MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh. You're listening to These Days on KPBS. A year ago, the debate over healthcare reform was all over the news. Some people were talking about government takeovers, and death panels. It's good that the misinformation has subsided but, now that the battle is over and healthcare reform has been signed into law, it seems like no one is talking about it at all.
So the question is, what happens now? When do provisions of the Patient Protection and Affordable Care Act start going into effect? And what will those changes mean to you? I’d like to welcome my guests. Stacy McMorrow is research associate in the Urban Institute's Health Policy Center. Stacy, good morning.
STACY MCMORROW (Research Associate, Urban Institute's Health Policy Center): Good morning. Thanks for having me.
CAVANAUGH: Gregory Knoll is executive director of the Consumer Center for Heath Education and Advocacy, which is an independent program of the Legal Aid Society of San Diego. Good morning, Gregory.
GREGORY KNOLL (Executive Director, Consumer Center for Heath Education and Advocacy): Good morning, Maureen. Thanks for having me.
CAVANAUGH: Well, you know, we’d like to invite our listeners to join the conversation. What aspect of the healthcare reform law are you waiting for? Do you think these changes are coming fast enough? Give us a call with your questions and your comments. Our number here is 1-888-895-5727, that’s 1-888-895-KPBS. Stacy, the Urban Institute has just released a report on the new health reform law. What was the purpose of this paper?
MCMORROW: We released several studies that are intended to look at the effects of the reform law on various populations. So there were a few studies done by some other folks here on the effects on older individuals, on children and young adults, and I did a piece that looked at the sort of overall effect on healthcare outcomes.
CAVANAUGH: I see. And so what did you find? Who will see the greatest benefit from the Patient Protection and Affordable Care Act?
MCMORROW: Well, in terms of outcomes, we tend to believe that the biggest impact is going to come for those 30 million individuals who are expected to gain insurance coverage as a result of the reform.
CAVANAUGH: Exactly, I think that’s probably – just a layman would look at that and say that’s probably going to be the people who will benefit the most. I wonder, when will that group, that group of 30 million, begin to access healthcare thanks to the new law?
MCMORROW: Well, most of the major insurance reforms come in in 2014 so the big Medicaid expansion comes in in that year as does the opening of the health insurance exchanges. And so that will be when those individuals start to gain coverage itself. When they actually start to see health benefits may be a little bit further down the road as they sort of catch up on some of the healthcare and preventive services that they may not have been obtaining.
CAVANAUGH: Stacy, since the Urban Institute felt that it had to do a number of papers about the healthcare reform law, I would imagine that it’s quite complex, is that the truth?
MCMORROW: That is very true.
CAVANAUGH: Is it understandable?
MCMORROW: In some sense, yes. In many cases, there’s a lot that is currently still being fleshed out. So there are things that need to have regulations written and so there’s a general sense of what’s in the law and the intention of what is in the law. But there are many things that the details are still not completely fleshed out.
CAVANAUGH: And who has been tasked with fleshing it out?
MCMORROW: I have to think that most of it will be directed by the Department of Health & Human Services and outside of that, I cannot really say.
CAVANAUGH: That’s really interesting. Greg, let me bring you into the conversation because I know that there are a number of elements of healthcare reform that will go into effect in the next few months. Can you tell us what those changes are?
KNOLL: Sure. In fact, our young adult population and people who are on Medicare or are retired will probably benefit the most, the quickest. Right now, seniors are getting a $250.00 rebate check from the federal government if they are on Medicare Part D and they have reached what they call the coverage gap or the donut hole, that is really like a second deductible that they have to pay where you have to pay full price.
CAVANAUGH: Right.
KNOLL: And that is – that’s been the source of some concern about scams, I should note, and I think it’s very important for people that should realize they have to do nothing to get this money. It’s coming directly to them at their address. And people that go door to door and say that for fifty bucks they’ll get you a $250.00 check, that is a scam and you should call the District Attorney’s office right away. We’ve heard of a number of those happening in San Diego. Also, there will be some funding available in 2010 to encourage employers who provide retiree health insurance to continue to do so and to continue to offer health benefits in 2010. Right now, we are – California is developing its, what is called its high-risk pool. This will help folks with pre-existing conditions who have been uninsured for six months to obtain some temporary insurance coverage. Now that was supposed to start in July for signups, it’ll probably be late August for signups and, hopefully, a purchase of coverage from participating health plans will occur in September. There has been some concern about this because it is going to be expensive, approximately $500.00 a month, plus some co-pays but as a gentleman I just talked to the other day who said, look, I have $5,000 a month worth of medications and I’m cutting them in quarters and…
CAVANAUGH: Right.
