Dr. H. Jack Geiger, Physicians for Social Responsibility

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Mark Masselli: This is conversations on healthcare I am Mark Masselli .

Margaret Flinter: And I am Margaret Flin t er .

Mark Masselli: Well Margret we have arrived at that threshold of the next phase
of the Affordable Care Act online insurance exc hanges are open for business this
week.

Margaret Flinter: That’s right Mark and now consumers will be able to sho p for
th e affordable health insurance in th i s new o nline marketplaces and ushers in
the new era folks cannot be denied coverage due to preexis ting conditions and
that’s a provision that will strike at the heart and the fears of millions of
American s who grappled with health problems and a lack of coverage , a really
big step forward I think.

Mark Masselli: Well this is notable and important new development. We can’t
ignore the disparity that still exists across the country, only 16 states in the
district of Colombia are setting up their own insurance exchange s and in many
states state government s are working hard to block any assistance in ac cessing
the federal exchanges. Thirty - three now in all and that’s a lot ground to cover
Margret.

Margaret Flinter: Yeah Mark , I have to keep saying, I think w e’re fortunate in the
S tate of Connecticut here we have a r obust plan in place and the pol itical will to
see it through and analyst are finding that folks in S tates who have promoted
their health care law are better informed and more like ly to utilize the health
insurance exchanges.

Mark Masselli: And there are some important milestones , you know , coverage
st
doesn’t acutely began until January 1 2014 b ut if folks are interested in getting
coverage o n the first day of the New Year you’ll have to signup on the exchanges
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by December 15 .

Margaret Flinter: So that’s an important date you have to signup on the exchange
t h st
by December 15 t o be covered on January 1 . But Mark Medica id expansion is
another important aspect to this increase cover age that we have talked about a
lot on our show. More states are expending Medica id coverage and at last count
I think we are up to 26 states which bo ards well for those folks who live above
the poverty line in those S tates but don’t make enough to qualify for insurance or
be able to afford it, i t’s going to help al leviate disparities and access to care and
t hat is something that today’s guest ha s made his life ’s wo r k .

Mark Masselli: Our guest this week is Dr. H . Jack Geiger , w ho i s considered the
founder of the Community Health Cent e r movement in this country having

opened up the first Community Health Cent e r s in the 1960s, he is not only a
physician but a lifelong activist for health equity as well.

Margaret Flinter: And Dr. Geiger is an inspiration to so many of us who ’ve
worked in the field of health care and in Community Health Centers over these
last decades , Mark, so we really look forward to that conversation .

Mark Masselli: We do and we also are going to have a visit from L ori Robertson,
managing editor of FactCheck.org t o d ispel another myth about ObamaCare.

Margaret Flinter: And no matter what the topic you can hear all of our shows by
going to CHC Radio and as always if you have comments please email us at
c hcradio.com or find us o n Facebook or Tweeter because we love to hear from
you .

Mark Masselli: And we’ll get to our inte rview with Dr. H . Jack Geiger in just a
moment but first h ere is our producer M arianne O'Hare with this week’s Headline
New s .

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M arianne O'Hare : I am M arianne O'Hare with these healthcare headlines.
Efforts to d efund Obama C are have continued righ t up to the October f o r a start of
the open enro llment of the o nline insurance marketplaces under the Affordable
Care Act. Over 40 attempts to defend the healthcare law have occurred in the
past year. But conservative ranks in the GOP looking at a last ( 0 :03:21 inaudible )
effort to stop the healthcare law in its tracks. ( 0:03:24 Inaudible ) the def u nding
measures to a must pass bill to keep the government going pas t the end of the
fiscal year , the s o called continuing resolution to keep government running until
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December 15 . Senate Democrat leader Harry R e i d e nsured the measure would
not pass the senate and would be sent back to the house for more discussion .
Meanwhile a series of ad campaigns have been launched across the country
both for and against an d health care law. Some ads urging folks to get covered
using iconic songs like B i lly Joel’s New York state of Mind - in this case it’s New
York S tate of Health . A Virginia based conservative group backed by the
billionaire Koch Brothers launched their o wn campaign urging young people to
opt out of the laws mandate that all Americans have health i nsurance, their first
online ads feature young people going for doctor appointments only to have
Cree p y Uncle Sam popup ready to look them over. The Obama admin istration
set a stage for another Supreme Court showdown on the president ’s health care
l aw this time to decide w he ther fo u r profit companies can be forced to provide a
full contraceptive coverage for their employees despite religious obj ections from
owner s. Administrations lawyers asked just ices to take - up the issue this f all, to
decide whether these corporations can claim a religious exemption to this part of
the health care law. And healthcare expenditures had been slowing down to
historically low grow th rate s in the past couple of years b ut prediction are out for

future health expenditures that a spike is predicted at about 6% growth well
ahead of the economic indicators for the rest of the country. The estimate is still
lower than the t y pical annual increase s before the recession hit. They attribute
that to the rising number of ba by boomers moving into medicare and the
expectation of the economy will improve according to a published online report in
health affairs. I am M arianne O'Hare with th i s hea lth c are headlines .

