25-64 Year Olds Are Dying Earlier and Here’s Why: Our Conversations with VCU’s Dr. Steven Woolf

Dr. Steven Woolf

[ M us ic ]

Margaret Flinter: Welcome to Conversations on Health Care 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 hea lthca re of the future.

This week, Mark and Margaret speak with Dr. Steven Woolf,
Distinguished Chair in Population Health at Virginia Commonwealth
University and Health Equity Director Emeritus and Senior Advisor at
the VCU Center on Society and Health. He tal ks about the just
released report , showing a decline in life expectancy among working
aged adults in the U.S. , a result of the lingering effects of the
recession, the opioid crisis and other so - called deaths of despair.

Lori Robertson also checks in , Mana ging Editor of FactCheck.org , looks
at m i sstatements spoken about health policy in the public domain,
separating the faith from the facts . We end with a bright idea , that's
improving health and wellbeing in everyday lives.

If you have comments, please e - m ail us at [email protected] or find
us on Facebook, Twitter, or wherever you listen to podcast. You can
also hear us by asking Alexa to play the program Conversations on
Health Care .

Now , stay tuned for our interv iew with Dr. Steven Woolf of the VCU
Center on Society and Health here on Conversations on Health Care .

[Music]

Mark Masselli: Welcome to Conversations on Health Care . I'm Mark Masselli.

Margaret Flinter: I'm Margaret Flint er.

Mark Masselli: W e’re speaking today with Dr. Steven Woolf , Distinguished Chair and
Population Health at Virginia Commonwealth University and Director
Emeritus and Population Health and Health Equity at VCU Center on
Society and Health where they conduct in - depth research on social
epi demiology. Cleared his MD at Emory University and his Master's of
Public Health at Johns Hopkins University and did his residency in
both Family Medicine at Fairfax Family Medicine and in prevention
and public health at Johns Hopkins. Dr. Woolf , welcome to
Conversations on Health Care

Dr. Steven Woolf: Pleasure to be here.

Mark Masselli: Well , your study is the straw that stirring the drink I think in
conversations around the country, and you just released this, I think
very concerning report indicating thi s substantial decline in life
expectancy in America , and the report is life expectancy and mortality
in the United States 1959 through 2017. It really lays out this rise in

Dr. Steven Woolf

mortality among working aged adults from 25 to 64 years of age. I
wonder if you cou ld share with our listeners the more important
findings and what it bodes for the overall life e xpectancy in the United
States ?

Dr. Steven Woolf: Well, you stated one of the most important findings, which is that the
working age population is experiencing this increase in mortality,
which basically means American adults are more likely to die before
age 65 than adults in other countries. That's pretty alarming. The life
expectancy decrease also is actually not a new phenomenon. It's
decades in the making. L ife expectancy is supposed to be increasing
and that's been the case for the past century in most industrialized
countries and in the United States as well. Ours has been increasing
for many years. I n the 1980s, the pace at which we were increasing
began t o fall off. It plateaued in 2009 and it's been decre asing for the
past three years.

Margaret Flinter: Well, Dr. Woolf , I think there's no other word to describe it , but
shocking, right ? I t's not really a new onset phenomena, the wheels
that have been drivi ng this drop in life expectancy actually probably
began moving backwards in the 1980s. I think you've said that the
Great Recession and the wake of the Great Recession, the pace
accelerated and certainly some regions were hit much harder than
others. There 's been a saying for a while that your zip code may have
more to do with your health than your genetic code. M aybe if you
could help us and our listeners understand, let's just take the
recession. How did that impact population health, and how has that
act ually been manifested in some of these higher mortality r ates for
middle aged Americans?

Dr. Steven Woolf: Well, the recession did not help matters. I can say that. Certainly it
had a severe impact on the whole country, but it's one that's really
lingered for marginalized communities and populations that have
been historically disadvantaged. I think it's actually important to
emphasize that the economic stresses that middle class and low
income families have been facing in this country predate the
recession . It really does go back to the 1980s that you mentioned,
when our economy underwent this major transformation that
resulted in the loss of manufacturing jobs, steel mills close , coal
industry and so forth , were really deeply affected and a lot of middle
i ncome workers who had depended on those industries for their
livelihoods and the communities in which they live , began feeling the
strain . We feel that these health trends that we're reporting now are
really the symptoms of the long - term exposure to those economic
stresses. The recession certainly hurt those folks even further , b ut I
think the health insult was already underway well before that.

Mark Masselli: It's going to be interesting to listen to the c onversations going on , on

Dr. Steven Woolf

the political trail certa inly , the conversations about income inequality
is also a public health conversation. Speaking in public health,
certainly the devastating expansion of the opioid epidemic, which has
led to hundreds of thousands of deaths. Thank God for something like
Narc an, which we saved tens of thousands, if not more lives . I'm
wondering if you could just focus in now , moving from the income
inequality to the opioid crisis . I think you've called these whether it's
alcohol abuse or suicide or opioid really de a ths of desp air, how
they've played a r ole in the increased mortality?

