Good afternoon and welcome to CSUMB's community forum on health care. I'm very
glad to have you join us. We're gratified by this healthy turnout for this event.
I'm gonna give make a few remarks to sort of acquaint you with how we're
planning to structure the the afternoon and early evening but before I do that
let me introduce the panelists that are gonna help us frame the conversation.
Starting with Pete Delgado. Pete. Pete's president and CEO of Salinas Valley
Memorial HealthCare System. And next is Gary Gray, CEO of Natividad Medical
Center. And Steve Packer, president and CEO of C.H.O.M.P. and Montage Health.
And Stephanie Sonnenshine, who's deputy CEO of the central
California Alliance for health. I also want to recognize the presence of
Congressman Jimmy Panetta, who's over there.
The congressman is obviously very interested in this issue and he's also
very much interested in a bipartisan approach to problem-solving and so the
spirit of this gathering is very much in tune with his approach and he will
provide us some closing remarks at the end of the event. And we thought we might
be also including Congress former congressman Sam Farr, is Sam Farr here?
Maybe he's still trying to park. Okay, so the purpose of this event is to provide
an opportunity for community dialogue across the political divide.
We had a very positive experience here in our campus shortly after the
presidential election where we brought together the the community to try to
process the the meaning and significance of the results of that election, and I
knew that not everybody was of the same mind about the outcome of the election
and so we conducted the discussion in a way that everybody felt included and
people engaged in respectful conversations, face to face like you are
all sitting now and generally it created I think a good reservoir of goodwill on
the campus, and I thought this is something that we need more of in the
country and the institutions of higher education I think can provide a forum
for these types of gatherings. And so I shared this with some colleagues in
Washington who encouraged me to write a piece about it that's been published
nationally, and I'm urging my fellow presidents across the country to to put
their institutions at the service of their communities
hosting these types of community forums on on difficult issues that we're all
grappling with and create opportunities for people to speak across differences
of perspectives and opinions in a respectful way and see if we can do our
little bit to improve the the culture of the political culture of the country and
improve civility and an empathy. So that's really the the larger overarching
purpose of this series of community meetings and of course today we're
starting it off with a bang with healthcare which is
certainly an issue that is controversial and that has become hot once again with
the the recent executive orders by President Trump that has really put this
issue on the front burner once again. Our panelists are going to their purpose
here they're obviously experts in this field, but their purpose is to provide us
with a brief overview of the topic, give us you know enough information that we
all share to be able to ground the conversations that we're going to have.
But really the action is going to be there in your tables in the
conversations that take place today. We have what we wanted to hear is give you
an opportunity to hear different perspectives from fellow community
members their values their hopes and their fears for the country in this
particular area. So the goal is to develop a deeper understanding of other
views and foster civilian moderation in our political culture. After the
panelists speak we will break into small discussion groups around each of the
tables for about 25 or 30 minutes and we have with us discussion facilitators,
students from our campus that have been trained for this purpose. In the
discussions we encourage you to distinguish as you present your
perspective you share your views between values that you hold, factual statements
that could be proved or disproved by evidence, and policy choices that you would make
based on your values and the facts as you believe them to be. So this is just a
little a little kind of organizing framework for the discussion to
distinguish between values what you hold important and that you hold dear and
those are choices one makes in terms of values, facts that you believe are true
about the healthcare picture, and policy choices that are the policy choices one
would advocate clearly would reflect one's values but we're also taking to
account the facts. And sometimes those issues are entangled and it's worth
disentangling in a measured and thoughtful conversation like we're going
