Speaker of the House Nancy Pelosi and Dr. Mitch Katz, San Francisco’s Director of Public Health, discuss the public option and the universal access program.

(Music)

Mark Masselli: Welcome to Conversations on Health Care. I am Mark
Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, it's our first show. You and I have known
each other for a long time since the early ‘80s but we were each involved
in health care a long time before that.

Margaret Flinter: Right; we started in the cradle. Mark was 19 when he
started the Community Health Center with a group of his friends.

Mark Masselli: And Margaret became a nurse right out of college. Over
the years, we have had lots of conversations about the cool things that
people are doing to reinvent the health care system some from all over
the world.

Margaret Flinter: Yes. And we have seen a lot of eyes glaze over at
parties as we went on and on about things like how to vaccinate a 100
people in an hour.

Mark Masselli: That was the first swine flu scare.

Margaret Flinter: Or the data on flossing.

Mark Masselli: But in the past few months we have noticed the kinds of
things that interest health care geeks are suddenly okay to talk about in
public, suddenly it's cool to be into health care.

Margaret Flinter: So we thought why don’t we just take the kinds of
things we talk about among ourselves and put it on the air.

Mark Masselli: That’s what this show is about, Conversations on Health
Care, how to change it, who is doing it right, how we are going to get
there.

Margaret Flinter: We will invite people to come and talk with us.

Mark Masselli: Pick their brains.

Margaret Flinter: This is our first show. We have an amazing lineup of
people to talk to.

Mark Masselli: First, Nancy Pelosi, Speaker of the House of
Representatives at ground zero on the debate and reform. She will give
us her take on where things stand.

Margaret Flinter: Next, we will talk about how San Francisco has achieved
what most cities can still only dream of, universal access to health care
and universal coverage like insurance but not; it’s a program called
Healthy San Francisco.

Mark Masselli: And we will also have the health care news headlines from
around the world brought to you every week by our own Lucy
Nalpathanchil who has had a long career in public radio, and we are glad
to have her as our producer. We will start with a look at recent health
care news.

Lucy Nalpathanchil: I am Lucy Nalpathanchil for this week’s headline
news. Nine months after President Obama came into o ! ce with the
promise to reform health care, Finance Committee Chair US Senator Max
Baucus has relieved his long awaited health care plan. Now the real work
begins. The President wants a bill on his desk that includes a public
option Senator Baucus’s plan does not include a public option. Here are
the next steps. There are two competing senate bills. After the senate
agrees on a final health care reform bill, both chambers will go into
conference and hammer out a final plan. We will continue to follow what
develops. As part of our healthcare headlines, we will bring you
newsmaker conversations. One of the key figures in health care reform
has been Speaker of the House Nancy Pelosi who is a leading proponent
of the public option. Mark and Margaret spoke with Speaker Pelosi.

Mark Masselli: Joining us by phone now is House Speaker Nancy Pelosi,
thank you for talking with us this morning.

Nancy Pelosi: I welcome that opportunity, thank you.

Margaret Flinter: Now the House seems ready to pass a health care bill
but the senate seems to be divided. Senator Baucus has just introduced
his plan before the Finance Committee and that plan doesn’t complete
upon -- What do you think can be done to expose the divide on this
issue?

Well the e " ort (Inaudible till 00:03:16) to the floor of the senate. There is
very strong support on the Senate Democrats for a public option so we
would hope that one would either be in the senate bill or they would be
receptive to agreeing to one in the house bill. But we are, now that the
senate has put out a mark and we will take that in this week out to the
Finance Committee, we are on our way to having a bill that we can send
to the President’s desk this year.

Mark Masselli: Speaker, we know you have been busy in Washington on
bringing about meaningful health reform but the debate now seems to be
focused in on the public option.

Nancy Pelosi: The public option guarantees that you will have health care
for the targeted population that you are trying to reach. On a national
level, the public option could possibly save over $100 billion; we are
waiting for the final number from the congregational budget o ! ce but
it's well over $85 billion that it saves. So what we are trying to do with
public option is to keep the health insurance companies competitive and
honest and also to have that competition lower cost as it improves
quality, expands coverage, and enables people to maintain what they
have if they like it at a cost they can a " ord by having this competition.

Mark Masselli: Now Speaker you have been out all over the country
talking to people, listening to people; what’s your suggestion for the
average citizen who is concerned and anxious about reform at this point
as it's coming to the end? How can they participate in the process over
the last remaining months and weeks?

Nancy Pelosi: It’s really important for everyday people to understand
what’s in this bill for them. It says that there will be important insurance
reforms that no longer can you be discriminated against by the insurance
company because you have a preexisting medical condition. If you lose
your job, you do not lose your health insurance. The insurance
companies will no longer be able to rescind your policy because you get
sick, and the list goes on. There is a cap as to what you can pay in
premium, there is no cap in what you receive in benefit; this is especially
important to the disability community of people with chronic disease.