Mark Masselli: We are speaking today with Dr. H . Jack Geiger , physician,
founding member of Physicians for Human Rights and Physician for Social
Responsibility and the individual acknowledges the father of the Community
Health Centre Movement in the United States . Dr. Geiger is currently professor
at Emeritus at the Sophie Davis S chool of Biomedical Education in New York
City . He is a member of the National Academy of Sciences and the Institute of
Medic ine where he received IO M ’s most prestigious award , the Lienhardt award
for outstanding contributions to minority health and also he is awarded the
Schweitzer Prize for humanitarianism. Dr. Geiger , welcome to conversations o n
health care.

Dr. H . Jack Dr. H. Jack Geiger: I am glad to be here.

Mark Masselli: You know , Jack you ’ re known as the father of the Community
Health Center Movement in this country, model you proposed in 1965 based on
your experience as a young American medical student stu dyin g this sort of new
kind of health care which was called Community Oriented Primary Care in S outh
Africa, what was that new kind of health care that you so w n and how did it
influence the proposals you would later make for the development of the first
Co mmunity Health Center in America?

Dr. H. Jack Geiger: Well I think the most striking thing was the as sumption of
dual responsibility that is that this institution , these community health centers
were responsible not just one by one for all of the indi viduals that came in a s
patients but equally for the he a l th of the population from which they came.
Ending the ( 0:06:43 inaudible ) , e nding se paration between primary care and
public health. When I worked in the examining rooms in S outh Africa, on the
wal ls of every examining room were graphs, histograms of the lowest information
on a prevale nt conditions in that community. Inciden ce rates for infectious
disease and like you could not look at an individual patient wi thout kn owing a lot
about t he popula tio n for which that person came and responsibility for doing
something about it to keep the next patient from coming in with that same
problem.

Margaret Flinter: Jack the seeds of the American Community Health Centre
Movement , th e two community health cente rs , one in Columbia Point in Boston
and one in Mound Bayou Mississippi Delta , really quite quickly grew to include
health center s in many of America’s cities and today of course all across the
country w e have more than 1 , 100 community health centers that s erve 20 million

people but I find it kind of remarkable that the fundamental requirements for an
organization to be recognized by the federal government as a community health
centre r emain remarkably true to your original vision and those principles of
com munity oriented primary care n early 50 years later which is a pretty long run,
I think by anybody ’s standards. Can you describe some of those principles and
requirements for us that you found essential to be in the guid ance that would
govern community hea lth centers in the US?

Dr. H. Jack Geiger: The first was the idea that the most vulnerable population s
of the United States the people in greatest need with the heaviest burdens of
disease needed something other than the fragmented primarily hospital cen ter ed
care. We did a survey at Columbia Point in Boston for example to find out what it
took for a patient to Columbia Point to get to downtown Boston, go to around
patient department clinic and comeback home. The average door to door time
for a patient at Columbia P oint to go get care in Boston and come back home
was 6 hours. And what did you do if you had three small kids and what did you
do if one of the children ha ve a sthma and that was a different clinic that you had
to go the next day. So the firs t principle was of comprehensiveness to put
everything under one roof, to create and when I say everything under one roof I
mean physician, nurse, social worker, pharmacy , laboratory all of the pieces that
required you to run around frantic al ly, i f you wer e of limited means . A nd the
second was the principle of community participation and ultimately community
control of what was now a community institution that belong to the population that
was being served. There is no other branch of the American Health Care
System in which the patient s themselves have that kind of voice in the services
that they are going to receive with regard to health care.

Mark Masselli: Dr. Geiger your work has been all about population health and
about understanding and addressin g what is now called the social determinants
of health and that’s been sort of the heart of the Community Health Centre
Movement and you are now sort of looking at the Affordable Care Ac t in its
principle s of patien t - centered medical home and you ’ve said t hat this is really
great news about the health care law is that community health centre
practitioners no longer will have to carry this weight alone . Tell us how you see
Obama C are addressing population health?

