Indiana Secretary of Social Services Dr. Jennifer Walthall Discusses Health Care Transformation Thought Medicaid Expansion and Waivers

Dr. Jennifer Walthall

Mark Masselli: This is Conversation on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret we are getting more clear signals from the Trump
White House on at least some of the approaches to replac ing ObamaCare, new
rules were issued last week by the Centers for Medicare and Medicaid Services,
some of which will change the consumer experience considerably.

Margaret Flinter: One big change the Trump administration is calling for a much
shorter enro llment period starting with the next Open Enrollment.

Mark Masselli: The new rule would cut in half the Open Enrollment period that
could significantly impact the number of people who are able to signup for
coverage. Many people wait till the last momen t to signup

Margaret Flinter: And there is another significant departure from the health law
coming from the new administration, lowering the minimum standards for care for
the plans to qualify for the exchanges. The Affordable Care Act established very
clear minimum standards for comprehensive coverage in order to be certified as
a bronze, a silver or a gold level. The new rule allows insurers to cover fewer
areas of healthcare meaning consumers will be getting less coverage while likely
paying more fo r their care.

Mark Masselli: Dr. Patrick Conway, the acting CMS Administrator and former
guest on this show said the proposal will take steps to stabilizing the
marketplace, provide more flexibility to states and insurers while giving patients
access to more coverage options.

Margaret Flinter: But a number of health industry advocates warrant, this is
going to lead to far more out - of - pocket expenses for consumers and at the same
time get less comprehensive coverage, just proposals at this point, Mark th e new
rules up for public discussion in March.

Mark Masselli: Meanwhile, Margaret, State Medicaid Directors across the
country are seeking clarity as they prepared for the 2018 enrollments and are
seeking to have assurances that they will be able to cont inue to serve their
vulnerable populations. Dr. Jennifer Walthall is the Secretary of the Indiana
Family and Social Service Administration, a state that launched its own
successful version of Medicaid expansion.

Margaret Flinter: This is a plan that was launched under former Governor Mike
Pence now of course the Vice President. It took a slightly different approach to
the Medicaid expansion and I am really interested to hear how the Indiana plan
worked and what other states might learn from their experi ence.

Dr. Jennifer Walthall

Mark Masselli: Lori Robertson, also stops by, the Managing Editor of
FactCheck.org, but no matter what the topic, you can hear all of our shows by
going to www.chcradio.com .

Margaret Flinter: And as always if you have comments, please email us at
[email protected] or find us on Facebook or Twitter because we love to
hear from you. We will get to our interview with Dr. Jennifer Walthall in just a
moment.

Mark Masselli: But first, here is our producer Marianne O’Hare with this week’s
Headline News.

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines. The
proposed $54 billion merger between insurance carriers Anthem and the smaller
Cigna Co rporation was blocked by an antitrust judge, a deal that would have
created the world’s largest health insurer. Anthem is appealing the deal and has
also filed a lawsuit suing Cigna for a little under $2 billion if it backs out of the
merger, Cigna counte r suing Anthem saying the larger carrier didn’t do enough to
eliminate anticompetitive elements of their business.

Meanwhile in a separate case, another proposed merger between Aetna and
Humana was similarly blocked by an antitrust judge, Aetna and Humana said
they would not further pursue their deal. In the meantime Humana announced it
would no longer offer health insurance coverage in a state market places
becoming the first major insurer to cast a no - confidence vote over selling
individual plans on the public exchanges for next year. And the Trump
administration did make some moves to dismantle the healthcare law assuring
new rules from the Centers for Medicare and Medicaid Services that would
significantly shorten the Open Enrollment period for the ma rket places, it would
also reduced a number of required benefits on the exchange plans.

Another reason to kick the habit, a study shows that current smokers diagnosed
with colon cancer are more likely to die from the disease than former smokers or
non - smo kers. Researchers examined 5 years survival odds and found current
smokers were 14% more likely to die during the study period than people who
never smoked. The effect was seen mainly among smokers treated with surgery
with no chemotherapy. That group h ad a 21% higher mortality rate. I am
Marianne O’Hare with these Healthcare Headlines.

