Governor Bill Ritter of Colorado on leading health-care reform at the state level.

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, we have turned the calendar page to May and
suddenly you feel like we are on the fast track to health reform implementation
starting this month.

Margaret Flinter: Well Mark, the White House has spoken primarily about the
immediate benefits of the bill and the nature prevents private insurers from
significantly raising premiums. But what I am hearing from my friends on Capitol
Hill is there is an extraordinary amount of work to be done to move from the
legislation phase to the implementation phase, and that’s where both the states
and the government are focused on right now.

Mark Masselli: I think they are more focused in on how to implement versus
whether. At the end of April states had to tell the Department of Health and
Human Services if and how they wanted to set up those High Risk Pools in their
state to help uninsured adults with preexisting conditions king coverage before
2014 when the official health insurance exchanges are up and running, almost all
of the states have responded with about 30% of the states opting for the
Department of Health and Human Services to operate that program for them.

Margaret Flinter: Well that’s a good sign. Hopefully a good indication of what's
to come in the next few years as we move forward. You know the thing is if
states get the choice about how to carryout their own High Risk Pool Program or
have HHS do it for them, I think people are going to accept it a little bit better.
Each state is unique. There are lots of options in terms of what you can do,
operate a new High Risk Pool along side your current pool, establish a new one if
you don’t already have one, let HHS take over and carryout the program in that
state.

Mark Masselli: And of course the point is to give the uninsured access to
affordable coverage and did we mention that federal government is footing the
bill?

Margaret Flinter: Well popular or not popular depending on your point of view I
guess but on that note let's turn to one state that laid the groundwork for health
reform with its own blue ribbon commission starting about four years ago and is
now poised to move forward with implementing reform. It’s also ironically one of
the healthiest states in the country and that’s Colorado. Colorado Governor Bill
Ritter is with us today to talk about how the Centennial State has been able to
position itself as a leader in health care reform implementation. We are very
happy to speak with Governor Ritter today.

Mark Masselli: And no matter what the story, you can hear all of our shows on
our website CHCRadio.com. You can subscribe to iTunes to get our show
regularly downloaded, or if you would like to hang on to every word and read a
transcript of one of our shows, come visit us at CHCRadio.com.

Margaret Flinter: And as always, if you have feedback, email us at
CHCRadio.com, we would love to hear from you. Now, before we speak with
Governor Ritter, let’s check in with our producer Loren Bonner with the headline
news.

Loren Bonner: I am Loren Bonner with this week’s headline news. As the
benefits of health care reform slowly trickle their way and this year President
Obama took the opportunity to highlight these early provisions that have already
gone into effect as well as those that are soon to be in place. In his weekly
addressed the president said many parts of the reform package are showing
results right now.

Barack Obama: Already, we are seeing a health care system that holds
insurance companies more accountable and gives consumers more control.

Loren Bonner: President Obama said the administration is working on drafting a
Patient's Bill of Rights that will do just that, put more power in the hands of
consumers and out of the hands of insurance companies.

Barack Obama: It will provide simple and clear information to consumers about
their choices and their rights. It will set up an appeals process to enforce those
rights. And it will prohibit insurance companies from limiting a patients’ access to
their preferred primary care provider, ob-gyn, or emergency room care.

Loren Bonner: Earlier this week the administration also unveiled First Lady
Michelle Obama’s action plan to fight childhood obesity. In February the First
Lady launched the Let’s Move campaign to solve the childhood obesity epidemic
within a generation. The First Lady says for the plan to succeed everyone has to
do his or her part.

Michelle Obama: No one gets off the hook on this one, from governments to
schools, corporations to nonprofits, all the way down to families sitting around
their dinner table.