Dr. Steven Woolf: Well, it might be helpful to start just by unpacking what's behind this
increase in working age mortality. Drug overdoses filled by the opioid
epidemic are the leading contributor for that increase by far . There
are many other factors, but it's the major player in driving the trend.
There's also been an increase in deaths from alcoholism and suicides
that was reported over several years , and it was not me actually , but
other resear chers who coined this term Deaths of Despair in an
attempt to try to weave together some explanation for those three
causes . O ur study found increases in 35 causes of death in this age
group and it extended well beyond substance abuse and suicides to
inclu de a variety of chronic diseases. W hile clearly opioids and drug
addiction are major priorities in trying to solve this problem , it's
actually more pervasive.

Margaret Flinter: Well, Dr. Woolf, one of the tenants of the work that we're doing in
Community H ealth Centers is that you will find disparities and health
status based purely on racial and ethnic grounds. Y our stud y is little
more nuanced and is really looked at this, I think in a very
sophisticated and complex way. I wonder if you could talk a littl e bit
about where racial and ethnic disparities fall on this , as well as the
role that economic disparities play ? H ow do we begin to look at this
across our very varie d society in the United States?

Dr. Steven Woolf: H istorically, communities of color, par ticularly African - Americans and
other minority groups have experienced disproportionately high
mortality rates and shorter life expectancy than non - H ispanic w hites
in our country . T hat's obviously been a focus not only at Community
Health Centers , but publ ic health at large and trying to close that gap ,
and actually , som e great progress has been made.

Margaret Flinter: Yeah, absolutely .

Dr. Steven Woolf: The initial studies reporting this increase in middle aged morta lity ,
which was around 2015 that a lot o f press attention went to it ,
claimed that it was only happening in whites that it was not occurring
in African - American s or other groups. The reason I said that though, is
because data that had not yet become available showing that it is in
fact increasin g in other racial and ethnic groups as well. We have so
many people, just in absolute number that are white in this country.

Dr. Steven Woolf

A lso there may be some differences in how this is playing out across
cultures and across groups with different histories in terms o f
privilege and disadvantage. The important point to realize though, is
that even with this increase in white mortality, it doesn't even come
close to the mortality rate in African - Americans. The sad thing is that
although we were making some progress in l owering the black white
mortality gap in recent years because of this trend now affecting
communities of color, we're seeing a reversal and some of the
progress that we had made is now being erased by this trend of
increasing midlife m ortality.

Mark Massel li: We're speaking today with Dr. Steven Woolf , Distinguished Chair and
Population Health at Virginia Commonwealth University and Director
Emeritus in Population Health and Health Equity at VCU Center on
Society and Health . I pull the thread on that a litt le because a little
counterintuitive in the sense that we've had the Affordable Care Act
out there for a number of years , 20 million Americans gain coverage. I
think we saw some positive results [Crosstalk] studies that showed
that it had an up take. Are yo u able to measure that impact about the
expanded health coverage and how Medicaid might have impacted
Medicaid now it's grown to about 75 million , 76 million people
covered? What's correlatio n between coverage and outcome?

Dr. Steven Woolf: First, I should just emphasize that there's evidence from other studies
not ours, about the health benefits associated with Medicaid
expansion , and of cour se, the broader health benefits for closing the
gap and in the uninsured . T he disconnect, however, has to do with
tw o factors . There's only so much importance to healthcare and this
I'm saying, as a physician, research has shown that healthcare only
accounts for about 10 % to 20% of our health outcomes. Even if we
were to arrive at the perfect healthcare system, we would probably
still be seeing this health trend because it's really being driven by
conditions outside the clinic that are responsible for this increase in
morbidity and mortality, we have to have access to good care , b ut the
root causes of this lie in the con ditions that we' re living at.

The other thing I want to emphasize is that although it's only been
apparent in recent years that life expectancy is decreasing , the
process was underway, as we said some years ago and what
happened was that although death ra tes were increasing from causes
like drug overdoses and alcoholism and suicides and the other ones
we've mentioned, we were making important gains in other areas so
death rates from Ischemic Heart Disease , from HIV AIDS, from cancer
were decreasing. They w ere offsetting those increases in mortality
from those other causes. What's happened in recent years is that
we've reached the tipping point where the increase in drug overdoses
or the others has become so large and so voluminous that it has
overwhelmed th e health gains that we achieve. Now we're starting to

Dr. Steven Woolf

see that rise and all kinds mortality , b ut it's a mistake to think that to
draw some correlation, for example, to the Affordable Care Act, or to
any recent policies, and assume that those are responsibl e for this
trend when clearly the dynamic was in play some years ago.

