s
major political p layers and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania . If you have a fact that you ’d liked checked e - mail us at
c hcradio.com , we’ll have Factcheck.org ’s Lori Robertson check it out for you here on
Conversations on Health Care.

(Music)

Margaret Flinter: Each week conversations highlight a bright idea about how to make
wellness a part of our communities and everyday life’s . It’s no secret that baby
boomers are ageing in large numbers and that means that those suf fering from age
related dementia around the rise as well. Four million Americans live with Alzheimer's
disease and we know that number will double by 2025. No cure and few drugs that can
stay off, its devastating effects. (22:48 Daniel Cone ) has devised a tool that is
improving the experience for these patients who’s quality of life declines along with the
loss of brain function. He wondered what will happen if you provide iPads for patients in
nursing home s that are loaded with their own personal playl ist of the songs they loved
when they were younger . In his first pilot program called Music and Memory , patients in
a nursing home were given the iPads with their own personalized song list and the
results instantly noticeable. Patients went from being n on - communicative and
disengaged to being animated and engaged. Patients like Henry featured in this
documentary on the program called Alive inside.

(23:24 Video )

Do you like music ?
Yeah, I am crazy about music, getting beautiful music, beautiful soun d.
What was your favorite music when you were young?
I guess Cab Calloway my number one band.
What’s your favorite Cab Calloway song?
(Singing)
(23:47 Video ends)
Margaret Flinter: (23:47 inaudible) explains one of the theories as to why t his progra m
works so well.
(23:52 Video )
See reality is because our memories of music are co - located in the brain with our
autobiographical memories when you say a song that’s familiar you are ticking off
memories that you had.
Margaret Flinter: The results from the Music and Memory program were so impressive
that (24:07 Cowen’s ) personalized iPad program is now being used in 50 nursing
homes throughout North America and many more are lining up.
(24:14)
We’ve done some research and feedback from the front line from the nursing homes
and from the staff is that their ability to provide care is facilitated and so that allow them
to get their job done , to pay attention to all the residents as much as possible and that’s
been a big win as well.
Margaret Flinter: A simple personalized application for a readily available piece of
technology that could dramatically impact the quality of dementia patient’s lives, now
that’s a bright idea.
(Music)
Margaret Flinter: This is Conversations on Health Care , I’m Margaret Fl inter.
Mark Masselli: And I’m Mark Masselli, peace and health.

Conversations on Health Care broadcast from the campus of WESU at Wesley an
University streaming live at wesufm.org and brought to you by the community health
center.