>> i said at the beginning of the book our biological wiring and i wanted to show how we had evolved the culture that was designed to validate us and not to challenge us. to contradict us. it gave us the illusion that our realities were water tight when really they were riddled with weak spots and places that would crunch in.

>> this week on "newsmakers" we're joined by the president and ceo of the hospital association. >> as the bills are being considered, the house passed

one, the senate is working on one, does this go anywhere near repairing some of the pieces that you would like to see fixed? >> the senate bill goes perhaps to dealing with private market sablization and dealing with the cost-sharing reduction issue which i think would address some of the instability that we see in the exchange part of the insurance market. so that's certainly something. but the large-scale reductions that would result from medicaid cuts as it relates to coverage, those are things that we have great concerns about. >> you mentioned some strong comments against where the current bill is going in the senate and in the house. but maybe you can go into a little what kind of negative effects do you see if this bill passed? do we see hospitals closing in rural areas? what you what would the bad effects be?

>> we look through it through the lens of coverage and coverage for the uninsured. and when things first passed it was intended to cover 32 million people. it ended up covering much less than that because of the supreme court decision with medicaid expansion. so for us the concern is coverage and the coverage lost that would result particularly as it relates to the medicaid program. medicaid serve our most vulnerable population. so many kids are on it that are disabled. one in ten veterans are on the medicaid program. two thirds of the money goes to taking care of elderly folks in nursing homes. so the cuts in medicaid program ich in both bills are rather dramatic, is a great concern to us. and then the coverage estimates that go beyond the coverage

losses in medicaid are also pretty substantial according to the congressional budget office. so for us the big issue really are all around the coverage losses that would result. and that's why we've been opposed to it. >> and patients who need the coverage, but as far as hospitals go, how are the hospitals affected? bottom line, with what could happen with the medicaid cuts? >> a couple of things. first it really is about patients and patients being able to get coverage and care. that's the number one priority. in terms of hospitals, when the deployed 15u d we -- 155 billion at the time for helping to fund coverage for what we hoped were millions of people. there were two pieces for funding the coverage.

the revenue side and series of reductions in spending. so for us, if we're going to see increased uncompensated care, given the fact that we forgave reimbursement to extend coverage that puts us? a real pinch. the medicaid reductions will put us in a real pinch. medicaid currently pays hospitals less than the cost of providing services. so if we're going to see reductions on top of what we've already contributed plus these new ones it's going to make it very difficult for us. what does that mean? it means the potential of making tough choices. it means that certain services may not be able to be provided. it means that there could be job losses because roughly 60% of the hospital's budget relates to employment. we may see delays.

so those are the tough choices that would result from reductions of this magnitude. but again the biggest concern for us really are the whole issue of getting people covered so they have access to care and they get it at the right place and the the right time and that our emergency departments don't continue to be the family doctor for people. >> so given these concerns, what is kind of your strategy been in terms of trying to oppose it or change it? are you going to run ads? are you having meetings on the hill? what is your strategy? >> a situation like this, obviously we work to try to shape the legislation and urge that the medicaid cuts not be a part of it. we urge that there be assistance to the nonexpansion states of which the house and senate did some limited things. and all object tivity.

we urge that they maintain the minimum benefit requirements but those provisions are still in the bill and that's why we're against it in terms of strategies obviously grassroots are -- our members speaking out. providing the data impact is crucial. we have done advertising and a variety of other techniques to make sure that our voices are heard. >> do you feel that any of that is getting through? have you been able to sit down with leadership in the senate convey these concerns and feel like they get it and maybe there are some changes coming? >> you know, we've had the opportunity to convey our concerns to leaders in the house to leaders in the senate. to people in the administration. they've listened to our concerns and i don't know if they really heard them which is why we are where we are and having real problems to this legislation and having to oppose it. >> going off of that there was

a lot of attention on the relatively secretive nature. but that was only a week or so ago. did you feel that before the bill was released there was enough input gotten from stakeholders or did you feel like the process was open enough? did you want it to be more open? >> for stake holders like us you could never have enough input of anything that's going on. and this process hasn't been out of sort of the textbook of how a bill becomes a law. that's certainly the prerogative of the leaders to go through. they have clearly run into problems among their own membership relative to the process what they have gone through. but we are where we are and in fact the process continues as congress will be returning to this coming week and we'll continue to see efforts on the senate side to cobble together

see if they to could pass it. and again we'll be out there expressing our concerns. >> we've seen a few republican senators come out against the version that is out there now and looking for some changes. have any of them specifically talked about hospital ors their concerns for their rural communities along those lines? >> absolutely. we've heard from people expressing a lot of the concerns that we share. the medicaid -- the need to maintain the medicaid expansions and to provide coverage and to ensure we don't lose that coverage. we've heard a lot of people mention that in terms of expressing concerns. talk about the rural issue and the issue of hospital closures. there are a lot of different responses that you'll see as a result to some of the reductions in the loss of coverage. closures could be one of many.

