Two Perspectives on Health Care Reform

(Music)

Mark Masselli: This is conversations on healthcare. I am Mark Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Margaret, today, we have got a great opportunity to hear
about healthcare reform from two di ! erent sides of the coin, policy and
practice. US Senator, Chris Dodd will join us for our newsmaker
conversation segment. Senator Dodd who chaired the Health Education,
Labor and Pension Committee this summer is back in the spotlight.

Margaret Flinter: Yes, he is. He has been working with Majority Leader
Harry Reid and Senator Max Baucus to develop a bill that merges the
interest of the senate finance and health committees and now they will be
including the public option in the bill that goes to the floor of the senate.

Mark Masselli: Great news.

Margaret Flinter: So we look forward to hearing more from Senator Dodd
on that front.

Mark Masselli: We look forward to that and on the flip side we are going
to our neighboring state to see if the Massachusetts Healthcare Reform
initiate can help inform the national dialogue. We will speak with Jon
Kingsdale, the Executive Director of the state’s independent heath
insurance connector authority. Three years ago, the state enacted a law
to mandate insurance for all. Margaret, it has gotten pretty close to its
goal. Only 2.6% of its residents remain uninsured.

Margaret Flinter: Wow! That is about close to the levels in most
European nations who already have developed universal coverage. Let’s
hear what he says works and what still needs to happen to achieve true
universal coverage.

Mark Masselli: But first, we would like to share our comment that we got
from one of last week’s listeners. We heard from David Aylward, the first
Executive Director of the mHealth Alliance, a partnership recently formed
by the United Nations Foundation to facilitate global innovation in the
field of mobile health. David was interested in last week’s show on
telehealth, in our conversations with Dr. Blumenthal, President Obama’s
National Coordinator for Health Information Technology. David wanted

to know how the federal government is connecting key data from
electronic health records to the 911 and EMS System. He says this
initiative would help create public demand and use of the EHRs if the data
was used to help save lives in emergencies.

Margaret Flinter: What a great idea! And David, we will be forwarding
your comments to Dr. Blumenthal’s o " ce and we will also be tracking
your progress for a future show. If you have feedback on our show, e-
mail us at [email protected] . We love to hear from you. Now let’s
get to an update on healthcare headlines from our producer Lucy
Nalpathanchil.

Lucy Nalpathanchil: I am Lucy Nalpathanchil with this week’s headline
news. As Margaret mentioned, the public option will be debated on the
senate floor that’s because Senate Majority Leader Harry Reid has
announced he will include a government run insurance plan and merge
finance and health committee bills. Reid’s announcement to bring back
the public option comes with a catch. The senate provision will allow
states to opt out of participating in the government run insurance plan.
This plan serves as a compromise between liberals who want a single-
payer system and moderates who support a smaller government role in
healthcare reform. Republicans have vowed a filibuster, so Reid must
gain support from all democrats and two independents in the senate to
have the necessary 60 votes to include the public option in the final
senate bill. US Senator, Chris Dodd has been working with Majority
Leader Reid over the last several weeks. Mark and Margaret asked
Senator Dodd about the next steps in hammering out a final bill.

Mark Masselli: Senator, thank you for speaking with us today.

Senator Dodd: Well, thank you both very much. I am delighted to be with
you.

Margaret Flinter: Great! Welcome Senator Dodd. You have been such a
key and pivotal player in the work of health reform this year. Can you
give us a sense of the progress towards the final bill and also a sense of
timing? What can Americans expect in the coming weeks?

Senator Dodd: The o " ce called the Congressional Budget O " ce which
does something to every bill around that they have called scoring. They
actually try to determine what each provision would cost or what each
provision would raise in revenues as some do; and then determine what
the overall cost would be to the American taxpayer. And so while we

have scores on both of the bill, the bill that I managed this summer and
the bill out of the finance committee, when you merge them and there
are some di ! erences that are merging here as a result of the merger then
you want to get a score on those, the Congressional Budget O " ce, that
could take several more days. You don’t want to rush this, you want to
get it done obviously, but you want to really go to floor of the United
States Senate having good numbers, numbers that you can rely on and
good policy positions to present to your colleagues, not that it won’t be
controversial, I expect this to be a lengthy debate on the floor of the
senate for the next easily two months as there are people who opposed
to this and many are in the republican side of the aisle are going to be
raising probably hundreds of amendments to this bill, so it could be a
lengthy process.

