Sara Collins, Vice President of Health Care Coverage and Access at the Commonwealth Fund

(Music)

Mark Masselli: This is Conversations on healthcare. I am Mark Masselli.

Margaret Flinter: A nd I am Margaret Flinte r.

Mark Masselli: Well Margaret some interesting news out of Congressional Budget
Office. They have downsized t heir projections and how much Obama Care will cost?

Margaret Flinter: Those original projections were that will cost the government roughly
$760 billion over 5 years and that number has been lowered to roughl y $520 billion or
20% reduction.

Mark Masselli: W ow and it’s doing to part to a lower productions of a number of
Americans seeking insurance on exchanges and therefore fewer Americans requiring
government subsidies and about 2 dozen states have refused to expand Medicaid so
there have been some upfront c ost savings in that sector as well.

Margaret Flinter: But things are changing on that front as well Mark. Some two dozen
states have chosen not to expand Medicaid which will provide health coverage to more
of their vulnerable populations. We are seeing a changing of the tune in the number of
traditionally conservative states as they find some ways to work with it.

Mark Masselli: And one of those states that worked with the Obama ad ministration is
Indiana and their Governor Mike Pence’s worked out a deal with the Obama
administration to expand Medicaid in the (inaudible 01:11) state. Some 350,000 Indiana
residents will be able to gain coverage under expanded Medicaid with some cavea t so
have more financial responsibility for cost sharing funds will also be raised on the
Cigarette Tax and healthy behaviors will be encouraged to cost saving incentives. It’s
an interesting approach.

Margaret Flinter: And the trend is continuing. Sev eral states are expected to debate
Medicaid expansion in the coming months including Florida, Tennessee, Wyoming,
Utah and Montana so a very interesting shipped underway and I might say we predicted
this would happen.

Mark Masselli: And to see what such coverage is done for Americans who have already
received it we can look to a recent report by the non - partisan Commonwealth Fund
which just released by any of report on health insurance in coverage and the evidence
is pretty clear Margaret. Those who have gained coverage either through online

insurance market places or through Medicaid expansions are gaining not only peace of
mind but access to care as well.

Margaret Flinter: Sarah Collins is the lead author on the report. She is the Vice
President of H ealth Coverage and Access at the Commonwealth Fund. She is joining
us today and she will break down the report but the bottom line more Americans have
gained Affordable Coverage and they are less likely to avoid visits to providers than
ever before.

Mark Masselli: We will also hear from Lori Robertson Managing Editor of
FactCheck.org who always is on the hunt for misstatements made about health policy in
the public domain.

Margaret Flinter: And no matter what the topic you can hear all of our shows by going
to chcradio.com.

Mark Masselli: And always if you have comments please email us at
[email protected] or find us on Facebook or @chcradio on Twitter. We would love
hearing from you.
Margaret Flinter: And we will go out our interview with Sarah Collins from the
Com monwealth Fund 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 healthcare headlines. 20% less
that’s the revised estimate from the Congressional Budget Office on what the actual
cost to American taxpayers will be able to course in the next 5 years to provide health
insurance for millions of previously uninsured Americans , the reason fewer states
expanding Medicaid than regionally expected leaving millions of Americans off the
insurance roles and a lower projection of those Americans buying coverage on the
exchanges meanwhile ofte n a moment ends in February 15

th
while the exchange have
been running smoothly on both the states and federal levels so not quite as much
urgency for signing up this time aroun d. Analys t expect the page to pick up as we wind
th th
down to February 15 and what about the Supreme Court, the March 4 hearing looms
on insurance questions whether the language of the ACA intended to provide tax
subsidies for residence in the states relying on the federal exchange, 37 of them so far.

If the High Court decides in fav or of the challenge it could undermine the extremely
popular aspect to the law that makes coverage affordable for millions Americans. 87%
of those who purchase insurance on those exchanges receive some kind of tax subsidy.
The Supreme Court decision expected in June and E - cigarettes and Your Health a
recent study by the Journal of the American Medical Association found that vaping or E -
cigs have much higher concentrations of Formaldehyde and other toxins than found in
cigarettes. California just one state now getting on the bandwagon to discourage
vaping especially among the youth population a recent showed in the past month 17 of
high school students had puffed on E - Cigarettes posting flavors like bubblegum and
cotton candy. One person become hooked on nicotine it’s estimated to spend $1.5
million just buying cigarettes alone. I am Marianne O’Hare with these healthcare
headlines.

(Music)

Mark Masselli: We are speaking today with Economist Sarah Collins PhD Vice
President of Health Care Coverage a nd Access at the Commonwealth Fund, a private
foundation promoting a high functioning healthcare system. Collins had led the Funds
National Program on health insurance since 2005. Prolific writer and analyst of health
policy Ms. Collins served as Associate E ditor at US News and World Report. She
earned her undergraduate degree in Economics from Washington University and her
PhD from George Washington University. Sarah welcome to Conversations on
Healthcare.

