Dr. Benjamin Sommers, Harvard School of Public Health

(Music)

Mark Masselli: Welcome to Conversation s on Health Care . I am Mark Masselli .

Margaret Flinter: And I am Margaret Flin t er.

Mark Masselli: Well Margaret , it’s round 2 for the open enrolment under the
Affordable Care Act, and so far roughly a 10 0,000 Americans were able to sign
up for coverage on the online insurance marketplaces during the first weekend of
open enrolment.

Margaret Flinter: Well indeed. The Federal Exchange, HealthCare.gov which
had so many problems last year, ran quite smooth ly Mark, accommodating half a
million customers in the first weekend of open enrolment, and there is really
pretty good news from the state exchanges as well. The handful of states that
forged ahead with their own insurance marketplaces experienced few of the
problems that they encountered last year.

Mark Masselli: Maryland has since adopted the system so successfully used in
Connecticut last year, and Massachusetts brought in a new contractor for their
exchange.

Margaret Flinter: The State of Washingt on experienced on issue on the first day
of enrolment and had to shut the system down for a while, but the problem was
quickly corrected and I think they were back up and running on day two, which is
impressive.

Mark Masselli: But on the whole the road s eemed far smoother in the second
round of open enrolment.

Margaret Flinter: Well some 20 million Americans remain uninsured after the first
open enrolment, and still so many Americans are not fully informed or just don’t
understand their rights and optio ns under the law. And of course we have to
note Mark that enrolment, that’s only the first step. We have millions of newly
insured customers, or Americans, who gained coverage under the Medicaid
expansion, and the question remains how will they learn to access and navigate
the health system for more proactive health care.

Mark Masselli: And that’s something our guest today is quite informed about.
Dr. Benjamin Sommers is an expert on Medicaid health reform and the impact of
coverage on the uninsured. He has been analyzing data and has some unique
insights into the effects of gaining coverage.

Margaret Flinter: L ori Robertson , the managing editor of Factcheck.org will look
at some more false claims spoken about health policy in the public domain, but

no matter what the topic you can hear all of our shows by going to
www.chc.radio.com .
Mark Masselli: And a s always , if you have comments , please email us at
chcradio@chc1. com
, or find us on Facebook or Twitter . At CHC Radio we love
hearing from you.
Margaret Flinter: We will get to our interview with Dr. Benjamin Sommers in just
a moment.
Mark Masselli: But first , here is our producer , Marianne O'Hare with this week’s
Headline News.
(Music) Marianne O'Hare: I am Marianne O'Hare with these Health Care Headlines.
What a difference a year makes since the second round of open enrolment on the federal and state - run exchanges began November 15

th
. There have been
relativ ely few glitches to report. Half million people were able to log on to
HealthCare.gov, the federal site on the first weekend alone. The 15 state - run
exchanges including the District of Columbia also launched portals with few
troubles to report. The chal lenge this time around is the need to reach more
urban minorities who are most likely to be uninsured and least likely to be aware
of the options they have under the Affordable Care Act. Next year the penalty
increases to $ 325 per adult or 2% of income ; i n 2016 it will be the greater of $695
or 2.5% of income. Meanwhile more states are considering expanding Medicaid
in spite of original opposition. Even in Texas, stalwart opponent Governor Rick
Perry commissioned an independent study to advice on whether the state should
expand Medicaid under the increased inclusion under the Affordable Care Act.
The commission strongly recommended doing so.

If you want to know if he loves you so , it’s in his kiss. Researchers in The
Netherlands conducted a detailed st udy to examine how intimate partners share
their microbiomes . There are about 80 million or so bacteria shared across the
lips during the average French kissing session. Couples who kissed at least nine
times a day were more likely to have similar saliva microbes. There are a
number of studies that show it’s healthy to have a high diversity of
microorganisms in your mouth, and they say “Hey, it might be fun to try.”

I am Marianne O'Hare with these Health Care Headlines .

(Music)

Mark Masselli: We are speaking today with Dr. Benjamin Sommers , health
economist, internist and Professor of Health Policy and Economics at the
Harvard School of Public Health . Dr. Sommers’ research is focused in on the

uninsured, Medicaid and national health reform. Dr. Somm ers has won
numerous awards for his work including the national Dissertation Award by the
AcademyHealth as well as the 2010 Best Resident and Fellow at Harvard
Medical School. He graduated cum laude from the Harvard Medical School
where he earned his MD. Dr. Sommers, welcome to Conversations on Health
Care.