Margaret Flinter: Speaker, what about the cost?

Mark Masselli: In terms of the cost, it's important for them to know that
unless we take action we are never going to be able to a " ord even what
we have now because the escalation in health care cost, premiums,

pharmaceuticals, you name it. So again to maintain, the President says if
you like what you have, you can keep it; well that can only happen if we
pass this bill, if the status quo would price that same option, that same
choice out of the means of many-many Americans. So, to people who
are listening and have concerns about what change may mean to them,
all they have to know that we must have the change for them to have the
choice to keep what they have. And they also should know that this is
important to individuals, it's important to families, it's important to
businesses, can be competitive with the escalating cost of health
insurance and it's important to our economy and to our budget; we can
no longer sustain the rising cost of Medicare and Medicaid and that’s why
we must have reform as well.

Mark Masselli: Speaker, you have talked a lot about the need for
innovation in health care; how is that reflected in the bill?

Nancy Pelosi: We try to improve quality and save money by having
innovation play an important part that we will have quality not quantity of
procedures that will have value not volume that will have health
information technology that will enable us to do things in a much better
way. So it's important for them to know that we need to take this step in
terms of innovation.

Mark Masselli: You have been a great champion for the electronic health
record. Do you see as one of the more important innovations that you
have been thinking about in seeing around the countries, you have
traveled around and talked with people in the health care field?

Nancy Pelosi: It really is. We, in anticipation of passing a health reform,
insurance reform bill now, earlier in the year when we did the recovery
package, we put billions of dollars into our health information technology
and we did so because this is central to again reducing cost to improve
quality. First of all, it takes your records to wherever you are and our
interest of making healthcare available closer to home and closer to the
workplace will mean the health records will follow the person. Therefore
whoever treats the individual will know what medicines they have taken,
what they are allergic to, what their history is and this is about time, and
time is very important in terms of treatment and success also in that,
physicians and health care providers are not spending their time and
resources on paperwork and red tape.

Margaret Flinter: Speaker, can you tell us how health reform will control
cost and address the issue of Medicare?

Nancy Pelosi: What we are doing will all be paid for A, B, will lower cost
over time, and more important than that, will prevent the escalation of
cost. In order to keep Medicare for example solvent and viable, it's
important for us to take the delay, fraud and abuse out of Medicare and
we can do that, in fact it's essential that we do that, in order for our
seniors and those who depend on Medicare and Medicaid I might add to
know that it is there for them. Since I mentioned seniors outside of it, in
the bill we will close the doughnut hole in the house bill. That’s one of
the di " erences between the house and the senate. So this is about
a " ordability for the middle class, it's about security for our seniors, it's
about accountability for our insurance company and it's about our
responsibility to the future.

Mark Masselli: Margaret, that was great Speaker came on, on our
inaugural radio show, she is quite passionate about the public option. It
will be interesting to see how all this plays out.

Margaret Flinter: It certainly will. And while the Speaker works to bring
about national health reform including a public option in her home
district in San Francisco, there is a great example of what could be called
a local option to cover the uninsured and create universal access it’s
called Healthy San Francisco. Here is Lucy Nalpathanchil with the details.

Lucy Nalpathanchil: Healthy San Francisco was launched in 2007 after a
large provider network was created made up of community health
centers, public clinics and nonprofit hospitals. It's not health insurance
rather it's a program that targets 73000 uninsured adult residents by
giving them access to quality healthcare within the borders of the city
and county of San Francisco. And all these are assigned to a medical
home or a health care facility that’s close to where they live so it's easier
to access primary care and other services. Two years later, 75% of the
uninsured have enrolled in Healthy San Francisco. Mayor Gavin Newsom
says the program, an example of a public option, has been a success.

Mayor Gavin Newsom: And I underscore this frame, this public option
where the sky has not fallen in, the world as we know it did not come to
an end, businesses did not rush up and out of this city and we have been
able to do it without increasing taxes and without creating a new
bureaucracy all those fears that some had fretted about when we initiated
this program.

Lucy Nalpathanchil: There have been several reports that outline Healthy
San Francisco’s progress. Recently Kaiser Family Foundation released a
survey of a release. Mollyann Brodie, Kaiser’s Vice President of Public
Opinion and Survey Research, says Healthy San Francisco is an example
for other municipalities who are trying to increase access to healthcare in
their communities although she says San Francisco has an advantage.

Mollyann Brodie: I think that this is showing that these kinds of
geographically specific programs are possible and that they can, and our
survey shows, provide access and help to uninsured residents. It's also
important to remember that there was an extensive infrastructure in
place for the program to build upon and so therefore it might not be the
model for all other communities.

