hearing wednesday for christopher wray, nominated to be the next f.b.i. director. will he relace james comey. that confirmation hearing gets under way 9:30 a.m. eastern wednesday morning and you can see it live on our companion network c-span3. c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's cable television companies and is brought to you today by your cable or satellite provider. greta: this week on newsmakers we are joined by the president and ceo of the american hospital association, rick pollack. thank you for being here. rick: thank you for having me. greta: we have anna edney of bloomberg policy reporter and peter sullivan who covers health care policy for the hill. let's begin with the affordable care act. does it need to be repealed and

replaced? rick: it certainly needs to be repaired for certain. anytime you and act legislation of this magnitude over a period of seven years or so, there are things that need to be corrected. even when it was enacted people knew from the day he was enacted they would need to have changes. you think about medicare and medicaid, how many times it has -- since 1965 how many times it's been amended and changed. so it's certainly is in need of repair. wholesale repeal of it, we have concerns in that regard. anna: are the bills that are being considered, the house passed one, the senate is working on, do those go anywhere near repairing some of those pieces that you would like to see fixed? rick: the senate bill perhaps goes in the direction of dealing with private market stabilization and dealing with the cost-sharing reduction issue, which i think would address some of the instability

we see in the exchange part of the insurance market. that is certainly something. the large-scale productions that would result from medicaid cuts as it relates to coverage, those are things we have great concerns about. peter: you have made some strong comments against running -- where the current bill is going in the senate and the house. on the senate bill, maybe you can go into what kind of negative effects do you see if the bill passed? do we see hospitals closing in rural areas? what would the bad effects be that you see? rick: we look at it through the lens of coverage and what this means in terms of coverage for the uninsured. when the a.c.a. passed it was intended to cover 32 million people, and ended up covering much less than that because of the supreme court decision with regard to medicaid expansions. for us the concern is coverage and the coverage losses that would result.

particularly as it relates to the medicaid program. medicaid serves the most vulnerable population. so many kids are on it that are learning disabled and have disabilities. one in 10 veterans are on the medicaid program. 2/3 of the money goes to taking care of elderly folks in nursing homes. that cuts to the medicaid program, which in both bills are rather dramatic, over $700 billion in one and over $800 billion and the other is a great concern to us. and the coverage estimates that go beyond the coverage losses in medicaid are also pretty substantial, according to the congressional budget office. for us the big issue really is all around the coverage losses that would result from the legislation, both in the house and senate and that's why we have been opposed to it. anna: that is really bad for patients, doesn't need the -- those who need that

coverage, those who will rely on it. as far as hospitals go, how the hospitals effected sort of bottom line with what could happen with the medicaid cuts? rick: well, a couple of things, first, it's about patients being able to get coverage for care. that is the number one priority. in terms of hospitals, when the aca was created, we redeployed $155 billion at the time towards helping fund coverage what we would hope would be millions of people. there were two pieces to funding that coverage, the revenue side and a series of reductions in spending. so for us, if we're going to see increased uncompensated care, given the fact that we forgave rume bursment to extend coverage, that puts us in a real pinch.

the medicaid reductions would put us in a real pinch. medicaid currently pays hospitals less than the cost of providing service. if we're going to see reductions on top of a we have already contributed, plus the new ones, it will make it very difficult for us. what does that mean? it means the potential of making tough choices. it means certain services may not be able to be provided. could be at there job losses because roughly 60% of the hospital's budgets relate to employment. we may see delays in the ability to upgrade our facilities or purchase new technology. so those are the tough choices that would result from reductions of this magnitude. again, the biggest concern for us really is the whole issue of getting people covered so they have access to care and they get it in the right place at the right time and that our emergency departments don't continue to be the family doctor for people.

peter: given these concerns, what has 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's kind of your strategy? rick: all of the above. in a situation like this obviously we work to try to shape the legislation and urge 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 have done limited things in all objectivity. we urge they maintain the minimum benefit requirements. but those provisions are still in the bill. and that is why we are against it. in terms of strategies, grassroots. our members are speaking out

providing the data impact is crucial. we had been advertising and a variety of other techniques to make sure our voices are heard. anna: to you feel like any of that is getting through? have you been able to sit down with leadership in the senate and convey these concerns and feel like they get it and maybe there is some changes coming? rick: we have had the opportunity to convey our concerns to leaders in the house, leaders in the senate, people in the administration. they have listened to our concerns, but i don't know that they really heard them which is why we are where we are and having a real problem with the legislation having to oppose it. peter: going off of that, there was a lot of attention on the relative secretive nature of the process. now we have a bill that has been released 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 like aha or did you feeling the process was open enough? did you want it to be more en, i guess? open, i guess? rick: for stakeholders like us, you can never have enough input and anything going on.