Dr. Benjamin Sommers: Thanks so much for having me.

Mark Masselli: We are right in the midst of the second round of the Affordable
Care Act , particularly the Medicaid expansion and the addition of young adults
who have been able to stay on their plan has been significant. Can you tell us a
little bit about in this sort of short period of time what the impact has been thus far
on population health, if you can?

Dr. Benjamin Sommers: Sure. The impa ct of expanding health insurance really
fall into a couple of different categories, and they play out over different time
periods, but the first and most immediate impact is that you increase people’s
access to health care services , and you reduce their fi nancial risk of catastrophe
if they have anything serious happen and they have large medical cost will they
be able to pay for it. When you look at the features of coverage expansion under
the Affordable Care Act , the very first one that took effect that impacted large
numbers of people was the provision that let young adults stay on their parents’
th
plans through their 26 birthday. This took effect starting in September of 2010,
and the results from that expansion were quite impressive and actually large r
than most of the original projections had been . Somewhere close to three million
young adults signed up who were otherwise uninsured, and got coverage to their
parents’ plans.

And we see reduced issues of paying bills in the emergency department, we se e
people more likely to have a primary care source that they can go to, more likely
to say that they can afford their needed medical care without any cost - related
barriers . And perhaps most exciting from the perspective of population health is
that even i n a fairly health age group we have seen people describe their overall
health status has having improved significantly since this policy went into effect,
and that’s a change that we haven’t seen for slightly older adults who were not
affected by this poli cy,

Margaret Flinter: We so often see that there are still the disadvantages in lower
income groups or minority groups, and I am wondering if we saw the kind of
success across the population for the group under 26 being able to stay on their
parents was it really limited to a more affluent group. Could you tell you a little bit
about that?

Dr. Benjamin Sommers: The way that the policy is set up is that to benefit from it
you have to have a parent that A, that you have an ongoing relationship with and

i s willing to add you to a plan, and B, that they themselves have private
insurance that they can add you to. So on the one hand you would think that
those features in particular would be more common in higher socioeconomic
groups, but there is a counterba lancing factor here which is that if you look by
income and education that the number of uninsured young adults was higher,
and so you kind of have this tradeoff and it may be that there are more parents
with private coverage who are in higher income group s, but many of their young
adult children already had coverage.

The challenge is that this provision affects a lot of young adults who don’t live at
home, and so when you are talking about say a 24 - year - old who is working on a
Master’s degree, we don’t kn ow if they are from high income families, lower
income families, but we do see that there are certain features that are pretty
strongly associated with bigger benefits from this law. So for instance, young
adults who ’ re not in school , and young adults who ’ re single were much more
likely to benefit from this provision, and the reason for that is because a lot of
people were already able to stay on their parents’ plans . At least they were age
23 if they were in school full time, but a lot of non - students di dn’t have that
option. And then the other factor is if you are married you essentially double your
chances that you yourself have a way of getting health insurance without your
parents, and so it was really kind of single people, non - students who were
par ticularly likely to benefit from this provision.

Mark Masselli: Dr. Sommers, when the Supreme Court upheld the legality of the
ACA but ruled against Medicaid expansion many states opted out, and I think
you and your colleagues have conducted a number of studies that demonstrate
the public health impact when Medicaid is expanded within a state, and you have
also analyzed what happens when the designation is broadened. You have
analyzed some long term data from states like New York and Maine. What have
th e data on Medicaid expansion in those states shown us?

Dr. Benjamin Sommers: We studied three states that essentially they expanded
eligibility to anyone whose income was under the federal poverty level, and it no
longer was a requirement that they have a child at home at a disability or be
pregnant, and what we found in studying five years before and five years after
these Medicaid expansions were a bunch of significant changes that were
positive. We found that coverage rates went up, the uninsured rate s declined not
surprisingly. People said they had an easier time getting the care they needed.
They were less likely to have costs interfering with their medical care. They said
they felt better. Much like with the young adults we found that coverage l ed
people to rate their own health more highly, and then probably most importantly,
we found that there was a significant decline in the mortality rate for adults in the
20 to 64 year old age group, who are really mostly the target audience for this
expans ion. And these were declined mortality that we were not seeing in similar
states that are nearby that did not expand Medicaid.