Margaret Flinter: Well, you've referred to this as a distinctly American phenomena , and
while life expectancy in this country is declining, the opposite is true
in all other affluent nat ions, which I think is you've said and your
colleagues in this area of research, say that we've got to pay more
attention to social determinants of health . I think you were once
quoted as saying that we would do better to make sure that teens
graduate from high school that it would have more impact than any
new blockbuster drug that might come on the market. T he changes
that we need in terms of population health and the social determents
of health all seem to me come out of policy . I wonder if you'd like to
highlight some of the ones that you and your colleagues think are the
most important when it comes to reversing this trend.

Dr. Steven Woolf: I think there's great opportunity in improving the social conditions,
not only for our hea lth, but for economic m obility. When I talk about
this, it's not like the solution to this health problem is some new
medical discove ry, some new drug that we need. The very policy
changes that we talked about for helping the middle class promoting
social mobility, economic deve lopment of our marginalized
communities are the same ones that will improve our health. I t's
getting access to a good education, jobs that pay livable wages,
affordable housing, transportation, infrastructure . Those are the
things that communities need and families need to thrive
economically, and to provide security for their children. I don't think
those all come from government necessarily. There's an important
role for government policy at the federal, state and local level , but a
lot of it comes from t he private sector in terms of creating economic
opportunity, and we see examp les of that across the country.

Mark Masselli: I want to pull the thread on Margaret's – first part of Margaret's
question, which dealt with other countries and I'm wondering to w hat
extent you can look at best practices or what are we seeing that's
different in those countries? Is it really on the opioid side? Or is it
because they have less of an income difference going on in the
population? What are you seeing and there's any be st practice that
we can try to contemplate ?

Dr. Steven Woolf: Well, I mean, one of the first things to say is that sometimes people
push back on the comparison between the United States and these
other countries because they are so different. W e're not Fin land ,
we're not Norway, we're not Japan. They feel that because we have
such a diverse population , there's some who incorrectly assume that
our health disadvantage is due to this diversity. As we just discussed,

Dr. Steven Woolf

the largest increase in mortality is in non - Hispanic whites. Other
studies that we've done over the years have shown that Americans
across many different subgroups do worse than their peers in other
countries so rich Americans have worse health than rich people in
other countries, insured Americans do worse t han average in other
countries.

One possible explanation for that might be that these other countries
provide stronger support systems for families and communities that
fall on hard times. I t's not that people aren't unemployed or poor in
other countries, but programs and services are in place so that they
can get through those times without it affecting their health as deeply
as it does in this country where there's more of a culture of expecting
people to fend for themselves when times get roug h . There are other
differences. You mentioned the opioid epidemic, which does not exist
in most of these other countries. The marketing of Oxycontin and
other prescription opioids that was so pervasive in this country was
not allowed in many of these other countries. T here are other
regulations and advertising contexts that may also explain some of
the differences we' re seeing.

Margaret Flinter: Well, there are some bright spots in the reports kind of an odd one
that people living in our coastal areas in th e United States have seen
some slight improvements in life expectancy, but it really does point
to some of the widening disparities, urban versus rural . Y ou're
determined to get to the root cause of this disparity and outcomes
and we want to cheer you on a nd that work and we'd love to hear
more about the partnership that your institute is participating in a
national committee funded by the National Academy of Sciences and
the Robert Wood Johnson Foundation to re ally dig down in greater
depth.

Dr. Steven Woo lf: I'm a member of a committee that the National Academy of Sciences
has established to look at this trend of increasing mid life mortality ,
and it's brought together experts from around the country to sort of
put their heads together and review the evide nce and try to get a
better sense of what's behind this trend and what explanations might
be brought to bear to understand what to do about it. I do want to go
back, though, to the point you made about the areas of the country
that are doing well. Our stud y was a state level analysis so we looked
at the state. T he Pacific states, as you mentioned, California, Oregon
and so forth, did relatively well . A s you mentioned a few minutes ago,
our zip code is very important to our health, zoom in on any of the
stat es that like they're doing well. If you're in South LA or areas of
Sacramento or Oakland, you're not seeing those positive health
trends and so we see this pervasively across the country 15 or 20 year
differences in life expectancy across census tracks tha t are just
separated by two or three miles. We need to have that broader

Dr. Steven Woolf

national perspective and see what states and regions are doing well
and not doing well. A lso think about local neighborhood level
solutions that are really powerful influence our heal th.

Mark Masselli: We've been speaking today with Dr. Stephen Woolf , Distinguished
Chair and Population Health in Virginia Commonwealth University,
and Director Emeritus in Population Health and Health Equity at VCU
Center on Society and Health . You can fi nd his report on the recent
edition of the Journal of American Medical Association JAMA, and you
can follow his work by going to www.societyhealth.vcu.edu . Dr.
Woolf , thank you so much for your contribution to public health,
animating the conversation for so many people , I think this is a
conversation that really everybody needs to be engaged in , and also
thank you for joining us Conversations on Health Care .