Dr. H. Jack Geiger: Well I think O bama C are is a first modest but enormously
important step for moving us away from very very c ostly, very inefficient
distribution and practice of care away from a free for service emphasis and on
outcomes. At least the process of controlling cost of what has become such an
outrageously expensive and inefficient system and in those respects that it
bankrupt s individual s an d threatens to bankrupt the country. We need to dispel
the myth however that underl ies banking everything Obama C are to the he a l th of
popu lation s i s determined by the very thing s you mentioned, the social
determinan ts of health , what you ’ re exposed to , what happen s to out in the real
world whether urban or rural, your income, your housing, your food, your

exposure to taxes . W hat Obama C are will do is number 1 , greatly improve the
quality and availability of primary care . S econdly , by greatly expanding
insurance coverage the number of people who have access to care i nsurance
alone doesn’t do it but it ’ s critical in providing access to care and that’s bringing
somewhere between 30 and 40 million more people with that kind of regular
access and providing what I have just described a patient - centered medical
home with an emphasis not on the individual procedure but on the goodness of
the outcome. It give s us the opportunity with a marriage of primary car e and
public heath interventions to start addressing the social determinan ts of health.
But we need to understand that unless we create greater equality in the society
no single heath care system is by i ts elf going to survive to produce health
equality. The evidence is overwhelming that encountered in poverty leads
almost in e v ita bly to a shorter life , one burden ed by chronic illness , to lower
educational opportunity , to all kinds of burdens that make one v ulnerable and
limit opportunity and achievement and bring g reater sus ceptibility to disease.
There is a whole series of studies demonstrating that adversity and poverty in
early childhood starts measurably to rewire the brains of those infants.
Healthcar e system is it going to be able to address that by itself?

Margaret Flinter: Well Dr. Geiger I want to stop there over for just a moment
before we may be go back to the social determina nts of health question and that
is something that I know you have tho ught about from your earliest days about
this team of people that are there to provide health care and I think we all feel like
we ’ re still likely to fall short so what’s your prognosis and what are your
observations about the current generation of student s of the health professions
and how they feel about going into primary care and the likelihood that they will .

Dr. H. Jack Geiger: Most of the predictions for the coming shortage of primary
care practitioners , physician s at least is in the range of high 30,000 or 40,000.
Now , we know that simultaneously with Obama C are there will be increased
demand , we know that from what happened in Massachusetts w h i c h greatly
expanded insurance coverage and utiliza tion of community health cent e r s there
by the way wen t up by something like 30% , there is very good evidence for what
happens to medical students at p resent for a variety of reasons. Idealism is very
h igh when people e nter medical school, that’s why they came in the main and
there is very good evidence that declines sharply and steadily over the first 7
years of training , it corrodes empathy and there are at least two reasons for that .
One is the enormous burden of debt that all medical students start to accumulate
and find that an almost insupportable burde n that drives them among other
things away from the primary care and into procedure based higher income ,
subspecialty practices . Second reason is a distorted reimbursement system and
then has got to change if we have to have any hope of solving this probl em at all.
Third, we are going to have to recruit increasingly from the pools that we know
are likeliest to be interested in primary care and even more are likeliest to
undertake practice in under - served areas of really vulnerable and sick
population s . W hat that really means is that we need to recruit from those very

populations and establish the kinds of pathways that remove the barriers both of
poverty and poverty of aspiration . We ’ re not doing nearly enough about that.

Mark Masselli: We are speaking today with Dr. H. Jack G e iger, who is
considered the father of the Modern Community Health Center Movement , is a
member of the National Academy of Sciences and the Institute of Medicine. Dr.
G e iger your activities in Healthcare go far beyond the examinat ion room , been a
founding member of Physicians for Human R ights, Physician s for Social
Responsibilities somebody who wa s there in the freedom marches in the south ,
tell us about that relationship between health and poverty, healthcare and other
human right s and your thoughts about the social responsibilities for this next
g eneration of medical providers.

