The Art of Compromise: Missouri Governor Jay Nixon on Navigating Health Policy in Hyper-partisan Times

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Margaret Flinter: Welcome to Conversations on Healthcare with Mark Masselli and
Margaret Flinter. A show where we speak to the top thought leaders in
health innovation, health policy, care delivery and the great minds who are
shaping the healthcare of the future.

This week, Mark and Margaret speak with former Missouri Governor Jay
Nixon, Democratic Governor who found much success at collaborating across
the aisle, in a largely red state . He is now a visiting Senior Fellow with the
Harvard T. H. Chan School of Public Health, where he has been sharing his
views on how we deal with health policy moving forward in this current
hyper - partisan reality, we are living in it.

Lori Robertson also checks in, Managing Editor of FactCheck.org looks at
misstatements spoke n about health policy in the public domain, separating
the fake from the facts. We end with a bright idea, that’s improving health
and wellbeing in everyday lives.

If you have comments, please email us at www.chc [email protected] or find
us on Facebook or Twitter, we love hearing from you. You can find a show on
www.chcradio.com or wherever you listen to podcast as well. And you can
hear us ask Alexa to play the program Conver sations on Healthcare. Now stay
tuned for our interview with former Missouri Governor Jay Nixon, here on
Conversations on Healthcare.
th
Mark Masselli: We are speaking today with former Governor Jay Nixon, the 55 Governor of
the State of Missouri, who recen tly completed two - terms in office. He has
also served as the state’s Attorney General and as Missouri State Senator
before that. Governor Nixon is a visiting Senior Leadership Fellow at the
Harvard T. H. Chan School of Public Health. Governor Nixon, welcom e to
Conversations on Healthcare.

Jay Nixon: Thank you very much .

Mark Maselli: Y ou ha ve recently addressed the Harvard School of Public Health on
strategies to address the hyperpartisanship in American politics and really
focused in around the issue of he alth policy. It is almost 10 years after the
passage of the Affordable Care Act. And the legal and political challenges
remain as divisive as ever. I wonder if you could give our listeners your
current assessment of the health policy debate and how the par tisan divide is
impacting us.

Jay Nixon: First of all, healthcare is complicated but the politics around is not. That’s one
of the most frustrating parts here, you take very personal, yet significant
issue like healthcare and when it gets ground down to th e simplicities of
talking points and wedge issues, you get pass the needs and the care. What’s
missing is thoughtful specific solutions about how progress can be made. I
think broadening that healthcare debate to include wellness, include other
issues arou nd this, I think is important but the partisan divide right now is
making it darn near impossible to get rational discussion without somebody

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attacking it. Right now, well I deeply appreciate the candidates talking about
healthcare and coming up with speci fic ideas, as we head into 2020 and I am
not overly optimistic that the election process itself is going to yield any new
specific insights.

Margaret Flinter: Well, Governor Nixon as a successful democrat in the largely red
state, I think we consider you a real expert on compromise. We really,
recently welcome Governor’s John Hickenlooper of Colorado and also Bill
Weld of Massachusetts to our show and what they had in - common was a
similar success at reaching across the aisle, to build consensus on some
pret ty major contentious issues. We would love for you to share some of the
strategies that you successfully used to bridge the political divide?

Jay Nixon: Well, first of all, I always use the word cooperate instead of compromise. I
always felt like, when I w as asking somebody to work on something if I told
them to, would they would be willing to compromise, that was kind of its way
to frame issues that made them defensive. What do they have to give up in
essence? And what we were really looking for is to move forward. All I would
usually ask folks is to cooperate. If you can get them into room and get them
into discussion, then good things can happen. You got to focus on the issues
not the partisanship, especially after being a governor in a state with two -
thi rds of the both the House and the Senate, the opposite parties. I mean
when people would walk up to me and say, I am a Democrat or I am a
Republican, they were getting ready to say ‘no’, they weren’t getting ready to
say ‘yes’.