Mark Masselli: We are speaking today with Dr. Jennifer Walthall, Secretary of
the Indiana Family and Social Service Administration. She recently served as
Deputy Stat e Health Commissioner and Director of Health Outcomes for the
Indiana State, Department of Health, Dr. Walthall is currently an Associate
Professor of Emergency Medicine and Pediatrics at Indiana University School of
Medicine. She earned her undergraduate degree from the University of
Houston’s Honors College and her Master’s in Public Health at Indiana

Dr. Jennifer Walthall

University. She earned her medical degree at Indiana University School of
Medicine, Dr. Walthall, welcome to Conversations on Healthcare.

Dr. Jennifer Wa lthall: Thank you so much, it’s my pleasure to be with you today.

Mark Masselli: Everybody in the country knows that there is a change of foot, a
new approach to health reform under the Trump administration. And you had a
very unique perch, Indiana cer tainly front and center now on the transformation
that it went through in its Medicaid program. You witnessed Indiana’s unique
approach to the Medicaid expansion, while a number of Republican led states
barked at the ACA, Indiana actually forged a the dif ferent pathway covering more
uninsured residents, living closer to poverty. If you could share with our listeners
what was unique about the Healthy Indiana program and why you think it worked
so well.

Dr. Jennifer Walthall: Well, the Healthy Indiana Pla n actually predated Medicaid
expansion. The goal here at FSSA is to promote the achievement of health and
success through independence. This model is built on the theory that we can be
partners with people to navigate their way into the commercial health access
markets through engagement and support, but that takes a lot of effort together
as partners. The bottom of my email has the graphic with our motto for the state
which is a state that works. And in order to achieve that goal we have to support
and build infrastructure for a healthy workforce. And we think that HIP can
continue to play a part in that. HIP is described as a consumer directed
approach to health coverage that actually replaces traditional Medicaid in Indiana
for all nondisabled users age is 19 to 64. And it’s referred to its consumer
directed because the basic and routine costs of healthcare are paid by the
patient - managed account versus the insurance company. And this is to promote
consumer behavior by giving patients greater contr ol over their own health
budgets and the healthcare that they receive.

The fact that it was built on the foundation of this existing program helped, but
another key to success of the program is that, HIP is structured so that it pays
doctors more to care for members. So instead of reimbursing doctors at
Medicaid rates, HIP 2.0 pays Medicare rates which are significantly higher and
this has helped recruit over 6000 new healthcare providers into the Medicaid
network which has increased access to care for ou r members. And our approach
has been from the beginning that it was insufficient to simply provide coverage
without making policy changes that would also improve access.

Margaret Flinter: Well Dr. Walthall, Indiana’s expansion increased coverage as I
un derstand to 350,000 previously uninsured residents and certainly many states
have struggled to then bounce demand with capacity on the clinical side and one
of the things that seems to have helped around the country in the first years
anyway after the ACA passed was the bump that states got to pay closer to the
Medicare rates for primary care. But I am also curious about the role that other

Dr. Jennifer Walthall

organizations like Community Health Centers may have played in helping to fill
that primary care gap with so many new ly uninsured residents and as you know
the longer people were out of care the more likely they had pent - up - demand.

Dr. Jennifer Walthall: You bet, we have seen an incredible surge of partnerships
around the primary care space, both from Community Health Centers and also
from bringing in a primary care workforce. And one of the things that I have been
very excited to be part of is the governor’s help workforce the commission, really
filling those primary care desserts for the state so that we improve acce ss to
healthcare in general. And HIP in particular, about 87% of our HIP plus
members used preventive health services during their first year of enrollment. So
that’s a pretty, that’s a pretty big deal in my mind. That we are seeing people
really engage and so about 75% overall of HIP members that were enrolled for
the whole year received preventive care services. And that’s a good number
when you think about where and how those services might have been received
before.

Mark Masselli: Well your former governor has gotten a promotion, he is Vice
President.

Dr. Jennifer Walthall: He did.

