Jennifer Tolbert, Director of State Health Reform, Kaiser Family Foundation

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Mark Masselli : This is Conversations on Health Care. I'm Mark Masselli .

Margaret Flint er: And I'm Margaret Flinter.

Mark Masselli : Well , Margaret the political wrangling over the Health c are Law continues
to play out in Congress. The Governm ent shut down over the Affordable Care Act,
hence raise the ire of the American Electorate. But in spite of those ch allenges and the
quagmire in Washington, m illions of Americans have begun shopping online for
Affordable Health Insu rance since the opening of the Insurance E xchanges.

Margaret Flinter: Well, Mark I guess political shenanigans are to be expected with such
a divided Congress but as we know the real work surrounding the Affordable Care Act is
being carried out all around the country in clinic s and State Health Offices, and Call
Centers where people are finding help from lots of t rained people, assistors , navigators ,
ou treached and enrolment specialist s and even traditional insurance brokers are
helping out .

Mark Masselli : Well we did get off to a rocky start but we were at war and there would
be technical glitches to work out once all the various systems were up and running. It
turns out the system wasn’t quite equipped to handle the large volume of calls t hat
came into the healthcare.gov we bsite for the federal exchange being relied upon in 36
states across the country.

Margaret Flinter: And each state b ase d e xchange had its own systems at your syncrisis
to sort out as well. Mark but this is one time when I'm really glad there’s a lot le a d time
you know there’s a full three months , almost a full three months before coverage goes
th
into place . I think people have until December 15 to get enrolled . A nd base on our
experience in Connecticut and joshing from some reports around the country, there
were glitches but they’re getting to the root of them pretty quickly and most of them
should be ironed out I think within a few weeks.

Mark Masselli : Mark Le vitt , who wa s President Bush’s top Health Of ficial when
Medicare Part D r olled out in 2006. H e knew that there were quite a few technical
glitches during the launch of that program as well.

Margaret Flinter: And I have noted Mark that there’s been very little criticism from the
I nsuran ce I ndustry, they are cautioning folks to be patient, perh aps give the system a
few more weeks before attempting to go through the process. Of course , they stand to
gain quite a bit of new business with th e s e millions of newly insured Americans b ut I
th ink their advice to sound and provid e s people a little more time to learn more about
the plans before they actually sign up.

Mark Masselli : And I might highlight a silver lini ng in all of these the millions of
American’s trying to log on to the sys tem reveals a larger truth that many in this country
are very eage r for the Affordable Health Coverage, the number speak for themselves.

Margaret Flinter: And our gues t today, is certainly keeping a very close eye on how the
uninsured are being assisted in every state in the nation, Jennifer Tolbert is the Director
of the State Health Reform at the Kaiser Family Foundation. She has a very in depth
understanding of the n ational picture and how the Health Care Law is literally coming to
li f e in every State.

Mark Masselli : Lori Robertson checks in from FactC heck.org.

M argaret Flinter: And no matter what the topic you can hear all of our shows by going
to CHC radio.

Marc Masselli : And as always, if you comments please email us at c h cradio.com , or
find us on Facebook , or twitter. We’d loved hearing from you .

Margaret F linter: We’ll get to our interview with Jennifer Tolbert in just a moment.

Mark Masselli : But fi r st , here’s our producer Marian ne O’Hare with this week’s Headline
News .

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Marianne O’Hare: I'm Ma r ianne O’Hare with these Healthc are Headlines . S eems the
software and even some of the h ardware attached to the online Insurance e xchanges
wasn’t quite ready for primetime . A ccording to analysis from inside the White House,
Todd Park, Administration C hief, Technology Officer pointed to some weaknesses in the
software system, supporting healthcare.gov . T hose problems highlight ed when the first
wave of millions of potential customers attempted to log on to the system. There are
teams of technical troubleshooters working round the clock to get the syste ms
functioning properly. And there were problems on the State Base Excha nges as well.
Maryland the District of Columbia, Connecticut, just some of the s tates that ran into
snag s in the first few days of bu siness for the State Base Excha nges. Todd Park s ays
these are actually text book occurrences anytime there’ s a large roll out of an IT system.
In the meantime a dditional c ouncilors having put on staff , at healthcare.gov to take
phone calls from folks having tro u ble with the online exchanges. Analysts do suggests
folks might want to wait a few more weeks before logging into the system. A ctual
st th
coverage doesn’t begin until January 1 and there’s a December 15 deadline to sign
st
up and time to begin coverage at the 1 of the year. Meanwhile, price tran sparency is
going to become a more common occurrence when it comes to selecting medical
procedures. The Health Care Law is going to encourage price tags on procedures
ahead of time like MRIs or C AT scans . So, Health Care customers will begin to shop
and compare and be aware their Health c are spending habits before they take action.