There is also some gateways into this discussion that I think are easier
gateways, to get to the broader discussions than others that are in the issue
and there maybe two examples, mental health and specifically then into
developmental disabilities area, areas where they are not par tisan
challenges. For example one of the programs that we put together has been
highly successful, is a thing called Partnership for Hope. We found that folks
with developmental disabilities, once they got beyond high school age, they
were actually degradi ng because there wasn’t as much socialization or help
around them. We put together a program to have those folks continue to get
help, continue to get training and also to give their parents or other
caregivers some time off. We found broad support through out the state.

Another thing that I always said was that it was better to talk if we had a
different facility, it was better to go to their house and talk about it.
Consequently I spent a fair amount of time when I was in the office going to
communities. If there was a leader there that was, who I was disagreeing
with on something we would sit down in their area. People are often times
more confident and comfortable in their own home areas and especially if
you can have people around them, that they know. And the other thing is you
got to stay positive. If you are in elective office or an appointed office, you
are not going to succeed in everything you want to do. I think staying positive
is really, really important. These days especially in the political a rea, folks

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gravitate towards division and negative, very, very quickly. I know it’s hard,
and it takes a long time, to get people used to your voice and your strategy
that I found over the long haul, people would listen to me more, if I was
talking about w hat we could do instead of giving excuses for why we couldn’t
do something.

Mark Masselli: Well, one of the things that you wanted to do was clearly, early in your term
was to pass a measure requiring coverage for all Missouri children on the
autism spectr um, to be given access to treatment. I guess it initially ran into
some strong opposition, but it looked like the strategy that you just laid out
for us prevailed. I am wondering if you could talk a little bit about that
measure and what other successes li ke that were you able to achieve in
moving policy, two - thirds of both houses are in the hands of the other party.

Jay Nixon: Yeah, one of the records I have is over 270 [inaudible] [00:06:50] legislation
that I did that I held those details, I sustained th ose details, that’s a lot of
times where I had to veto bills and then go out and talk to folks about why
that what they were doing was the wrong policy and we needed to work
together to alter that. But back to autism for a second, I think for me it was
one of those kicking moments, I used to get up every morning and ride when
I was governor and this was one where I had a discussion with myself,
because in my first year, I really wanted to push autism coverage to insurance
for all Missouri families, got a vo te in the Senate, overwhelming, just couldn’t
get through the house in those final days. A lot of the folks around there was
saying, you should attack the speaker of the house, and there is going to be
another year with kids not getting that coverage. I sh ould note this morning
about 4,000 young folks who were involved in that ABA treatment to turn
their lives around because of us coming together and getting that done.

But I learned and knew that the speaker of the house had some families that
have had som e challenges in the autism spectrum, so instead of like attacking
them, we went down to this district and went to the autism center, had yet
another hearing and discussion, invited him to be there. The bottom - line is,
in the first few months of the next se ssion that Bill passed overwhelmingly. I
think that was a good example of how I held the low of my fire, it may gain
something politically for divide and there but we actually got it done.

I think a couple of other areas where we are really able to bring people
together was in keeping the cost of college down, I mean you are seeing all of
the discussion nationwide, I mean Missouri was number one in the country
keeping tuitions for four colleges down. We didn’t do that just by cutting
their budget. Conseque ntly, in my years we were able to up the number of
four - year public college degrees by 36%. We were able to up those two - year
degrees by 44%. For me that was one of the examples of things we were able
to get done, to move higher education forward. We also moved our
graduation rates, out of high school up to this and improved the top - 10
levels. By the time I was done, as governor, we didn’t have any of our schools
who were on the, on unaccredited list anymore. All of that was done in a very

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bipartisan way an d I think we will stand the test of the time as a good effort
by folks to move the state’s opportunities forward.

Margaret Flinter: Governor Nixon, one health policy challenge that I would like to ask
you about that I think you were unable to surmount. I i magine this was quite
near and dear to your heart because it would have meant to so much to so
many of your residence, was the expansion of Medicaid under the Affordable
Care Act, which I think would have brought coverage and access to tens of
thousands of your people. As recently as the last year, I understand there was
an attempt to try and get Medicaid expansion through a ballot measure but
that effort was blocked. What did you learn from that experience in Missouri
around being unable to get that Medica id expansion through?