Dr. H. Jack Geiger: I came from that background of activism well before I
developed an interest in medicine and decided to try to become a physician and
the answer came obviously that one has a responsibility as a physician to join or
create the organization s that do that kind of work to a life that addresses what we
know are root causes in justice and i nequity of disease in so many of the v e ry
patients tha t we ’ re see i n g. One of the first of those was Physician s fo r S o cial
R esponsibility which way back in the early 1960s when our government like
many other governments was trying to tell the population that nuclear war
wouldn’t be so bad if you just dug a sh elter in your backyard you ’d probably be
okay o f doing the first real analysis of the medical consequences of a thermo
nuclear war and that was followed during the 1980s and the worst of the nuclear
arms race and the cold war b y physicians doing what we ca ll the Bombing Run
going city to city across the United S tates , getting on televis i on , putting up a map
of wherever we were and saying here is the bulls eye that will be created by a
one megaton thermo nuclear blast, just one , and that was an important and it
turned out to be a comp e lling contribution. In the same way Physicians for
Human Rights formed in 1986 and both of those organizations ended up sharing
in the Nob el Prize for Peace . Physicians f o r Human Rights was organized in
exactly the same way to bring the skills of physicians to the investigation and
documentation , crimes against humanity, war crimes, there was a marriage of
that impulse with the creatio n of this new community institution. The community
health center in addressing , taking the re sponsibility not just to treat people but to
address those social determinan ts of health . Back in Mississippi w e started to
address social determinan ts because they were so overwhelming . What is it that
you do when you discover that people’s primary sour ce of water was to collect
rain water in old pesticides barrels . What is it that you need to do when you
discover that people are literally trying to shoot squirrels or gather pecan nut s
because mechanization h as destroyed the ( 0:19:38 inaudible ) culture. People
have virtually no income it was d emean when we arrived was less than 600
dollars a year for family of fo u r. Whenever we saw a child in such a f amily with
infectious disease and malnutrition we wrote prescriptions for food, so much
meat, s o much m ilk, so much vegetables and arranged to have that family fill
those prescriptions at local black grocery stores which sent a bill to the

community health center which paid for it out of the pharmacy budget . T he
governor of Mississippi screamed his worst f ears had been realized soviet
communism, he thought had come to the Mississippi Delta and he yelled at
Washington and our funders in Washington ( 0:20:26 inaudible ) came down and
yelled at us and me and said what I think we were doing and I said well what ’s
was wrong with it and he said well a pharmacy and a health center is for drugs
for the treatment of disease and I said the last time I looked in the book the best
therapy for malnutrition was food and he went away because th ere was really no
honest answer to that question. It is that spirit that still informs community health
center and has to inform our whole approach to what we are doing and t here are
many venues both in volunt ary, non - government organizatio n s to do that.

Margaret Flinter: Dr. Geiger I know that our audience appreciates that you are
able to take a very long view of w here we ’ve been in this country in health care.

Dr. H. Jack Geiger: I think that’s nice statement for how old I am.

Margaret Flinter: And in our understanding of the i mpact t o social determin a n ts
on health but I know that you’ve lost none of your vision looking to the future and
none of your passion for the future and I think I ’ ve come to the conclusion that it’s
the case that every generation n eeds to discover some of this ( inaudible 0:21:35 )
to name the issues and formulate a response and that was ( inaudible 0:21:38 )
recently when we had the pleasure of interviewing Dr. Rishi Manchanda who has
written a new book the Upstream Doctors and which he calls for a new focus o n
social determin ants and getting upstream to prevent illness and reduce their
burden and I want to give a chance to say with all the new incredible technology
to ols at our disposal today, do you foresee a new era and how we address those
so cial determinan ts of health and how do you think when you just put your vision
cap on this generation of public health and primary care practitioner s will be
fighting them ?

Dr. H. Jack Geiger: Well let me put me in a plug, there is a documentary about
that first Missis sippi Health Centre . It’s really very e asy to find, all you have to do
is Goo gle four words out in the rural which is part of that documentary’s title. We
attracted recruits for physicians and nurses and others that had always wanted
the opport unit y to d o this kind of work among v ul nerable populations , f or example
at the Beaufort Jasper Health Center in S outh Carolina early on they discovered
that they were confronting a virtual epidemic of hypertension and then they
discovered that the reason was that pe ople who were drinking brackish surface
water their only source of supply which had a monstrous salt content. So major
part of their work became installing water systems that reached the deeper
aquifers and gave people what most of the rest of the society had access to
decent, clean, safe water. Well the way we have to that now I think because the
tasks of providing medical care are so consuming without abandoning our
interest in social determina nts to be actively promoting collaboration with other
segmen ts of government and a private sector that is the housing authorities, the

transportation authorities, the education authorities. We have high school based
community health centers that give us that opportunity . We have at least four
community health cen ters that now h ou s e charter high schools within their walls
and so investments that we can make jointly with others. We community health
centers that we can make jointly with other agencies both public and private in
education , ho using, employment, job tr aining, environmental protection are the
way we have to start going after those problems now rather than undertaking all
of those burdens as pr imary responsibilit ies on our own. We are adding lawyers
to the teams of community health centers through medica l legal partnerships,
college students through health leads and we need to expand that pattern and to
address not just palliative efforts but structural efforts to change t he distributions
of opportunity in the society.