and we've heard senators express those concerns from various states. i know before the idea of repealing and replacing obamacare and even before obamacare the the closure of was a big issue. did the aca help that? did that law actually -- were you was a big issue. able to ma gap a little bit? >> you know, over the last i guess five years we've seen about 187 hospital closures, about a quarter of those have been in rural areas. some of that is as a result of budget preshrs. others are as a result of reconfiguring or redefining an h because one of the things that we were in the process of doing in the field is trying to provide care in a variety of different settings, not just the buildings that we know and we love and people depend upon

trying to coordinate care in various settings. so some of that is a result of reconfiguration. some is a result of not being able to survive in tough environments r. hospitals have been a bit more unspoken in some of the other areas of the health care industry. the insurers played a big role have boon a bit more quiet. there's been some attention on that. do you ever when you're talking to insurer colleagues say we wish you would be a little more outspoken, we would wish you would oppose this more? >> we really focused on those in the provider community that share the same position and whether it's the american medical association and several physician groups, whether it's the aarp, whether it's the diabetes, the march of dimes, the american heart association. we've been working in coalitions and held three forums in different cities in

reno and cleveland and in denver just over the last several weeks together as a coalition. and it is significant i think that the provider organizations that are on the front line of delivery nurses as well the ones that had the most concerns with it. some of the other sectors of the health care field have different types of concerns because a lot of their concerns tend to be on the tax side and wanted to see certain taxes repealed that in fact they do in the house and senate bills. so within the health community i think the provider side that delivers the care on the front lines and the patient side significantly have been very aligned. >> why do you think that it is sort of that side that isn't getting what they're looking for? you mention the taxes are being cut in the house and senate though. >> right.

well, you know, it's always popular to cut taxes. and that's something that has been a part of the discussion and that's something that those sectors are the beneficiaries from. and that's where their interest and their focus tend to lie. >> are you generally pushing for -- are there particular changes that you think have some reasonable chance of happening that you're pushing for or your general attitude is we need to start over with a whole new bill? >> when we look at the packages before us and some of the tweaks that are being considered, we don't think they go far enough and we would say let's reset and restart. again, we have a list of concerns which we wish they would address but they don't seem to be moving in that direction. they're pretty big as it relates to the medicaid cuts and as it relates to the issues

around maintaining the same level of coverage that we have now. but it appears as if the focus is going to be more on tweaking the existing bill as opposed to a re-start and that's why we are where we are. >> senator ted cruz has proposed an amendment to the senate bill that would deal with obamacare regulations. one of them being preexisting conditions. what are your thoughts on that? >> we have real concerns about that approach. what you do or what we understand that proposal would do -- and of course we haven't seen any paper on it yet. it would further bifurcate the insurance markets and essentially say you're going to have beyond compliant plans -- a nch ca plans and compliant plan. we're concerned the sick folks would end up in the compliant plans. the younger and potentially healthier folks would end up in the noncompliant plans.

which will presumably be cheaper because they won't be comply nt. >> they won't be covering preexisting conditions. >> exactly and won't be covering the essential benefit requirements. so what happens is you have a lot of the high-risk folks in the compliant plans and the premiums will just go up for them. we don't think that's a good solution. i know that's something that people are discussing. >> what does that mean for hospitals? >> well, for hospitals it means, again, the fact that you will have a lot of people with what we tend to call potentially skinny plans that have very high deductibles. and that means that for us we'll have a lot more people coming through that may not be able to meet those deductibles and those copayments. and for us it becomes uncompensated care. we're kind of special when it comes to health care. we take care of everyone that walks through our doors by

virtue of either federal law or our mission. so for us a lot of that really becomes uncompensated care. and uncompensated care means that private premiums for everyone else just goes up because if you're paid less than your cost on medicaid, you're paid less than your cost on medicare. and if you're providing a significant amount of charity care, which we do, then more uncompensated care just means that we have to charge everybody else more. and i think all of this just increases premiums. >> one of the things that obamacare did that sometimes is set in motion these programs how payment works. you're paying for quality rather than quantity. with these repeal bills do you see that damaging those efforts? is there anything in the senate bill, for example, that you think would actually go after

these sort of core drivers of health care costs and make things more efficient or would the bill sort of set bark those efforts? >> that's a an interesting question because one of the things that was part of the aca was we were going to move forward integrated care. more value than volume. more quality than quantity. those are all things we support. those are all things headed in the right direction. the tools to do that, that were in the aca, whether they were bundling or accountable care organizations or medical homes -- you can go down the list. all those things are good they head in the right direction. are they perfect? no. do they need improvements? yes. should we be looking at a little more creative options? yes. this goes back to the question of of course it needs to be modified as it goes along. but the real important point that you raise is none of this is being discussed.