Jay Nixon: Well it was disappointing, I mean to have the federal dollars out there to
have the opportunity to affect communities and we are seeing what happen
because of that we are having yet another rural hospital closing. We see
he alth outcomes slip in our state, but we didn’t just sit in our hands, we
couldn’t get through the legislature. We were able to get a 140,000 new kids
covered by Medicaid by just getting out there and doing some good gumshoe
work to make sure that every fam ily that had a kid that was eligible got
signed up, that’s a trend that has changed dramatically. Now with the 60,000
to 70,000 -- just in the last year on Medicaid, Missouri, you have to work at
these things to make it happen.

But it was a disappointment and I think it’s something that you try to get
done. I think the politics of it got caught up and I also think of both sides a
little bit. But the bottom - line is that, that law is still out there and while the
reimbursement numbers are dropping a little b it, I am hopeful that in the
future Missouri joins number of states, Democrat and Republican governors
and legislators that are moving forward to expand Medicaid and make
healthcare available for the working poor in Missouri and in America.

Mark Masselli: We are speaking today with former Missouri Governor Jay Nixon who also
served as the state’s Attorney General and as a State Senator where he is
focused in on environmental legislation. Governor I want to shift from
healthcare to climate change, we are jus t seeing such natural disasters
accelerating in the country and there unfortunately it seems to be a partisan
disagreement over that threat as well. You have experienced unimaginable
destruction with the level - 5 tornado that struck Joplin, Missouri in 2011 ,
leaving many dead, thousands were injured and I am wondering what you
learned from that disaster and the recovery. And how has it shaped your
approach to this discussion that’s going on?

Jay Nixon: It’s certainly was a chilling reminder of how as the pla net changes and warms
the threat of these types of storms are going to increase; science shows us
that. In that year 2011, not only do we have that EF5 in Joplin, it killed a 161
people and put 1,100 people in the hospital, wiped out nine schools, 700
busi nesses, 7600 houses and almost 11,500 cars. The City of Joplin and the
community rallied and built things back and it’s stronger today than it was

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before, but that same year, we had floods in Northwest Missouri that took
out 65 levees, with a tornado that hit the airport in St. Louis, we had the
flooding of the Missouri River and Mississippi River that necessitated Corps of
Engineers to blow up the levee in Birds Point and flood out half a county. And
that was also the year that we had to close I - 70 one nig ht because of over 30 -
inches of snow caused, the highway had to be closed and ploughed.

Yes, I have seen that, but I also have a long history in this area, back in the
late 80s, I was on the first what they called the Ozone Commission, to begin
the public policy issues around what was then seen as a hole in the ozone,
that could cause problems. But I do believe that we as a people have to
depoliticize science and have to depoliticize the discussions around climate
change. If we don’t, we will continue to s ee things get worse and not get
better and quite frankly, we are to point now, where in just a very few short
years, it could be a reparable damage, especially when you talk about the
levels of water and the types of tornadoes and cyclones that follow alon g the
way. Science is in and it’s up to those folks that are in public service, not to
scare people, but to educate people so that we can all work together for the
strategies and can make the world safer and better in long run.

Margaret Flinter: Yeah, ther e is another issue that’s very much on the forefront, I would
say and that’s the issue of rural health and access to healthcare in rural states
and communities, certainly the opioid use disorder crisis has made that
obvious, the closing of rural hospitals, the difficulties recruiting people to
come and practice as healthcare providers, what’s your perspective of what’s
needed to really build rural health infrastructure and does technology play a
role in this?

Jay Nixon: I think that technology does play a s pecific role because you have got to give
people access to professionals and sometimes the only way to do that is
through distance communication of various sorts. But the bottom - line is that,
easy access to healthcare is the best way to make sure that peop le live a
healthy lifestyle and if they do have problems that they get the better
outcomes. We had a significant Telehealth effort, it’s called MO
BroadbandNow, which was to hook up all of our hospitals, hook up all of our
healthcare networks to telecommun ication, the ability to not only just
communicate by a screen but also move tests around, especially as the
population in some of these areas continues to have fewer folks, you are just
not going to get the bricks and mortar investments that are necessary to
move things forward.