Mark Masselli: And you now have a new governor Eric Holcomb who is probably
found himself in a little interesting situation and the Vice President of course is
focus ed in on repealing the Affordable Care Act. Governor Holcomb has written
to the federal government employing them to continue funding the Medicaid
expansion, what is the best way forward in this transition period and what do you
expect is likely to happen ?

Dr. Jennifer Walthall: Well I will tell you, I was appointed FSSA Secretary on
th st
January 9 and was very excited on January 31 to be part of the team that
submitted the additional HIP 2.0 waiver application with Governor Holcomb. So
here in Indiana, we are proposing the next iteration of HIP which is even better
than what we have now. We believe that the Healthy Indiana Plan has given us
the ability to think about how a state program can succeed when it’s given the
flexibility to meet the needs of th e state in a fiscally responsible way. And we
believe that federal reform should give states more flexibility to design programs
that work. We think that Federal Government should expeditiously approve
waivers that are substantially similar to waivers ap proved in other states and
provide a pass a permanency either allows waiver policies to become permanent
features of the program after being approved twice and demonstrating proven
results.

Margaret Flinter: Dr. Walthall, you know we followed the crisis that you all found
yourself in with the spike in the opioid epidemic in the significant spike in the
number of HIV and Hepatitis - C cases. We know that you were very involved in

Dr. Jennifer Walthall

responding to the crisis and developed an innovative kind of triage approach t o
tackling the outbreak, could you share with our listeners a little bit about that
crisis, what might public health officials and communities in other states learned
from your experience?

Dr. Jennifer Walthall: The HIV, Hepatitis - C and opioids outbreaks response in
Scott County really has informed the way that we are moving forward with the
ongoing opioid epidemic, to be part of that response has been one of the most
profound and rewarding experiences of my professional career. And truly the
most import ant change is the way that we frame our efforts, that the HIV
outbreaks and its roots in the opioid crisis are a Aquarian call for economic
development, education and connectivity in our communities. And to this end our
governor now has the director in hi s office to oversee this work so that our state
agencies and stakeholders can collectively build on this response.

And Dr. Adams, our Health Commissioner and I often reference a young man,
who told us early on in the response that HIV saved his life. The access to
health coverage and all of the resources that opened to him truly did save his life.
And our hope is that the roadmap of emergency needs, capacity buildings and
prevention programming will be sustainable and effective. And I will give you an
e xample of each of those.

Emergency tools include widely available and unrestricted naloxone use and
local control of syringe - exchange program. Capacity building includes
recruitment and retention of the mental health workforce at all levels. Training of
primary care providers in substance - use disorder treatments including
medication - assisted therapy, an immediate connection of patients to services
that their moments of need and three is the big one, which is prevention and
prevention really is all about infrastructure and education, it’s about thoughtful
provider rules around acute and chronic narcotic prescribing. And we are really
excited about Indiana’s unique data capability through what we call the
Management Performance Hub which connects data acro ss all state agencies, to
move towards both predictive analytics and also true implementation science
analysis of the outcomes effectiveness of our efforts.

Mark Masselli: We are speaking today with Dr. Jennifer Walthall, Secretary of
the Indiana Family and Social Service Administration. She also served as
Deputy State Health Commissioner and Director of Health Outcomes for the
Indiana State Department of Health. One of the main reasons Indiana’s
Governor Holcomb is seeking support for the Medicaid expa nsion model is
expressly because it will help state officials continue to battle this epidemic, I
wonder if you could share with our listeners how the program resources are
going to be used and again, what might other state officials learnt from the
Indian a experience.

Dr. Jennifer Walthall

Margaret Flinter: So this particular component of the HIP 2.0 waiver seeks to fill
treatment gaps by adding new services that will include expanded in - patient
detox services, residential treatment services and addiction recovery support
ser vices and peer recovery support services, housing support service and
relapse prevention services. Currently we are only able to reimburse for a 15
day stay in these types of facilities through managed care programs, but this
waiver would allow Medicaid s ome total to reimburse for short - term service of up
to 30 days. Then what that would do is expand access to nearly 15 new facilities
and have increased capacity at 12 others which fills a huge treatment gap that
we are seeing and feeling right now. And t wo things I really have to mention,
important populations to remember and those are pregnant women and those
who are incarcerated. And so the expansion of services for pregnant women
through continuation of HIP, we have seen the opioids epidemic manifest itself
through Neonatal abstinence syndrome. And making sure that we are supporting
Indiana’s pregnant women through these services to safely stay connected and
deliver healthy babies is important.