Dr. Steven Woolf: My pleasure and thank you for b ringing attention to this issue.

[Music]

Mark Masselli: A t Conversations 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 n onpartisan, 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: In the November Democratic Debate , Senator Bernie Sanders s aid
that the United Nations is projecting , “ Hundreds of millions of climate
refugees in the years to come as a result of climate change. ” The UN,
however, doesn't currently endorse a particular estimate and the
term climate refugee is in many ways problema tic. His remark is
similar to a comment the UN Deputy High Commissioner for Refugees
made in 2008. Well at a Climate Change Conference , the official said
that between 200 million and 250 million people would be displaced
by 2050 because of global warming, but that figure is likely flawed,
and it was also more than a decade ago. More recent statements
from UN officials do not indicate the agency endorses an estimate. In
2011, for instance, the High Commissioner for Refugees said there
was no consensus on a n umber and a 2016 FAQ available on the
agency's website says quote, “It is hard to say,” how many people will
be displaced by climate change.

Scholars in the field don't use the term climate refugee because
refugee has a very specific meaning in internatio nal law. For one the
term refugee applies to those crossing international borders .
Research shows people affected by climate change usually move
within a country first. In 2014, the UN International Organization for
Migration stated in a report that there was great uncertainty about
the figures, noting that the forecast for the number of environmental

Dr. Steven Woolf

migrants by mid century vary widely between 25 million and one
billion. The actual figure the report explained will depend on a host of
factors that are large ly unknowable at this point. For more see our
website at FactCheck .org . I'm Lori Robertson , Managing Editor of
FactCheck .org.

[Music]

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a proje ct of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you h ere on
Conversations on Health Care.

[Music]

Margaret Flinter: Each week conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. It's estimated
that the majority of a person's lifelong health expendit ures are often
spent in the final months of life. D eath is one of those topics that
generates the least amount of conversation in the clinical setting. For
folks who end up critically ill or facing a terminal diagnosis like late
stage cancer, this can ofte n lead to poorly communicated end of life
wishes being discussed with the clinician who then often re sorts to
extreme interventions.

Dr. Manali Patel : There's this unspoken misconception that by having honest
conversations about prognosis that we are someh ow removing the
hope that patients are coming to us looking for. Actually, most studies
that have evaluated this have shown that when you provide honest
prognostic information to patients and allow patients to be part of the
decision making about their goa ls of care , they actually have more
understanding of their disease process and better satisf action with
their care overall.

Margaret Flinter: Dr. Manali Patel is a Clinical Researcher at Stanford University School
of Medicine. Her earlier research at Stanf ord Edu did an interesting
finding. Late stage cancer patients felt more comfortable talking
about end of life issues with a layperson as opposed to a clinician. She
and her fellow researchers followed patients at the Veterans
Administration Palo Alto Heal thcare System for 15 months after they
were diagnosed with stage three or four or recurrent cancer. Half the
people were randomly assigned to speak with a lay worker about the
goals of care over a six month s period and the lay workers were given
a rigorous 80 - hour course and clinical observations befo re being
assigned to the study.

Dr. Manali Patel: She learned as she went and as the project went through the cycles of

Dr. Steven Woolf

starting the implementation and ramping up and then at the end, she
came to that realizati on that these conversations really are not scary.
We had hired her specifically because of her service orientation and
because she had a very supportive ear and that's really the main crux
of this interventio n was finding the right person.

Margaret Flinter : 92% of the participants who received the layperson intervention,
compared to only 18% of the control group, were likely to have end of
life directives in their Electronic Health Record , and more likely to
have communicated their wishes to their clinician s as well. Often
choosing hospice over emergency room interventions , the health
costs of both groups varied as well. The average cost of care for the
intervention group in the last month of life was about $1,000 versus
$ 23,000 for the control group . Dr. Pa tel said one of the more
interesting findings was much higher patient satisfaction .

Dr. Manali Patel: We found that the satisfaction scores went up for the patients in the
intervention arms that they went down for patients in the control arm
as well as the satisfaction with the decision making across all six
scores of dissatisfaction with decisions fail, we found overwhelmingly
that the patients in their invention arm were very satisfied with the
decisions that they had made regarding their medical treatmen ts that
the patients in the control arm really did not have much movement at
all in t erms of how satisfied they were.

Margaret Flinter: A low resource compassionate, patient - centered intervention that
assist terminally ill patients, their families and thei r clinicians to have
a frank discussion about end of life wishes, improving patient
satisfaction as such a sensitive and challenging time. That's a bright
idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli .

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, o r wherever
you listen to podcasts. If you have comments, please e - mail us at
[email protected] , or find us on Facebook or Twitter. We love
hearing from you. This show is brought to you by the Community Health Cente r.