KNOLL: …half, $500 a month for – I would rather pay for my premium if I could get my prescription drug coverage. So it’s going to help some people and it may – it still will be beyond the range of others. But it’s…
CAVANAUGH: Greg, let…
KNOLL: Yeah.
CAVANAUGH: Let me stop you there…
KNOLL: Sure, sure.
CAVANAUGH: …because we’re going to be breaking this down a little bit. You’re giving us a lot of information and I want to make sure people have a chance to really understand it. I want to make sure – remind our listeners that we’re taking your calls at 1-888-895-5727. Let me stop you and ask you about the retiree healthcare. What does that provision actually require businesses to do?
KNOLL: Well, there are a number of changes with regard to what health insurers can and cannot do. But with regard to the ability to give rebates to employers who will continue health benefits, that is something that has never been done before and gives a financial incentive to employers to continue benefits. We have no information yet as to how many are going to take advantage of this opportunity.
CAVANAUGH: I see. I see. And what should listeners be doing now, I wonder, to prepare for these reforms that are going to be taking place in the next few months?
KNOLL: Well, I think the best thing that they could do is have at their fingertips a phone number to call, a website to go to. The Health & Human Services of the federal government has just come out with a new website called healthcare.gov. They have a lot of information about what is coming up and how it affects you. I think that also – I’m the vice chair of San Diegans for Healthcare Coverage. We are fielding calls and getting back to people within 24 hours with their questions. That number is 619-231-0333, and though I have hesitated to do it, the best way many times is just to give me a call at my direct private line, and I will get back to you within 24 hours. It is 619-471-2620.
CAVANAUGH: Brave man, Craig (sic). Thank you.
KNOLL: Yeah, really. Anything for PBS.
CAVANAUGH: We have our own number if you’d like to join the conversation. It’s 1-888-895-5727. And Debi is calling us from Carlsbad. Like to take a call right now. Good morning, Debi, and welcome to These Days.
DEBI (Caller, Carlsbad): Good morning. My question was in regard to how this bill was written and I feel that the woman who’s there who had to study parts of it and – Why is it written so complicated that even someone who is very intelligent and who has the time to actually look at it and study it can’t really say what the exact details are?
CAVANAUGH: Stacy, why is it so complicated?
MCMORROW: Well, I think it’s complicated for a number of reasons. Legally, they have to be very careful in terms of what is written in the bill itself because it’s going to be, you know, it’s a legal document and it has to be flexible as well. And I think that’s one of the major reasons that it is a little bit complicated is because in an undertaking that’s this kind of ambitious, there has to be some flexibility built in. And so some of the things that are not completely clear in the details are because we’re, you know, there are things that are going to need to be worked out and that has to be built into the legal language so that we’re able to work them out as time goes on.
CAVANAUGH: Now, for instance, in your report, Stacy, you find some benefits to the healthcare law that are kind of contingent effects rather than actual benefits that people might claim. For instance, tell us how you see healthcare improving because of a new emphasis on preventative care.
MCMORROW: Okay. Yeah, well, we know that preventive care is very important to people’s health and that it’s one of the major issues for uninsured individuals in that they don’t get enough preventive care, that they tend to wait until they’re sick to end up at the doctor’s office or, in the worst case, at the emergency room. So the bill does a few things to try beyond simply expanding coverage to individuals so that they should be able to access preventive care but it also eliminates cost sharing for various populations to get preventive care services. So Medicare, for instance, currently has to pay 20% co-insurance on most of their care. Under the bill, that cost-sharing will be eliminated for preventive care services that are recommended by the U.S. Preventive Services Task Force and that comes into effect in 2011.
CAVANAUGH: And it seems to me, from reading your report, Stacy, that you have – there’s this feeling that you have in the description of this that it’s going to encourage this kind of care all across the board, even for people who perhaps don’t get Medicare benefits. It’s just going to – it seems that it’s going to turn the emphasis of the healthcare system around a little bit.