As far as the professionals we had some success and number of loans
forgiveness programs, in which we helped an extended sponsoring doctors
and other professionals. We also worked together in a bipartisan way to pass
a measure that added about 1,700 healthcare professional degrees in
Missouri. It just always struck me that if we could fill that gap by educating
folks here that we could fill those shots at home and that also means a
healthier lifestyle. So I think it’s important for people to remember that the

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healthcare area is one that you have not only doctors and nurses and
dentists, but there are many other series of professionals that help people in
the quality of their healthcare from dieticians, to mental health professionals,
to others. If you can continue through your education system in those
communities, to empower and license folks, then you are going to have local
people that are staying in their communities and you are getting better
health outcomes.

I really do believe that technology and education are both tools that can level
the playing field hopefully, between the cities and in rural areas. But we all
got admit that if you got a really significant surgery, a heart transplant, a
significant cancer surgery, that often times you are going to have to go to the
population centers, because that’s the only place where you are going to
have that high level of experience expertise. Transportation is also important,
being able to transport people from their community, 10, 50, 100 miles away
that’s part of the quality of rural healthcare.

Mark Masselli: Governor Nixon, you come from a hardline state and you have had to address
sort of a wide variety of issues of importance, gun control, LGBT rights,
climate change and disaster r ecovery. We have got all this coming up in the
2020 election cycle. But I am wondering what new compact do we need to
start really addressing these issues that politicians need some consensus on.

Jay Nixon: I think like we have almost slipped over to polit ics and governing being a
contest as opposed to a civic responsibility. I was a co - chair for a while of the
National Civics Education with Governor Ducey in Arizona, to make sure that
people understand. We passed a measure here in Missouri that says that y ou
got to pass the citizenship test by your senior high school. I think giving
people deeper understanding of how the levers of power can deliver for
them; I mean I think folks are kind of scared to get into politics and to public
service, they are scared to go meet with their legislator sometimes. I think
some of the best things that happened, were individual citizens feeling
empowered. And it’s not about protest, it’s about progress. We need to
empower people to feel like they can speak out and reach out.

And right now when you nationalize political coverage, when you nationalize
news which we are moving to with the closing of many small town
newspapers, small radio stations and others and replacing those with to
either serious radio or whatever national TV it is, it begins to lose the touch
at the local community. I think one other thing that folks need to do is
reinvigorate some of that local media. I am not going to say we all have to go
back at Benjamin Franklin’s day and set type, although Georgia and I got a lot
of newspapers, I have still one of the Luddites that actually reads
newspapers. To put it in the flip way, I mean Tip O’Neill wasn’t wrong when
he said, “all politics is local” that’s also true about policy. I think right now
empowering people to get involved, not just negatively, not just because they
are upset with something. But because they should have a higher expectation
is important.

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I will tell you, when I was in college, if I was doing a report, I had to go to the
library, look up a b ook and go the Dewey Decimal System, figure out where it
was in the library, walk up in the library, get that book and guess what, if
somebody else has already checked it out, I had to bring back a piece of
wood and give it to the librarian and they would tell me in two days the book
would be back, that’s not the way it is for these kids now. They have the
whole world on their phone. The bottom - line is that information is available
to folks and I am a big believer that where are at a transitional time, whic h
we are going to move away from just communicating by tweet or Instagram
and we are actually going to start having discussions. But that only happens if
we respect other people, if we embrace diversity, if we embrace people’s
differences. I do think I am very optimistic that the younger people of this, at
least of this country and this state, are more willing to embrace diversity,
more willing to listen to other people than I think some of the politicians are.
I think that’s a good sign for long run.

Marga ret Flinter: We have been speaking today with former Missouri Governor Jay
Nixon. Now a visiting Senior Fellow at the Harvard T. H. Chan School of Public
Health. You can learn more about his work and follow him on Twitter
@govjaynixon. Governor we want to thank you for your leadership, your
lifelong commitment to public service and for joining us on Conversations on
Healthcare Today.

Jay Nixon: Thank you very much.