[Music]

Dr. Steven Woolf

24:29

You've been listening to conversations on healthcare, I'm Mark the salad and I'm Margaret
planter piece of health conversations on healthcare is recorded it w e
su at Wesleyan University streaming live at ch ic radio.com iTunes or
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We love hearing from you. The show is brought to you by the
community health center.

Mark Masselli: We're speaking today wi th the Retired Three - Star Navy Admiral Joe
Sestak, a Candidate for the Democratic Presidential nomination. He
represented Pennsylvania's Seventh Congressional District from 2007
to 2011 in the U.S. House of Representatives . Admiral Sestak served
as Directo r of Defense Policy at the Office of National Security under
President Clinton, and served in the U.S. Navy for 31 years. Thank you
for your service . He is a graduate of the U.S. Naval Academy , earned
his Master's in Public Administration and his PhD in Po litical Economy
from the John F. Kennedy School of Government at Harvard
University . Admiral Sestak, welcome to Conversations on Health Care .

Joe Sestak : Mark , it's good to be with you and with Margaret and please it's Joe.

Mark Masselli: Joe , that’s corre ct, Admiral Joe, if you don't mind, I think that's how
people are on the trail refer you to and you came into the process
late, you had reasons of course your teenage daughter was recently
treated for brain cancer for a second time and you say that really
shaped your experience as you thought about engaging in politics. I'm
wondering the factors that drove you to enter the race and your
thoughts on the Ame rican healthcare system as well.

Joe Sestak Right , got married late in life and come back from the war and my
daughter was four years old and had brain cancer. After the first
operation at Walter Reed Military Hospital , the doctors took U.S.
aside and said we couldn't get a total resection, and they said, we
think it's Glioblastoma . That probably means only about 90 days , and
beca use of the military health care system, we were able to take her
elsewhere. F rom children's the Mass General to one of the two
proton beam therapy machines at the time, all of a sudden I truly
understood The National Security begins at home in health security. I
changed from being an independent to being an independent
happens to be a Democrat. I ran in nearly two to one Republican
District on one refrain. National Security begins at home in health
security.

I taken in 2005, the soo n to be called Romney Care , Massachusets
Health Care Plan , and I ran on that. I knew everybody needed
accessible, affordable health care, do the same thing I had, and we
passed the Affordable Care Act. When my daughter's brain cancer

Dr. Steven Woolf

came back last year, h owever, I wasn't planning on getting in this
presidential race. We were taken aback. Only percent of children ever
survived Glioblastoma . She was into the end zone and all of a sudden,
there it was. We went through it all again and after we had the proton
beam therapy, the surgery, she couldn't go through the same
chemotherapy. T hey had one of these new drugs. It only been
approved by the FDA with Metastatic breast cancer, but it had the
same element, same chromosome so to speak, that's up in her brain.
FDA hadn't approved it for that and so we were denied. We
eventually appealed and wanted not took two lessons from it. It was
chromosome cancer or gene cancer, and yet government hadn't
caught up with that. Government needs a better type of relationship
with the healthcare community.

Number two, is I began to wonder if the middleman was really
necessary where, why did I need someone wasn't even a medical
doctor to be saying what could or could not be? I got into this race for
different purpose obvio usly than healthcare to try to unite our
country and help the country in the world again with someone who
understands global affairs but I'm so still driven by National Security
begins at home, and how those lessons I j ust learned the second time
around, move me tow ards a different approach to health care for
universal healthcare.

Margaret Flinter: Well Admiral , I think it's fair to say that you're somebody who walks
the walk and I read the during your political career in Pennsylvania ,
you are known to have walked ac ross the entire s tate. That's a pretty
big state –

Joe Sestak : 122 miles.

Margaret Flinter: -- i n an effort to truly connect with voters in your state, which has so
many very diverse regions, and you wanted to slice of victory there, I
understand you've wa lked across New Hampshire. I imagine you have
a lot of stories about what you've learned from these experiences and
what are you learning from the walking towards/ tours this time?

Joe Sestak : Well, the very first event I did was actually across the U.S. Na vy
Seabee Bridge , which connects Vermont with New Hampshire .

Margaret Flinter: That’s right .

Joe Sestak : And I wanted to go before I started the official walk into what's called
Brattleboro Retreat , which takes care of 5 , 000 individuals who have
challenges in mental health. O nce again, it struck me . The biggest
disease we have in America is mental health . We have less psychiatric
beds today than we did in 1850. In fact, the largest psychiatric
hospitals Rikers Prison , and I wrote it for this Mental Health a nd
Ad diction Equity Parity Act, but we aren't enforcing it. As I walked, I

Dr. Steven Woolf

met with social workers or others who work in this area , and I would
always go into prison on Veterans Day to visit my fellow veterans.
Again, there's so much last assets and this p rison was the most
progressive prison I've meant where the superintendent says you
can't control as we're taught as corrections officer to control human
nature, you can manage it with incentives and disincentives. W hen
you're brought in, if you behave and you sit down, no handcuffs or
anything, nobody sitting around you and you get up and sign in and
wait for somebody behind the desk to call you forward for check in, or
do not behave and you're slowing into a sm all little slammer right
there, and he begins to treat with respects or an app , and with that
type of approach, the reentry and recidivism programs are so much
better and I saw wonderful people. I call them heroes from small
business women trying to start up a brewery to stop by a gun show,
because I wanted to say that I respect the Second Amendment right,
the Heller Decision said, but I didn't want assault weapons fans there,
all those experiences I tr easure having walked across me.