why? because it really isn't on the table. and a lot of these techniques are by and large thing that is enjoyed bipartisan support. i really haven't heard people say let's get rid of these things. let's repeal these things. frankly i don't know that you could under the rules of reconciliation. so these are things that we continue to be focused on because they're the rights things to do to improve care, create efficiencies and in the midst of all of this unpredibblettability we try to stay focused on this as well. >> so you think those efforts can continue even if those bills pass it would leave a lot of that untouched. >> right. on the regulatory side how some of the things these could be implemented and the speed in which they could be implemented is certainly open for discussion. we had been pleased that h.h.s. has said that on some of the projects they would do them on

a voluntary basis rather than on a mandatory basis. we think that's a better approach. but i think that's a direction that again is going to continue to the move. and again that really hasn't been a partisan one. >> talk about -- because we often hear from our viewers, i went to the hospital, i was there for an hour, and i got a bill for x amount of dollars -- thousands of dollars. and the public does not understand what costs so much when they visit a hospital. >> right. and a lot of times when people receive these bills it's really a statement of what they charge -- a charge might have been. not exactly what they're libel for out of pocket because -- lieable for because the insurer has negotiated a rate with the hospital and it's much lower than what that charge may be. very complicated, i know. you look at medicare or

medicaid and they just pay hospitals a rate. there is no price. there's a rate. we get what it is that they provide as a payment. there really isn't much of a negotiation there. at's roughly 40-45% of a hospital's ref new. so when you see those, there's a real delta there between what may be on that bill versus what you're libel and out of pocket expenditures. now, the other part of all of this was for a hospital perspective again we're unique. we provide care for everyone that walks in the door. so, again, for a lot of people there's a hidden tax if you will to pay for the uninsured. 23 with the aca and the million that are covered are under it. there are still tens of millions of people not covered. so we're still in that situation where you have that proverbial cost shift or hidden

tax which raises the cost for everyone. at the end of the day there is no free lunch where you're taking care of everyone. >> would it be a good idea then to be more trance parent what those costs are and what the actual payment would be if they didn't have insurance. if there's something -- they're having knee surgery and wants to compare cost would that be the idea that aj would be hee hind? >> the whole issue of price transparency is something that we understand and support. in fact if you go to a government site for the most common procedures there's information on pricing. 44 states already require hospitals to put out what the rates are or certain comparisons for the rates. but we also have to remember that what consumers really want to know is what their out of pocket exposure is. that is really something that insurers also have to be a part

of. we also have to recognize that we're not dealing with manufacturing widgets there. we're taking care of people. and people are different, conditions are different, people react to certain situations in a different way biologically, fizz onlyically wise. so it's a lot more complicated but we know we have to be more transparent in pricing and we're working to do that as best as we can. >> maybe returning to the aca in our final minutes. if there were going to be some sort of bipartisan effort to fix the aca, aside from this bill, what are some of the big fix that is you guys would like to see in some sort of bipartisan effort? >> we would welcome a bipartisan effort. the first thing would be the cost-sharing reductions to stabilize the exchanges. in the exchanges where we have seen premiums go up and that's the sliver of the individual market, you know, 7% of all are in the individual nongroup

market. half are in the exchanges. it's that sliver that we have seen real problems with skyrocketing premiums. all of the studies suggest that fixing the cost sharing reductions would address that issue that would give confidence to the insurers and that ought to be top of the to do list. >> any more fundamental i guess changes to the aca that you would look for? >> i think that's probably the most significant one for right now. that is stabilizing those exchanges that you can continue to provide coverage for people of limited means through that mechanism that represents helping people buy private insurance. >> what are you looking for next? what are you watching for next as this the debate continues on lawmakers will return from their fourth of july breaks? and there could be a if you

will -- what are you watching for? >> what we're all watching for as they return next week is what are the changes that the majority leader will make to the bill that is out there? and as we all know, senator mcconnell is extremely skilled and able and he will -- i guess way -- see what he can do to accommodate different folks. there's already talk about trying to address the issue of opioids. and other things they have been talking about. senator cruz's proposal will be out there. next week there will be a week of both tweaking, see what tweaks survive the parliamentary review from the byrd amendment. see what the score would be. i suspect the week after next will be when we go back to seeing a product that is ready to be voted on. so everybody would be looking on what changes will be next week. >> let's end our conversation with the opioid portion of