MCMORROW: Well, that’s the intention. There are a few other elements. Medicaid will also be involved in this type of work where Medicaid will actually – states will get additional federal financing if they also choose to cover preventive care benefits without any cost sharing. And the private plans that will be offered in the health insurance exchanges will also be required to offer those preventive care benefits without any cost sharing to the individual. So it’s sort of an across the board attempt to really place an emphasis on preventive care.
CAVANAUGH: And, just to be clear, what kinds of services are we talking about when we talk about preventive care?
MCMORROW: So there’s a list of services that are recommended by the Preventive Services Task Force. They’re rated at various levels, and those that are rated A or B are those that will be covered without any cost sharing. Those include things like cervical cancer screening for women, colorectal cancer screening, high blood pressure screening, things of that nature.
CAVANAUGH: So, in essence, since there’s no more co-pay, they are – if you are covered under Medicare or Medicaid, free.
MCMORROW: Yes.
CAVANAUGH: Okay. All right. Let’s – We are taking you calls at 1-888-895-5727. Let’s hear from Don calling us from North Park. Good morning, Don. Welcome to These Days.
DON (Caller, North Park): Hello, everybody. Good morning.
CAVANAUGH: Good morning.
DON: Thanks for the opportunity to make a comment. And I also had a question for the panel there. My comment was I’m a military retiree and like I’ve always had a lifetime of like just great, you know, preventive healthcare, well, health management, personal health management. I’ve always taken great care of myself. But recently I experienced an injury and anyway I also experienced some problems with getting adequate medical treatment, and the problem is is that, well, I had encountered a situation where, let’s see, a couple of agencies, the Medical Care Recovery Unit and the VA Regional Counsel indicated that I’d received some treatment that didn’t occur and they didn’t provide any statements or anything like that.
CAVANAUGH: Let me ask you something, Don.
DON: Anyway, the problem is that I was wondering if the new health bill is going to increase like the bureaucracy and allow like, you know, some things like that to occur where…
CAVANAUGH: Let me just get a…
DON: …anyone can give a call to indicate…
CAVANAUGH: Don, are you covered by the VA? Do – Are you covered by the VA?
DON: Well, as a retiree, I was supposed to have an insurance program called TRICARE.
CAVANAUGH: Uh-huh.
DON: And like all during the health reform debate it was amazing to me how much – how many myths and things like that about the adequacy of military medicine is.
CAVANAUGH: Let me find out if this is going to affect TRICARE, Don. Greg, does this new health reform law impact TRICARE services at all?
KNOLL: I don’t believe so.
CAVANAUGH: Okay. All right. And, Stacy?
MCMORROW: I am not clear on that.
CAVANAUGH: Okay, so I’m sorry, Don, but we just don’t have an answer for you. It seems like the Veterans Administration Healthcare System, it seemed me during this debate, was going to stay autonomous of this healthcare reform. Gregory, is that the kind…
KNOLL: I think that’s right except that they are doing a lot to work with other providers in healthcare. There was a recent study in San Diego about sharing EMR medical records between people who were Kaiser and at the VA. You can do that with closed systems and with similar computer systems. And I think, though, that we’re reading more and more about the inability of the Veterans Administration to deal with brain trauma, victims of bombings and stuff from Afghanistan and Iraq because – just because of the sheer number. So it may be that in the future there will be pilot partnerships between the VA and private providers to pick up the slack. I mean, one of the problems here is that the reason it’s so complicated, I mean, let’s be clear, this is one of the most important pieces of social legislation since the Civil Rights era and it necessarily – I mean, if you think 2000 pages of law are a lot, I mean, the regulations themselves that are really where the devil is in the details, those regulations are going to be a lot more than 2000 pages and are going to fill library rooms and are really going to be the meat of how this plays out. And I think what Stacy said is really important. It is supposed to be flexible so that as we go on and we learn lessons we can improve it, but it certainly is a comprehensive approach to do something that we’ve never done in this country but that is being done in every other part of the world.
CAVANAUGH: Now just one question before the break, Greg, and that is do the – for college students, for kids who have just graduated college, there is a benefit that they can take – that it goes into effect right now? Is that a…?
KNOLL: In September.