to have. After this we will reconvene and provide an opportunity for groups for
those groups that wish to to do so to report on how their discussion went and
some of the highlights, and also to ask a question to the panelists that may have
emerged from the conversations. In particular if there are questions of
fact that remain unresolved, certainly this is the group that can answer those
questions. So now let me turn to our first panelist that I'm going to call on,
Steve Packer, who will discuss the basic health care picture in the U.S. and how it
compares to the International contest. Thank you, Dr. Ochoa, it's a pleasure
to be here with all of you and I appreciate having the opportunity to
join the panel. It's a modest request Dr. Ochoa asked me in five minutes or less to
describe the U.S. healthcare system and it's and and how it compares in an
international context. So basically I think we all know that health care is a
major component of our economy. Health care spending comprises somewhere
between 17, 17.8 and 18 percent of our of our GDP last year we spent about 3.2
billion dollars on all types of health care; that is on drugs, physicians,
hospitals, post acute care, physical therapy,
home health, across the entire spectrum - over three billion dollars. So I think it
goes without saying that healthcare is a major economic driver and in many if not
most towns and cities across the country, health care organizations are
the major employer or a major employer. So not only is it a consumer of of costs,
it actually healthcare is actually a major employer and and helps to drive
our economy while at the same time millions of healthcare workers work
every day to meet the health care needs of their friends and neighbors and their
communities. And yet we spend more on health care than any other country
developed country in the world. At 17.8%
the next closest country is France which spends 11.6 percent of its GDP on health
care. There are many drivers of the increased cost of health care in the
United States today and I'll touch on some of them, but first and foremost I
think it's important for us to look at the cost of health care relative to all
elements of health and we tend to focus on health care as being just the
delivery of clinical care. But the determinants of health and and what
drives health as defined by by the World Health Organization is much broader than
simply health care that's delivered. In fact, our impact on on the health of a
community, health care delivery has a relatively small impact on the health of
a community relative to other drivers so the w-h-o has broken this down but
other organizations have as well. But about ten percent of the health of a
community or of a population is driven by genetics. What genes are we born with?
What risk factors do we carry with us generation to generation? Forty percent
of the health of a community is is determined by socioeconomic drivers. Is
there food insecurity? Is there housing? Is there
safety? Is there adequate education? Adequate transportation? Is there
overwhelming poverty? It's striking and this has been
replicated over and over and demonstrated that by zip code in major
urban areas, there can be marked differences in mortality and average
average life expectancy. Zip code to zip code can differ just based on on
earnings and socioeconomic status of those zip codes. 30% of health is driven
by behavioral choices that individuals make. Do they exercise? Do they smoke? Do
they have a healthy diet? Do they do they drink alcohol in excess?
10% of health is really determined by the physical or built environment. Again,
adequate housing access to parks, access to walking trails, and 10% of health of a
community's health is driven by access to care and the quality of care that's
delivered. So while we spend more than any other country on the delivery of
health care, most every other or every other developed country spends far more
on those other determinants of health on on socio and economic security on
improving the built environment and on addressing behavioral issues:
alcoholism, tobacco use, exercise, obesity. So we spend about one and a half times
more than any other country on health care whereas as a group all of those
other countries spend about one and a half times more on on those other
determinants of health than we do. Having said that it's important to ask so other
than a disproportionate or under investment on the determinants of health
what are the other things that drive the cost of health care in our country? There
are many, certainly a fragmented payment system where we have so many different
ways for health care to be paid. We have government programs, Medicare covering 55
million Americans, Medicaid covering 74 million Americans.
