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

Sara Collins - Commonwealth Fund

Mark Masselli: This is conversations on health care. I’m Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Maselli: Well Margaret, the Obama administration is wrapping up details as
they prepare to make way for the incoming Trump admini stration. The president put
his signature on the groundbreaking 21 st Century Cures Bill but he is also taking
action to ensure that certain health programs remain unscathed moving forward.

Margaret Flinter: And the Obama administration ordered the final ization of a new
rule at the department of health and human services that ensures $ 500 million
earmarked for healthcare and family planning through Planned Parenthood as
hundreds of clinics throughout the country can’t be t a mpered with – clearly a bold
act ion.

Mark Masselli: This new rules keeps funding intact much of which comes from the
Medicaid budget and ensures that patients get prevent ative screening as well as
family planning.

Margaret Flinter: Well – and Mark it’s important to remind our listene rs that no
federal funds are used for abortion services at Planned Parenthood which accounts
for only about 3% of the services they actually provide and it’s also interesting to
note we’re hearing reports of women flooding provider offices across the count ry with
request s for long term contraceptives p robably thinking that these services may not
be covered under new configurations in the Affordable Care Act .

Mark Masselli: Our guest today is very well versed in the improvements that have
occurred in Ameri can health care since the passage of t he ACA. Sara Collins is Vice
President of Healthcare Coverage and access at the commonwealth fund which is
dedicated to fostering the growth of high quality healthcare systems for all
Americans.

Margaret Flinter: An d Lori Robertson , managing editor of factcheck.org stops by but
no matter what the topic, you can hear all of our shows by going to chcradio.com.

Mark Masselli: And as always if you have comments please email us at
[email protected] or find us on Facebook or Twitter . We love hearing from you.

Margaret Flinter: We will get to our interview with Sara Collins in just a moment.

Mark Masselli: But f irst, here’s our producer Marianne O’H a re with this week’s
headline news.

Marianne O’Hare : I am Marianne O’H are with these healthcare headlines. With the
talk of an imminent repeal and replace of the Affordable Care A ct under the Trump
administration state based Medicaid directors are scrambling to prepare for what
could be a big shift in policies affecting the ir departments in coming years. Millions
of Americans gained coverage under the Affordable Care Act through the laws
Medicaid expansion. 31 states expanded Medicaid including California which has
the highest percentage of State residents now covered thro ugh their program known

Sara Collins - Commonwealth Fund

as Medical. It’s uncertain at this time how many Americans will lose coverage in a
wake of repeal and replace as that reality unfolds.

The healthcare law has actually led to hiring growth throughout this sector . Now a
study out of UC, Berkeley warns full repeal of the Affordable Care Act could cost the
State of California some 208 ,000 jobs. The s tudy predicts the repeal of the ACA
would cost 63 ,000 jobs in Los Angeles County alone. The Berkeley study isn’t the
only indicator o f significant job loss, should the J L P leadership succeed in repealing
the Affordable Care Act both the American Hospital Association and the Federation
of American Hospitals warn there could be significant , even dire loss of income
leading to massive layo ffs should repeal go through . According to a piece in Modern
Healthcare health economist s Dobson DaVanzo & Associates warned that based on
a latest ACA repeal bill put forth loss of coverage for millions of Americans would
lead to a net loss to hospitals of some $168 billion . Both trade groups sent a letter to
President - Elect T rump urging him to consider the economic as well as health
implications when putting forth any repeal legislation.

Need medical attention, wan t to live longer? Your chances may be better with a
female doctor. According to results from a long term study recently published in the
journal of the American Medical Association women doctors do a better job at
keeping patients healthier longer. Researchers at Harvard examined a random
s ample of Medicare patients hospitalized between January 2011 and December
2014 looking at more than 1.5 million hospitalizations. Patients who saw a female
doctor were less likely to die within 30 days of leaving the hospital. They were also
less likely to get readmitted within a one month span of their initial discharge.
Harvard School of Health researcher Dr. Ajay Shah noted that women physicians are
more likely to do evidence based medicine and follow clinical guidelines . He
surmised women doctors ar e more likely to communicate in a way patients report is
simply more effective. I’m Marianne O’Hare with the healthcare headlines.