Mark Masselli: Speaking of controversy, the most recent polls, CNN and
The Washington Post ABC show that the majority of Americans support a
public option; around 60% of Americans say it should be a fundamental
component in of the bill, but it wasn’t included in the legislation passed
by the Senate Finance Committee. Why is there such a disconnect and
what are the fears of those opposed to the public option?

Senator Dodd: We have public options in Medicaid and Medicare and VA
Care and what they call Tricare. So it’s already established how valuable
that could be for sectors of our population. The public option here
although really stang about and said, do you want to keep cost down,
which all do, I presume we all understand how important it is given the
escalating cost, healthcare cost rises five times faster than wages in our
country. And if we do nothing by the way; if we do that, which goes of
arguing for this, say just leave this alone, leave it for a later day. We are
told by experts that that cost $12000 a year in the next seven years and
Connecticut across the country would jump to close to $25000 a year and
premium cost with the private carriers. Obviously that is unacceptable.
We can't sustain that. So the public option brings down cost, the one we
know that, and secondly, provides options. I am a federal employee. I
get about 23 options a year, it’s part of the Federal Employees Health
Benefit package. Now I am not suggesting I want to get 23 options,
although frankly I like having those options. In many states, in many
jurisdictions one or two insurance companies so dominate the market
that there are no choices or very limited choices. The public option will
provide people with additional choice and that is as American as apple
pie.

Margaret Flinter: Senator speaking of changes, one really quite radical
change that looks like part of the final bill is the elimination of
preexisting conditions as grounds for denying coverage. Now from our
perspective as healthcare organizers and providers, this alone has the
potential to reduce a lot of misery and su ! ering by families who have
been priced out of health insurance when they need healthcare the most.
That was a big step to take and it seems clear that the tradeo ! for the
insurers would be to require almost everybody to have health insurance.
Can you comment on how you achieve this?

Senator Dodd: Yeah, it is absolutely critical, you are right, because we do
require that people have health insurance and again we are all benefited
by that when people do. As a result of more people be involved and
having insurance, getting it when you are hopefully not ill and not sick in
anyway, then obviously that allows money to build up so that when
claims do occur, they are the resource to take care of them and by doing
so, we can have the market reforms that allow free screenings, free
physicals, doing away with what you call the preexisting condition, which
is correct and that is they can't all of a sudden drop you or raise your rate
without any reason whatsoever because you all of a sudden have a
condition. That is when you sparingly increase the number of people and
it spreads out the risks then obviously that’s what it makes it possible to
have this elimination of the prohibition on portability in preexisting
conditions, so everyone benefits from that and as you do that that also
brings down cost as well. And when you have things like screenings and
physicals, as many of you may know, I went through that prostate surgery
this summer, I discovered early that I had a very spike PSA rating which is
one indicator of prostate cancer. So I had that operation that was not
inexpensive to get an operation, open surgery and get it done. But had I
not discovered it and had it gone on longer, had it gotten to my lymph
nodes or my blood or my bones; that operation could have easily cost a
quarter of a million dollars rather than the very reduced cost, it was
because I caught it early. So having screenings, having physicals is a
great way not only to serve your health and keep you alive and keep you
healthy but also reduce cost tremendously.

Mark Masselli: Senator the President has said that he believes that this
health bill needs to be bipartisan reflecting all Americans. You’ve had
extraordinary success in bringing about bipartisan support. You did it in
the past which was the Family and Medical Leave Act and in helping
families save there Home Act; not only bipartisan support, but very
conservative support. What’s going to take to get the final health reform

legislation with all members of both parties joining in and is it possible in
this political climate?

Senator Dodd: Well I hope so and maybe your last point is the most
important, we are you know this politics is always involved, it would be
foolish to suggest otherwise. But I think there has been so much
misinformation about a lot of this that it’s polarizing people and that
hurts. Part of the job in the coming days will be to reach out and listen to
each other. We finished our bill in July, it ended up having a partisan vote
at the end, it was 13 to 10 votes in the health committee on which I was
acting as the acting chairman. But I must tell you as well, we considered
300 amendments over five weeks in 23 sessions during that time. A 161
of those 300 amendments were o ! ered by my friends and the public
inside of the aisle that we accepted more than half of the amendments to
adopt in that bill, very good ideas. But they contributed substantially to
the product. We are a better bill today because they o ! ered those
amendments. Again I am not suggesting they like everything in the bill,
nor did I for that matter. He is the chairman of the committee. And I was
disappointed we didn’t come out of that committee as some partisans
support going forward. So my hope is we will do that. But it is the
means to the end, it's not the end in itself and too often I think we
confuse those two.