Additionally we are able to now start signing folks who are incarcerated up for
healthcare coverage so that they don’t have a gap when they are released back
into the community. And so this has been a great move for us to be able to
improve health outcomes in this vulnerable population as well.

Margaret Flint er: Well Dr. Walthall I was so glad to hear your reference before
the focus on the provider community and you yourself are an educator, you have
been Professor of Pediatrics at the Indiana University School of Medicine and I
am really curious how your wor k in the public sector and in public health has
informed your approach to training the next generation of healthcare
professionals.

Dr. Jennifer Walthall: I am a pediatric emergency medicine provider. And we
have a large residency program and it was a s imple observation as a teacher
that our emergency medicine residents were quickly becoming very jaded and
almost predictably burned out at a point in their residency, by the bombardment
of seeing one patient at a time and never seeing that there was an end to what
they were doing. And it was my hope that somehow we could both train
providers how to provide extraordinary care at the bed side, but also use those
patient encounters as a lens to the more global problems in healthcare that each
of those patient s represented. And that the resident could then connect to not
only the patient but then also the community.

And in 2006, I started a program called the Emergency Medicine Advocacy
Project and there were three layers to this program, community outreach,
systems improvements and health policy. And it was through this very simple
observations that really the whole way that we deliver our residency care training
has transformed, it’s now it’s own beast, it has almost all of the residents as a
member. I act ually have to go back to school to get my masters in public health

Dr. Jennifer Walthall

to keep up with several piece and they are smarter than I am, and all three of
these layers have really changed the way that we think about training, okay not
just am I going to give you th e right medicines but can you read and understand
the instructions that are part of that medication do you have the transportation
options to get to the specialty providers that I think that you need to see. Are you
going back into healthy environments wh ere you are asthma education is actually
going to make a difference and these are the kind of providers, this particular
project has turned out some folks who are doing really incredible work across the
country as health services researchers as a global me dicine, academic experts.
And so I think going back to the old adages for providers that you are either at
the table or on the table, really is a call to arms for all of us to be the voice for the
voice list in our communities and makes us understand the power of being part of
a solution that is bigger than ourselves. And I think that alone helps our trainees
understand their points of being part of this impressive and powerful movement
to provide health to our country.

Mark Masselli: Well I do want to pick up on that phrase, “solution is bigger than
ourselves” and talk a little bit about the ongoing discussions that are going on in
Washington about repealing the Affordable Care Act as Seema Verma is the
Trump administration’s choice for administrator fo r the Center for Medicare and
Medicaid Services and you have seen her brand of innovation at working in
Indiana. And I would assume will be brought to the broader context of CMS. But
what are your thoughts about how the powers to be in Washington should
approach this dismantling of the healthcare law, so that access in care isn't
hampered at the state level and how do you envision a way forward that will
insure continued advancement in population health.

Dr. Jennifer Walthall: Well we certainly think th at federal reform should be
approached very thoughtfully. And with recognition that states are all in different
places, and considerations should be given to states that choose to expand
coverage for their citizens with the promise of a certain level of f ederal funding to
support that. We are excited about the idea of allowing state flexibility, we think
that we have the capacity to deliver these programs effectively, efficiently and in
an innovative way that works for our state populations. And I would encourage
everyone in this space and as we have these conversations that are difficult and
important, to think about a couple of things. And the first always keeping in mind
the lens of health equity, will the decisions that we make widened outcomes
gaps, we need to make sure that we are thinking about the most vulnerable of
our population because we got into some health outcomes issues because we
didn’t, health equity really has to be the beginning and the end of our
conversations around policy. We need to look at also at the same time, how are
we funding prevention and public health. So where does public health and
prevention funding fit into this picture, I think is important as we move forward.

