Genevieve Kenney, Health Policy Center, Urban Institute

Genevieve Kenney - Urban Institute

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret interesting report of The Commonwealth Fund this week ,
people with mental illness do better when the y have a medical home where they are
more likely to receive comprehensive and coordinated care.

Margaret Flinter: Well I think that that’s something that we would say we have known
from many years of experience Mark, behavioral health issues are often so hard to
identify and even harder to treat in a fragmented health system. And with 1 in 5
Americans experiencing some kind of diagnosable mental health issue within a given
year , that is just a huge need and it underlies so many other health issues.

Mark Masselli: And we also know that people who do receive treatment and
intervention, more than half of those people get that care in primary care settings.

Margaret Flinter: Well The Commonwealth Report also acknowledges that without a
substantive coordin ated care system behavioral health patients were more likely to fall
through the cracks and also didn’t receive timely referrals when they needed it. And we
have learned this in our own practice Mark , when a primary care provider can give a
point a warm hand off down the hall so they are seen immediately that’s just a huge
barrier that gets removed.

Mark Masselli: We do know one thing, once the previously uninsured population gains
health coverage, they are more able to avail themselves at primary care resources
which in turn leads to better access to all types of care including behavioral health
services.

Margaret Flinter: And gaining access to insurance coverage is something that our guest
today knows quite a bit about, Genevieve Kenney is the Co - Director of the Health Policy
Center at the Urban Institute and has done some considerable work analyzing the
impact o f getting coverage on health outcomes especially with the Medicaid population.

Mark Masselli: And Lori Robertson stops by, the managing editor of FactCheck.org ,
she is always on the hunt for misstatements spoken about health polic ies in the public
domain .

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

Genevieve Kenney - Urban Institute

Mark Masselli: And as always if you have comments , please or find us on Facebook or
Twitter ; we love hearing from you.

Margaret Flinter: We will get to our interview with Genevieve Kenney 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. Drugs and
their costs : Some 30 million Americans are grappling with diabetes and those numbers
are expected to triple within a couple of decades as the nation’s population ages and
the costs are notable. Cost of diabetes drugs have skyrocketed. The cost of the
hormone insulin – one of the most important treatments for diabetes – rose nearly 200%
between 2002 and 2013. The large increase in costs largely explained by much greater
use of newer type of insulin known as analog insulins much more costly than the human
insulin they replaced, but some good news in the report the cost propel [PH] of
metformin actually fell by 93% from 2002 to 2013.

And the US isn’t the only country grappling with an opioid crisis, according to a recent
report Europeans spend abo ut $24 billion a year on illegally obtained narcotics. New
technology: encrypted networks and digital currencies have opened up a new market for
online supply of illicit drugs. According to a study done by the Rhode Island Department
of Health young adul ts have seen a huge spike in a whole range of STDs , between
2013 and 2014 cases of syphilis grew by 79%, HIV infections were up 33% and
gonorrhea cases increased 30%.

Rhode Island says the recent uptake in cases follows a national trend. The state’s
heal th department blamed high risk behaviors that have become more common in
recent years using social media to arrange casual and often anonymous encounters ,
but Tinder isn’t the only social media site that’s lead to a spike in STDs , according to a
several studies a 2013 New York University study found Craigslist responsible for 16%
increase in HIV cases. The study urges clinicians and public health officials to do more
to get this message out to their younger audience about their vu lnerabilities. I am
Marianne O'Hare with these healthcare headlines.

(Music)

Genevieve Kenney - Urban Institute

Mark Masselli: We are speaking today with Genevieve Kenney, PhD, Senior Fellow
and Co - Director of the Health Policy Center at the Urban Institute . She is a nationally
renowne d expert on Medicaid, the Children’s Health Insurance Program also known as
CHIP and broader health coverage issues facing low - income families in this country.
Dr. Kenney published over a 160 peer - review articles on insurance coverage, access to
care. He r recent focus has shifted to the impact of the Affordable Care Act. Dr. Kenney
earned her masters in statistics and her PhD in economics from the University of
Michigan, Gene vieve welcome to Conversations on Healthcare.

Dr. Genevieve Kenney: Thanks so much for having me.

Mark Masselli: You know the Urban Institute has such a deep root formed initially it's
kind of interesting back at the LBJ Administration in 1968 so that independent
economist could analyze the effectiveness of government policies launched during the
so - called The Great Society, maybe you could talk to our listeners about the evolution of
the Urban Institute’s mission from that initial launch 50 yea rs ago and how it's evolved to
address the 21st century realities.