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 award - winning journalist and Managing Editor of
FactCheck.org, a non - partisan, nonprofit consumer advocate for voters that
aim to reduce the level of deception in U.S. poli tics. Lori, what have you got
for us this week?

Lori Robertson: In the past four months, five states passed laws that ban abortion
once a heartbeat becomes detectable during a pregnancy. That prompted a
reader to ask us, when do doctors hear a heartbeat du ring pregnancy and
when is the human heart fully developed. The short answer is that a
developing heart has all of its primary structures after about nine weeks of
pregnancy. Some forms of ultrasound can detect cardio activity in an embryo
in the sixth wee k. But a heartbeat wouldn’t be audible until about 10 weeks
on a Doppler fetal monitor. Since cardiac activity can be detected in the sixth
week of gestation abortion rates advocates such as Planned Parenthood,
refer to these state measures as six week abo rtion bans, others including
proponents call them heartbeat or sometimes fetal heartbeat legislation. All
of the state laws allow abortion if the pregnant woman’s life or physical
health is severely in danger, none of the laws are currently in a fact and s ome
have been blocked in court.

We consulted multiple scientific reviews and spoke with experts on heart
development and maternal fetal medicine. Heart development occurs over a

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four week period starting in the six week of pregnancy. Scientist are able to
identify all of the major structures after nine weeks and one day of
pregnancy, when the entire process is largely complete. Heartbeats are first
detectable with a transvaginal ultrasound. Usually after six completed weeks
of pregnancy, the real - time scan however doesn’t produce an audible
heartbeat it’s visual only, showing a flicker, the slight movement of the
developing heart while it beats. What most parents experience as the first
audible heartbeat during pregnancy comes from a device known as a Doppl er
fetal monitor.

Technically the heart sounds that the machine produces are not the actual
sound of the fetus’s heart beating. The sound is the amplified version of the
difference between the transmitted and received signals. To hear a true
heartbeat, ex pecting parents can turn to a stethoscope which picks up fetal
heartbeats after 20 to 22 weeks and that’s my factcheck for this week. I am
Lori Robertson, Managing Editor of FactCheck.org.

Margarent Flinter: FactCheck.org is committed to factual accuracy f rom 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 wil l have FactCheck.org’s , Lori
Robertson, check it out for you, here on Conversations on Healthcare.

[Music]

Margaret Flinter: Each week C onversations highlights a bright idea about how to make
wellness a part of our communities into everyday lives. It’s a k nown fact that
the current generation of American children is more obese than any previous
generation. Out of Washington DC Community Health Center, Unity Health
Care, a pediatrician was in a quandary over how to tackle this growing health
scourge. He bega n with the unique solution targeted to a teen patient whose
body mass index had already landed her in the obese category. What he did
was write a prescription for getting off the bus one stop earlier on a way to
school, which made her walk the equivalent o f one mile a day. Dr. Robert
Zarr of Unity Community Health Center understood that without motivation
to move more, kids just might not do it. The patient has moved from the
obese down to the overweight category, certainly an improvement. He then
decided t o expand this program by working with the DC Parks Department,
mapping 388 of them so far.

Robert Zarr: How to get there parking, is parking available, if someone is going to drive,
bike racks, there is the section on pads, park safety.

Margaret Flinter: D r. Zarr writes park prescriptions on a special prescription pad in
English and Spanish with the words RX for Outdoor Activity, and a schedule
slot that asks, “When and where will you play outside this week?”

Robert Zarr: I like to listen and find out what it is, my patients like to do and then gauge
the parks I prescribe based on their interest, based on the things they are

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willing to do.

Margaret Flinter: Ultimately, Dr. Zarr says, he wants to make the prescription for
outdoor activity adaptable for pediat ricians around the country. One day, he
would like to be able to track his patient’s activities in the parks. RX for
outdoor activity, partnering clinicians, park administrators, patients and
families to move more, now that’s a bright idea.

[Music]

Mark Ma sselli: You have been listening to Conversations on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Peace and health.

Moderator: Conversations on Healthcare is recorded at WESU at Wesleyan University,
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