Two Americans and a German have shared the Nobel Prize in Physiology this year.
American James Rothman, a Professor at Yale and Randy Schek man a p rofessor at U
C al Berke ley a nd G erman Thomas Sudho f were awar ded the prize for discoveries on
how the body’ s cells decide when and where to de liver molecules they produced. The
Nobel assembly said the three have solved the mystery of how th e cell organizes its
transport system. I ’m Marianne O’Hare with these Health care Headlines .

(Music )

Mark Masselli: We are speaking today with Jennifer Tolbert, Director of the State
Health Reform at the Kaiser Family Foundation and Associate Director of the
Foundation Commission on Medicate and the uninsured which is leading efforts to
monitor Implementation of the Affordable Care Act, she also manages Kaiser’s State
Health facts a source of state level data covering 600 health topics prior to joining the
foundation Ms. Tolbert served as the Ass istant Vice President for Policy at the National
Association of Public Hospitals and Health Systems. Jennifer , welcome to the
C onversation of Health C are .

Jennifer Tolbert: Thank you very much; it's a pleasure to be here.

Mark Masselli: As you well kn ow we are in that early phase of expanding health
coverage to millions of Americans but there are as expected growing pains attached to
this phase of the implementation of the Affordable Care Act of the launching of the
online insurance exchanges to name o ne and you are focus at the Kaiser Family
Foundation is on monitoring the status of their intersection between each state of
vulnerable populations and their access to health coverage either through insurance or
the safety net programs like medicate. But central to improv ing access to health
coverage are these new health insurance exchanges which were supposed to be simple
and easy to use and yet there have been numerous reports of problems across the
country so what is it that makes these exchanges so com plicated to navigate and what
ideas do you have to making the system more user friendly?

Jennifer Tolbert: Well these systems are quite complex and they have to house a great
deal of data on the individuals that are applying for coverage as well as on al l of the
plans that are available through the market places. So these are very complex systems
and we really are breaking new ground in terms of how people will apply for coverage .
And so it’s not surprising that there are and have been some glitches and I think what’s
going to be imperative is as we move forward whether these glitches can be fixed in
time for people to enrolling coverage. Now thankfully we have got a six month open
st st
enrolment period which last from October 1 until March 31 of next ye ar so there is
time to get these systems fixed and hopefully the y will be and we have seen certainly at
the state level there have been some problems not just with the healthcare .gov website
but also with some, they’ve website particularly in Maryland and in Washington state.
Those websites seem to be running much more smoothly now. So I think this is going
to improve over time and should continue to enable people to enrolling coverage before
st
coverage begins on January 1 .

Margaret Flinter : So Jennifer you oversee the Kaiser Family Foundation analysis of
health coverage and from your perspective when you look at how differently the
Affordable Care Act implementation playing out state by state. Can you highlight some
of those differences for our listene rs and maybe share your perspective and how do you
expected to actually impact population health across the country?

Jennifer Tolbert: So one of the interesting aspects of the Affordable Care Act is it
delegated implementation of the coverage provisions of the law to the states. So states
were giving me option to run their own market place which is one of the main vehicles to
which people who are currently uninsured today will gain coverage and then also they ’d
have responsibility for implementing or in some cases not, the ex pansion of the
medicate program which is another very important coverage component included in the
Affordable Care Act and so what we ’re seeing not surprisingly is that the implementation
is playing out differently across the states. Since -- so what we’ve seen is 16 S tates
plus the District of Columbia opted to run their own market places, another 7 S tates are
actually partnering with the Federal Government on running the market place and then
that meant that in 27 S tates the Federa l Government is operating the market place.
Now you know when it comes to sort of the consumer experience I am not sure that it
matters a great deal whether the state or the Federal Government runs the market
place because consumers will have a similar ab ility to go to the website to apply for
coverage online to search for, shop for qualified health plans that meet their needs and
ultimately enrolling coverage.

W e’re obviously seeing slightly more problems with the healthcare.gov website may
hinder at lea st over the short term, people’s ability to, you know, shop for and enrolling
coverage in the states where there’s a federal market place, but I think those problems
will be ironed out overtime. But I think where we’re seeing the biggest difference is ove r
state decisions around the expanding the Medicaid program. And here the law
envisions that all states would expand their Medicaid programs to cover low income
adult with incomes up to 138% of the federal poverty level, or about $15000. But the
Supreme Court decision on the law that upheld the constitutionality of the law, but did
limit the ability of DHHS, the Department of Health and Human Services to enforce the
Medicaid expansion. Right now we have about half the states, 26 states that are
moving fo rward with the Medicaid expansion, but that’ll leave just less than half of the
states that are not currently moving forward. And unfortunately in those states there will
likely be a coverage gap, because low income individuals in those states won’t be
el igible for coverage. And, you know we like they remain uninsured.

