Proceedings of the Twenty-Second National Conference: First Day Opening Plenary Session (Part 2, Sundwall)

We gratefully acknowledge the sponsorship of the Sparrow Hospital/Michigan State University Family Medicine Residency Program of Lansing, Michigan for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:


Dr Mark Clasen, Wright State University: Thank you Rick (Flinders).

The Awarding of Plaques for Newly Inducted Senior Fellows in the Coastal Research Group’s National Consortium on Community-Based Medical Education:

Dr Clasen: Somebody once said that 90% of life is just showing up, but the four Senior Fellow plaques I am about to present represent more than just showing up for a decade of these conferences. We’re all very passionate about these issues in our own vineyards and we bring our own expertise to each of these National Conferences.

So the first senior fellow is Dr. Ana Bejinez-Eastman. (Applause) The next Senior Fellow is Dr. John Geyman.

Dr Sundwall: In his case, Senior is an understatement. (Applause and laughter)

Dr Clasen: Did you hear that, John? It was some irreverence from Dr Sundwall, Don’t worry about it!

The next Senior fellow is Dr. Mitchell Kasovac. (Applause) And the final plaque is awarded tp Dr. Warwick Troy. (Applause.) And would Dr. Jonathan Weisbuch stand please? He will now become one of the Fellows, There he is. [For a list of the Fellows and Senior Fellows, see Fellows and Senior Fellows: Four New Senior Fellows Inducted into Coastal Research Group’s National Consortium.]

First Plenary Panel

David N. Sundwall, MD

Our first plenary panel will be on the subject of “How Will it work?: The Path to Implementation or Deconstruction of the Healthcare Law “. We have, first, Doctor David Sundwall and then Dean Richard Clover presenting.

 

David Sundwall, MD, University of Utah: Good morning! I can’t tell you how pleased I am to be back here. I “feel the love” and it is a pleasure to see so many friends from previous conferences.

I’m a Senior Fellow too. Although I was teasing John Geyman, I am old too, and received my plaque many years ago. I’ve been coming to these National Conferences for two decades!.

I look forward to the National Conferences, not so much to what I will hear but to be with the people who are here. I thoroughly enjoy this group of folks and the ideas we wrestle with together.

Front Cover of “Landmark: America’s New Health Care Law” – The Staff of the Washington Post (first edition, 2010)

I plan on discussing with you today this historic time of change in health policy in the United States. To begin, I would like to recommend the book titled: Landmark: America’s New Healthcare Law and What it Means for All of Us, written by the Washington Post health policy senior staff.

I recommend it, because it is a comprehensive overview of the  new legislation, but also provides at the beginning a succinct history of previous efforts at “health reform” in our country and how we finally got to passing the “Patient Protectioand Affordability Care Act” (PPACA), also referred to as the ACA.

This is a very good book, but I must acknowledge that in my opinion it is somewhat biased. And I’m not saying that because I’m a Republican. (I should say not just because I am a Republican), but everything I read in this book suggests that the authors seem to think that if Republicans raised any objections to the passage of the draft legislation it was perceived as though they were simply being obstructive, and served as an “obstacle” to its passage. Isn’t that interesting? It does not seem to be acknowledged in the book that the Republicans might have had a legitimate point of view.

In fact, there was not one Republican vote for this legislation in the Senate, and the resulting backlash to some of the provisions in the law that was passed in March 2010, suggest there may in fact have been significant and legitimate concerns that should have been addressed in a more deliberative legislative process.

I briefly will describe the PPACA, organized according to P” words: its Policies first, then its Politics and then I will provide my Prognosis. I don’t want to trivialize or minimize this 1100 page bill, nor to shortchange the many aspects that are included, but its primary objective is to expand health insurance coverage for the uninsured – by expanding public programs and facilitating the purchase of coverage in the private sector. This is the number one policy objective which most consider commendable.

But let’s consider the politics, which have been exceptionally partisan on this issue. The rhetoric on both sides has been heated and polarizing, and to a degree that I didn’t expect. In fact, while many laud President Obama for accomplishing what so many failed to do before him, this will be used against him in the next Presidential election, portraying him as favoring “big government” over the private health care system, although his plan builds upon the private health insurance system in our country (to the chagrin of many of his liberal supporters).

As I mentioned, the primary purpose of the law is to expand health insurance coverage to those who don’t have it. Because this includes Medicaid, I will refer you to: The Medicaid and CHIP Payment and Access Commission (MACPAC) website at www.macpac.gov.

(See also Activities of the Fellows and Senior Fellows of the Coastal Research Group: Dr David Sundwall is Vice Chair of Federal Panel on Medicaid and CHIP Payment and Access.)