Loren Bonner: Her action plan presents a series of 70 specific
recommendations, such as lowering the relative prices of healthier foods and
reducing the marketing of unhealthy products to children. The generational goal
is to return to a childhood obesity rate of just 5% by 2030 which was the rate
before childhood obesity first began to rise in the late 1970s. In the coming
week’s cabinet members and administration officials will hold events that
highlight the ways in which different government agencies can do their part to

address the childhood obesity epidemic. This week we are looking to states that
can service models for health care reform implementation. In addition to
Colorado, Wisconsin has gained attention as another state that is in an ideal
situation to successfully bring health care reform to all its residents because of
the work it’s been doing prior to national legislation. Governor Jim Doyle set out
on the path four years ago to make sure as many people in Wisconsin had health
insurance coverage. Karen Timberlake is the Secretary in the Department of
Health Services in Wisconsin.

Karen Timberlake: Governor from the beginning has really believed that
Wisconsin and frankly all states ought to do what they can do to make sure that
they can meet the health care needs of their citizens and then ultimately there
are going to be pieces of this problem that states can not solve on their own, but
there is an awful lot that states can do and we have really demonstrated that in
Wisconsin.

Loren Bonner: Before National Health Care Reform passed Governor Doyle use
the flexibility the Federal Government gave states in the Medicaid Program to
make sure Wisconsin was able to cover everyone, even low income childless
adults, a group that has had some of the most difficulty finding coverage. This
lead to 98% of the population in Wisconsin having access to affordable health
care one way or another. However, due to the high demand from the childless
adult group, 20,000 or so people had to be waitlisted for the program.

Our Childless Adults Program operates under a kept waiver and so not only do
we have now today about 25,000 people who are on a waiting list. We have
many more people we believe who haven't come forward at all because they
know that the program is kept. We also by terms of the waiver have had to
require that people either go without health insurance for a full 12 months before
they sign up or we have had to require that they recently lost employer
sponsored health insurance due to a recent job loss, so all of those conditions
exclude people from the program. Those kinds of limits would be listed from our
Childless Adults Program and the National Health Care Reform.

Loren Bonner: Under President Obama’s Health Care Legislation states can
apply for an early extension of Medicaid beginning this year instead of in 2014 for
states like Wisconsin that have already expanded their Medicaid program
enrolling early could provide an added benefit. The provision could mean the
federal government for the first time would pick up a portion of the tab for those
enrollees despite the potential for states to receive increased federal support for
the Medicaid programs in 2014 in the short term at least one state Michigan
expects things to get worse before they get better. In Michigan where one in six
residents is now covered by Medicaid low reimbursement rates are forcing
physicians and hospitals to reduce services to these patients and even close
parts of their hospitals. Although health care providers are lobbing against more
cuts to Medicaid, the states budged crisis makes it more likely. States that

choose to take the federal government up on this offer to extend Medicaid
services now would still have to pay their share of the new Medicaid cost until
increased federal support begins in 2014 when the expansion is required of all
states. Let's listen out to the interview with Colorado Governor Bill Ritter to learn
more about what Colorado has been doing on its own to provide more residents
with quality health care as well as its recent efforts with national reform.

Mark Masselli: This is conversation on health care; today we are speaking with
Governor Bill Ritter of Colorado. Welcome Governor Ritter. Governor Colorado
has made significant scribes implementing health care reform and at the end of
April you signed four bills into law design to increase your health care work force
and help consumers obtain policies in plane easy to understand language, it
sounds like you are well prepared for National Legislation and in fact reading the
report of the Colorado Blue Ribbon Commission it looks like the conditions
recommendations align very closely with the final national reform bill. What are
the most important next steps for the Colorado to advance the Health Reform
Agenda?

Bill Ritter: Well I think our most important next steps are to look at all the things
that are part of the National Health Care Reform and how can a state best
implement those. What are the things that we can do, in a way I would like to
think about it as usher in reform from the national level. So, we had already done
a variety of things that help us and actually take us down to the right path as you
mentioned, we had commission that was actually pointed by my predecessors, a
bipartisan group, I put a few people on it. But they have made a variety of
recommendations and they really you know looked at the situation in Colorado
and said these are the things that you can do over time. We begin immediately
legislating a variety of things to really work on their recommendations and we
have just done a variety of things that are about ushering in reform now because
you are right they do the National Health Care Reform and our state efforts
match very nicely. So I put in an executive order in place and it really is about
appointing a group of people that will do the things that are really necessary in all
of our departments that you know will be touched by Health Care Reform. We
have 10 different state agencies or the major agencies. 10 different agencies
that we think one way or another will have to take some action to make National
Health Care Reform as I think feasible as is going to be in any state.