Dr. Genevieve Kenney: Well I would say that the Urban Institute’s current is to bring
objective evidence to bear on pressing social and economic problems and to inform
policy decisions , t he specific research and policy questions have evolved as well. As
you indicated the Urban Institute was founded during the time of great unrest, distress in
America’ s cities and over the next five decades our population has become more
heterogeneous and more complex many of the issues once considered specific to urban
America gravitated outward to all corners of the country.

Now in terms of the health policy group , w e have an interdisciplinary team of more than
50 researchers and we focus on a broad range of issues affecting private and public
health insurance coverage including Medicare and Medicaid. Many of our projects
today focus on the Affordable Care Act and it s implications, but we also are focused on
understanding other changes in health and health policy.

Margaret Flinter: Well Genevieve I am looking back to 2010 with an estimated 50
million Americans with no health coverage which meant really pretty poor a ccess to
health care. And you were able to chart [PH] the impact of lack of coverage on these
populations long before the passage of the Affordable Care Act and now I think are able
to chart some of the impact of having coverage, what is the notable chang e, what are
the impacts that you are seeing?

Genevieve Kenney - Urban Institute

Dr. Genevieve Kenney: So we have been studying health insurance coverage for
decades, who has it and who doesn’t since we know that having health insurance
coverage does not guarantee access to care. And what we know from the decades of
research evidence that has accumulated is that being uninsured puts people at much
greater risk of going without or delay in care that they need, not getting immunizations
and other preventive services and have experiencing med ical debt and related financial
burden associated with meeting their health care cost.

We also have evidence from multiple studies that Medicaid improve self - reported
mental and physical health status in adults and are really exciting emerging research
ba se that finds reductions in mortality associated with expansions in coverage. We are
also beginning to understand more about the long term effects of health insurance can
have on people’s lives. In particular there is growing evidence that the expansion of
coverage to children and pregnant women that began back in the 1980s with Medicaid
and that were furthered with the enactment of the Children’s Health Insurance Program
or CHIP in 1997 have had long term effects. We are seeing evidence that they have
l ead to a reduction on chronic health care conditions and mortality and increases in
educational attainment and income later in life. So as we pivot to look at the Affordable
Care Act and the impact of the coverage expansions there, we are going to have to be
patient because the effects do not materialize overnight.

Mark Masselli: Dr. Kenney we have covered about 20 million under the health law thus
far, but many more Americans still remain uninsured, the number of states that have
refused the Medicaid expansions, maybe you could talk to our listeners about those
states that did not expand Medicaid and what has the impact been to the overall
population health as well as to those states bottom - line?

Dr. Genevieve Kenney: It was one of the primary mechanism s by which the Affordable
Care Act sought to reduce un - insurance. It was targeted at non - elderly adults with
incomes below a 138% of the federal poverty level, so tha t’s about $16,000 for a single
adult annually or $27,000 for a family of three. The Medicaid expansion under the A CA
targeted non - elderly adults, prior to the ACA in most states few poor adults, who were
not pregnant or disabled were eligible for Medicaid particularly , if they did not have
children still few poor adults qualify for Medicaid the un - insurance rates in this group
was the highest of any group prior to the ACA about 40% back to coverage. But in
2012 the Supreme Court decision put the decision of whether to expand Medicaid in the
state’s hand not all states have avail themselves of that opportunity. To date 31 states
and the District of Columbia have expanded Medicaid coverage. The 19 states that
have not expanded Medicaid are concentrated in the south , of the southern states only
Arkansas and Kentucky , and now Louisiana that’s expand this summer have expanded

Genevieve Kenney - Urban Institute

Medicaid. We found that between 2013 and 2015 the share of uninsured adults living in
the south rose from 42% to 48%. But it also has outsized impacts of African Americans
who are uninsured because a disproportionate share of them live in the south. So what
this means is that where you live affects whether you qualify for subsidized health
insurance coverage under Affordable Care Act.