Mark Masselli: We had the opportunity to talk with some of your fello w candidates
around Health Reform and we have different camps. Some folks are
embracing Medicare for all but you say that there's a better approach
focusing in on the Affordable Care Act as well as creating a public
option , and I'm wonder if you could tell us what s ets your health
strategy apart.

Joe Sestak : In fact, I think it's a worthy goal Medicare for all, but in the military,
you learn piss poor planning is piss poor execution . After you had a
government that decades ago could be in four years, Japan and
Germany, but yet that same government was unable recently to roll
out a healthcare website so you want to pause for a moment and say
what is the best approach to achieve it gaining the trust of
Americans ? So what I want to do is as president is immedia tely fix the
Affordable Care Act with all those horrible executive orders that have
been issued, and have taken away, what made it work, very fine
engineering model that did give coverage not only to so many, but it
also began to cut down upon the cost to our economy . As you all
know, according Institute of Medicine, because of the younger and
uninsured, we lose somewhere between $100 billion and $ 140 billion
a year.

I tell everybody Obamacare was actually passed as one of the first or
second piece of legi slation in 1789 with our first Congress . They
mandated that all the sailors had to have health care, and actually had
to pay for part of it. They didn't want scurvy at sea to destroy the one
solid economy keel ships that were going to bring raw material fr om
America to England to be turned back into finished products. As I tell
the Tea Party patriots your forefathers the Tea Party is actually
established Obamacare –

Dr. Steven Woolf

Margaret Flinter: So that goes over well.

Joe Sestak : It's not just for the individual, it's for the common good of America.
W e don't lose that $100 billion, $40 billion in our economy as they go
to emergency room , sicker rooms more days. T hen , as I voted for on
Congress, you want to have a public option. W e need to make sure it
works because 255 million Americans have some sort of private
healthcare. W hat we need to do is have it be a transition of choice
initially, to where if it does provide better access, better care at lower
costs, to where your company's paying directly to a private hospital , a
for - profit hospital like Johns Hopkins or Mass General, more and more
people will jump into it as it proves itself. T hen , after four to six to
eight years or so you can start saying it's worth and we begin to get an
idea of what the cost is, but we nee d to test it out then you can move
towards that Medicare for all .

People still want to select private health care code , b ut more
important than that is what about the world county and my speech
here to the Polk County Democrats , they said, you're going to be
losing 20% of your hospitals in rural counties over the next few years.
In fact, the same percentages in New Hampshire where they're going
to lose five of their remaining 70. W hat happened with all these world
hospitals all their for - profit, no for - pro fit is possible is ever going to go
back to the rural county is what I believe the second track should be
one towards the VHA the Veterans Administration Hospitals , which
the New England Journal of Medicine despite the bad news you see at
contra or public institution as compared to like Mayo Clinic . You find
New England Journal of Medicine has rated it equal to or better than
any private or public healthcare provider in American 11 major
industry. T herefore, you should have another track with an option
that moves itself towards this government hospital , government
doctors to see if that's what ca n survive in the world hospital. Here in
the rural counties as they lost their hospitals , they pay like $8
premium each month to have a medevac committing a helicopt er for
an emergency. But they still get stuck with a $36,000 bill. W e
need to step back in my party and say, wait a moment. One size
doesn't fit all . M y party needs to make sure we don't forget those in
the world.

Margaret Flinter: Well Admiral, looking b ack on your career, you've certainly been
engaged in passing some of the most significant legislation, the
Affordable Care Act that we talked about already , and you also
mentioned the Mental Health Parity Act. There's another act that
maybe doesn't get tal ked about as much now but was really very
instrumental , The American Recovery and Reinvestment Act in its
support for practices moving large scale, from paper to electronics,
but it's been costly in some of the burdens that have placed on
providers and hea lthcare systems that weren't there before. I'm sure

Dr. Steven Woolf

you're also hearing that this is also a big concern for people within
healthcare around the cost and the burden of the technology . Why
don't you share with us your thoughts on that transition a nd where
we are in the country?