Lucy Nalpathanchil Back in San Francisco, health care providers like
Christina Ng say the program has changed the lifestyles of many in
release.

Christina Ng: They really want to come in and give themselves a
checkup, make sure everything is okay, stay healthy so we do see a
change in how patients are accessing health care now.

Lucy Nalpathanchil: Ng works at Northeast Medical Services, a
community health center that’s based in San Francisco’s Chinatown. She
says Healthy San Francisco helps bridge the gap for most of their patients
who live at or below the 500% Federal Poverty Level and who don’t have
access to any other state or federal health care program. How is it paid
for? The cost is taken care of by city and state dollars and by San
Francisco employers who are mandated to pay a small fee per hour for
their employees. The cost for Healthy San Francisco participants is
dependent on a sliding scale based upon their income. For
Conversations on Health Care, I am Lucy Nalpathanchil.

Margaret Flinter: Lucy thanks for your report. And joining us now by
phone is Public Health Director for the City and County of San Francisco
Dr. Mitch Katz. Thanks for speaking with us today.

Dr. Mitch Katz: Thank you for the invitation to join you.

Margaret Flinter: Well, welcome Dr Katz. And you know the whole
country is thinking about health care access for the uninsured. Your
Healthy San Francisco program is a great model to learn from. Was there

as much of a struggle to get health care reform in your city as we are now
seeing nationally?

Dr. Mitch Katz: In San Francisco we, in many ways, focused on a simpler
question than the federal government is looking at right now. We
focused on the moral imperative to cover the uninsured. I think one of
the challenges that the federal government has is they are looking at how
do we cover the uninsured, how do we bend the curve, how do we fix the
hole in Medicare drug coverage while we really attack a narrower but I
would argue very important question.

Mark Masselli: Dr Katz, I know that San Francisco has put together a
large provider base made up of community health centers, public health
clinics, safety net hospitals. But most physicians belong to small private
practices; have you been able to engage those providers in your initiative?

Dr. Mitch Katz: We have now. Your description is correct in the
beginning, our network was the public provider and our terrific federally
qualified health centers. But now we have been able to expand to all of
the nonprofit hospitals, Kaiser and even a physician association. So we
now have the Chinese Community Health Association which has
individual doctors and those doctors are able to see our patients. The
one thing we will never be able to do in our model is contract with
individual doctors because we don’t pay claims, we pay an amount of
money per person, kid for per month. So the model would be
generalizable to any place where doctors are associated within private
provider organization or some glue that holds them together.

Margaret Flinter: So you have a lot of innovation in Healthy San Francisco
and one of the areas that we have been so impressed with is the
technology and the way you have used technology to leverage access to
care and to eliminate the delays and the waste that we sometimes see in
the healthcare system. Tell us about that.

Dr. Mitch Katz: We have found technology has been the answer to a lot
of problems our system su " ered from before. So even without all of the
coverage part of Healthy San Francisco when we went to our new model,
we had one Internet system that all of our providers could use to enroll
our patients. And this accomplished two goals; one was that we were
now able to get our patients benefits that they were entitled to that they
didn’t even know they were entitled to. So in enrolling our 46000
members, it turns out that almost 5000 of them were entitled to Medicaid
and didn’t know it and that turns out to be good for them and it turns out

to be good for our providers because they now get a higher level of
reimbursement. By having this common system also now we know where
everybody is getting care, we know how many people are not getting care
at all and we have eliminated the duplication that comes from someone
going to one clinic on Monday and going to a di " erent clinic on
Wednesday, the person who see them on Wednesday doesn’t even know
that they were seen on Monday. So we are big advocates for trying to
come up with a common Internet system so that anyone can use it,
Internet systems are used by our Storefront Clinic that’s in the poor
section of the city because it doesn’t require that people has
sophisticated computer equipment.

Mark Masselli: We are talking with Dr Mitch Katz, San Francisco’s Health
Director about innovative health access program for the uninsured in the
city. Dr. Katz, one of the hallmarks of this initiative is your commitment
to establishing medical homes for everyone enrolled; can you explain this
idea for us?

Dr. Mitch Katz: Under our old system, people went wherever they went
that day and they got whatever care they got; no one person was
responsible. I learned this when I went to first my computer sta " and
said well I want to know what percentage of women over the age of 50 in
my system got mammograms and I was very disappointed at the low
number but when I went and talked to my providers, they started looking
at the list and they said well she goes over here and she goes over there
and she just came once and I suddenly realized that without a unifying
system, there is no accountability. So, under our new system, each
person has to choose a primary care home and that’s the only place
where the care is provided under Healthy San Francisco. And then from
the provider point of view, now each provider has a certain number of
people for whom they are responsible. If that person doesn’t get a
mammogram, then I go to that person and I say why are your
mammogram levels only 40% of eligible women while the doctor in the
room next door to you, she is able to get 90% of her women
mammograms.