Margaret Flinter: Well, Governor you are the Chief Executive of a State where
about 20% I think of residents have had no health insurance so certainly a very
important issue and I noticed in that Blue Ribbon Commission and
congratulations on what a bipartisan group it was, till his recommendations were
to create the individual mandate and to establish the connector or the health
exchange and of course we saw that come through in the final health reform. We
are curious how is that received by the residents of Colorado in general, it’s the
individual mandate something that people appreciate as a strategy to cover the
uninsured and what about the connector as well?

Bill Ritter: For our purposes we look at those recommendations and really and if
you look at it the commission recommends sort of incrementalism in our
approach and what we did was decide those are the two of the things that need
to come from you know need to come at the federal level. We have looked at
other state so the states who got ahead and we look at some of the difficulties
that they had in those states and so in terms of the individual mandate it's not
that the people of Colorado have said no we are not going to do this, or we don’t
want that. What we have said is there is a way to go about this but we have to
stereo step it, so this is our third year of legislating recommendations from the
commission and we have not put in place a mandate or an exchange and I will
tell you very clearly that’s because I believe it was important for federal health
care reform to happen or to happen in a comprehensive way and for states not to
try and piecemeal this. I was a person who was very happy that health care
reform got passed. There were things in it I might have liked to have seen that
were not a part of it, but that’s just the way it was you know and so those things,
those individual mandates and the state exchanges are both part of national
reform and then I think that’s the wisdom in waiting is that it did come, and we
weren’t out ahead of it in setting up something that actually wound up not
mentioning what the national reform piece.

Mark Masselli: And something you were out ahead of governor was your
Medicaid program has gotten some high marks for innovation in terms of
expanding coverages as well as improving quality and containing cost through
various pilot programs. What are some of those innovations and how could that
be an example for other states?

Governor Bill Ritter: So there is a bunch of things we have done here and thanks
for mentioning it Mark. It’s always good to be able to talk about your success as
we. We test the Health Care Portability Act using hospital provider fees for every
bed patient, every, you know, patient bed that’s occupied the hospital pays a fee,
get a matching amount of money from the Federal Government its Medicaid
brought down and that’s significant new dollars and that helps us expand
coverage in a really serious way. We just passed it last year and we are setting
up the coverage expansion now and that will be I think fully implemented really in
another year and a half to two years. But that takes us a time that’s just new
money into the system, helps us receive the federal reform in a very serious way.
Because of the expanded populations we were already be dealing with before
the federal reform is fully implemented. We also have established Medical
Homes for Children so now there are 236,000 kids who are provided with
Medical Homes and Medicaid in our Child Health Insurance Plan plus Program.
We have a goal still of expanding the enrolled kids. We have improved the
quality of care through what we call Care Coordination. Certainly we think
transparency and the use of Information Technology is important and you saw
that as well and National Health Care Reform. They have a new pilot called
Accountable Care Collaborative and it allows this state to better contain health

care cost because we still really believe that cost is a part of this calculus that
you know in order to improve quality and improve access got to drive down the
cost of care or at least arrest the increase. And so we have a whole pilot that’s
going to work on that. It’s plan-centered and it manages care that is focused on
delivering I suppose you would say efficient and coordinated care that approves
the overall health appliance. So we are doing it on a pilot basis but I was just in
Grand Junction last about a month ago that’s the western part of the state and
they are looking at this and saying this is really what you need to do in a
significant way throughout the state because they had been doing as a
community and you can see that their costs have been driven down, they were
featured in a New Yorker article where they have prepared McAllen in Texas with
Mayo Clinic and Grand Junction because of what they have been able to do from
integrating their care.