Joe Sestak : I was a large proponent of the electronic medical records. In fact, I
had to go to the VA and this was back like in 2005 time period , and as
the VA was the first to do electronic records. I sat there in the doctor's
office, he was doing one check up on me and all of a sudden someone
calls me said just a moment that that -- tell I've just put in the medical
order or something and I was back then that was like getting your first
Xerox machine on a ship in the early 70s. I have heard whether it was
from the New Hampshire Medical Society or whether as I met with
doctors out here in Iowa, exactly what you said. What has happened
is this has become almost more overly done because of billing issues.
Getting the right codes or the ri ght paymen ts are made these are
being the insurance companies have it to where the original purpose
of this, hey, everything's there quick slips , you can see the past
history, you see all the past results and everything and there it is. I f
it's become over ly burdensome, and everyone says it has because of
that we need to streamline this. T his could actually be part of the
benefit of eventually getting to Medicare for all to where you don't
have that insurance company that is worried about profit and
payment s. T hat's the central complaint I've heard about this system,
part of it just might have to be to make sure this Medicare fall system
works because the burdensome that every doctor has had.

Mark Masselli: We're speaking today with Retired Three - Star Navy A dmiral Joe
Sestak a Candidate for the Democratic Presidential nomination,
Former Director of Defense Policy at the Office of National Security
under President Clinton. He also represented Pennsylvania Seventh
Congressional District in the U.S. House of Rep resentatives. Well
Admiral, it's probably easier to navigate the democratic landmines
than it was navigating the battles that you as a commander of the
aircraft carrier your battle group during Afghanistan?

Joe Sestak : Don’t be so certain about that.

Mark Masselli: Well, I'm not sure. I was going to ask if there are some similarities , b ut
you also were somebody who made waves during your time in the
Bush Administration recommend ing a large r share of the military
budget be diverted towards enhancing Cybersec urity and really sort
st
of thinking about the 21 Century technology. Talk to us about your
sort of plan for how we strengthen and harden our important dat a
that we're trying to protect.

Joe Sestak : I have been in this area ever since 1995 where I was hande d a folder
by my boss National Security Council and said, You're the one who's
going to set up the portfolio on protecting critical infrastructure,

Dr. Steven Woolf

damn from being hit by cyber attacks, and this is 1995 or others types
of facilities that we rely upon , Wall Street being taken down and our
health records , all of a sudden the best of them and / or the damage
done to them. In fact, as you mentioned, I carried it forward to the
Navy and as a Three - Star Admiral, I said, we don't need 375 ships.
We're still measurin g ourselves unfortunately in this modern era on
how many pieces of units we have. It's the broadband capability that
shows you how good you can be. I n the military, I advocated that this
go to about 260 shifts, we can go from about 12 carriers to nine and I
were game this was about 120 staff, with using computers for all this
and say, Look, if you're able to do a strike, like we did with into the
centrifuges of Iran take down their centrifuges where they could use
them, wow, how less expensive and how much more effective that is
and trying to drop thousands of potentially bombs to get through 300
feet of rock to destroy that facility. That's the change we need.

In fact, that plan met with a great opposition not just from the
military industrial complex beca use President Eisenhower said it's
really a congressional military industrial complex. As one senator said,
when he met me and I was running for Congress, he said, Joe, I
remember you, you're the admiral that wanted to cut my submarine
fleet, but the man w ho worked for me is now in charge of the Civic
and has actually said, America is the first loss of command of the Seas
by the U.S. Navy since World War II , China has it , and we need more
cyberspace. W ith regard to our records, this is an immense issue. In
particular, the 5 G network is being developed. As you know, you've
seen it in the newspaper about Huawei and others like President
Trump and what's going on here. T he truth of the matter is this 5 G
network wireless will revolutionize economy and warfare by different
means. China's to its belt road initiative has already had 70 countries
that take its predatory who's it enforces him to buy digital road, which
is you will buy our 5 G network.

Whoever build the 5G network will own it, and only three companies
do. W hen you put that piece there everything that you say the
wireless will go through this piece of equipment, and you don't have
to hack anymore and so if you have a medical meeting, if Artificial
Intelligence development for medicine, if electronic reco rds are
passed via wireless, they will see everything. All they have to do is
download off their server and they can go down and take down any
critical structure that's connected to wireless without having to fight
through. This is probably except for clim ate change the greatest
threat to America's dream today. Y et, we aren't doing anything about
it from our side. T here's only two things we need to do is remember
much like President Eisenhower said we need a road system or
President Lincoln said we need an intercontinental railroad. Wall
Street wasn't going to build , it was too expensive in so he finished it
up. We need someone to understand this new infrastructure. The 5G

Dr. Steven Woolf

network needs a public private venture to be done with it. T hen ,
second, we need to do what America's greatest strength is to convene
the world of allies and friends in a rules based world order that stands
together and says this is fairness and just ice of how this equipment
will be used or not used. Everything that will be in that medical record
as it's passed on wireless will be copied and done with . Never mind
the kind of warfare that can be done by taking down Wall Street just
because the 5 G network has to be connected by Huawei.