Margaret Flinter: Well I think it’s really helpful for our listeners to hear about what
the impact of several years of expande d coverage has been on the health of the
people of your state.

Dr. Benjamin Sommers: Sure. What we found in some ways was very similar to
the Medicaid findings, which was that we found people were gaining coverage;
they were less likely to have trouble paying for their care. We were able to look
at some additional outcomes and found that people were more likely to have a
preventive health visit. If you looked a t the types of cause of death, it really fit in
with the framework of health care making a po sitive impact. We found that there
were bigger declines for things like heart disease, diabetes, blood pressure
management, infections and cancer, which are conditions that we think early
detection, early treatment and chronic disease management with heal th
insurance are likely to be much more beneficial than for say things like car
crashes.

The evidence really does suggest that giving people health insurance makes a
positive impact both in terms of access and perceptions of health, but also
important pop ulation measures like mortality. I will add that we do have to think
about the political context too though that Massachusetts had a pretty united
bipartisan approach to this health reform . It was passed by then Governor Mitt
Romney . Obviously nationall y, things are quite contentious, and we see a lot of
states that are really reluctant to expand Medicaid that are trying to slow down
the implement ation of the coverage expansion. If the laws aren’t implemented as
well because there is opposition, that ma y very well play out in the benefit on the
general population.

Mark Masselli: We are speaking today with Dr. Benjamin Sommers, health
economist, primary care practitioner and Professor of Health Policy and
Economics at Harvard School of Public Health. I want to pull the thread a little on
sort of the political observation and just wondering what the role has been of the
research that you have done about the outcomes on those states that have been
reticent to expand their Medicaid program.

Dr. Benjamin S ommers: The Medicaid expansion decision is interesting though
from the political perspective, in that it doesn’t quite fit into the traditional partisan
divide in the way that lot of the other features of health reform seem to. And the
reason for that is the Medicaid expansion is there for the taking, and the federal
dollars, which are quite generous are also there for the taking. For the new
Medicaid expansion under the ACA, states don’t pay anything for the first three
years, and only pay 10% in the lo ng run. So you have a lot of vested interest in
the states that want to see that federal money brought into the system. You have
physician and other provider groups, you h ave the business community that says
this is positive revenue that could come into our state economy, and then of
course you have the advocates for people who would gain coverage through the
expansion.

So you have a lot of groups that maybe traditionally aren’t huge fans of federal
programs saying “This is a little bit different though because the money has
already been required in the law, the question is whether our state is going to
miss out on it.” And so that argument has actually been fairly effective in several
states with Republican governors who have put their support behind th e
expansion. I have been encouraged that there has been I think a reasonable
debate about what the expansion coverage would mean for people’s lives. There
have been for a long time s om e s tudies that suggest that people with Medicaid
might do worse than o thers, but typically those are our studies that are really
subject to the flaw that people who are in Medicaid look entirely different than
those who are not.

Fortunately, there are some other studies including ours that take another
approach which is to follow longitudinally with either natural experiments, or in
one case in Oregon a randomized trial where pe ople will have their names
picked off a lottery list to get offered Medicaid, and that’s offered pretty clear
evidence that you don’t harm people by giving them Medicaid. Our study found
that mortality impact ; the Oregon study didn’t find any blood pressure or
cholesterol changes within 18 months of getting coverage , b ut overall I think we
have hopefully added some meaningful data to the debate that’s made it clear
that giving people Medicaid coverage when they were uninsured certainly has a
positive impact and ought to be taken into account.

Margaret Flinter: I was so interested to see you were quoted in a study recently
published in Health Affairs that found a very high degree of satisfaction among
the country’s Medicaid recipients, and I look at so much that’s changed , certainly
the expansion of the community health centers across the country. But what do
you attribute this to? Do you think we ha ve really made progress?

Dr. Benjamin Sommers: You know, it’s really interesting because Medicaid often
gets a bad rep in general discourse, but if you look at the general population it’s a
pretty popular program. For instance, a survey that was done du ring some of the
budget negotiati ons over the past several years, people were asked whether they
supported major cuts in Medicaid to help reduce the deficit, and if you believe d
that Medicaid was a terrible program that seems like a pretty reasonable
appro ach, but the majority opposed any cuts; they liked it as it was. When you
ask people if they know someone in their own lives who has been impacted by
Medicaid, more than 50% of Americans have at this point either a friend or a
family member who has been i n Medicaid , and that will only increase under the
ACA. And then when you look at the people who have the most familiarity with it,
which is what we were doing in this three state survey that you mentioned, we
asked people in three fairly conservative stat es, Arkansas, Kentucky and Texas
to describe their general perceptions of Medicaid, and 80% of people supported
expanding Medicaid. And when we asked people to compare having Medicaid to

having private insurance, the majority said Medicaid would be as goo d or better
for their overall health care quality, which is really kind of striking.