When we looked at the uninsured and expanding states and non - expanding states in
2014, we found that just 44% of the uninsured in that states that are not expanded
Medicaid were eligible for some kind of financial assistance under the ACA and that
compares the 68% in the states that had expanded Medicaid. Every federal and private
survey that tracks coverage has found a dramatic drop in the uninsured since 2013,
somewhere around a 40% decline for adults give or take depending on the survey. And
when we looked at states that have expanded versus not, we see a drop of over 50% in
the uninsured rates offer adults in expansion states compared to just about 25% in the
non - expansion states. And we are also be ginning to compile evidence on specific
implications of Medicaid expansion for state.

We have evidence from in - depth studies from Arkansas, Kentucky and Washington, and
all have found there were state physical gains that outweighed the increases in state
costs. And that comes about for a number of reasons including the fact that the states
were using state programs to provide care for some of the uninsur ed s particularly for
mental health services and substance abuse treatment services, but it also comes
a bout because with the Affordable Care Act the federal government is paying a higher
share of the cost for this population.

Margaret Flinter: You know Genevieve when thinking about Medicaid some of the
things that covers that people don’t usually think ab out in terms of support it might
provide to the states thinking the home visitation programs for low - income families
reaching in and identifying where we have particular high risk, high need situations, do
you see a willingness among the Medicaid programs to expand coverage to deal with
some of the really challenging problems beyond even the day - to - day medical care that
people need?

Dr. Genevieve Kenney: Medicaid is targeted at meeting the needs of often our most
disadvantaged populations with disproporti onately complex healthcare needs.

Margaret Flinter: Exactly.

Dr. Genevieve Kenney: So when you look for example at the profile of Medicaid,
historically it's been much higher than what type of cover age has addressed and I think

Genevieve Kenney - Urban Institute

you too are focused on the economic piece and I think there is the longest history with
children, benefits for children in Medicaid is designed to meet not only medical needs
that are then identified but also to diagnose and s creen for and treat developmental
issues cognitive issues and other kinds of health problems before they emerge.

Mark Masselli: We are speaking today with Genevieve Kenney, PhD, Senior Fellow
and Co - Director of the Health Policy Center at the Urban Insti tute. Genevieve I want to
pull the thread on the uninsured while we have seen some great strides made in getting
minority population to embrace insurance coverage and there is always a recalcitrant
sector of the population many so called young invincibles are likely to skip seeking
health coverage and there are many who still find coverage unaffordable due to
inadequate income and high out - of - pocket expenses, could you talk to our listeners
about th is sector of the population?

Dr. Genevieve Kenney: As you indicate the number of uninsured has dropped
dramatically since 2013 but we still have close to 30 million uninsured in this country so
it's still a large number. And I think you are also absolut ely right that the remaining
uninsured is a mixed group of people in terms of the reasons that they are uninsured. If
we look in 2015 , it looks like very relatively , if you are uninsured by choice , but data
suggests that of the remaining uninsured in 2015 , about 17% said that not wanting
health insurance coverage was the reason that they did not have coverage. Now some
of these people like the immigrant groups who flagged and poor adults living in one of
the 19 states that have not expanded Medicaid don’t have an affordable health
insurance option available to them , so that’s clearly a true affordability issue . But others
are available for subsidized market place coverage but don’t know that that assistance
is available to them while study after study fin ds significant knowledge gaps among the
remaining uninsured both about the subsidies that are available for coverage and the
penalties that are in place for people who don’t have coverage.

In addition, a number of the remaining uninsured are eligible for Medicaid or CHIP but
not enrolled and so that’s another distinct population with specific underlying reasons
than policy responses to address.

Margaret Flinter: Well Genevieve we often talk on the show about the impact of zip
codes on health, some say a better indicator of health outcomes than almost any other
single factor . And we recently had Marc Edwards on the show, the Virginia Tech
engineer who uncovered the depth of Flint, Michigan water crisis and there is a
communi ty with high unemployment and high poverty rates and the most vulnerable
poor women and children seem to have perhaps been the most a ffected by the
exposure to toxic drinking water, I wonder if you sort of reflect upon as you conduct your

Genevieve Kenney - Urban Institute

research at the H ealth Policy Center, what other factors besides health coverage comes
into play when you and your team are analyzing policy impacts on population health?

Dr. Genevieve Kenney: Well when we look at population health we certainly consider
health insurance coverage and the health care system as determining factors . But we
also recogniz e host of other factors related to where people live, where their children
are in school, where they are playing affect their health and wellbeing . And the kinds of
other fac tors that we consider include housing attributes and circumstances , individual
access to affordable food , safety concerns , the quality of the physical and social
environments , education, housing regulations, job trai n ing, food nutrition assistance,
crime and crime prevention . So we have a number of research initiatives that draw from
not just researchers in the Health Policy Center , but from experts around the
organization that investigate how non - medical, social factors are affecting th e health of
our population.