this process has not been the textbook of how a bill becomes a law. that is the prerogative of the leaders to go through. they have clearly run into problems among their own membership relative to the process they have gone through. we are where we are. in fact the process continues as congress will be returning this coming week. we will continue to the efforts on the senate side to cobble together enough votes to see if they can pass it. again, it will be out there expressing our concerns. anna: we have seen a few republican senators come out against the version that is out there now and looking for changes. have any of them specifically

talked about hospitals are there concern for rural communities? rick: absolutely. we have heard from people expressing a lot of the concerns that we share. the need to maintain the medicaid expansions and provide coverage for people and ensure we don't lose that overage. we have heard a lot of people mention that. in terms of expressing concerns. talk about the roll issue and hospital closures. there are a lot of different responses you will see as a result to some of the reductions in the loss of coverage. closures could be one of many. we have heard senators express those concerns from various tates. anna: i know before the idea of repealing and replacing obamacare, and even before obamacare closure of hospitals was a big issue. did the aca help that? did that law actually -- were

people able to close the ap a little bit? rick: over the last five years we have seen about 187 hospital closures. about a quarter of those have been in rural areas. some of that is the result of budget pressures. others are the result of reconfiguring or redefining. ne of the things we are in the process of doing in the field is trying to provide care in a variety of different settings, not just in the buildings we now and love and people depend upon. trying to coordinate care in various settings. some of that is the result of reconfiguration. some of that is the result of something not being able to survive in tough budget environments. peter: hospitals have been in general more outspoken than some of the areas of health

care industry. the insurers who played a big role in obamacare passing has been quiet. do you in your talking, do you say we wish you would be a little more outspoken, would you oppose this like we are? rick: we focus on those and the provider community that share the same position and where is the american medical association and several physician groups, the aarp, the diabetes association, the march of dimes, the american heart association. we've been working with coalitions and have 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, have 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 want 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 thesignificantly have been patient side aligned. anna: why do you think it is at side that isn't getting what they are looking for versus that he mentioned taxes are being cut and house and senate bills? rick: it is always popular to cut taxes. hat is something that has been a part of the discussion and that is something that those sectors are big beneficiaries rom.

that is where their interests and focuses tend to lay. peter: under other chances that have a particular chance of happening you are pushing for, or is your attitude that we need to start over with a whole new bill? rick: when we look at the packages before us and we look at some of the tweaks that are being considered, we don't think they go far enough. we would say let's reset and restart. we have a list of concerns which we wish they would address, but they don't seem to be moving in that direction. hey are pretty big as it relates to the medicaid cuts and as it relates to the issues around people maintaining the same level of coverage we have now, but it appears as if the focus will be more on tweaking the existing bill as opposed to a restart. that is why we are where we are. anna: senator ted cruz has

proposed and amendment to the senate bill that would deal with obamacare regulations, one being pre-existing conditions. what are your thoughts on that? rick: we have concerns about that approach. what we understand that proposal would do and of course we haven't seen any paper on that but it would further bifurcate the insurance markets and essentially say you will have noncompliant a.c.a. plans and compliant plans. we are concerned that frankly the sick folks will end up in the compliant plans, the younger and potentially healthier folks will end up in the noncompliant plans. the noncompliant plans, of course, will presumably be cheaper because they won't be compliant with the essential benefits. anna: they won't be covering pre-existing conditions? rick: exactly. they will be covering the essential benefit requirements you have in the compliants. you will have a lot of the high risk folks in the compliant plans and the premiums will go

up for them. we don't think that is a good solution. i know that is something people ave been discussing. greta: what does it mean for hospitals? rick: for hospitals you have a lot of people with what we tend to call potentially skinny plans that have very high deductibles. that means that for us we will have a lot more people coming through that may not be able to meet those deductibles and those co-payments and for us it becomes uncompensated care. we are 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 will become uncompensated care. uncompensated care means private premiums for everyone else just goes up. if you are paid less than your cost on medicaid, paid less in your cost on medicare, and if

you are providing a significant amount of charity care which we do, then more uncompensated care means we have to charge everybody else more. i think all of this just increases premiums. peter: one of the things obamacare did that sometimes less covered was set in motion programs about how payments work. trying the idea of you paying for the quality rather than the quantity of services. with these repeal bills do you see that damaging those efforts? with that change those efforts? is there anything in the senate bill that you think what actually go after these sort of core drivers of health care costs and make things more efficient, for with the bill set back those efforts? rick: that interesting question. one of the things part of the aca was this notion we would move towards coordinated care, integrated delivery. people would focus on reimbursement more for value than volume, more on quality

