Alan Weil, Editor-in-Chief of Health Affairs

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Mark Masse ll i: This is Conversations on Healthcare . I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masse l li: Well Margaret, folks looking for Virginia to expand Medicaid or
going have to wait two years. Democratic Gov ernor Terry Mc A uliffe was fighting
against the conservative tide hoping to expand Medicaid in the state but after
much political wrangling during the budget process, Virginia legislature approved
the budget that had a measure ineffectively blocking the gov ernor from being
able to do so.

Margaret Flinter: Well Mark, we have seen some five million Americans gained
health coverage across the country and states that approved the Medicaid
expansion. And this would have been a chance for hundreds of thousands of
working poor Virginians to get health coverage, but conservative majority won out
in this case.

Mark Massel l i: The cost to that coverage is fully covered by the f ederal
government for three years. There won’t be another chance to expand Medicaid
for another two years in Virginia .

Margaret Flinter: A number of conservative states that opposed the Affordable
Care Act still opted to expand Medicaid in the states, it makes economic sense
bringing billions of healthcare dollars into the state office and allowing millions of
economically challenged Americans to gain coverage.

Mark Masselli: We only need to look at Massachusetts to see what that means,
Margaret. In a few years since most of the states residents gained access to
coverage, the death rates have gone down between 3% and 4%, that’s due in
large part to folks who have been uninsured before getting good preventative
healthcare .

Margaret Flinter: And our guest today , he has been working in the trenches of
improving healthcare for Americans for a long time. Alan Weil was the Head of
the National Academy for State Health Policy. He is now the Editor - in - Chief of
Health Affairs, the peer - reviewed publication for health policy in this country.

Mark Masselli: And we are looking forward to that con versation , Margaret, as
well as hearing from Lori Robertson from FactCheck.org .

Margaret Flinter: And no matter what the topic, you can hear all of our shows by
googling CHC Radio.

Mark Masselli: And as always, if you have comments, please e - mail us at
www.chcradio.com or find us on Facebook or Twitter , we love hearing from you.

Margaret Flinter: We will get to our interview with Alan Weil in just a moment.

Mark Masselli: But first, here is our producer Mariann e O'Hare with this week’s
Headline News.

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Marianne O'Hare: I am Marianne O'Hare with these Healthcare Headlines. For
the fifth year in a row, an independent survey done by the Commonwealth Fund
has found U.S. ranks behind all other industrialize d nations when it comes to
value and outcomes in healthcare . The study conducted by the respect ed think -
tank Commonwealth Fund compared healthcare cost and outcomes in the U.S.
to nations like England, The Netherlands, France, Canada , and others. They
fo und that for the fifth year in a row when it comes to cost , Americans fared the
worst of all their counterparts in terms of out of pocket healthcare expense and
that we ranked last in everything from infant mortality, maternal mortality, life
expectancy, h eart disease, diabetes and other life altering chronic illness. The
study found 34% of those polled had waited or delayed seeing a doctor or failed
to fill a prescription due simply to the cost. One of the key contributors to high
cost and poor outcomes was the high rate of uninsured Americans. As millions
of Americans gained access to coverage primary preventive care they will start
do positively impact population health according to the study , but the report also
elucidated systematic problems througho ut the healthcare delivery system that
need to be address ed before these rankings can meaningful improve. Meanwhile
the other indicator of improved health outcomes is h ealth literacy. The recent
spat e of newly insured Americans has revealed the chasm betw een those who
gained coverage and those who actually understand how to use the healthcare
system. This lack of health literacy has been addressed by the Centers for
Medicare and Medicaid . They were offering outreach assistance to those having
trouble nav igating health insurance as well as the healthcare system. B ike
sharing programs or sweeping the nation city good for the health of the riders,
right? Well, the short answer is yes unless you forget to bring your helmet. The
study looked bike related br ain injuries in cities with bike sharing program versus
control led cities without those programs brain injury and the bike share cities was
up on average 14%. I am Marianne O'Hare with these Healthcare Headlines .