Private insurer, private employer based insurance covering 155 million
Americans. The VA system covering many million Americans. And then those who
have to go out and purchase insurance individually, or more recently on the
exchange, comprise a small portion - about seven percent of Americans. And then
still many Americans uninsured. A second driver of health care - so fragmentation
is a is certainly a driver of cost in terms of disparate and different payment
systems. A second driver of cost is our long-standing payment for
essentially fee-for-service rather than paying for value. So as long as our
society continues to reward people for doing more people will do more. And only
when we change the payment methodology to to something that actually rewards
providers for keeping people well rather than for doing more well will spending
be moderated. The third is is the United States is the the R&D and certainly the
pharma development lab for the entire world. And all of the costs borne for the
development of many technological advances in general and certainly Pharma
in particular are born in the United States. So we when we sell our
medications that are developed in the states in other
countries, they do not pay for the other costs. They don't pay the same amount
that we do for those drugs. They're unwilling to pay for the development
costs of those drugs. A fourth cause of a driver of cost are unfunded mandates. In
this country we have mandatory staffing ratios, we have seismic requirements as
it relates to our buildings, and any number of other regulatory requirements
that that that don't make a lot of sense. The lack of coordination between
providers across a fragmented system can can lead to waste and redundancy and
testing and can drive costs. And finally we need to at least mention the role of
the consumer or the patient. And we have high consumer expectations
in this country and those high consumer expectations compare and contrast to
what one sees in Canada where you can wait three or four months for an MRI. I
don't know a single patient who's willing to wait three or four months for
an MRI. So consumer and patient demands help to drive and fuel increased
spending. So I think I would close my my five minutes by by encouraging everyone
to wherever possible take the time to research facts and from reputable
sources. I think the Commonwealth Fund, I think the Centers for the Center for
the CDC, the World Health Organization, the Kaiser Family Foundation are all
very credible sources of information. I've spent a lot of time discussing
facts. I think we're going to talk a little bit now more about the values
that underlie some of our decisions as well, and to that I think, Dr. Ochoa, should I
turn it over Stephanie?
- Yes, yes. Our next speaker will be Stephanie Sonnenshine, who will talk about the underlying values that come into play with healthcare policy choices.
Okay. Can everyone hear me okay? I have a little
bit of a cold so that will sit closer - thanks for letting me know that I needed
to get closer - so I'm Stephanie Sonnenshine. I'm the deputy CEO of the local
medical plan here in Monterey County. We also serve in Santa Cruz and Merced
counties and I'm really excited and thrilled to see all of the people in the
audience here tonight that are interested in in discussing something
that's so important to me from a professional perspective. The topic of
values as it relates to healthcare is really an interesting one and one that's
so important because ultimately healthcare is really personal to each of
us. We have a personal health care story about why we're seeking health care or
how our perspectives were informed. And so looking at some of the underlying
values is is important to the dialogue. So when I was researching for the topic
and preparing for today I did a little bit of internet research just about what
kind of publications are out there talking about the underlying values of
our healthcare system and they really mirror those that you
expect to hear when we're talking about our country. So things like Liberty,
things like solidarity, responsibility, medical progress, you see a lot about
integrity stewardship, you see a lot about efficiency, privacy, and quality. So
all of those are things that you would think about when you speak about our
country when you talk about our country and they all relate to the health care
system. I am NOT a policy person. I don't work for a think tank. I'm a health plan
staff person and we are a local health plan that provides services and so I
thought it might be useful for me to talk about values in the context of how
we deliver services to our members because that really provides you a more
practical example about values at work. So from the Alliance's perspective our
mission is to provide accessible high-quality health care at a low cost
to our local residents through innovation. And when we talk about
innovation what we're speaking of there is really looking at local solutions. So
how do we leverage our local talent to drive towards
improvements in the local delivery system? And so when you think about
something like access that really is about whether patients can get in to see
the provider that they need to see at the right time. It doesn't do any good
for people to not be able to access care. And so it's about the right care at the
right time, and from a managed care perspective you're really looking at
preventive services. So how do we keep people well? You want to balance what the
system is providing from the perspective of keeping people healthy as well as
having services available when something goes wrong, which I think all of us in