 

The first MACPAC report, on the Internet as a Google Document

[This commission was first convened last summer and is meeting on a regular basis. We just published our first report which I’m very proud of and it’s available on the Internet at the website listed above. Our second report, on “managed care” and Medicaid will be published on line on June 15, 2011, the same day it is delivered to the Congress.]

Medicaid Eligibility Increased

Medicaid is significantlhy expanded by increasing the level of eligibility from 100% of the Federal Poverty Level (FPL) to 133% to 138% (depending on how you calculate it). Whichever percentage in that range you choose will add an estimated 16 million more Americans to the Medicaid rolls, by virtue of their being eligible due to their income.

Health Insurance Exchanges

The new law also expands coverage by making it easier and more affordable for people to purchase health insurance coverage by requiring states to establish “health insurance exchanges” by 2014. I think this is a good idea. We have one in Utah, and Massachusetts has one. We’re the only two states that have  such web-based exchanges up and running right now.

The federal government considers this is a mechanism for improving people’s ability to purchase health insurance through a web-based portal, where one can get more affordable coverage that will hopefully be portable, and not necessarily tied to one’s place of employment.

By the way, the states are really struggling with how to do this – many of them are scratching their heads and saying do we want to do this? Some have already said “Hell no we won’t go” – we’re not going to comply with this particular requirement of the law (e.g., Louisiana). Others are spending quite a bit of money to get one up and running. But regardless, the purpose is to improve access to health insurance coverage – to make it more affordable and portable.

Health Insurance Becomes Mandatory

The legislation’s third major change is to mandate that by 2014 everyone in America will have to have health insurance coverage. That will mean that those people not currently enrolled in Medicaid who are entitled to be, will come “out of the woodwork” (that’s the phrase often used) and get enrolled. In Utah, we estimate that one third of the people entitled to Medicaid aren’t currently enrolled, because they’re either reasonably healthy or don’t need or don’t feel like they need coverage. Now they’ll have to do so, which will put another burden on states to cover those newly eligible people.

Health Insurance Must Cover Pre-existing Conditions

The fourth aspect of increasing health insurance coverage is through changes in insurance regulations.  The PPACA has already taken care of the practice of insurers denying coverage to a child with a preexisting health condition, by making it illegal. Eventually that will apply to adults, although it is being phased in.

So the foundation of the PPACA is to improve and expand health insurance coverage for Americans. Does it get us to where Dr. Geyman would like us to be? Not quite. It’s not universal, although it would cover about 96% of the population, if fully implemented. It would be a significant increase and improvement if you agree that having health insurance is healthy for you. In my opinion, it’s good for the public’s health to have health insurance.

The Legislation’s Public Health Features

However, it’s not just about insurance: there are a number of public health provisions in the law. I was a state health officer for six years, from 2005 through 2010, and got to know the state health officers throughout the country. I have great regard for them as individuals, understand the weight of their responsibilities, and the importance of their work and that of the local health departments, too.

There are many things in the legislation that would strengthen the infrastructure for public health. There’s a new prevention trust, which has “real money” authorized for traditional public health activities. For decades, we’ve had a preventive health services block grant for approximately $100 million. The PPACA increases this to half a billion dollars a year. Then, if  the law is implemented as it’s written, it would continue to increase up to $2 billion – from half a billion dollars this year, to $2 billion over the next four years.

I believe this is sound public policy and would enable us to strengthen significantly the infrastructure of public health throughout the nation. Some of  the public health provisions are absolutely “spot on”; they focus on the top killers – cancer, diabetes, obesity, lung disease. It really would help us address our most preventable causes of illness.

Health Care Workforce Provisions

Another important policy the PPACA addresses is a perceived shortage of health professionals. – It goes beyond strengthening the public health infrastructure and addressing preventable diseases, and renews the federal attention to what I think is particularly relevant to our meeting  – a focus on health workforce.

That doesn’t get talked about much. There are efforts to increase the training programs for primary care and for public health professionals, including other health providers – nurse practitioners and physician assistants. There’s also a significant increase in the National Health Service Corps.

So there are provisions in the legislation broader than insurance. It speaks to public health, and to the health workforce.

The Politics of Health Insurance Reform

As mentioned above, we have run smack dab into the politics of health reform, which are nasty and in my view counterproductive. I had no idea that there would be such a push back. The reaction seems in part to be based on policy, but it is mostly based on philosophical questions. What is the role of government? What is the role of the federal government? What is the role of state governments? Why do we need to take on this big of an expansion during a time of economic hardship?