Sara Col lins: Thank you very much for having me.

Mark Masselli: Well so much has changed over the last couple of years. We are
nd
currently in the 2 year of enrollment under the Affordable Care Act and more than 20
million Americans who were previously uninsure d are expected to have signed up for
coverage and that really dovetails with the Commonwealth Funds recently released
report on health insurance coverage in America and it’s the first time since you started
collecting this data that there has been a decline in the number of uninsured Americans.
Can you tell our listeners more about your reports, findings and how significant change
this really is?

Sara Collins: So the Commonwealth Fund has been conducting the biannual health
insuran ce survey since 2001 and we asked adults ages 19 to 64 about their health
insurance coverage and then we asked them several related questions about their
ability to get healthcare so in our latest survey we feel that in the second half of 2014 so
it’s firs t year the Affordable Care Act major coverage expansion. We found that a

number of adults who lacked health insurance declined from an estimated 37 million
people in 2010 or about 20% of the population to 20 million people in 2014 or about
16% of that pop ulation. The decline in 2014 is the first statist ically first significant
decline measured by the survey since it began in 2001 and we are seeing that the
uninsured rate is at the lowest level since 2003. Some groups that have particular
benefitted from the expansions, the uninsured rate among young adults ages 19 to 34
has to declined sharply from about 27% in 2010 to 19% in 2014 and this is a lowest
uninsured rate among young adults since 2001 and there are also striking declines
among low income a dults. The rate of uninsurance among people with incomes below
47,000 for a family of four dropped from 36% in 2010 to 24% in 2014 so the uninsured
rate in this income group is now lower than it was in 2001 so you can really see the
effects of those cover age expansions helping people who were at the highest risk of the
uninsured people who had low and moderate incomes and young adults.

Margaret Flinter: But your report is showing a promising trend beyond just coverage.
People are actually utilizing care in ways that they may not have been able to in the
past particularly among young and poor Americans and you know we could have
(inaudible 08:20) on those reasons but let’s ask you as the expert elaborate on the
significance of those findings for us.

Sara Collins: Sure so we looked this question about whether people are using a health
st
plans just after the end on 1 April enrollment period and we asked people who had
either new Medicaid coverage or marketplace coverage and we asked whether or not
they used their new plans to go see a doctor or a hospital or a pay for prescription drugs
and about 60% said they had used the plans to go to a doctor or a hospital or pay for
prescription drugs. So I thought that was pretty striking that people were actuall y
already using their pla ns given that we are only in the first part of 2014 and then we
asked whether or not they would have been able to access or afford this care priority
getting a new health insurance and about 62% said they would not have been able to
get the care that they got on with their new health plans and this is consistent with what
we know about the new insurers. About 60% were uninsured prior to getting the new
health coverage and about 75% of people we were uninsured when t hey got care and
had used their coverage so they wouldn’t have been able to get this care prior to getting
the new health insurance. So we are also finding the people who have health insurance
are getting health care that they wouldn’t have gotten in the past and that is likely
because the people who had individual market plans that they didn’t cover the full set of
benefits that they get now under the Affordable Care Act and so we are seeing
improvements in both insured and uninsured people .

Mark Massell i: The Supreme Court ruling had a big impact in terms of Medicaid and we
saw a lot of states who didn’t but what did your survey find in those days that chose not
to expand Medicaid to the more vulnerable populations, what impact has that decision
had on the lives of the uninsured of those still priced out of the healthcare system.

Sara Collins: We looked at adults who had income under 100% of poverty in those
states compared to states who had ex te n ded their Medicaid programs so people’s with
incomes under 100% of poverty are not eligible for either the Medicaid expansion or for
subsidized private plans to the marketplace and the uninsured rate people who had
income under 100% of poverty in those 24 states that had not extended their programs
w ith substantially higher about 44% uninsured under 100% of poverty compared to 30%
and said that had expanded programs whether states running there on marketplaces or
whether or not they are extending the market programs and what we find is that the
Medica id expansion is much, much more important.

Margaret Flinter: And a kind of big is a question that came up often in the debates
leading up to the passage of the Affordable Care Act when they had that card and went
out in search of care would they be able to find somebody to provide that care. What
were your findings there when you talked to people or is that part of the domain of
questions that you ask?

Sara Collins: We ask people whether or not they try to find a new primary care position
and then we asked how long they had to wait to get an appointment then what we find
people who are newly covered were largely similar to wait times among the broader
insured population.

Margaret Flinter: But we will have the strength towards increased cost saving and high
deductibles. How has that higher cost saving burdened impacted the American
consumer overall? What are you saying there?