Margaret Flinter: Well maybe that explains why when the Kaiser
Foundation surveyed your participants in Healthy San Francisco, they
found 9 out of 10 people say they are satisfied with coverage and even
the Local Chamber of Commerce supports it. But there have been some
concerns about the burden on small businesses who may have trouble
with these costs, how are you addressing their concerns?

Dr. Mitch Katz: Well certainly this has been a di ! cult issue. The
Employer Spending Requirement that we have in San Francisco has been a
challenge for those businesses that have traditionally not provided health
benefits, and that’s heavily the restaurant industry. The rest of San
Francisco businesses, when we first started the program, we found out
that about 80% of businesses were providing insurance or some other
health benefit. And so for that 80% it wasn’t a problem at all and some of
those people even said well gee it's unfair that I am paying for health
benefits and my competitor across the street is not and so I am at a
disadvantage, let’s level the playing field. But, in the restaurant industry,
that’s just not true and it has been di ! cult, it's a very cut throat industry
where profit margins are very small.

Mark Masselli: Moving a little away from San Francisco, cost, quality,
access, choice, these are all the big drivers in health reform debate.
What's your advice to President Obama and Speaker Pelosi?

Dr. Mitch Katz: They have a very tough job. At many times I have
wondered if it really can all be done in one bill. I admire our Speaker’s
work on behalf of a public option, I believe that a public option is
necessary in order to guarantee that our especially for-profit insurance
companies o " er meaningful benefits to people. But it is a very tough
road when you are trying to do so many di " erent things and my hope is
that if we can't pass an overall bill, then that at least let's do what we can
do to make lives better for the uninsured.

Margaret Flinter: Now Dr. Katz it's only been a few years but of course we
want to focus some attention on outcomes. We know the data on
outcomes when people don’t have insurance or access to care. Do you
have any outcomes yet that you can point to and say here is the benefit
of having made this investment?

Dr. Mitch Katz: From the kinds of study we know not only that people are
satisfied but 40% of people say that they have fewer unmet needs to
health care than they had prior to the program. So I would consider that
an outcome although it's subjective, it's somebody reporting it isn't on
the basis of data on utilization rates. In the next phase of the evaluation
what we are going to be looking at is Emergency Room use that’s
inappropriate and hospital admissions that are inappropriate meaning
that they are avoidable; I should say Emergency Department visits that
are avoidable, hospital visits that are avoidable and try to see whether we
can show decreased rates. We do know that since starting Healthy San

Francisco, our Emergency Department use has been less than a
comparable population seen by Medicaid.

Mark Masselli: You know Dr. Katz we just have a short time left, can you
tell us what's next in San Francisco in terms of innovation in health care
access and what excites you?

Dr. Mitch Katz: So we are up to 46000 of the 60000 uninsured and I
want to get to 50000, and then I want to focus some more e " ort on what
I would call population prevention. So, for example, I want to be able to
contact every smoker and be able to o " er them a nicotine patch with the
hopes that they will stop smoking even before they have ever gone to see
their doctor, I want to approach them about increasing their exercise and
improving their diets without necessarily ever seeing the doctor because I
think we can make a lot of inroads in making people healthier.

Margaret Flinter: Dr Mitch Katz, Public Health Director for the City and
County of San Francisco, thank you for joining us today.

Mark Masselli: If there is one thing that everyone in the health care
debate can agree on, it's that access to medical care is just one part of
the puzzle, we also need to create healthy lifestyles. Each week,
conversations will be pointing out a bright idea about how to fit wellness
and healthy choices into the daily life of your community.

Margaret Flinter: This week we heard from a group of parents who found
a healthy solution to a modern problem. Most parents have fond
memories of walking to school as a child but years of media attention on
the possible danger of strangers has made the sight of a child walking to
school an endangered species, the unintended consequence of life that’s
more sedentary and less independent than children in previous decades.
One school in Kansas has their kids hopping on a new kind of school bus
this fall, the walking school bus. Parents in each neighborhood take
turns supervising groups of walking kids; the kids learn the joys of
independence and they get some exercise but with fewer risks. North
Lawrence Elementary School in Lawrence Kansas has had great success
with the program since school started.

Mark Masselli: For some families it's important that their kids are
learning to save the environment and fight obesity at the same time and
it doesn’t hurt that it's kind of fun too. If you would like more
information on how to set up a walking school bus, in your town, go to
www.walkingschoolbus.org . Now that’s a bright idea.

Margaret Flinter: And I am Margaret Flinter.
Mark Masselli: And I am Mark Masselli, until next time, peace and health.
Lucy Nalpathanchil: Conversations on Health Care, broadcast from the
Campus of Wesleyan University at WESU streaming live at
www.wesufm.org and brought to you by the Community Health Center.