So the people who have incomes that get them into Medicaid and have
experience with it generally are positive about it, but I think as many of us who
had private insuranc e probably can relate to there are challenges of having
private insurance as well, and we have all had to run into it various times I
imagine. There are major issues. When we know that doctors are less likely to
see a new Medicaid patient than they are t o take a new Medicare or privately -
insured patient, a lot of that is related to how much they get paid to do so. And
the bureaucracy of interacting with the state Medicaid office isn’t always easy for
providers, and that’s another factor that state and fe deral leaders could focus on
in trying to make sure that the Medicaid benefit does remain valuable and high
quality.

Mark Masselli: Dr. Sommers, you also did a recent analysis of the makeup of the
newly insured since the first round of open enrolment, an d there was a
percentage of Americans who gained coverage through their employers. The
unemployment rates obviously improved, and so it stands to reason that there
are more people who are picking up insurance through their employers. What’s
the picture l ook like for employee health coverage as more employees are
thinking about creative ways to provide coverage for their companies ? I know
there is a new round of projections by CMS. It turns out that not a lot of people
shed their health coverage to send people into the ACA, so a couple of questions
there.

Dr. Benjamin Sommers: This is an area that I think the general public and
policymakers are really interested in for the simple reason that even with all the
changes going on with the ACA with Medicaid expansion, with the new
marketplaces, the majority of Americans still get their coverage through work,
and most Americans are generally happy with that coverage and don’t want to
see dramatic changes to it. So that was really the underlying premise of a l ot of
the decisions made for the ACA, both when it was being written as law and then
implemented by the Department of Health and Human Services, trying to keep
people in coverage that they like without disrupting it . And I think we all
remember the contro versy from last year when people were getting cancellation
notices , and the president was being held accountable for the statement “If you
like your health plan you can keep it.”

That turned out to not really be much about the employer side; that was real ly
ab out people who were buying plans directly from insurers. On the employer
side, it’s a little too early to say for sure because we don’t have the really high
quality federal surveys that tell us about employer coverage. We don’t have that
yet for 201 4 because things come out on a little bit of a time lag. What we do
have are some data sources like the Gallup tracking poll, and that’s what we
used in the study in The New England Journal of Medicine that you mentioned.

And what we found there was acro ss all different types of coverage that about 10
million more adults had insurance in 2014 after the first open enrolment period
compared to the baseline trend befo re that open enrolment period, and that took
into account that the unemployment rate and inc ome and other measures that
could poten tially throw off the estimates.

So we were trying to kind of filter out the economic recovery from our results, and
we still found a major change in the insured rate. The survey doesn’t really have
that high quality measurement of the type of insurance, and we will have to wait
for that , but what we can look to is the experience in Massachusetts which is
pretty informative again because the law in Massachusetts was setup in some
ways similarly to the national law. A nd what we found in Massachusetts, and
what has been shown in previous work by several economists that have studied
it is that if anything , employer coverage seemed to go up in the state after the
health reform, and there are couple of reasons for that. T here are really two big
reasons, one is that the Massachusetts law like the federal law includes
incentives to employers to offer insurance.

In particular if you are a large employer and you don’t offer coverage to all your
workers, or if any of them go o n the marketplace and get a tax credit, you pay a
penalty for that. And so this has been referred to as the Employer Mandate, and
it’s designed to make sure that large employers are offering insurance, which the
vast majority already do, but to try to sho re that up. The other reason that we
can see a positive change in employer coverage is actually the individual
mandate, and so this is the requirement that all individuals have health
insurance, or they pay a tax penalty at the end of the year . And this seemed to
have the impact in Massachusetts of encouraging workers to go to their
employers if they weren’t getting insurance and saying “I want it. I am going to
be on the hook for a penalty; I want you to offer me insurance.” And if the
employer offered it to them , some people used to say no, that now say “Well
wait, if I don’t take this I am going to get hit with that penalty.” So we saw more
workers actually accepting the offer when it was made to them. So there is good
reason I think we might see so me of the similar dynamics playing out nationally,
but it s a bit too early to say for sure.