Mark Masselli: Clearly for many of the big states like Taxes and Florida this has an
enormous impact, first of all there are millions and millions of eligible Medicaid
recipients who’ll g o without -- but also it’s an enormous loss of financing to the health
care system within those states. So what are you hearing out there, do you see any
light at the end of the tunnel for some of these states?

Jennifer Tolbert: We are seeing some movem ent among a handful of states particularly
in the Midwest, where there was initial opposition to the Medicaid expansion, so
Michigan is now moving forward . Pennsylvania , the governor came out and said that he
is supportive of a Pennsylvania approach to ex panding the program. Unfortunately, you
know there are still a number of states that are not likely going to be moving forward
st
with the Medicaid expansion prior to January 1 , which means that there are going to be
a lots of people without a coverage opt ion, now we've estimated that in the states that
are not moving forward, there are about six million people, who would have otherwise
qualified for Medicaid, who will likely remain uninsured. And importantly as you
mentioned states that don’t expand Medic aid are giving up a lot of Federal Funding, the
Federal Government is picking up a 100% of the cost of those who are newly eligible for
the expansion. But the first three years, and then phasing down to 90% by 20 - 20, but
that still translates to about $40 billion across the states that are not currently moving
forward with the expansion. So this is an important decision that states are making that
is going to have both financial implications as well as significant implications for
uninsured residence in t hose states.

Margaret Flinter: We have been referring folks for a while now to the health insurance
subsidy calculator a really terrific tool that’s offered on your site, that site is kff.org, I’m
just going to repeat it again it’s a health insurance sub sidy calculator, because it allows
people to really take a look and see how does this work for them in terms of what kind
of subsidy would they qualify for it. But there is also a tremendous amount of health
information available, and that Kaiser website and you're in charge of the state health
facts page. That tracks over 600 indicators in each state that have an impact on health.
I wonder if you could highlight some of what you see as the most significant health
indicators and maybe those that are most sensitive, are most likely to be impacted by a
major shift and coverage across the United States.

Jennifer Tolbert: As far as our state health facts page this is something I'm very proud
of -- and we have been for many years’ now collecting data, state level data on a
number of health indicators across a broad set of categories. And I will say you know
as we've been engaged in this debate over the health reform and then implementation
of the Affordable Care Act. A lot of the data that we have on the si te has been very
valuable. And I’ll point you our data on health insurance coverage, we have 80
indicators that break our health insurance coverage by family status, by age, by income
and I think it's very informative, and they're particularly for underst anding of who the
uninsured are, and you know what issues that they are facing when it comes to getting
health insurance coverage.

But in addition we have a category, a health reform category where we are -- has been
and will continue to capture informati on and data on the implementation of the
Affordable Care Act. So right now we have information on things like state decisions
around establishing their market places as well as the Medicaid expansion decision.
But moving forward we hope to be able to pro vide a lot more data on participating plan
in the market places as well as enrollment numbers when they become available, so
that consumer can go and policy makers can go to one site to get a lot of this

information. And so we’re hoping to capture that an d really turn it into incredible
resource for policy makers as well as the public.

Mark Masselli: We are speaking today with Jennifer Tolbert, a Director of the State
Health Reform at the Kaiser Family Foundation and the Associate Director of the
Foundat ion’s Commission on Medicaid and Uninsured which is leading the efforts to
monitor implementation of the Affordable Care Act in states across the nation. And
Jennifer while the technical glitches are being worked out at the federal level and
certainly as you’ve mention some of the state basic changes are doing. Well, if you
need some fine tuning, consumers that were still navigating new territory. In a recent
article posted it one of the five things folks should look out for when utilizing the online
in surance market place, what should consumers be looking out for and ---

Jennifer Tolbert: What I can say from my own perspective, when consumers, I surf
these websites and shop for coverage, I think there are numerous things that people
should keep in min d, you know as they look at their health care and health coverage
options. And importantly, I think most people are a very much focus on the premiums
and so what they will pay on a monthly basis for the coverage and granted that is a
important thing to k eep in mind obviously that effects okay consumers pack a books
and, you know their budget. But it’s also important to looked at other components of the
health insurance coverage. Things like what are the out of the pocket cost? So how
much are those ded uctable? How much more people have to pay out of pocket before
the health insurance coverage kicks in? What providers participate in the plans network
-- may be they are getting care for a chronic condition or ongoing treatment for a major
health condition . Consumers will want to look at those provider network s and make
sure that their providers are participating.

Margaret Flinter: Well Jennifer, I think that is great advice for consumers and am I
correct in understanding that there is also some longitud inal studies that are planned
that perhaps Kaiser is leading, where you are going to survey as a side of subjects over
six months intervals into the future to see what their experience actually is?