CAVANAUGH: In September.
KNOLL: Yes.
CAVANAUGH: Okay, and what is that?
KNOLL: Dependent coverage in the state of California ends at 19 or upon college graduation. That’s the state of the law today. The new healthcare reform will allow students, and there’s a lot of statistics about kids who get out of college and for the first six months have no coverage, for the first year have a job that doesn’t provide coverage, those students will be allowed to stay, up to age 26, on their parents’ coverage. There also has been a move to make sure that all kids under 19 must be covered regardless of preexisting conditions. So those are two real benefits to children and young adults.
CAVANAUGH: And both of them start in September?
KNOLL: Yes.
CAVANAUGH: Okay. All right then. We do have to take a short break. When we return, we’ll continue to talk about the healthcare reform law and what benefits go into effect and when, and start – and continue taking your calls at 1-888-895-5727. You’re listening to These Days on KPBS.
CAVANAUGH: I'm Maureen Cavanaugh. You're listening to These Days on KPBS. My guests are Stacy McMorrow, research associate in the Urban Institute's Health Policy Center. And Gregory Knoll, executive director of the Consumer Center for Heath Education and Advocacy, an independent program of the Legal Aid Society of San Diego. We’re talking about the healthcare reform law and when its various aspects will start going into effect. Stacy, I know that you have to leave us soon but I wanted to ask you about a rather interesting part of your policy paper here and that is the questions about the capacity of the healthcare system to expand to adequately treat the growing population of the insured as this healthcare reform benefits go into action. What did you find in your paper?
MCMORROW: So there are a few concerns here. There are provider access issues in our system as it stands today. Medicaid payment rates are lower than rates from Medicare and from private insurers to providers. And so Medicaid beneficiaries oftentimes have trouble finding a doctor who’s willing to accept that insurance. There’s also shortages in rural areas and growing evidence of a primary care shortage in the U.S. and the extension of coverage to over 30 million individuals, many of whom will be Medicaid beneficiaries generates some concern that whether or not the system will be able to handle that increase.
CAVANAUGH: Does the law address this problem at all?
MCMORROW: It does. It does. There are a few things in the law that are hopeful – hopefully, going to alleviate some of these issues. Medicaid rates for primary care services will actually be increased temporarily, for now, to 100% of Medicare rates, so they’ll be equal in terms of what they pay providers for primary care services. And Medicare itself will also be increasing its payment rates to primary care providers. There’s also going to be some additional support through loans and scholarships for physicians to enter primary care or locate in rural areas as well as some incentives for training for nurse practitioners and non-physician providers that could provide primary care to sort of underserved populations.
CAVANAUGH: Well, I want to thank you so much for being with us. I know that you have to leave us. Stacy McMorrow, research associate in the Urban Institute's Health Policy Center, thank you.
MCMORROW: …so much for having me.
CAVANAUGH: And my guest now is Gregory Knoll, executive director of the Consumer Center for Heath Education and Advocacy. And we are taking your calls at 1-888-895-5727. Let’s take a phone call now. Katherine is calling us from Temecula. Good morning, Katherine. Welcome to These Days.
KATHERINE (Caller, Temecula): Good morning. I have a statement and a question.
CAVANAUGH: Sure.
KATHERINE: I’m so glad we’re having healthcare reform. Over the years, my husband and I have had two coverages and the insurance companies would fight each other, who’s going to pay and no one would ever pay. It was worse than any government bureaucracy that ever existed. We – Our healthcare system has gotten worse and worse and worse. I’ve traveled all over the world, I’ve been to other first world countries, and we’re put to shame. But anyway, my point, at 55 I retired from the airlines. I was working two jobs. They promised us healthcare for the rest of our life. Of course, they reneged on that. But I had to go to my other job because – to get a better pension. We were also screwed on our pensions. So I stayed with my other job and six months ago they said if you don’t retire now, who knows if your pension’s going to be there? I’m fifty-nine and a half years old. That job does not have health insurance for retirees so I’m like in a Catch-22 right now. I don’t know what to do. My pension—my husband is now disabled—is not going to be enough to cover the exorbitant healthcare costs in this country. Now I’ve worked two jobs.
CAVANAUGH: Right.
KATHERINE: I have not been lazy, and this is what my country does to me.