Margaret Flinter: We have been speaking today with Dr. Benjamin Sommers,
health economist, primary care provider, and Professor of Health Policy and
Economics at the Harvard School of Public Health with the research focus on
health reform and Medicaid expansion. You can learn more about his work by
going to www.hsph.harvard.edu . Dr. Sommers , thank you so much for join ing us
on Conversations on Health Care today .
Dr. Benjamin Sommers: Thank you so much for having me.
(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly in the know when it comes to the facts about health care refo rm and policy.
Lori Robertson is an award - winning journalist and managing editor of
FactCheck.org, a nonpartisan, nonprofit consumer advocate for voters that aim to
reduce the level of deception in US politics. Lori, what have you got for us this
week?

Lori Robertson: The most common questions we get from our readers are about
viral emails, you know the frightening sounding messages that one relative
always seems to be sending to his entire contact list. We have been debunking
those types of messages f or years including many about the Affordable Care Act,
and while there may be a few chain emails floating around that are true, the vast
majority we have researched are false. Sometimes they have a grain of truth;
other times they are completely bogus. O ne email made 48 claims about the
Health Care Bill when it was being debated in Congress. Only four of the 48
claims were accurate. We suggest a healthy use of the Delete key when dealing
with these often anonymous messages riddled with exclamation point s, capital
letters and spelling errors and simply outrageous claims.

One email said an emergency room doctor in Tennessee said the Affordable
Care Act was denying dialysis to some Medicare patients, and would deny care
to those over 75. A hospital told u s the account was fabricated by a guest in the
doctor’s home who wanted to further a political point. There are more hints for
readers that an email is false. If an email claims a legitimate source backs up the
claims, check it out. Often the source con tradicts the email. Other times the
sources (inaudible 21:27) satirical news story. One email claimed that
Ob amacare called for free gasoline service stations for low income people.
Apparently not everyone understood that was a joke. Maybe the message
challenges you to do the math. Break out the calculator; you may find the
numbers simply don’t add up. Our skepticism is also peaked whenever we see a
message arguing that it isn’t false . Urging us that this is not a hoax! makes us
think that ’s exactly what this message is. And that’s my fact check for this week.
I am Lori Robertson, Managing Editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players , and is a project of the An nenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org ’s Lori
Robertson check it out for you here o n 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. As the saying
goes m usic soothes the savage beast , and according to a r ecent study
conducted by Queen's University in Belfast , Ireland , there is some empirical data

to back that up. In a first of a kind longitudinal study, children suffering from a
variety of behavioral and emotional conditions who were exposed to music
ther apy in addition to traditional therapies had far better outcomes than those
children in a control group that offered traditional therapy without music therapy.

Dr. Sam Porter: It’s not a matter of them being given music or choosing music;
they actually m ake music along with music therapist assisting them. So the idea
is for them to express themselves through music.

M argaret Flinter: Lead researcher Dr. Sam Porter said there has been anecdotal
evidence that music improves mood in children and adolescent s as well as
adults, but his study revealed just how effective the music therapy was.

Dr. Sam Porter: An improvement in communication . Now there were two very
interesting secondary outcomes , l evels of depressions and levels of self - esteem,
and in the se condary outcomes we found a statistically significant difference
between the control group and the intervention group.

Margaret Flinter: Dr. Porter says in a group given musical therapy it showed
overtime more interaction with their surroundings, and a b etter response to the
traditional therapies as well, and he says the effects were sustained overtime.

Dr. Sam Porter: (Inaudible 23:54) marvelous things like music therapy as the
things (inaudible). There are no side effects. It is not a dangerous ther apy to get
kids involved in . That is just such a good way and a harmless way of doing
things.

Margaret Flinter: The study was conducted in conjunction with the Northern
Ireland Music Therapy Trust which sees the promising findings as an incentive to
inc orporate this relatively low cost non - invasive therapy into standard protocols
as an additional tool to enhance outcomes for the youth population which often
suffers negative side effects from powerful medications. A simple targeted music
therapy approach , age appropriate and showing great efficacy in improving
outcomes for young patients with minimal side effects and lasting benefits, now
that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Health Care. I a m Margaret Flinter.

Mark Masselli: And I a m Mark Masselli, peace and h ealth.

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