Margaret Flinter: Well congratulations on that good work and have a well
deserve reputation around the Patient Centered, Medical Home for Children that
we have read about for a long time. You know another area that is just so critical
for states is the workforce issue. Can you tell us a little bit how you have
invested or incentivized the development of primary care providers to deliver on
cure both in your urban and your rural areas in the state?

Bill Ritter: We have done things as it relates to nurses and those are some of the
bills that I just signed this past month. It has to do with nurse education
programs and loan forgiveness is a big issue I think because coming out of both
nursing schools but also kind of medical schools these kids have such significant
debt burdens that they will gravitate toward a specialty while they are in medical
school and not to our primary care. So we are trying to develop loan forgiveness
and we have a small program, we have expanded on that this year but at the end
of the day significant loan forgiveness I think is necessary to really incentivize the
workforce to gravitate to our primary care and away from some of the specialties.

Margaret Flinter: Today, we are speaking with Colorado Governor Bill Ritter.
Governor Ritter, much of Colorado is rural. We know that people living in rural
areas have unique challenges. On an average they are older and more likely to
have a chronic health problem, how have you been addressing the health care
needs of rural Colorado residents?

Bill Ritter: We signed a two-pieces legislation in April that will increase and
strengthen the workforce in rural and underserved areas so that’s back to their
workforce. Colorado Health Services improves existing public and private Loan
Repayment Programs for professionals to practice in the rural and the
underserved communities and that is a part of it. The other one that I talked to
you the Nurse Education Bill improves the state existing nurse loan forgiveness
program but maybe significant is all that we have also partnered with
UnitedHealth and they are using a technology that is really sort of a remote
mobile technology for health care, goes into these counties, we have counties in

Colorado where there is no physician practicing in the county. And it gives
patients in rural Colorado communities expanded access to physicians who are
here in Denver because of the ability to teleconference. You know you have a
health professional in the mobile van kind of like the book mobile of my youth that
now has you know a full, really a full medical office which is able to travel from
community to community and then there is technology for teleconferencing or
looking at the mobile technology but also eventually it’s putting actual stationary
buildings in rural Colorado. We are in counties where there is no practicing
physician and allowing people to again use that teleconferencing technology
where you just video conference for the physician. All the tests are being done
remotely but their results are being fed into the physicians’ office and he can
diagnose you and diagnose certain things without ever been able to see them.

Mark Masselli: Very innovative.

Margaret Flinter: Governor Ritter, you are really doing some great work out there
and one thing that you must be very proud of is that Colorado holds the
distinction of being one of healthiest states in the country. It's a leading state and
the lowest rate of obesity in the United States, so that’s terrific. But you aren’t
sitting on your laurels. I know you have introduced your own physical activity and
nutrition program to get people even more active and engaged in healthy
lifestyles. What kind of infrastructure does it take for a state to create and
maintain that kind of wellness?

Bill Ritter: First of all, we are very proud of our state’s low obesity rates. But if
you looked at one place where the things that you are heading in the wrong
direction is still childhood obesity and I am really proud of the First Lady Michelle
Obama and her efforts to reduce that. You asked the question about
infrastructure, there is one infrastructure that’s totally under utilized in United
States of America and it's our schools. We put in place an in child hunger by
2015. At that program, we are dealing with a group called Share Our Strength
and what that is, is going into these schools and doing all we can to get kids who
qualify for school lunches, school breakfasts and the Summer Nutrition Programs
to get them there. Currently, for school breakfast I think only about 15% of the
kids who qualify for a school breakfast actually go there and that’s because
schools haven’t thought about all of the things you know to get kids there on time
and when you might actually feed kids you know feed them in the second period
as opposed to before the first period and you will have a greater participation. So
that is certainly a part of it. And then you know we partnered with Kaiser
Permanente as well on a wellness program and a state wellness program. They
put money into it and have a state wellness infrastructure for that but I would say
that as it relates to Childhood Obesity, the most important thing is to focus on our
schools. It sounds kind of counterintuitive that you would see kids more to keep
them from becoming obese but it's actually true that if you feed them nutritious
meals at the right time, then kids don’t go to, you know they don’t gravitate to
junk food and to sodas at 11 in the morning is their first meal of the day.