Mark Masselli: We have been speakin g today with Dr. H . Jack Geiger father of
the Community Health Center Movement in this country and founding member of
Physicians for Human Rights and Physicians for Social Responsibilities . You
can find out more about his work by going to p hysicians forhum anrights.org. Dr.
Geiger , thank you so much for joining us on conversations on health care today
and making a difference for all Americans.

Dr. H. Jack Geiger: It’s been a pleasure to talk with you.

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Mark Masselli: At Conversations on Health C are we want our audience to be
truly know when it comes to the facts about health care reforms and policy
through Lori Robertson is an award winning journalist and managing editor of
factcheck.org a non - partisan, non - profit consumer advocate for voters tha t aim to
reduce the level of deception in US politics. L o r i, what have you got for us this
week ?

Lori Robertson: Well some of our r eaders have asked u s whether the health
care law contains a hidden text o n hunting and fishing equipment. The answer is
n o. This rumor started spreading after Cabela’s, a Nebraska sporting goods
st
store mistakenly charged some customers on January 1 for a medical excise
tax, that ’s what it said on their receipt s and at least a few images of those
receipts have been circulat ing on the internet. A spokesm a n for Cabela’s told the
Omaha World - Herald that a glitch in the cash register system caused the error
that this ( inaudible 0:26:13 ) only happened on the one day and all customers
were offered a refund. Now the health care l aw does contain a 2.3% excise tax
on certain medical devices , it isn’t a direct tax on consumers, it’s a tax on
manufactures and importers of medical devices . These are items typically used
by medical professionals and there is an exemption for things lik e eye glasses,
contact lenses, hearing aids and devices generally purchased by t he public for
individual use. One viral email by an anonymous author claims that the IRS
website says that the tax would apply to items that include sport fishing

equipments , tackleboxes, bows and quivers and gas guzzler automobiles but
whoever wrote that email is wrong . Those are the items that were already taxed,
not by the health care law and they were in the list of excise taxes in general,
they are not subject to any new 2.3% medical device tax and not manufacture d.
F or this week I am L ori Robertson , managing editor o f factcheck.org.

Margaret Flinter: Factcheck.org is committed to factual accuracy from the
country’s major political players and is a project of the Ann Ar bor Public Policy
Centre at the University of Pennsylvania. If you have a fact that you would like
check email us at chcradio .com we’ll have factcheck.org L ori Robertson check it
out for you here on conversations on health care.

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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. New York City
Mayor Michel Bloomberg has been taking a number of hits lately for attempting to
ban everything from Styrofoam pa ckaging for takeout food, to large sugary drinks
in restaurants and city run facilities. Bloomberg has nonetheless forged to head
t he sites his interest in not only improving the health of his New York City
constituents but in setting an example for other public officials to follow around
the country. It's been 10 years since Mayor Bloomberg launched his first
controversial ban ending smoking in bars and restaurants throughout the city’s
five burrows. The proposed smoke free air act was met at the time wit h a
hailstorm of criticism and dire warnings of loss business and tax revenue due to
the ban. But at a recent gathering at a vulnerable old New York City Watering
Hole the Old Town Bar of Union Square, Bloomberg share facts that borrow quite
a different s tory since the ban went into a fact health officials estimate that
10,000 lives have been saved and reduce smoking rates in a dramatic reduction
and exposure to second hand smoke. And the restaurants and bar owner swept,
they have apparently seen the ligh t as well. The Mayor was flanked by Old
Town’s owner Gerard Meagher who was one of the band most vocal opponents
at the time. Meagher compared his taverns receipts from before and after the
ban and found his business actually increased by 20% turns out o nce the ban
was in place in the perennial blue haze of smoke was gone people began to
spend more on the restaurant food. Smoking bans are now come in place
across the country, boarding well for the health of those working in bars and
restaurants as well a s the patrons. A municipal smoking ban that not only
improves a health and wellbeing of workers and patrons but it has turn out to be
good for the business bottom line as well. Now that’s a bright idea .

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

Mark Masselli: And I am Mark Masselli, peace and health.

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