this. thags something that americans feel across the country and it's important to many of the senators. they're not -- they've said no unless there's more money to deal with opioid addictions. what are hospitals seeing? >> i'm really glad you raised at because congress passed legislation to address both the opioid problem and the behavioral health problem and here we are dealing with medicaid that has provided care to so many people that are suffering from opioid addiction and from behavioral health problems. and the rolling back of the medicaid expansions and the the cuts to the medicaid prab by virtue of going to the per capita caps are moving in the opposite direction as it relates to taking care of those types of populations that have a lot of need. this is the coverage vehicle to help them. and providing money for opioid programs as opposed to giving

people access to a comprehensive care package we hink is the way to go. that is not just throwing more money toward state programs for opioid abuse. we think you need to get people the full comprehensive set of medicaid d that the program is probably the best way to do that. >> we appreciate you being on "newsmakers." >> thanks for having me. >> we're back with our reporters. let's begin with the american hospital association. they obviously are not for complete repeal and replace. they would like repair to the faredable care act. where does this group stand as opposed to the other major players in any health care debate that happens in

washington? >> they've been some of the most outspoken against the bill. they've been more opposed to it than some of the other big players. the insurance industry has been much more quiet and hasn't really taken a firm stand either for or against. they're sort of playing their cards closer to the chest. but the hospitals have been more out there saying we are directly affected by this. we're out there providing care to people and this would have some damaging cuts. and the more people without insurance and it would be damaging. >> so ana is their influence being felt on capitol hill? >> i think that they felt that it is being heard. they have gone in, they've been able to say their peace and talk to some of the members and some of the leadership but they don't feel like those changes that they need are really being put in there so certainly they're trying to elevate it and they have some recent ads that the american hospital

association has been put out and trying to work other avenues. more in opposition to the bill than thinking they might get any changes in there. >> so the senate bill under the one drafted by leader mcconnell along with his working group as the viewers know there was no vote he wanted to make some changes. what have you heard about these changes? >> he has a tough task because he sort of has complaints both on the conservetive side and on the moderate side that he is trying to address. on the moderate side we'll probably see more money for opioid numbers, $45 billion in funding to fight opioid addiction which is something the moderates want but it's not clear that's even enough to win over their votes. on the conservative side there's an amendment from senator cruz of tax that would allow insurers to start selling some plans that don't meet all the obamacare regulations. but there's a fear from the

more moderate members that might hurt people with preexisting conditions. >> these proposed changes have been made. these have been sent off to the congressional budget office to give them a score. when might we hear and what happens next? will probably here sometime next week when the congressional budget office will finish calculating what the cruz amendment might do for this bill. the ideal for the senator cruz is that he likes premiums to go even lower. human like to see that the even bigger. -- he would like to see that the even bigger. the cbo has been graciously telling us when something is going to come out and if it brings people on board, we could see at the week after. host: one of the votes looking

like right now? >> seems like they don't have it right now. they don't have it to pass right now. it seems like there were many as 10 or so no votes. i'm sure that will be going up as they are making changes, but there do seem to be some real hard-nos. we have seen senator rand paul, susan collins, and dean heller, the free hardest nos. they all want substantial changes. it will be hard to do enough to win over some of those people. host: if it does pass the senate, they have to reconcile their differences with the house legislation. what is the timeline? >> the idea we have been hearing from the house is they might go ahead and pass what the senate it will be another vote for them on a slightly different bill. be comingthat could because when a love of the house

members voted for their version, saint we hope the senate makes these changes here and there, some of the changes are in their comest of the idea most likely would be that they would take it up rather than try to take it up in the middle with both the bills. host: and all this before the august break? >> that is the plan coul. [laughter] od a lot to do in a short peri of time. >> staffers have been telling us there is no legislative text, but they have been working all the time. much thank you very both of you for helping out with "newsmakers" this week. thank you. "q&a."ght on >> i'm not asking anybody to compromise their values or beliefs. i'm asking them to open their eyes to other people so that you

can figure out your place in this infinite world. >> brooke gladstone, cohost and managing editor of wnyc's "on the media." she discusses her book "the trouble with reality: a rumination on moral panic in our time." she looks at what constitutes reality today and how that criteria has changed over the years. >> i set up at the bigamy of the book -- the beginning of the book are biological wiring. we have involved culture that was designed to validate us and not to challenge us, certainly not to contradict us. they gave us the illusion that our realities were watertight when really they were riddled with weak spots and places that would crunch in. >> tonight at 8:00 eastern on c-span's "q&a."

"after words." >> someone like steve jobs can sell this product and be forever associated with it when it's just a shade of the story. he was certainly hands-on and had a lot to do with it, but the truth is even the iphone as it was developed at apple, and would not have happened without scores of people working around the clock. >> brian merchant on the creation and development of the iphone in his book, "the one device." these interviewed by steve lohr. the iphone was born as the software interaction paradigm and was born behind steve jobs i' back. this crew guys that i documented in the book basically experimented. it was freewheeling research. it was fun, kind of wild stuff. they