than quantity. those are all things we support. those are things headed in the right direction. the tools to do that that were in the a.c.a., whether they or care ling organizations or medical homes, you can get on the list, all those things are good things. they had in the right direction. are the perfect? no. did any improvements? yes. should we be should we be looking at more creative options? yes. this goes back to the question of a corsini to be modified as you go along, but the important point you raise is none of this is being discussed. why? it really isn't on the table. a lot of these techniques are by and large things that enjoy bipartisan support. i really haven't heard people say let's get rid of these things, let's repeal these things. and frankly i don't even know you could under the rules of reconciliation. so these are things that we

continue to be focused on because they are the right things to do to improve care, in reate efficiencies and the midst of this unpredictability we try to stay focused on moving in that direction. peter: you think those efforts can continue even if the bill passes? it would leave a lot of that untouched? rick: right. on the regulatory side, how some of these things continue to be implemented, the the d in which they may be speed in which they may be implemented is certainly open for discussion. we have 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 the better approach. i think that is the direction that again will continue to move. that really has not been a partisan one. greta: we often hear from our

viewers that we went to the hospital, was there for an hour and i got a bill for x amount of dollars, thousands of dollars. the public does not understand what costs so much when they visit the hospital. rick right. and a lot of times when people receive these bills is a statement of what a charge might have been. it is not exactly what they are liable for out-of-pocket because very often an insurer has negotiated a rate with the hospital. it is much lower than what the charge may be. and it gets very economy indicated, i know. you would get medicare or medicaid. they just pay hospitals a rate. there is no price, there is a rate. we get what it is they provide us. a payment. there really is not much of a negotiation. that is roughly 45% of the hospital's revenue. when you see those there is a real delta between what may be on the bill versus what you're

liable in out-of-pocket expenditures. the other part is the hospital perspective, we're unique. we provide care for everyone that walks in the door. again, for a lot of people there is a hidden tax to pay for the uninsured. even with the aca and the 23 million that are covered under it, there are still tens of millions of people that are not covered under it, even under its best day. we are still in that situation where you have that proverbial cost shift or hidden tax which raises the cost for everyone because at the end of the day there is no free lunch when you are taking care of everyone. greta: five minutes left. go ahead. anna: would be a good idea to be more transparent about what those costs are and what the actual payment would be if they did not have insurance? or if there is someone who was

to compare having knee surgery or something, with that be something the aha would be behind? rick: the whole price transparency is something we understand and we support. in fact, if you go to a government site, hospitalcompare.org for the most common procedures, there is information on prices. 44 states require hospitals to put out what the rates are, for certain comparisons for the rates. we also have to remember what consumers really want to know is what their out-of-pocket exposure is and that's something insurers also have to be a part of and we also have to recognize we're not dealing with manufacturing widgets here. we are taking care of people. people are different, conditions are different, people react to certain situations in a different way biologically, physiologically-wise. it's a lot more complicated. but we know we have to be more

transparent in pricing and we are working to do that as best we can. peter: returning to the aca and 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 fixes you guys would like to see in some sort of bipartisan effort? rick: we welcome a bipartisan effort. the first thing on the list needs to be the cost sharing reduction to stabilize the exchanges. in the exchanges we have seen premiums go up, and again that is the sliver of the individual market. 7% of all lives are in the individual, nongroup market. half of those lives are in the exchanges. it's that sliver that we have seen real problems with skyrocketing premiums. all the studies suggest that fixing the cost sharing reductions address that issue to the insurers to stay in for the next plan year and that ought to be top of the to-do

list. peter: any more fundamental changes to the a.c.a. you look for? rick: i think that is probably the most significant one for right now. that is stabilizing those exchanges so we can continue to provide coverage for people of limited means through the echanism that represents helping people buy private insurance. greta: what are you looking for next? what are you watching for? lawmakers will return from their fourth of july break and it could be a floor vote. what you watching for? rick: we are watching for one of the changes that the majority leader will make to the bill that is out there. as we all know, senator mcconnell is extremely skilled and able and he will i guess in his own words be twisting that rubik's

cube to see what he can do to accommodate different folks. there has been talk about trying to address the issue of opioids. there have been other things i -- that they've been talking about. senator cruz's proposal will be out there. we will see the tweaking, see what tweaks survive the parliamentary review, whatever 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 will be looking at what changes will be made next week. greta: let's end our conversation with the opioid portion of this. rick: i'm glad you brought that up. greta: that is something americans feel across the country and it's important to many of the senators. they have said no unless there's more money in there to deal with opioid addiction. what are hospitals seeing? rick: i'm glad you raised that because congress passed legislation to address both the opioid problem and the

behavioral health problem. 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. the rolling back of the medicaid expansions and the cuts to the medicaid program by virtue of going to a per capita caps really 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. providing money for opioid programs as opposed to getting -- 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. when you give people the full -- we think you need to give people the full comprehensive set of services