(Music)

Mark Masselli: We are speaking today with Alan Weil , newly installed Editor - in -
Chief of Health Affairs, a leading peer - review journal on health, healthcare and
policy. Before that Mr. Weil was Executive Director of the National Academy for
State Health Policy. Mr. Weil, an attorney wa s director of the new federalism
project at the Urban Institute , a frequent speaker and author on Health Reform

Policy. Mr. Weil co - authored several books including Federalism and Health
Policy and served on President Clinton’s consumer commission on the quality in
healthcare industry, co - authoring the patient bill of rights. He earned his masters
in public policy and law degree from Harvard. Alan , welcome back to
Conversations on Healthcare .

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

Mark Masselli: And it's been since 2011 when we discussed the Affordable Care
Act and lots ha ve happens since then, eight billion Americans enrolled on and
received coverage on the exchange and five million access covers to Medicaid
expansion. Now if you break it out b y states it's been a patch work quilt, only
about half of the states choosing to expand Medicaid and we are seeing many
Americans still left out on the promise of health coverage . What would your
assessment of the outcomes from state to state is that is y ou envision would
happen?

Alan Weil : I don’t think anyone had anticipated the country is splitting quite the
way it has and two elements were certainly not foreseeable by me. The first I
think I have a lot of company on which is the Supreme Court after all is
responsible for having made the Medicaid expansion something that the states
could choose to participate in or not as the law was written, all states were to
expand to Medicaid and we are going to have a uniform national platform of
coverage. Now w ith the court’s rewriting of the statute they said the federal
government cannot tell states that if they fail to expand Medicaid they will lose
their base funding for the program and we have what you just described. I truly
don’t know a single person who thought that was where we are going to be at
this point. We knew there was disagreement obviously over the Affordable Care
Act when it was enacted . But what I didn’t foresee was how much states would
become a place where even after the law was enacted a nd signed that there
would be such a division about whether or not implementing the law was
something states we are willing to participate in it all . And so you have the
significant element within the Republican Party that basically said anything you
do t hat is involved in implementation of the law is asthma but actually you should
not take any steps to implement. And that is a big factor I think in a division
today and certainly not one that I expected.

Margaret Flinter: Well certainly, Alan, you obvio usly are a long time health policy
advocate and expert, you have contributed frequently to Health Affairs and now
you are the Editor - in - Chief of what we think of is the peer - review journal for
health policy. Now the journal began back in 1981 and we under stand (inaudible
7:22) over 120 million unique visits per year at the website . So for our listeners,
may be tell us a little more about the journal ’s history, who the major participants
and contributors are, and if there is any new directions that you are planning for
the publication.

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

Mark Massell i: Let me pull the thread a little on that is you take on the metal as
Editor - in - Chief and so in this ever - changing world of how readers consume sort
of where that audience is not so much on the content side but on the delivery
side, thoughts about that e ven in the state position that Health Affairs as you
have others who are quite anxious about the transformation and what it might
necessitate for organizations like yourself?

Alan Weil : Well, we occupy a unique space and one thing I think we all have to
remember is there is not one typical reader particularly for the policy work we do.
We are reaching CEOs of organization s, we are reaching young staff members
on Capitol Hill, we are reaching practicing clinicians around the country, and
indeed, around th e world who are trying to understand the changes that are
occurring. And I think we all know with the pace of change in how information is
distributed and disseminated. Those different audiences are looking to different
sources. It's making sure that as we think about our audiences we have
appropriate distribution channels for the range of mechanisms that they are
accustomed . Our core asset is credibility and non - partisanship is a very
important part of that. Our peer - review process and as long as we b uild from that
core some people will be Googling at topic and they will find that some people
will read a blog entry, some people will read a tweet, and as long as we retain the
quality of our content, I think we can reach people the way they are used to
g aining access information.

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

Alan Weil: I remember going to dozens of conferences a couple of decades ago
where people said that you can't have high quality affordable system for
everyone. I really believe it's the practice of medicine and the e vidence - based
behind that practice that’s changed in these years along with some good thought
leadership . We now understand that when people get access to appropriate care
they actually stay healthier and it cost us less certainly in a long run and
someti mes in the short run if people obtain care rather than if we denied them
care. We have also learned a lot about quality that was in its infancy a couple of
decades ago and understanding the problem of overuse. So there is now a
framework in the Affordabl e Care Act obviously now everyone agrees with the
approach it takes but most of the attention goes to the elements of the Affordable
Care Act design to expand access care through more health insurance. But
there are major elements having to do with cost p articularly modifications to the
Medicare program which is the biggest level the federal government has and
major initiatives to improve quality. And the hope of course is that we can bring
those together in a reinforcing way as opposed to a competitive w ay. I do think
our thinking about those three elements has shifted fundamentally with a very
positive sense of what’s possible as opposed to what I remember which was sort
of resignation that well this is the best we can do.