Mark Masselli: This is Conversation on the Health Care and we are
speaking with the United States Senator Chris Dodd about Health care
Reform.

Margaret Flinter: Senator, supposing this does pass by the end of the
year, what kinds of changes will the average American see in their health
care and when do you think they will see it?

Senator Chris Dodd: Well, again, we haven’t finalized the bill, right, I’ve
got to be careful of saying exactly what’s in this because we are still
working on this. But the idea we think is done immediately like closing
that donut hole for older Americans or at least a good part of it,
providing for those paying for immediate brief screenings and physicals
(Inaudible) to identify problems they may have or have a sense of security
moving forward, a lot of these provisions will take some time over a
series of years before it can kick in everything because it will. We are
fundamentally o ! ering and changing something that’s been around now
for 70 or 80 years. We try to keep the program alive so if you like what
you have, you like the insurance you have with your private carrier, we
are not mandating that you leave that. We are trying to help small

employers as well because if they get treated barely with the cost of
health care, they are paying 80% more of a health care cost than other
larger employers, we are trying to eliminate that. Individuals, self-
employed people, they are allowed for pooling so that they can obviously
get reduced cost and spread out the risk there they can have health
insurance more available to them.

Margaret Flinter: Senator Chris Dodd, Thank you so much for speaking
with Conversations on Health Care today.

Senator Chris Dodd: Thank you both.

As we wait to see how federal lawmakers shape Health Care Reform for
the nation, some say the State of Massachusetts could be a model for
reform. In 2006, the state passed landmark legislation to achieve new
universal coverage for all residents. The plan includes an individual
insurance mandate and called on the public and private sectors to share
in the financial responsibility of the plan. It also expanded the state’s
Medicaid program. Three years later, some of our Massachusetts
residents and graduate student 26-year-old Eric Grey is one of the
residents who is benefitting from the plan. He works as an independent
contractor for an education agency and doesn’t have insurance through
his employer.

Eric Grey: It would be far more expensive if I had this buyer plan directly
from one of those providers than it’s through the Mass Health
Connectors.

Margaret Flinter: The Massachusetts Health Connector is the
independent state authority that promotes the reform plan. It helps
residents choose between two options; the Commonwealth Care plan
which is a subsidized government insurance program for individuals with
income below 300% of the federal poverty level, or Commonwealth
Choice, an insurance exchange of private plans for residents to choose
from. Grey has an insurance plan from the exchange that he chose by
applying online.

Eric Grey: It’s sort of a one-stop shop for all the di ! erent plans from the
di ! erent companies and they have the HMOs, the PPOs and very easy for
me to find something that fit my budget and got the coverage that I
wanted.

Over the last three years, the state has enrolled an estimated 430,000
people who were previously uninsured. Lindsey Tucker, Health Reform
Policy Manager with the Consumer Advocacy Group Health Care for All,
points to this number as an example of success.

Lindsey Tucker: We are no longer in any way of the experiment. We are
over 97% insured in our states and we have approval ratings that are the
envy of any politician, well above 60% of the public support the law.

Margaret Flinter: There have been problems with the reform plan for; 1,
the cost of health care in Massachusetts continues to increase, and 2, all
those new insured residents have put pressure on an already squeezed
primary care system. Dr. Allan Goroll is the Professor of Medicine at
Harvard Medical School and Chair of Massachusetts Coalition for Primary
Care Reform. He says a reform plan must also strive to improve the
quality of care.

Dr. Allan Goroll: If we are really going to fix health care in the country,
and I think this is being recognized in Federal Legislation, we have to
strengthen the primary care base at the same time or even before we
expand health insurance to everybody.

The state has taken notice of these challenges and just last summer, a
special state commission was created to work on long-term cost control
provisions. Massachusetts has also passed incentive programs to expand
the primary care workforce such as tuition reimbursement for medical
students who enter primary care. Overall, there is widespread approval
from the public, government leaders and physicians for the plan to
continue. A recent poll by the Robert Wood Johnson Foundation and
Harvard School of Public Health found that 70% of Massachusetts
physicians support the law and 75% want the law to remain in place. To
find out more about Massachusetts Reform Plan, Mark and Margaret
spoke with Jon Kingsdale, Executive Director of the state’s health
connector, an independent authority that promotes coverage of the
uninsured.