and the medicaid program is probably the most effective way to do that. greta: rick pollack, president and c.e.o. of the american hospital association, we appreciate you being on "newsmakers." rick sure. hanks for having me. greta: and we're back with our reporters, anna edney with bloomberg and peter sullivan with the hill. the american hospital association are obviously not for complete repeal and replace. they would like repair to the affordable care act. where does this group stand as opposed to the other major players in any health care debate that happens in washington ? peter: they have been some of the most outspoken against the bill, more opposed than other players. the insurance industry has been much more quiet, has not really taken a firm stance either for or against. they are playing their cards closer to the chest. the hospitals have been more out there saying we are

directly affected by this. we are out there providing care to people and this would have some damaging cuts and more people without insurance and it would be damaging. greta: so, anna, is their influence being felt on capitol ill? anna: i think they felt being heard they have gone in and able to say their peace and talked to some of the leaders in their worship, but they don't feel there are changes that they need or put in there. certainly they are trying to elevate it and they have some recent ads the american hospital association has put out trying to work other avenues more in avenues more in opposition to the bill than thinking they might get any changes in there. greta: peter sullivan, the senate bill under the one drafted by leader mcconnell and along with this working group, pulled it back, as our viewers

no. there was no vote. he wanted to make some changes. what have you heard about these changes? peter: he has a tough task because he had complaints on the conservative and moderate side he is trying to address. on the moderate side we will probably see more money for opioid -- the number is $45 billion to fight opioid addiction. is not clear that is even enough to win over their votes. on the conservative side, the amendment from senator cruz of texas to allow insurers to on t selling some plans obamacare. there is a lot of fear from the more moderate members that it might hurt protections for people with pre-existing conditions. that is a big question as to whether that amendment and be in the bill. greta: these proposed changes seven made.

the talk about the ted cruz amendment. these have been sent off to the congressional budget office to give them a score. when might we hear and then what happens next? anna: we will probably here sometime next week when the congressional budget office will have finished calculating what the cruz amendment might do for the bill. the idea from senator cruz is to have premiums go lower. there was some reduction in the original bill. he would like to see that get even bigger. if we see cbo next week, which they having graciously telling s when something is going to come out and possibly if that looks good it will bring people aboard and we could see a bill the week after. greta: what are the votes looking like right now? peter: it seems like they don't have the right now. they don't have enough to pass it right now. when they pulled it last week it seemed like there was as many as 10 or so no votes. i'm sure there will be going up as they are making changes. here do seem to be some real

hard noes, only three noes would doom the bill which adds to the challenge. we've seen senator rand paul, susan collins and dean heller seem like the three hardest noes maybe and they all want substantial changes. it will be hard to do enough to win over some of those people. greta: if it does pass the senate, they have to reconcile the differences with the health legislation. what is the timeline? anna: well, the idea we've been hearing from the house is they might pass what the senate passed. it would be another vote for them on a slightly different bill. they knew that could be coming because when a lot of these house members voted for their version, saying we hope the senate makes these changes here and there some of those changes are in there. the idea most likely would be they would take it up rather than try and figure out where to meet in the middle both of those bills. greta: all of this before the august break? anna: that is the plan. peter: a lot to do in a short period of time.

anna: i think these staffers have been working and there are many days where they tell us they don't have legislative text yet. it is coming up tomorrow. these guys are working all the time. greta: we thank you both for your participation in helping us out with "newsmakers." thank you. >> tonight on "the communicators." >> what they're doing there is five g trials and i tell you what, peter, it was giga bit fast wireless. that's something i never thought i'd see in my career in my lifetime. that is home broadband fast. that's fiber to your house fast. and it's really, really exciting. >> c.t.i. president meredith atwell baker and what the 5-g network will look to consumers and building out to broadband to rural areas and the recent spectrum auctions.

and she is interviewed by margaret harding mcgill. >> if it costs that much to invest, how do carriers make a return on that? >> well, it's going to mean $500 billion to our economy and three million jobs. so one out of every 100 person is going to have a 5-g job. but, again, it's only if we get it right and that really does mean we've got to move on spectrum, we've got to get a pipeline of low, medium and high band and we got to get this infrastructure right because as we roll forward, we need to build 300,000 small cell sites in the next few years. and what a small cell looks like is maybe a pizza box. it's small and it's going to be attached to everything because these are going to be much more dense networks. they're going to be on traffic lights. and streetlights. the sides of buildings and so what we really need, and this is really important, we need an infrastructure that rethinks how we site. >> watch "the communicators"

tonight at 8:00 eastern on c-span2. the senate judiciary committee will hold the confirmation hearing this coming wednesday for christopher wray, the nominee to be the next f.b.i. director. if confirmed he would replace james comey who president trump fired earlier this year. that confirmation hearing gets under way at 9:30 eastern this coming wednesday morning and you can see it live on our companion network c-span3. > this week on "q&a," brooke gladstone, she discusses her book "the trouble with reality" , a rume nation of moral panic in our time.