Mark Masselli: We’re speaking today with Sara Collins , Vice President for
Healthcare Coverage and Access at the Commonweal th Fund , a private foundation
which aims to promote a high functioning healthcare system. She led the fund’s
national program on health insurance since 2005 conducting a number of national
surveys on health insurance and the impact of gaining coverage. S he served as the
associate director of the New York Academy of Medicine and served as the
associate editor at US News and World Report . She earned her PHD in economics
from George Washington University. Sara welcome back to conversations on
healthcare.

Sara Collins: Very nice to be here.

Mark Masselli: So 100 years old. Congratulations , my God. You oversee the funds
analysis of the insurance coverage and access to care which is safe to say has
m ade some dramatic advances in recent years . In fact , s ince the passage of the
Affordable Care Act the uninsured rate in this country is at a historical and I’m
w onder ing if you could maybe put this is context to the mission that you have and the
foundation’s goals for the past century.

Sara Collins - Commonwealth Fund

Sara Collins: The Com monwealth Fund was founded in 1918 with a broad charge to
do something for the welfare of mankind and the foundation’s first President , Edward
Harkness thought that healthcare was a primary way to fulfill that mission because
health was key to ensuring tha t people could achieve their full potential and there
were many gaps at the time in people’s ability to get healthcare just like they are now
it may be at a much worse level.

Early grants by the fund included some for medical research , we provided funding for
research that led to the PAP test – screening for cervical cancer , and we also made
grant s to establish hospitals in rural areas of the United States that lacked medical
facilit ies . If you fast - forward to the 21 st Century it became increasingly clear that
health insurance coverage is the key to ensur ing that people can get the healthcare
that they need but the rate of people who were uninsured kept going up so we really
began to fund res earch on in this area and we’ve just continued that over time.

M argaret Flinter: Well Sara , one of the areas that you are very expert in is Medicaid
and coverage particularly for the most vulnerable among us and perhaps most
effective access route to health coverage since the passage of the Affordable Care
Act happene d because of the Medicaid expansion in so many states . You just
released a Medicaid fact sheet at commonwealth that puts this expansion into
perspective. How has the Medicaid expansion changed the landscape for
Americans?

Sara Collins: Well , the expans ion of the Medicaid under the Affordable Care Act has
made it one of the nation’s largest health insure rs and an estimate d 13.3 million
people have gained coverage since October 2013 but even in the 19 state s they
have yet to expand medical eligibility , ab out 2.4 million people enrolled in these
states. People found out they were eligible after the Affordable Care Act passed for
Medicaid and the other major change that the Affordable Care Act made in Medicaid
program was simplifying enrollment , so people e ven in the states that haven’t
expanded Medicaid are finding it much easier to sign up. The Commonwealth Fund
Affordable Care Act trackin g survey – we found that 3 o f 5 of these newly insured
adults in the Medicaid program were un insured prior to gaining their new coverage
and half were either uninsured for more than 2 years or never had health insurance
coverage.

Mark Masselli: And the other side is that well millions have gained coverage on the
exchange s, the numbers are smaller than in the Medicaid gr oup but your s tudy found
this sector of insurance buying population still had a big impact on the health
economy. What has been the economic impact been?

Sara Collins: About 10 million people have coverage through the market places now
and also about pr ivate an estimated 8 million people have coverage in the individual
market outside of the exchanges. But we have found through our surveys that
marketplace coverage has improved access to healthcare for people who are
enrolled and improved the affordabili ty of health plans that people buy on their own .
Prior to the Affordable Care Act pass age the individual market was just notoriously
difficult to navigate , people were often turned down because of preexisting
conditions and about 60 % of people told us in 2010 , who had tried to buy a plan in
individual market , couldn’t find a plan they could afford .