Mark Masselli: Jon, thanks so much for speaking with us today.

Jon Kingsdale: Oh, my pleasure.

Margaret Flinter: Welcome Jon. How has this past year’s state and
national economic crisis impacted the reform e ! ort for you in
Massachusetts?

Jon Kingsdale: We have actually weathered it pretty well. When I say we
have weathered, that I mean health care reform has and we have been
able to maintain a good coverage for most of the folks who were
beneficiaries in state reform. We just had a state survey result that
showed virtually unchanged level of coverage, so again more than 97% of
residents in Massachusetts are covered. But we are certainly under
pressure to save money wherever we can and I think frankly the biggest
impact has been on some of the Medicaid payment rate because with the
maintenance of e ! ort, requirement of the federal stimulus package is
very little that Medicaid program. Again, outside a reform, just the
state’s Medicaid program can do is save money other than to look at
payment rate. So, that’s actually been a significant issue.

Mark Masselli: Massachusetts has the lowest percentage of uninsured
residents in the country at 2.6%. First of all, congratulations. You have
credited that success to the individual mandate, tell us why the mandate
plays such a powerful role in Massachusetts’ success and by extension, I
assume in the national reform e ! orts?

Jon Kingsdale: The mandate really has two separate and critically
important consequences. One of course is it gets folks’ attention and it
motivates a lot of people to sign up for insurance. And the second sort
of consequence of it though is that it’s actually by bringing folks into
their risk pool, into the insurance who consider themselves healthy, who
are maybe an accident or a diagnosis away from needing significant
medical care but are willing to take that risk, we have actually been able
to reform the insurance market in such ways that actual bring prices
down for individuals who buy insurance. So we literally had a 20%-plus
reduction overnight in the price of buying insurance directly on your own
as a result of reforms that include the mandate.

Margaret Flinter: We have been following your e ! orts to now address
cost through your new special cost commission. But what can you tell us
about better health outcomes or any savings that Massachusetts has
realized through decreased admissions to hospital for preventable
conditions for instance?

John Kingsdale: Well, I wish, Margaret, I can tell you more. We know that
a significant increase in the number of residents here who report a
routine source of care, a primary care clinician as a consequence of
reform, we know that we’ve got reduced financial barriers to
appointments, billing prescriptions, access to care. But for somebody to

be able to see a detectable change in overall health status of the
population when frankly 90% of health status is a function of income and
environment and inheritance and so forth. Because we have got another
6%, 7% or 8% of our population insured that’s going to take years frankly.
So I can't give you, I can't say the statistics of this you know folks in
Massachusetts are living longer or infant mortality is down or I think.

Mark Masselli: John Under the law residents must have insurance
through their employer or by enrolling in the state’s subsidized plan,
commonwealth care or through the private insurance exchange,
commonwealth choice but what about the person who can't get it through
their employer or doesn’t qualify for a sub set or just can't a ! ord to
purchase insurance on their own.

Jon Kingsdale: Well that’s a real problem and you know we would like to
be at 99% or 100% insured I think a lot of European countries have you
know universal insurance but still 1% or 2% are uninsured and at 2.6%,
2.7% for this past year that rate is very, very good, but it's not a 100% and
we got to figure out a way think when perhaps when the economy
recovers see if we can't use a strained analogy, put the ball across last 2
or 3 yards to remain on a field.

Margaret Flinter: You know we talked about primary care a moment ago
and the fact that as more people became insured they begin to utilize
health services and this is a good thing we want people to choose of
primary care provider if they haven’t had one and to use that primary
care provider for their health care but didn’t this pent up demand if you
well, put a lot of stress on the system and show that there really just
weren’t enough primary care providers especially may be as you got out
into more of your western part of the state, how has Massachusetts
addressed this.

Jon Kingsdale: Good question, because the shortage of primary care is a
national problem but there are particular pockets of shortage in
Berkshires then in the Cape Ann, the island. And one other great things
about reform has been that one frankly we get public policy on the move
so that leaders and providers and government o " cials are concerned to
make something that they have invested a lot of resources in old
experiment work they have actually been even more open than normally
to looking at consequential issues such as the cost issue, which we are
paying a lot of attention to, and the issue of access to primary care so we
are seeing two very concrete changes already and I expect those to be
more in Massachusetts.