Second, we have to keep in mind and anything that doesn't go over
wireless goes to underground cables, and Huawei and other Chinese
companies have now laid about a third of them 98% of
intercontinental communication goes by undersea cables. T his critical
infrastructure, this cyberspace, it is actually giving Chi na all the
commercial intelligence it needs at no cost and all the military
capability it needs in order to hide potential damage. It's what it's
doing to its rigoro us citizens today . If you go to my website you can
see how they've all been incarcerated no t just physically but by digital
incarceration wherever they walk , they have a government phone and
their faces are copied on street lights, etc. Sounds daunting , but that
is really cyberspace the new domain of warfare and why another
aircraft carrier isn' t worth its cost when you can have this whole
capability to either use or protect yourself from.

Margaret Flinter: We've been speaking today with Retired Three - Star Navy Admiral Joe
Sestak , a Candidate for the Democratic Presidential nomination. You
can le arn more about his very distinguished military career and his
contributions to political life by going to www.joesestak.com , or
follow him on Twitter @JoeSestak. Admiral, thank you so much for
your service, for you r dedication to this country , for your insights and
for joining us on Conversations on Health Care today.

Joe Sestak : Thank you Margaret and Mark for having me aboard . It's a real
pleasure.

[Music]

Mark Masselli: A t Conversations on Health Care, we want ou r 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 n onpartisan, nonprofit consumer advocate
for voters that aim to reduce t he level of deception in U.S. Politics.
Lori, what have you got for us this week ?

Lori Robertson: A popular Instagram post falsely claims that more than 1 , 100 people
died from reactions to the flu shot in 2018 and suggest that the
immunization gave some ch ildren polio. The flu vaccine cannot give
anyone polio and there is no evidence to support the 1 , 100 figure. Flu
shot is the single best way to protect against seasonal influenza, a

Dr. Steven Woolf

viral disease that in some years kills tens of thousands of Americans.
Flu shots have a good safety record. As the Centers for Disease
Control and Prevention explained, the most likely side effects are mild
and include soreness or redness at the injection site, headache, fever
and nausea . A more concerning side effect is a serio us allergic
reaction, which could lead to anaphylaxis. A n analysis of CDC data
identified just 33 instances of vaccine triggered anaphylaxis after
more than 25 million vaccine doses. Of those cases, only one person
was hospitalized and no one died. The Ins tagram posts claim that
1 , 100 people died from the flu vaccine in a single year has no basis.
Published studies rarely, if ever observed deaths plausibly tied to the
flu vaccine.

The post second claim that the flu shot may give children polio is also
fa ls e . Polio is a potentially deadly and highly infectio us disease caused
by the polio virus . Flu vaccine has nothing to do with polio and does
not contain any polio virus . Since 1979 no cases of polio have
originated in the United States , and that's my fact c heck for this week.
I'm Lori Robertson, Managing Editor of factcheck.org.

[Music]

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 Univ ersity of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com , we'll have
FactCheck.org's Lori Robertson check it out for you here on Conversations on Health Care.

[Music]

Mark Ma sselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. In the
emergency room, clinicians are confronted with a myriad of
unpredictable medical crisis that sometimes can be challengi ng to
diagnose .

Dr. Josh Landy: And this is really hard, especially if you're in a busy tertiary care
hospital and you're there and it's 4:00 a.m. and there's almost nobody
else to talk to you unless you have a specific question to wake
somebody up to ask them and t hat's the existential dread of
medicine.

Mark Masselli: ICU Physician Dr. Josh Landy was noticing a growing trend of image
sharing via smartphones to crowdsource second opinions from friends
and colleagues across the country. H e created figure on e a sort of
Instagram for doctors in which images can be de - identified, but
shared across a dedicated social media platform that would allow
input from c linicians within their network.

Dr. Steven Woolf

Dr. Josh Landy: And what the network does is it lets you take a picture of a case and
submit it for conversation for learning , for teaching and for any other
reason why you might n eed to take a picture of a case.

Mark Masselli: Doctors are using the app to communicate not only with colleagues
within their hospital settings, b ut around the world where someone
might have superior expe rtise with a certain condition.

Dr. Josh Landy: A nurse in Haiti put up a picture of a little baby. W hen this baby was
born with an un usual skin condition, she didn't know what it was and
if it was safe to let the baby leave. S he put up a picture and within a
few hours 16,000 people logged hundreds of responses. What that
means is we can change what is the traditional way of a patient
accessing medical care .

Mark Masselli: A free downloadable app off ering secure HIPAA compliant image
sharing among clinicians around the world, tapping the collective
expert instantly. Now that is a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flin ter: And I'm Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or wherever
you listen to podcasts. If you have comments, please e - mail us at
[email protected] , or find us on Facebook or Twitter. We love
hearing from you. This show is brought to you by the Community Health Center.

[Music]