this room can relate to and have probably experienced. That requires
participation and collaboration, both from patients in terms of making smart
choices, and that the care that they access that would imply that you would
have a choice and so from a value perspective you want to think about what
that means to you in their dialogue. It also means I would say working with
our local providers to ensure that they have choice in terms of how they engage
in the system. So access is multifaceted and it calls upon some of those values
like freedom of choice, responsibility, and choosing care, stewardship of
resources to making sure that that access is available. Another value that
we highly prize is the quality of our
services. So ensuring that our members have access to strong clinical outcomes,
to programs that show that they're effective, and that is something that we
work with our local providers on and with the state so quality of service is
something that's really important. And as Steve alluded to, patient experience in
our health care system is incredibly important and we're really learning more
about how to engage with our members. That's about communication and
having people understand the choices that they have available but it's also
about getting people activated and engaged in their own care and that goes
back to the concept of choice. Finally, innovation. We are a nation that likes
self-determination. In anything that you read about a value-based analysis for
for an issue in our country people really look towards how do we do it
ourselves? How do we come forward with the solution? How can we be creative? And
so at the Alliance we really partner with local providers, local community
partners and organizations to try to figure out what's the right solution in
each community at that time for a given issue and I think that that's something
that is a theme that we will see, hear a lot about as the national healthcare
debate goes on. So those are just a few examples of how a local grassroots
health care organization would look at the concept of values and put those into
play in developing our own policy. You know for us we work in both the local
and the federal sphere, we're subject to federal regulation so we have to figure
out how do we take these broader federal policy constructs and make them
practical and allow ourselves to operate within those through local innovation
through our efforts here to work with our members and providers to put
solutions in place. So those are just a few thoughts that I would throw out for
you as you start to think about your conversations. And I will turn it back
over to president Ochoa. - Thank you. Thank you, Suzanne.
Next we'll turn to Peter Delgado to provide us an overview of the main
features of the Affordable Care Act. - In five minutes by the way.
Welcome. Thank you for joining us today on this very important topic and very
timely. There are so many good points about the Affordable Care Act. Well I'll just
you know kind of go really quickly. For example, the health benefits. It is now
they raise the bar you've got ten essential benefits that all insurance
have to provide, including those very difficult mental, mental health, addiction
chronic disease, etc. And no one is no longer a denied coverage on pre-existing
condition. That's huge. They eliminate the caps or the lifetime
benefits and they also extended coverage for our children up to 26 years. Those
are just some highlights but the top three benefits from my perspective is
now you have a larger pool of insured folks. In California the uninsured came
down from 17 percent to 7.4%. We have much more folks that are that have the
the benefit of the insurance to be able to take care of their families, to do the
preventive health that's necessary. Then you all also have a very strong
incentive to provide better care and that is from moving moving away from
fee-for-service to more of value-based care.
Moving away from very fragmented to bit more organized, moving away from the
episodic to population health. And last but not least is the overall cost is
designed to reduce the overall cost. Now the first year, first couple of years
because preventive health services weren't provided was pretty expensive.
But the idea is to catch your loved ones who are subjected to you know cancer, for
example, you want to catch them on stage one.
Not stage two, three or four. Stage one. There's a 98% chance that we can correct
it, that we can beat cancer. There's a there's a patient I remember, that was
in our ER, an inpatient for 17 times in 12 months. 17 times. We finally met with
that patient in educate the individual about his medical condition, put him into
a population health structure, and we have not seen him in ER yet since. So
those are the kinds of things in population health that this Affordable
Care Act has been incentivizing and to not only improve care but to lower cost
in the long run. Thank you. - Thank you. So really I couldn't tell Pete how you
felt about the Affordable Care Act. So we're gonna turn to Gary Gray, who's
gonna look at the pluses and minuses of the Affordable Care Act as they have
emerged in its implementation by our health care providers and associated
institutions. Hi, good evening, I'm Gary Gray, I'm a family physician and CO at Natividad Medical Center - I'll move the mic closer - I really want to give you a
perspective so I'll give you a - I'm inherently biased. Healthcare is good and
access to healthcare is good so I'm just gonna put that on the table right up
front. And I think what I'd like to do is just take folks back to and those take