Mark Masselli: We are speaki ng today with the Editor - in - Chief of Health Affairs,
a leading peer - review journal. Before that, Mr. Weil was Executive Director of
the National Academy for State Health Policy, a non - partisan organization,
helping states achieve excellence in health poli cy and practice. On he focused
much of your efforts on improving population health on the state local levels, you
work at NAHP and the Urban Institute centered on the importance of state policy
directors being essential to improve population health, and w hat do you see in
the states, what’s exciting about population health?

Alan Weil : When I think about the Affordable Care Act it creates a number of
tools that states can use, the coverage expansion creates a financing
mechanism to give people access to c are, the changes in Medicare payment are
catalyst for thinking about accountability in healthcare system. So between state
and local, there are opportunities to think more holistically about the health of the
population a nd particularly to identify priori ties for action. And so one of the most
powerful efforts that I observe is when a community looks at its own population
health statistics and they say we really need to focus here on children with
asthma who are ending up in the hospital when with appropr iate preventive
services, they wouldn’t have to do that. Then you cannot just generalize about
population however you can harshness the resources of the community to
actually do something concrete.

Margaret Flinter: I think it ties to something that you have talked about this
federalism and healthcare . And there has been this fierce debate on states
rights that the Affordable Care Act precipitated. So may be talk just a little bit

about this new federalism and also do you see the possibility of increas ed
regionalism coming into play around healthcare in the future?

Alan Weil: Well, we are certainly seeing regional differences in the response to
the Affordable Care Act . And many of our largest cities set on state borders and
so certainly, the opportun ity to work across state lines to try to solve problems is
a practical necessity. And we do see right now I think it would be in naïve to
deny that the Affordable Care Act embraces an activist role for government in a
healthcare sector. It says we have a market failure. We have lot of people who
can't afford coverage and we are going to solve that by resources to those who
otherwise wouldn’t be able to afford it. And that raw [PH] conception of the word
that the state has a primary role in addressing the ir social problem that not
everyone agrees upon and we have regional differences and the view of that. So
some of this is state federal but actually much of the attention around the
Affordable Care Act is just around public sector versus private sector an d the role
of government no matter what level. Now what I have not seen is a serious effort
to define an alternative pathway to achieving the goals of the Affordable Care
Act . On the one hand, the state roles and implementing the law are many and
that’s been my focus for some time. But a national division over the role of
government is somewhat discussion than division over whether it should be
federal or state and I actually think a lot of the opposition to the Affordable Care
Act is much more about rol e of government than it is federal versus state.

Mark Masselli: We want to spend a little time talking about payment reform,
Massachusetts started off, it's initial reform and they have some good outcomes
in terms of their access issues. But talk a litt le bit about the landscape around
payment reform.

Alan Weil: The Affordable Care Act was a catalyst. It's happening in the private
sector as well as in the public sector. The term often used as Accountable Care
Organizations and the idea is to pay for the care of a population and to reward
those who deliver cared to that population . They can keep depending on the
payment models on share of what they save by reallocating their resources s o
there is no question that this is a real phenomenon . Payment re form is a tool
and the real question is what the goal and then you can ask given the goal what
kind of payment will support the goal. And to then reimburse them, pay them for
each thing that they do on the expectation and understanding t hat what they did
was valuable. Well, we are now starting to understand and many physicians
would agree that a lot of what they do is not valuable, intervention s that help
people live a healthier life tend not to be paid nearly as well as cutting someone
open and fixing so mething their body or scanning them.

And so payment reform for what to enable those who delivered care to think
differently about the choices that they make. But that then gets to our quality
matrix, our quality matrix are still fairly primitive particul arly when it comes to
people with complex healthcare needs. Again returning to my federalism

routes/roots , I would say that the working out of the meaning of quality and the
purpose of payment reform is something that is much better done locally or at the
state level than nationally that our efforts to change payment at the national level
tend to be pretty clunky. They are directionally appropriate but the details are
complex and they need to be worked out by people who are sitting around the
table with t rust who can say this is how we are going to measure quality, yes this
is how patients view quality, this is how clinicians view quality, this is a payment
model that will support. That’s – from my perspective , that is by necessity a local
discussion and it's what ties all of these topics together .