Margaret Flinter: We have been speaking today with Dr. Jennifer Walthall,
Secretary of the Indiana Family and Social Services Administration. You can

Dr. Jennifer Walthall

learn more about her work by going to in.gov/fssa or follow her on Twitter
@confectionsmd, Dr. Walthall we want to thank you so much for joining us on
Conversat ions on Healthcare today.

Dr. Jennifer Walthall: Thank you.

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 jou rnalist and Managing Editor of FactCheck.org,
a non - partisan, nonprofit consumer advocate for voters that aim to reduce the
level of deception in U.S. politics. Lori, what have you got for us this week?

Lori Robertson: Senator Ted Cruz claimed “ObamaCar e is discouraging people
from going to medical school and training to be doctors”. Actually medical school
applicant and enrollees are at an all - time high. Atul Grover, Executive Vice
President at the Association of American Medical Colleges told us the group
hasn’t seen any indication of declining interest in medicines since the Affordable
Care Act was enacted. He said there are many more qualified applicants than
room at the nation’s medical schools. Total medical school enrollment has
increased every year since President Obama signed the ACA into law there are
88,304 students enrolled in medical schools this school year that’s up from
77,371 in 2010, a 14% increase.

The Senator’s office pointed us to a 2015 report prepared for the AAMC that said
the U.S. is facing a 90,000 shortfall in doctors by 2025. Cruz’s spokesperson
argued the healthcare law has increased the demand for more physicians but
interest in medical schools has not kept up with the demand. But the AAMC says
the primary cost of the do ctor shortfall is an ageing population. And the shortfall
projection has been revised downwards it was more than a 130,000 doctors in
2010. The reason, the shortfall has grown smaller is that the number of
physicians completing med school have gone up. To address the doctor
shortage, the AAMC set a goal of increasing first year medical school enrollment
by 30%, by 2015/2016 up from the 2002/2003 level. That was nearly
accomplished on schedule. The enrollment rose by more than 27%. The AAMC
executive v ice president told us that medical school growth wasn’t the problem in
meeting the doctor shortage. Instead he pointed to the lack of residency position
that teach in hospitals and that’s my FactCheck for this week, I am Lori
Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactChecks.org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com we will have FactCheck.org, Lori
Robertson, check it out for you, here on Conversations on Healthcare.

Dr. Jennifer Walthall

Margaret Flinter: Each week conversations highlight a bright idea about how to
make wellness a part of our communities into everyday lives. Stanford - based
bioengineer Manu Prakash has the simple goal, he wants to create a portable
medical labs small enough to fit in the backpack and has already developed a
tool that fits the bill. While sitting under a tree in Uganda, he noticed that the
local medical clinic store was propped open by an expensive centrifuge machine.
One that was reliant on electricity, now broken and no longer in use. And he
wondered, how could he create a portable centrifuge that would be inexpensive
to make, easy to operate and easy to replace. His inspiration came from a
simple ancient childhood toy, the Whirligig, a toy that functions by pulling two
ends of a string, threaded through a round object like a button.

Manu Prakash: So we spent a significant portion of this time truly understanding
the mathematical face based for how you can convert linear motion into rotational
motion. And there are some beautiful mathematics hidden inside this object.

Ma rgaret Flinter: So he took this simple toy idea to another level, creating a
human power centrifuge made from simple components, paper twine and plastic,
all together each paperfuge as he calls it, can be constructed in under two
minutes and cost only 20 cents and yet remarkably it works extremely efficiently.

Manu Prakash: We are able to essentially make a centrifuge that spends all the
way to 120,000 rpm. In the lab we can separate and pullout malaria parasites
from blood, separate blood plasma.

Marg aret Flinter: It’s currently being tested for malaria diagnosis but is being
readied for far more complex diagnostic challenges.

Manu Prakash: This is a tool that requires no electricity, no infrastructure you
can carry them around in your pockets for a price point of 20 cents.

Margaret Flinter: The paperfuge, a cheap but highly effective field through for
clinicians providing a portable solution to diagnostic challenges creating a quicker
pathway to diagnosis and treatment, now that’s a bright idea.

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

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare broadcast from the campus of WESU at Wesleyan
University streaming live at wesufm.org and brought to you by the community
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