CAVANAUGH: Well, let’s find out, Katherine, if there’s anything in the health reform law that’s kicking in soon that’s going to be of help to you. Greg, is there anything?
KNOLL: Well, there’s nothing in the health reform law that deals with your pension but if you’re talking about your health benefits continue, we talked a little bit about that earlier.
CAVANAUGH: Right.
KNOLL: About the incentives to your former employer at some point to continue you on health benefits and get a tax break or to get money paid in from a fund to cover his costs, so that’s – you should ask about that as should most – many retirees. You won’t have to pay for cost of preventive care, as we’ve talked about, in 2010 so your regular checkups, breast and cervical cancer screenings, you should not have to pay for in twenty – after twenty – September of 2010. So, you know, it is an issue of trying to be an advocate for yourself. I tell everybody whether you’re accessing your regular care as it is today or trying to access something from – that’s come about because of healthcare reform and the Affordable Care Act, you still have to be an advocate for yourself. And to go and get knowledge about what things are being implemented and when and then challenge your insurance company and your providers to know as much as you do about it.
CAVANAUGH: And I’m wondering, what are you hearing from San Diegans, Greg, in terms of their immediate healthcare and needs when it comes to healthcare reform?
KNOLL: Well, there’s a number of things. I wanted to go back to something Stacy had said about the healthcare reform’s ability to try to meet the problem of capacity and the ability of having providers to take this large number. In San Diego, we’re anticipating that about 697,000 people are uninsured and with various restrictions on who can benefit from the new healthcare reform, so probably about 520,000 new add-ons. The question is, where are they going to go?
CAVANAUGH: Right.
KNOLL: We have a great system of community clinics in San Diego. We’re very lucky for that. That will be a lot of the medical home for the new folks. But the fact is that going forward in this new environment means doing things like more than two years they’re going to raise the Medicaid rates to Medicare, as Stacy said. But that’s only for two years and it’s only for primary care. That does nothing for any of the specialty care. And if you’re walking around with a MediCal or Medicaid card in San Diego now, there isn’t a single orthopedic surgeon that will help you unless you’re part of a managed care environment, which is why the State of California is looking right now to putting all of the special populations, seniors and persons with disabilities into this new managed care environment on a mandatory basis. So that’s coming down and people need to get ready for that.
CAVANAUGH: Right.
KNOLL: And so those are some aspects of what’s going on but there is something in all of this that can benefit each pocket group. There are disparity studies that are going to be done for Latinos and African-Americans. There are special programs for women that they won’t have to pay for. So there’s – there is a lot in here and people really just have to be able to call somebody and speak to somebody who’s knowledgeable…
CAVANAUGH: And find out, yeah.
KNOLL: …and find out what is available so they could take advantage. Probably the best thing for everybody, insured or not, are the new improvements to health insurance practices, stopping insurance companies from dropping your coverage if you become sick, putting a ban on what’s called those lifetime limits on benefits.
CAVANAUGH: Right, the caps, right.
KNOLL: Right. Banning annual limits on benefits, adding free preventive care under the new private health insurance plans, extending the coverage for young adults, the 19 and under on pre-existing, and everybody else until 26.
CAVANAUGH: And those caps on lifetime insurance benefits, they go away this year, right?
KNOLL: Yes, that’s correct. And, you know, it’s funny. I was talking to somebody I’ve known for years who’s back on the east coast who got – had his own foundation and got ill and got put into a rehab center and they reached their lifetime cap, something they never thought they would.
CAVANAUGH: Right.
KNOLL: They’re now living – They had to sell their home. They’re living in a one bedroom apartment so that the wife can be near his rehab facility and all their money has gone to healthcare, all their retirement, their only possession, their home. It is something that this healthcare reform has got to make sure never happens again.
CAVANAUGH: Let’s take another call. Virginia’s calling us from Del Cerro. Good morning, Virginia. Welcome to These Days.
VIRGINIA (Caller, Del Cerro): Oh, I think my question has been answered regarding MediCal and Medicaid and specifically I was going to ask about the coverage for mental illness. But I think I got my answer. But I just wanted to ask another question…
CAVANAUGH: Sure.