Mark Masselli: This is conversations on healthcare. We are speaking with
Jon Kingsdale, Executive Director of The Massachusetts Health Connector
an independent authority established by the state to promote coverage of
the uninsured. Jon, with attention on Capitol Hill to pass National
Healthcare Reform this year some have said Massachusetts reform plan
could be the model for the nation, but you noted in your testimony to the
United States Senate that anything so ambitious is reforming one sixth of
our economy cannot be captured in a single piece of legislation but
involves some degree of trial and error learning by doing so is it fair to
say that your recommendation would be to get the coverage piece first
and then go to controlling cost.

Jon Kingsdale: I do think that the important thing is to get movement, to
get o ! the dime and if access is all that they can do that that’s critically
important because frankly we don’t have it national health cost
containment policy right now. We don’t have anything other than every
recession we get 5 to 10 million more uninsured and I think as in we have
found in Massachusetts nationally if we stop this sort of the cost
containment policy that says we will just have more insured, it's actually
going to add to the momentum to address cost squarely. So I hope
Washington will do both but at a minimum we have to deal with the moral
issues about covering people.

Margaret Flinter: And let me follow up on that question about addressing
cost. One model of interest is the State of Maryland’s model on
controlling hospital cost. And there they have shown over really quite a
long period of time now that cost control regulation has driven down
hospital cost far below the national average and still maintained a strong
hospital system. Is this a model of control that you think might be useful
in our national reform dialog?

Jon Kingsdale: Well I am going to look internationally here for a minute
you know every society that have you know universal coverage, every
advanced economy has some form of national rate setting or a public
program that sets grade and a lot of the issues that we deal within cost
are not about over utilization. They are really about the cost of
producing a day in a hospital or a visit or a pill. So whether it's rate
setting or some kind of more e ! ective competition I think all those
options should be on the table and we should be looking very carefully at
states like Maryland that seem to have done a very good job.

Mark Masselli: Conversations on healthcare focuses on innovations in the
nation’s healthcare delivery system. What future innovations excite you
or whose work should we be keeping an eye on?

Jon Kingsdale: Well I think that the conversion if you will of greatest
need, medical need from acute care which we have done a pretty good
job in this country at addressing to chronic illness is got to capture the
attention of the innovators whether it’s more continuous contact by
telephone and electronic medical records with folks who have long term
product requirements for communication and access monitoring or group
models of delivering care, folks with chronic illness I think we have got to
find a way and I am very excited that we are at places like Kaiser and
elsewhere finding new ways to deal with chronic illness in a population.

Margaret Flinter: Jon Kingsdale, Executive Director of the Massachusetts
Health Connector, thank you for speaking with us today.

Mark Masselli: Each week conversations highlight to bright idea about
how to make wellness a part of our communities in everyday lives.

Lucy Nalpathanchil: This week we focus on a program that uses an
interactive garden classroom to teach kids about the importance of
nutrition and building community. In 1995 an abandoned lot adjacent to
the Martin Luther King Jr. Middle School in Berkeley, California was
transformed into a one-acre garden. It became The Edible Schoolyard,
the brainchild of chef Alice Waters, for many credit was starting a local
food movement through her nonprofit Chez Panisse Foundation. The
garden space helped change public education by integrating gardening,
cooking and the sharing of a daily lunch into the core curriculum using
math, science and the humanities the Edible Schoolyard teaches 1000
middle school students each year through hands-on lessons about
growing vegetables, fruits, herbs and flowers. What's the goal? The
Edible Schoolyard not only teaches young people about creating and
sustaining an organic garden but they also learn how to prepare, serve
and eat food that’s good for them. This is especially relevant when
according to the US Department of Health and Human Services nearly one
in three children are either overweight or obese. These life lessons are
taught through cooperative work and positive interactions with their
teachers, community volunteers and their peers. The interactive program
reaches several hundred visitors a year and has helped launch a " liate
programs in New Orleans and other cities across the country. Are you
interested in planning a garden or kitchen program in your school go to
www.edibleschoolyard.org , the Edible Schoolyard educating students

about the connections between food choices and the health of
themselves and their communities. Now that’s a bright idea.

Margaret Flinter: This is conversations on healthcare. I am Margaret
Flinter.

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

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.