Sara Collins: The larger trend in US health insurance coverage both in poor pla ns and
in individual market is the assistive risk from insurers, from employers on to employees
and people who are enrolled in health insurance plans and that’s really occurring
through the use of higher deductibles. In 2003 about 54% of people who had employer
based policies had a plan with the deductible and that increased to 81% by 2013 and
the size of the de d u c tible also grew tremendously over tha t period or an increase of
146%. So what people are having to spend out of pocket when they go to the do ctor
had just increased substantially over a time and what we find about 40% of adult
delayed getting needing care because of the cost.

Mark Masselli: We are speaking today with Economist Sarah Collins PhD Vice
President of Health Care Coverage and Acces s at the Commonwealth Fund. Ms.
Collins has led the Funds National Program on Health Insurance since 2005. Sara
mission of the Commonwealth Fund is to promote high performing health systems and
it’s no longer about access, the question is access to what and so I want to talk a little
bit about quality of care. In America we still rank poorly in this county in terms of
outcomes compared to other industrialized nations and how have our measures on
outcomes improved since the passage of the Healthcare Law?

Sara Collins: So about half of the law was really devoted to improving quality and at
lowering the rate of growth and healthcare cost. Those provisions have received much
less attention than the insurance reforms but the reforms includes testing alternative
was of paying for health services as well, new way s of organizing healthcare prov iders
to revive coordinate care. These are mostly focused on the Medicare program and
while there have been no major changes in national performance as a result o f these
changes so have that really been some notable improvements. From 2012 to 2013
Medicare hospital readmissions decreased by 10% for their readmission and this is
likely helped by Medicare’s, hospital readmissions and reduction program which was
impl emented on to the Affordable Care Act. Medicare is hugely influential program in
the country because of a large some of the people who are covered by it and so it has
major repercussions throughout the delivery system so we are seeing major changes in
how healthcare is delivered in the United States and how providers are being paid and
those changes are just underway and ongoing.

Margaret Flinter: Well I believe that Congressional Budget Office just released the
report suggesting that the projecting cost of paying for health insurance over the next 5
years is about 20% lower than originally projected. Tell us more about some of the
findings and both your report and the CBOs that really suggest improvement in the cost
containment arena specifically our ha ving been able to insure so many more Americans
under the Affordable Care Act .

Sara Collins: Yeah so I think that’s an extraordinary finding that the projected spending
over the next decade as you mentioned 2011 to 2020 has fallen by 600 billion since
2010 and this is despite an additional $1 trillion in spending four premium tax credits
and expanded Medicare to cover reproducted 27 million more people . On 2013
National Healthcare costs or estimates have increased about 3.6% annually and this
th
was the 5 consecutive year spending growth that was the lower 4%. The other place
that we are seeing and you mentioned that the study that we just released on what’s
dri ving the large premium increases that health plans all have to submit their larger
incr eases in premiums 10% or more to rate review now that’s the provision of the

Affordable Care Act. The major factor driving those increases with the underlined rate
of growth and medical cost that the fact that they were seeing a slowdown in healthcare
cos t is translated into slower premium growth. We looked at growth and premiums and
deductibles and what we found the annual rate of growth and premiums dropped to a
slower rate of growth and this happened in the 3 years following the implementation of
the A ffordable Care Act and there are various theories about why this is happening
partly deriving from some of the health reforms in the Affordable Care Act and this
broader reorganization of care that we are seeing in a delivery system. The recession
probabl y also had something to do with that and whether or not to (inaudible 16:21)
more out of pocket further deductibles how much is that contributing to just people using
less care which is not necessarily a good thing. The other thing that I would mention
here that’s so important what’s hurting families is that their incomes haven’t grown so
even though we are seeing a decline in the rate of growth in healthcare cost incomes
are also gro wing really slowly so even more slowly than the rate of growth in healthcare
cost so a people spend as a share of their income continues to climb.

Mark Masselli: And that’s sort of the horns of the dilemma. We have always good news
about things that are happening. We have the issue of maybe by next year 25 million
Americans covered under the Affordable Care Act and yet probably 20 million left out,
the lot of people who are not legally present in the country are also out there who aren’t
covered. The o ther states who haven’t opted into the Medicaid expansion program. So
what are your predictions about the populations remaining?