VIRGINIA: …if I could? So this is still an employee-based system and this kind of brings up about kind of providing health insurance that has contributed to runaway inflation and the cost of health insurance premiums and pharmaceutical companies threaten to the competitiveness of the American manufacturing and so it’s become an untenable burden in small business and I want to ask that question as to how this is going to change. And so we treat healthcare as a commodity for sale…
KNOLL: Right.
CAVANAUGH: Right.
VIRGINIA: …rather than a public good.
KNOLL: That’s right.
VIRGINIA: And I guess you’re getting the indication now that I’m sort of a single payer advocate.
KNOLL: Yeah, that’s right.
VIRGINIA: But I’d like for you to answer that for me.
KNOLL: Well, the single payer approach is one that just simply – just for sake of politics could not be entered into the discussion. However, in the new exchanges that are being talked about, those exchanges will be created, they’re insurance exchanges that will be created by every state. Some states may get together and do regional exchanges. California has decided to apply to be its own exchange, statewide exchange. They will provide one-stop shopping so it will be easier to compare plans and prices. There’ll be a lot of transparency around what plans offer the best coverage for the best amount of money. There’ll be – If you are eligible for insurance through an exchange, you will be able to get that insurance beginning in 2014 and then all health plans in the exchanges have to cover a full range of benefits, going to your previous questions. This includes medical, mental health, prescription drugs, rehab services, and you will be able to pick among four different levels of coverage to fit your needs. But the thought is that premium – once you get everybody in the pool, once you get the healthy 19 to 40-year-olds in the pool, we believe that rates should come down as much as 10% for everybody across the board by 2014.
CAVANAUGH: Even people who have private insurance.
KNOLL: That’s exactly right.
CAVANAUGH: Right. Let me ask you, how is California doing in being proactive in getting out the word of – for healthcare reform and also taking on the initiative to make sure that these reforms are in place when they’re supposed to go into effect.
KNOLL: Well, let me answer that two ways, both the statewide and then for San Diego County.
CAVANAUGH: Umm-hmm.
KNOLL: One thing that’s very important to remember is that there is going to be a very real role to play for individuals, advocacy groups, and the counties throughout the state in the actual implementation of healthcare reform. There is – there are things anticipated in this legislation like navigators that will be in every county that will be – to make the trip smooth for people transitioning into healthcare reform benefits. On the state level, there is a lot going on because this current administration will be done in, I guess, November after the election in December (sic)…
CAVANAUGH: Umm-hmm.
KNOLL: …and they are negotiating what’s called—this gets complicated—but an 1115 waiver that will try to speed healthcare, in essence, brings healthcare reform up before 2014 and starts moving people up to 200% instead of 133% FPL and trying – Federal Poverty Level, meaning folks that are…
CAVANAUGH: Right.
KNOLL: …up to 200% above Federal Poverty, will be able to go into this. But the great thing is that they’ll be able to merge what now are populations that cannot get coverage, and that’s the single adults.
CAVANAUGH: Right, so California is trying to improve…
KNOLL: Yes.
CAVANAUGH: …what’s in the Patient Protection and Affordable Care Act to make it better here than it is perhaps in other states.
KNOLL: And make it – yes, and make it statewide in nature, take all these little things they’ve been doing all over the state, putting them into a huge waiver, coupling that with healthcare reform, to do the right thing, which is to maximize federal dollars coming to California to improve the lives of all Californians from a health standpoint. You know the real thing about – There’s plenty of problems to work on, too. There’s a lot of problems around capacity and there’s problems around – But these problems have been going on, Maureen, for 20, 30, 40 years. It is problems that have always been with us. The difference is there has never ever been an incentive to fix it. And it takes passing a law like the Affordable Care Act and making healthcare available for everybody that forces us to say, okay, now what are we going to do…
CAVANAUGH: Gregory…
KNOLL: …about these problems?
CAVANAUGH: …thank you so much. Thank you for making so much of this very complicated issue clear, at least clearer. I know that we’re going to revisit it. Thanks so much.
KNOLL: Thank you, Maureen, for having me.
CAVANAUGH: I’ve been speaking with Gregory Knoll, executive director of the Consumer Center for Health Education and Advocacy, an independent program of the Legal Aid Society of San Diego. If you’d like to comment, please go online, KPBS.org/thesedays. And stay with us for hour two of These Days coming up in just a few minutes right here on KPBS.