Margaret Flinter: We have been speaking today with Alan Weil , Health Policy
expert, and Editor - in - Chief of Health Affairs, the leading peer - review journal on
health policy. You can learn more about his work b y going to
www.healthaffairs.org and you can follow him on Twitter by going to
www.twitter.com/healthaffairs . Alan , thank you so much for joining us on
Con versations on Healthcare today.
Alan Weil : It's been a pleasure.
(Music) Mark Masselli: At Conversations on Healthcare , 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 a ward - 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, in a new twis t a democratic group is attacking a republican
senate candidate for supporting “government - run healthcare .” That phrase has
been a mantra for republicans attacking the Affordable Care Act and those who
support it , but neither this new democratic attack no r the old republican ones are
true. The democratic group senate majority pack is (inaudible 20:25) attacking
the Representative Bill Cassidy, Louisiana Senator Mary Landrieu , main GOP
opponent. It says Cassidy wrote a plan that’s been called Obamacare li te. True,
it was called that by an opinion columnists but it's not an accurate description. In
the 2007 Bill Cassidy wrote while Louisiana State Senator wouldn’t have created “government - run healthcare , ” add claims with government bureaucrats making
medi cal decisions. There is nothing like that in the bill which would have set up
the state insurance exchange to serve as clearing house for individuals and bus inesses by insurance .
The proposal also was a far (inaudible 21:06) from the federal Affordable C are
Act which didn’t exist at the time. Cassidy built didn’t include subsidies for low
income people, a mandate to have insurance or pay fine or a set of essential health benefits that insurance had to cover like the ACA. The Louisiana Bill

called for st ate officials to come up with new health insurance proposal design to
reach universal coverage in the state but that never happened. The bill died
quietly in committee without even a public hearing. Cassidy meanwhile has
(inaudible 21:36) attacking the A CA saying he voted against it because it would
lead to c ancel plans, expensive premiums, no guarantee that you could keep
your doctor. But that was all true before the federal law was passed. And that’s
my fact check for this week . I am Lori Robertson , managing editor of
FactCheck.org .

Margaret Flinter: FactCheck.org is 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, t ha t you would like
checked, e - mail us at www.chcradio.com . We will have FactCheck.org's Lori
Robertson check it out for you here on Conversations on Healthcare .
(Music) Margaret Flinter: Each week, Conversations highlights a bright idea about how
to make wellness a part of our communities and everyday lives. According to Michigan Organic Farmer, Michele (inaudible 22:31), healthcare spends too
much time and money trying to fix the problems that are caused by a p oor diet
that the powers would be at the Henry Ford West Bloomfield Hospital , I agree
with her. For years she had offered organic food growing and cooking demonstrations at the healthcare facility just outside of Detroit. But when officials
drew up plans to renovate the hospital three years ago, they decided to take it to
th e next level. A million dollar certified organic hydroponics greenhouse and
garden were built and less as hired a way from her farm to run the operation.
Michele: We really wanted to change the way that food culture was done in a
healthcare setting. When you have the opportunity to heal someone it is very
important that what they are eating becomes part of that plan.
Margaret Flinter: The facility now provides most of the nutrition al organic greens,
vegetables, fruits and (inaudible 23:16) used in the food that is prepared there, not just for patients who come there to heal but for their families and hospital staff as well .
Michele: It's rather seasonal. In the winter time and in the fall, we changed to
more “tolerant” crop and then in the summer time like this time we are now
transitioning to the point where we were picking tree, tomatoes, and we had sweet peppers, and things like that that we will be supplying for the kitchen.
Margaret Flinter: (Inaudible 23:38) says there is an educational components for
the program that’s ongoing and multi - generation al.

Michele: Right now, we are averaging 3,000 students per academic school year
that go to Healthy Habit program. We have a demonstration kitchen inside of our
hospital and then we have the greenhouse right behind the hospital. So we
utilize those components to make sure that we have (inaudible 23:58) especially
our use and our community what does it take to have the foundatio n of Healthy
Habits.

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

Michele: The idea of being just the hospital doesn’t work anymore. You have to
be a community center for wellness.

Margaret Flinter: Now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations o n Healthcare . I am Margaret Flinter.

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

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