Sara Collins: So I think that the Medicaid Expansion is one of the most important
pieces of that (inaudible 17:26) and with the addition of Indiana this week 28 states in a
district have expanded all its bill to further programs and about 6 states are in serious
discussions right now to expand all truly for their programs but that’s always about 16
states and two of them a re very large, Texas and Florida have not yet expanded
(inaudible 17:45) for the Medicaid programs and there isn’t a lot of discussion
happening yet. We are seeing huge increases in Medicare enrollment in spite this slow
take up by stats so about 10 milli on people newly enrolled in Medicaid estimate 10
million since the 2014 but that will continue to be a major issue. Enrollment has gone
extremely well in the marketplaces the self enrollment period and probably set to at
least exceed the estimate for the administration put out this year. About 9 million
people expected to be covered through the marketplaces so we will continue to see that
the number of people insured to the marketplaces and the number of people to
Medicaid climb over time. But really the single biggest threat to coverage improvements
is the case now before the Supreme Court King V. Burwell which challenges the IRS
rule that federal subsidies are available in all 50 states not just so instead of running
new on marketplaces. If the Supreme Court were to rule in favor of the plaintiff an

estimated 9.3 million people might lose their premium tax first in 2016 so most people
who get coverage through the marketplaces right now are eligible for tax c redits. 34
states have federal ly operated marketplaces. About 9.3 million people are projected to
lose their tax credit as a result the urban institute estimated say of those about 6.3
million would likely become uninsured because they couldn’t afford their health
insurance that and a s that group of people loved the marketplaces in those states
premiums would jump up in those states which means even people who don’t have tax
credits would begin to find their healthcare coverage unaffordable so that’s about 7.5
million people will becom e uninsured as a result of the decision so this is a major issue
and a big concern.

Margaret Flinter: We have been speaking to with Economist Sarah Collins PhD Vice
President of Health Care Coverage and Access at the Commonwealth Fund , a private
foundation that promotes a hig h functioning healthcare system. You can learn about
Sara’s work in the broad scope of work at the Commonwealth Fund by going to
commonwealthfund.org. Sara thank us so much for joining us on Conversations on
Healthcare today .

Sara Collins: Thank you so much for having me.

(Music)

Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it comes to the facts about Healthcare Reform and Policy. Lori Robertson is
an award winning jour nalist and Managing Editor of FactCheck.Org a non - partisan, non -
profit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

Lore Robertson: In the state of the union address Pre sident Obama said that “more of
our people are insured than ever before.” That’s based on an administration analysis
that compares the second quarter of 2014 2 year past. We don’t have the full 2014
number yet. The White House’s Council of Economic Advi sors used data from the
National Center for Health Statistics to estimate that the uninsured rate is at or near the
lowest level in 5 decades. The data go back to 1963. The Council of Economic
Advisors compares the percentage without health insurance for the second quarter of
2014 that’s 11.3%, two yearly figures from the past. That’s the lowest rate that only
0.1% percenta ge point below the rate in 1974, 1978 and 1980. The figure for the first
six months of 2014 however not just the second quarter is higher at 12.2%. It remains
to be seen how the whole year will compare to the past. In fact if we look at National
Center for Health Statistics numbers for those w ithout health insurance under age 65

the first six months of 2014 had a higher percentage of uninsured than 1974, 1978,
198o and 1982. Obama also said that about 10 million uninsured Americans had
gained health coverage in the past year. That figure is s upported by a quarterly survey
conducted by the urban institute and that’s my FactCheck 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 Anna Bird Public Policy Center at the
University of Pennsylvania. If you have a fact that you would like checked Email us at
CHCradio.com. We will have F actCheck.org Lori Robertson check it out for you here on
Conversations on Healthcare.

(Music)

Each week conversations highlight a bright idea about how to make wellness a part of
our communities in everyday lives. As the saying goes music suits the sava ge beast
and according to a recent study conducted by Queen’s University in Belfast Ireland
there is some empirical data to that back that up. In the first of a kind longitudinal study
children suffering from a variety of behavioral and emotional conditio ns who are
exposed to music therapy in addition to traditional therapies had far better outcomes
than those children in a control group that offered traditional therapy without music
therapy.

It’s not a matter of them being given music or choosing music t hey actually make music
along with music therapist assisting them. So the idea is for them to express
themselves through music .

Margaret Flinter: Lead researcher Dr. Sam Porter said it’s anecdotal that means that
music improves mood in children and Ed lessons as well as adults but his study
revealed just how effective the music therapy was.

Dr. Sam Porter: Our primary item was an improvement in communication and there
were two variant existing secondary outcomes, leve ls of depression and levels of self -
esteem.

Margaret Flinter: Dr. Porter says in a group given music al therapy it showed over time
more interaction with their surroundings and a better response to the traditional
therapies as well and he says the effects were sustained over time.

Dr. Sam Porter: I mean that woman is a marvelous things by music the rapy. It’s the
things that is not, there are no side effects. It is not dangerous therapy to get kids

involved and it is a predaceous way of getting kids to improve their health. 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 incorpo rate
this relatively low cost non - evasive therapy as an additional tool for the youth population
a simple targeted music therapy approach , age appropriate and showing efficacy in
improving outcomes for young patients with minimal side effects and lasting b enefits.
Now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Healthcare. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli. Peace in health.

Conversations on Healthcare broadcast from the campus of WESU at Wesleyan
University , s treaming live at wesufm.org and brought to you by the Community Health
Center.