Mark Masselli: Governor, your background gives you a unique insight to the
difficulties people face in eating basic human needs. As a District Attorney, you
are a leader in establishing victim services and you and your wife later spent a
few years as missionary volunteers in Zambia. I think our listeners would be
interested in how your early working forms your position on health care and
human services?

Bill Ritter: If you live in a developing country like Zambia and we lived in a
remote part of it, the poverty is pretty serious and I would say abject poverty
would be the right descriptive and you know we saw serious nutrition problems
and serious health problems and what you see there is the sort of the extreme
example of what a lack of nutrition and a lack of health care can do to the quality
of life of kids and to families. And we also saw it’s interesting the thing that
doesn’t change anywhere in the world is that kids nutrition status and their health
status improves with the mothers’ education. So that’s why we have also taken
such time and energy to really focus on how we are educating our kids here in
Colorado. We have a 25% dropout rate and what I can tell you is that will impact
the health status of those kids that you know the dropouts are having, it will
impact their nutrition status and their ability to learn. Something that we as a
country I think really have to come to grips with because we work on the
education issues but we don’t necessarily integrate those with nutrition or health
issues and they are very much they need to be integrated. As we debate health
care in this country we have to understand that the debate over health care isn’t
just about health care, it's about the quality of life you can associate with the
better education or better educative population.

Margaret Flinter: Governor Ritter, we would like to ask all of our guests this
question, when you look around the country and the world, what do you see that
excites you in terms of innovation and who should our listeners of conversations
be keeping an eye on?

Bill Ritter: I just think that we have some good models here in Colorado that I
would turn to in. I have already mentioned Grand Junction it has a patient
centered clinic for the uninsured. They all are using a community wide health
information technology exchange so to maximize its efficiency and quality. Its
Medicare per patient cost are far below the average but we have an intercity
model in Denver, the Denver Health System. So the Denver Health System is
also this model of integrated care and they could show how they could keep cost
down, how they can care for the underinsured, the uninsured, you know the
otherwise underserved in a way that decreases cost pretty significantly. But they
are also a model of care for trauma. They are one of the best trauma centers in
the United States if not the best trauma center in the United States. I found that
out about two months ago when I fell off my bicycle and broke a few ribs but I will
tell you this is this great health system where we could learn a lot if we thought

about integration more and you know to some extent, I tried to curb the kinds of
cost increases we see that are result of competition.

Mark Masselli: Today, we have been speaking with Colorado Governor Bill Ritter,
a National Leader in Health Care Reform, thank you so much for joining us today.

Bill Ritter: Thank you.

Mark Masselli: Each week, Conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives.

Margaret Flinter: This week’s bright idea focuses on the First City-Wide US
Bicycle Sharing Program. Denver Colorado’s B-Cycle Program launched in late
April with 500 bikes at 50 stations around the city offering Denver residents a
green alternative to cars for running errands and short commutes. Members can
sign up for the daily or a yearly pass, pick-up and drop-off the bike at any of the
stations around the city, several of which are solar powered. B-Cycles founding
partners designed the program specifically for US cities, universities and
corporate campuses where the focus is on health. The bikes are equipped with
GPS systems so users can track mileage, calories burned and carbon offsets.
The Bicycle Sharing Programs were first made popular in Europe, maybe the
most well-known is Paris Bicycle Rental System that has made over 10,000 bikes
available at 750 stations around the city. After a successful pilot program at the
2008 Democratic National Convention where DNC attendees on a 1000 bikes
drove 26,000 miles and burned an estimated 818,000 calories, possibly
preventing as much as 9.3 metric tons of carbon emissions, Denver became the
first US city to officially set up a Bike Sharing System. Minneapolis and Boston
are planning and installing programs in the coming months and many more US
cities and college campuses are looking at doing the same thing. Denver’s Bike
Sharing Program is grabbing our country’s attention as a viable transportation
option that can help improve the health of Americans and reduce our carbon
footprint. Now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Health Care, I am Margaret Flinter.

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

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.