Sara Collins - Commonwealth Fund

The change is that the marketplaces and the regulations for that whole market ha ve
just really had a dramatic effect on people who don’t have coverage throug h a job
and have to buy it on their own. In our tracking survey we’ve asked people whether
they would have been able to access or afford this care prior to getting their new
coverage. Among people with marketplace plans about 51% said they would not
have been able to access or afford that care prior to getting their new coverage but
even large shares of people who previously had insurance noted an improved ability
to get healthcare and marketplace enrollees have consistently reported high rates of
satisfa ction with their health plan. About 60 % are eligible for the most generous
premium tax credits and also reduced cost sharing in the form of lower deductibles
and lower copay s . About a third our young adults and about a third our older adults
– 50 and ol der , so those cost sharing subsidies and the premium tax credits have
really made health plans as affordable as people in employ er based plans.

The law has also created a number of consumer protections that guard against
catastrophic losses , bans on preex isting condition exclusions. There are bans on
lifetime benefit limits so health plans can’t cut off your health coverage when you hit
a certain amount like they did in the past. There are also bans on insur ers canceling
peoples ’ policies when they becom e sick, this was a big problem prior to the
Affordable Care Act .

Margaret Flinter: Well Sara, most American s still gain access to health coverage
through their employers. There is higher deductibles and higher out of pocket cost
for almost all healthcar e consumers and many attempt to lay the blame at the feet of
Obama care somehow for this trend which you say is misleading , so what’s really
driving this rise in the out of pocket cost for the health consumer?

Sara Collins: About 57 % of people under age 65 have coverage through an
employer and that’s close to what it was prior to the affordable care act so it just –
Affordable Care Act really hasn’t affected employer coverage. Some of the critics of
the Affordable Care Act have claimed that the law is d riving higher premium and
deductible cost for businesses and their workers but we found in a recent study of
federal data that premiums in employer health plans actually grew more slowly on
average in the 5 years following the passage of the affordable car e act than they did
in the 5 years prior to the law’s passage and the reason why so many families are
still pinched by the ir healthcare costs even though we’ve seen a slowdown in
premiums is that income growth really hasn’t kept pace with healthcare cost s in
many areas of the Unites States.

We found that employ contributions to their premiums , along with their deductible
amounts , amounted to about 10.1% of US median income in 2015 and this is up
from about 6.5 % of median income in 2006 . So what people ar e paying for their
premiums and their deductibles as a share of their income has gone up because
their incomes haven’t risen fast enough to keep pace with those higher cost s and
deductibles are a real problem for people in employ er base d plans as well as i n
plans that they buy on their own.

Mark Masselli: We are speaking today with Sara Collins , Vice President for
Healthcare Coverage and Access at the Commonwealth Fund . Sara,

Sara Collins - Commonwealth Fund

President - Elect Trump has obviously talked during the campaign about immediatel y
setting to work to repeal the health law. How does the Commonwealth Fund view
the potential impact of repeal and replace? Walk us through some of those
scenarios.

Sara Collins: Things are rather uncertain right now, President - Elect Trump and
congress ional republicans have promised to repeal and replace the Affordable Care
Act . They are now planning to repeal parts of the law such as the subsidies that help
people afford marketplace plans and the Medicaid extension through a
congressional process know n as budget reconciliation. They would do that with a
2 - to - 3 - y ear transition to allow them to come up with a replacement for the Affordable
Care Act and they also pledge to block grant the Medicaid program to significantly
change how that program is finan ced just by taking some sum of money and giving it
to state s.

But a repeal would destabilize the individual insurance market , one of the proposals
is to eliminate the penalties for not having health insurance coverage so eliminating
the individual mandate affectively by removing the penalties that people have to pay
if they don’t have health insurance coverage . So you might trigger the exit of
insure rs from market and it also creates a lot of uncertainty for the 31 states that
expanded Medicaid especially since there is great uncertainty as to what the
replacement would look like . If they a re repealing the Medicaid expansion, does that
mean they will have a lot few er dollars to cover people, so just really tremendous
uncertainty.