The Politics of the Mandates

The point of most contention seems to be related to the mandates. Let me tell you how difficult it was for a state health officer like myself when the bill was enacted. The governor, within a day, said that he I wanted me to analyze this bill and tell him what it means for the state of Utah – what it will cost us, and how we would benefit from it. Within the same day, he joined a group of 26 other states in suing the federal government, on the basis that it could be unconstitutional for the federal government to require individuals to buy health insurance.

During the next cabinet meeting I said, “I’m feeling a little unclear here, do you want me to help implement this or do you want to fight it.” He said “Both, we’re not going to miss a penny, we’re not going to skip a beat, we’re going to take advantage of every aspect of this legislation we can, and by the way, we’re going to join the class action suit.” So, you might consider this duplicitous, or you could say it’s pragmatic. And I think it’s probably a little of both. He was practical in that he didn’t want for us to miss out on benefits or funding.

So the politics are extreme. It’s still playing out. In my state Medicaid is part of the health department and it was painful part for me that Medicaid came to be considered a proxy for “big government”, and not acknowledge it as a public assistance program that is part of our “safety net”, our collective conscience to care for those most in need in our society.

So Medicaid’s been demonized. We had a headline in the Salt Lake Tribune “Taming the Medicaid Monster”, that I found offensive. How do you think this make people who are Medicaid beneficiaries feel? My prognosis for the PPACA legislation is guarded. I think it’s going to be changed, but I hope it will not be repealed, and that many of its provisions go forward.  egardless, I think we need to be nimble and to get ready to adapt to whatever aspects of this law are eventually implemented.

The Implementation of MACPAC

MACPAC was authorized in 2009 as part of the CHIP (the federal Children’s Insurance Program) reauthorization, but it wasn’t funded until PPACA was enacted. MACPAC previously had been limited only to Medicaid and CHIP, but now it has a number of new responsibilities.

Coordination of Functions with MEDPAC

There is a direct parallel between MACPAC and MEDPAC, the Medicare Payment Advisory Commission, that has a 20 year experience in advising Congress. Both are 17 person commissions with defined (and some potentially overlapping) responsibilities.  The new law requires coordination and cooperation between the two commissions.

Published and Planned MACPAC Reports

I do highly recommend the first MACPAC report, if you want to become a student of Medicaid. This is, without question, the best primer on Medicaid you’ll ever read, because it presents the history and then it discusses the current challenges, and the budget issues. We included something that I think is most useful, that’s called MAC Stats. The report is on the web.  It will include data on who is enrolled, and what the expenses were to the extent we have the state data. So it is very, very useful.

Charge to Avoid Advocacy

Here’s the politics. I’m one of 17 commissioners, I’m the Vice Chairman, Diane Rowland Sc.D. is the Chair. She’s an unquestioned expert on Medicaid, and a long time, highly regarded activist for Medicaid. She heads the Kaiser Family Foundation’s Washington office. Rowland is well identified with Democrat Congressman Henry Waxman and is a proponent of Medicaid. I’m there primarily to provide balance and make sure that they know we’re not just promoting expansion of Medicaid and advocating for an even larger role of the federal government.

We met with various Hill staffers and were told absolutely no way do you come up here and advocate for Medicaid. That isn’t why you were created. We want data and information. So that’s exactly what we are providing. We are not a policy group; we’re an information group.

Conservative policy institutions in Washington (e.g., the Heritage Foundation) are proposing that Medicaid be dramatically changed – be “block granted” to states. Block grants, which were in the past considered that to be a radical idea, are now widely discussed as an alternative way of financing this and other programs. So at our meeting we held just last week I made a strong case for saying that MACPAC doesn’t have a position on block grants. We’re neither against them nor for them. We’re going to be the source of information for Congress. If they choose to go down that path, they’ll have a reliable source to go to, to report on the consequences of block granting Medicaid.

We’re proud of our first report. We’ve have another one coming up in June. We have a report due in March and June of each year; and our next one will be about managed care. We’ll eventually do something about drug pricing. We’re also going to focus more on CHIP. I hope to schedule a report on graduate medical education, but we’re not there yet. (Tim Henderson and I’m going to be calling on you to give us some help with that.)

I will tell you the one most interesting charge we have in light of this National Conference is how to come up with an “early warning system” to identify problems with access to needed and appropriate care for Medicaid beneficiaries in a state. We will look at enrollees, availability, utilization and access.  I’m just not going to go through the details of this, because it’s too complicated, but we are very much concerned with how the new law impacts the primary care system, and how we would strengthen our capacity to provide primary care.

At breakfast today we identified some of the barriers to doing that (See  22nd National Conference – Breakout Group Questions for Monday, April 18, 2011 Group 5), but I’m supposing by the end of the National Conference on Wednesday I’ll have more of the answers. And thank you for all of your attention and wisdom you’re going to give me; and to inform you on my contributions to  MACPAC.

Thank you.