Mark Masselli: We have been speaking today with Genevieve Kenney, PhD, Senior
Fellow and C o - D irector of the Health Policy Center at the Urban Institute. You can learn
more about their work by going to urban.org and you can fo llow her on Twitter
@ kenneygm . Gene vieve , thank you so much for joining us.

D r. Genevieve Kenney: Thank you.

(Music)

Mark Masselli: At Conversations on Healthcare , we want our audienc e 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 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 Affordable Care Act hasn’t been a major focus of the Presidential
Campaign thus far, but we have fact - checked several claims about it from both sides.
Let's take a look at some of the top claims.

Republican Ted Cruz claims that the health care law had been a job killer and had
forced millions into unemployment and part - time work , but the economy has added
millions of job since the ACA and fewer people are being f orced to work part - time not
more.

Genevieve Kenney - Urban Institute

Democrats Bernie Sanders and Hillary Clinton triggered misleading claims about
Sanders ’ single payer health care plans. Clinton’s campaign claims that Sanders want
to dismantle Medicare whilst Sanders said he wouldn’t te ar up the ACA. In fact,
Sanders had proposed replacing the entire current health insurance system with a
single payer system in which everyone has insurance paid through tax dollars.

Republican Donald Trump claimed that healthcare premiums under the ACA were going
up 35% - 45% - 55%. He was talking about proposed rate increases for 2016 for some
plans on the individual market, other plans had proposed decreases in rates or single
digit increases that didn’t have to be submitted for review.

A Kaiser Family Foundation analysis found an average 10.1% increase from 2015 to
2016 in individual market premiums in major cities and 49 states in Washington DC,
that’s before factoring in tax credits. In one of the democratic presidential debates,
Clin ton said that the Affordable Care Act had helped more African Americans than any
other group to get insurance. But t he Obama Administration’s own figures show a
larger drop in the uninsured among Latino, 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 Annenberg Public Policy Center at the
University of Pennsylvania. I f you have a fact, that you would like checked, email us at
www.chcradio.com . We will have FactCheck.org's Lori Rober tson check it out for you
here on Conversations on Healthcare.

(Music)

Margaret Flinter : Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Right now , there are about
three and a ha lf million people living in refugee camps around the world . Whether
displaced by wars or natural disasters , the play of these people is often the same, living
in squalid conditions intensities that provide little protection from harsh elements and
these c onditions pose serious threats to their health and wellbeing. The IKEA
foundation has taken the parent company’s widely successful do - it - yourself approach to
home furnishings and applied it to the problem of inadequate housing for displaced
refugees. They have created a do - it - yourself dwelling that can be shipped and
assembled anywhere.

Jonathan Spampinato: So first and foremost there is the very well - known flat tech
approach that IKEA has pioneered. Secon dly, the materials and the product itself, so
it’s a shelter it’s not a tent .

Genevieve Kenney - Urban Institute

Margaret Flinter: Jonathan Spampinato is the H ead of Communications and Strategic
Planning at the IKEA Foundation. They are working closely with the United Nations
Organizatio ns working on the ground trying to assist refugees in Somalia and other
parts of the world.

Jonathan Spampinato: We extended that to also include funding for an innovation unit
within the UNHCR s o they could think more long - term , s o providing that fundin g ,
allowed them to start the refugee housing shelter looking at how to design a better
shelter.

Margaret Flinter: And since on average a person is likely to spend up to 12 years in a
refugee camp , these IKEA structures have some unique properties that can make the
experience more bearable.

Jonathan Spampinato: The walls and the roof are made out of a new fancy version of
basically a plastic material that is much more durable but very, very light weight and still
it's insulated .

Margaret Flinter: The IKEA Foundation currently has prototypes b eing tested in various
refugee camps and will scale up productions once refinements are made . And true to
IKEA , the price point is going to come in under $1 000 per structure ; a deliverable,
a ffordable , d o - it - yourself dwelling that can provide some sense of dignity, privacy and
protection for families who are struggling as refugees , now that’s a bright idea.

[00:23:01 to End – Repetition of Bright Idea segment ]