The Urban Institute proj ects an increase of 30 million people without insurance
coverage just under a repeal scenario what we might see through such a
reconciliation process. This is nearly 60 million people more that were without
coverage prior to the Affordable Care Act . In t erms of replace what are we likely to
see the current proposals and legislation including proposals by congressm a n Ryan
and Price include flat tax credits that would replace the kinds of means - tested tax
credits we have now under the Affordable Care Act th at are pegged to premiums in
people’s income. Insurance carriers in order to participate in the marketplaces and
make sure that people aren’t charged more on the basis of their health anymore, you
have to maintain a pretty broad risk pool so one idea is t o provide people a onetime
open enrolment period and require them to then maintain continuous coverage
across their lifetime , they will be charge d higher premium s or face penalties but this
really doesn’t fit in the reality of people’s lives.

Over 2004 to 2007 89 million people were uninsured for at least one month so this
type of replacement for the individual mandate really doesn’t fit how people’s lives
unfold over the course of a year . Just a note on the state high risk pools and you
couldn’t find an affordable plan and you might have to get coverage through a high
risk pool. There’s been c onsiderable experience in the United States with high risk
pools, this approach is both very expensive for enrollees and also for the federal
government and general ly they are ultimately unsustainable over time.

Margaret Flinter: Well Sara , when you look at the current landscape, are there areas
of bipartisan agreement what are to happen – are there some elements , and we
certainly heard during the campaign everybod y said that there were things that could

Sara Collins - Commonwealth Fund

be improved but where do you think there is opportunity for some bipartisan support
of changes to the Affordable Care Act ?

Sara Collins: Well there are definitely challenges in the Affordable Care Act right
now , t hey are imminently fixable . One of the problems that we see in our survey
data – If your income is higher then the subsidies start to phase out and what you
pay in premiums grows, people also have higher deductibles at higher income level .
So those subsi dies could be increased , people with higher incomes could be made
eligible for more generous tax credits , they could also be made eligible for the ir cost
sharing subsidies that have helped so many lower and moderate income families.

The other thing that happened this year we saw higher premiums in most state
market places , a key reason for this this year was the phase out of a program that
was designed to keep premium cost s low and to help cover the health insurers ’ cost s
when they have an enrollee that has a very expensive medical event. But the law
has really been successful in terms of covering millions of people , reducing peoples ’
out of pocket cost s, and rather than thinking about repealing the entire law about
making the parts of it that aren’t wor king very well function more efficiently.
Policymakers really have to work together to improve those programs over time as
they evolve.

Mark Masselli: Sara any change in the direction of Commonwealth Fund ? Change
of administration, maybe change of focu s , have you sat back and reflect ed on the
election and made any strategic change or Commonwealth Fund pretty much having
a longer term vision?

Sara Collins: Well we’re continuing to survey people about their health insurance
coverage, we will be intervie wing people over the next year so just to identify
problems that people may have gaining health insurance coverage. We will certainly
be monitoring the individual insurance market, the marketplaces for problems that
may arise as a result of efforts to rep eal the law . So, we will continue our focus on
tracking insurance coverage in t he United States. We view health insurance
coverage, universal health insurance coverage as a central part of achieving of a
high er performing healthcare system overall. Ever yone has to have health insurance
coverage so we’ll be looking for places where people may be losing their coverage
and addressing policy options to help improve coverage.

Margaret Flinter: We’ve been speaking today with Sara Collins , Vice President for
Healthcare Coverage and Access at the Commonwealth Fund , a private foundation
that seeks to promote a high functioning healthcare system . You can learn more
about their work by going to commonwealthfund.org or you can follow her on twitter
by going to @ sa racollins_. Sara , thank you so much for joining us today on
Conversations on Healthcare .

Sara Collins: Thank you so much.

Mark Masselli: At Conversations on Health c are we want our audience to be truly in
the know when it comes to the facts about healt hcare reform and policy. Lori
Robertson is an award - winning journalist and managing editor of factcheck .org, a

Sara Collins - Commonwealth Fund

nonpartisan, nonprofit consumer advocate for voters that aim to reduce the level of
deception in US politics. Lori, what have you got for us th is week?