Jennifer Tolbert: Yes we are – we have a number of surve ys under way to a kind of
assess the impact on people of the changes that are being implemented through the
Affordable Care Act. And so one survey is based in California and it’s a panel survey of
2000 uninsured adults. Which means we are going to be tra cking these people over
time and we will be surveying them at four points in time, so we just releases the
findings from the base find survey and we will be out in the field again talking to these
people in April where we will focus on kind of enrolment, t he emolument process and
the experience of people as they applied for coverage. And then in addition to this
California survey, we are also doing a national survey of low income adults that will also
be targeted in three states, s o we will have samples fr om three states in addition to a
national sample. We are conducting two waves, basically a base line and than a follow
up in a year to gaze what the effect or impact of the Affordable Care Act has been on
people. And then I will just – that in addition t o these larger surveys, we also are
conducting our monthly tracking poll which is design to really gaze more attitudes about

the law and we will be -- I think important as implementation proceeds to kind of see if
there is any change in how people perceive d the law and so, I think all of these surveys
together will help us better understand how this law is effecting people overtime .

Mark Masselli: We’ve been speaking today with Jennifer Tolbert Director of the State
Health Reform at the Kaiser Family Foun dation and the Associate Director of the
Foundations Commission on Medicaid and Uninsured . You can learn more about their
work by going to KFF.org . Jennifer , thank you so much for joining us on Conversations
on Healthcare today.

Jennifer Tolbert: Thank you so much it was a pleasure.

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Mark Masselli: At Conversations on Health Care 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 journalist and managin g editor of factcheck.org , 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?

Lori Robertson: We have seen true and false claims about the healthcare navigators
these are the federal workers funded by the Affordable Care Act that educate the
uninsured about their options and exchanges and help them enroll for coverage. Let
start with the false, house of republicans’ claims on the energy and commerce
c ommittee’s website that a Fox news reports makes clear that navigators were going
door to door to enroll Americans after the Obama administrations said that they would
not be going door to door. But the Fox News report was mistaken, the workers that
showe d weren’t navigators they were representatives of the United Way of Florida and
a group called Enroll America. Neither group received federal funding under the
navigator program we spoke with both groups and centers for Medicare and Medicaid
services to c onfirm that. Now for the true, Senator John Barrasso claims that navigators
don’t have to go through criminal background checks that ’s t here is nothing in federal
statute that requires such checks. A handful of states, five of them to be exact have
added that requirement and there are other safeguards aim that protecting against
identity thieves which was Barrasso’s concern and that’s my FactCheck for this week .

I ’ m Lori Robertson Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is com mitted 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
chcradio.com. We will have FactChec k.org’s Lori Robertson check it out for you here on
Conversations on Health Care.

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Margaret Flinter : Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday lives of the roughly 2.3 mi llion
American soldiers who return from multiple tours in Iraq and Afghanistan as many as
20% have returned with so called invisible wounds post traumatic stress disorder
traumatic brain injury, anxiety, depression and stress while the Federal Government h as
been shining a spotlight on the problem, there simply aren’t enough soldiers getting the
treatment they need and their families and loved ones suffer along inside them.

Doctor Barbara Van Dahlen is a licensed clinical psychologist who saw the need
grow ing and decided to do something about it. In 2005 she and a handful of colleagues
launched an organization dedicated to creating a network of volunteered counselors
and therapists who would devote their time to treating soldiers and family members it’s
ca lled “ Give an Hour ” .

Dr. Barbara Van Dahlen: We are a national network of mental health professionals who
provide free mental services to our returning troops, their families and their
communities.

Margaret Flinter: And her organization has grown. She has created a network of 6500
licensed therapists in all 50 states the District of Columbia Porto - Rico and Guam and
they have provided thousands of hours of free therapy to all veterans who reach out to
them and they are also working with the federal gove rnments initiative to train the next
generation of doctors and mental health professionals to recognize the unique
characteristics of PTSD and related conditions.

Dr. Barbara Van Dahlen: We will work with our mental health association partners our
non - pr ofit partners our veteran service organization partners and the White House is
joining forces initiative to insure that the next generation of mental health professionals
are properly prepared to support those who serve in their families.

Margaret Flinter : Doctor Van Dahlen is planning to expand her services to families who
suffer the long terms effects from the recent storms that had impacted the north - east
her work landed her on Time Magazine 2012 lists of the 100hundred most influential
people in the w orld Give an Hour creating a network of volunteered therapists who are
helping soldiers and the families who suffered from the impact of their service using that
network to better trained future clinicians to treat these disorders, now that’s a bright
idea .

Margaret Flinter: This is Conversations on Healthcare I’m Margaret Flinter.

Mark Masselli: And I’m Mark Masselli peace and health.

Conversations on Healthcare, broadcast from the Campus of WESU at Wesleyan
University, streaming live at www.wesufm.or g and brought to you by the Community
Health Center.