Lori Robertson: Well factcheck.org took a look at the biggest political falsehoods or
whoppers of 2016 , among them were several healthcare claims. For instance
democratic presidential nominee Hi l lary Clinton pushed for policies to lower
prescri ption drug cost s but early in 2016 she misleadingly claimed in a TV ad that “ in
the last seven years drug prices have doubled ” . The reports sided by her campaign
said brand name drug prices on average had more than double d but more than 80%
of filled pres criptions are for generic drugs which have seen a price drop of nearly
63%.

During the primary debate Senator Ted Cruz claimed that millions ha d lost jobs and
been forced into part - time work because of the Affordable Care Act, but jobs
statistics at the t ime didn’t back that up. The economy had added millions of jobs
since the employer mandate and fewer people were working part time for economic
reasons. In discussing the wait - time scandal at the Department of Veterans Affairs
President Obama suggested t hat his administration fired a whole bunch of people
who were in charge of some of these facilities. At the time of Obama’s remark, only
nine people ha d been fired from the VA for issue s pertaining to patient wait - time
according to VA document s. Of those 9, 4 were senior officials at one facility in
phoenix. That’s not a whole bunch of people who were in charge considering USA
Today reported employees at 40 VA facilities manipulated data indicating how long
veterans waited for appointments including supe rvisors in at least 7 states who
instructed employees to falsify data.

In the realm of fake news, fake medical records for Clinton circulated on social media
and some conservative websites purporting to show that she suffer s from seizures
and dementia. C linton’s long time physician released a statement to factcheck.org
calling the documents f alse and reiterating her diagnosis that Clinton was “ in
excellent health and fit to serve as President of United State ” and that’s my fact
check for this week. I am Lori Robertson, managing editor of factcheck.org.

Margaret Flinter: Fact c heck.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 yo u have a fact that you ’d like checked, email us at
chcradio.com , w e will have f act c heck.org's Lori Robertson check it out for you here
on Conversations on Health c are.

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Pregnancy is normally an
exciting time for most women but according to research and estimated 10% of
prenatal women experience some kind of depression during their pre gnancy and
many are reluctant to treat their depression with medication for fear of harming the
fetus.

Margaret Flinter: In fact a higher percentage are experiencing lower grade
depressive symptoms so they might not meet full criteria for major depressiv e
episode but they’re having significant symptoms that are getting in the way of feeling

Sara Collins - Commonwealth Fund

good and left untreated those mild to moderate symptoms can progress and in some
cases lead to more serious postpartum depression.

Mark Masselli: Dr. Cynthia Battle is a psychologist at Brown University with a
practice at women’s and infants ’ hospital and providen ce . She and her colleagues
decided to test a cohort of pregnant women so see if a targeted prenatal yoga class ,
which combines exercise with mind fitness te chniques , might have a positive impact
on women dealing with prenatal depression.

Margaret Flinter : And it was a typical kind of Hatha yoga that would include physical
postures, breathing exercises, meditation exercises and we enrolled 34 women who
were pregnant , who had clinical levels of depression , t hey all had medical clearance
from their prenatal care provider s and they would come to classes and we measured
their change in depressive symptoms over that period of time.

Mark Masselli: Not only were w omen able to manage their depressive incidents,
they also bonded with other pregnant women during the program and found
additional support from their group.

Margaret Flinter : And the initial signs from this research are really encouraging , so
we found th at women on average were reporting that they worried pretty much less.

Mark Masselli: A larger study with control groups is being planned with the
assistance of the National Institute of Mental Health.

Margaret Flinter : Women who are depressed during p regnancy unfortunately do
often have less ideal birth outcome . So one thing we’re interested in seeing is when
we provide prenatal yoga program can it improve mood and then can we even see
some positive effects in terms of the birth outcome.

Mark Massell i: A guided non - medical yoga exercise program designed to assist
pregnant women through depression symptoms , helping them successfully navigate
those symptoms without medication , ensuring a safer pregnancy and a healthier
outcome for mother and baby. Now that’s a bright idea.

Margaret Flinter: This is Conversations on Health c are. I'm Margaret Flinter.

Mark Masselli: And I'm Mark Masselli, peace and health.

Conversations on Health c are, broadcast from the campus of WESU at Wesleyan
University, streami ng live at wesufm.org and brought to you by the Community
Health Center.