you back to 2005. And those that you walk through the halls of the average
Hospital - certainly the average public or safety net hospital in the state of
California or in the United States. And I was reminded of this by one of my
colleagues who's actually in the in the audience - but so take you back to
mid-2000s you've walked through our Hospital and there would be 15 or 20
people who had zero insurance. Zero insurance. When we looked at trying to
qualify these individuals for some type of coverage they can get medications,
doctor's appointments, the supplies they need for the care, it was really nearly
impossible. So what the ACA has done has really changed that. It's
given people access to care. So today if you walk through the
hospital I would argue whether it be in California or somewhere else instead of
having 20 patients in our Hospital that are uninsured it's more like four or
five. So the uninsured rate has been certainly cut in half in some regions,
even more by the ACA, and and I think again it really speaks to the power - I
think Pete and I sound like we agree - I think the power of the ACA has really
been improving access to care and and I think that's one of the major pros when
you think of coverage expansion, certainly in the state of California. You
know Medicaid enrollment, Medical in California, you know went from 8.6 to
over 13 million. It's a pretty huge increase. The uninsured rate in the state
of California went from 17% to about 8.6 percent. So a tremendous decrease,
absolutely tremendous decrease. I think as Mr. Delgado mentioned the care is
different now. It used to be acute care. We would put
out the fires and send folks home. Now we can actually help them address their
issues. When I think it was mentioned the ten essential elements of health plans
that are required under the ACA, one of the biggest gaps that that helped fill
was actually mental health. So previously many of us had access to physical
care but many of us also lacked access to to behavioral health or mental health
care. I think the ACA pushed employers to
provide insurance so folks with more than 50 employees must must offer health
insurance. The middle class earning up to 400% of the poverty level received tax
credits to go out and buy insurance. Medicaid was expanded to those
individuals up to 138 percent of federal poverty level poverty level. And just to
give you an idea where that is it's about 16,000 dollars a year.
I think 138 percent for a single individual is somewhere around 16 to 17
thousand a year. For those of you who are on Medicare or Medicare age you might be
familiar with it with the infamous doughnut hole, something I didn't quite
understand. I really like doughnuts. What the doughnut hole is is that
you'll get reimbursement for prescriptions up to a certain point and
then there's this gap where you have to fill in with your own money and then the
insurance picks up again. Part of the ACA legislation was to make that hole
smaller or shorter and I think by 2025 that actually will be reduced
considerably considering there's not a major repeal and an overhaul of the ACA.
I think what are the cons are one of the challenges? You know I admit it I think
health care is important, I think primary care is really important is when you
think the ACA is created millions and the
estimates that somewhere between 20 and 30 million new visits to primary care
physicians in the U.S. So if you can think how that taxes the system of
health care. So for example the American American the American Association of
medical colleges estimates somewhere between twenty to thirty thousand twenty
to thirty thousand deficit in the number of primary care physicians in the near
future and certainly it speaks to - and by primary care providers I'm being
all-inclusive here - non-physician providers as well. Since implementation
those of us who are in the hospital business, we noticed our ED utilization -
our emergency department visits went way way up. Why is that? Because people didn't
have access to care are now utilizing the emergency department because there's
a primary care shortage and it's hard to get in, so you can kind of see some of
the challenges associated with with with that care. And I think finally to wrap it
up I would argue that most of us are going to pay more for health care next
year no matter what and and I think that's a negative. We haven't we do not
quite have a handle on the cost of health care. Premiums continue to go up,
whether you're buying through the exchange, whether you're you're you're
you buy through commercially insured through your employer. The cost cost are
in fact going up and and the ACA has cost our systems more in the short run,
and the long run - assuming things remain reasonably intact - preventive care will
ultimately achieve some level of cost savings for for our system. But we have
an exceedingly complex system. So we're public payer, we're private payer, we're
public provider or private provider. I'm not certain there's another system
out there that is quite as complex as as our own health care system. So that's it, thank you.
Okay, thank you, thank you panelists for setting up the conversations. So now we're gonna
break up into our small group discussions and we're going to take
about 30 minutes - for this phase of the evening. You have the facilitators and
your tables are gonna get the ball rolling, and we also have provided in in
case you you need this help we or you want to use it we have a few starter
questions that we have put on the table for you to use to get the
conversation going. But if you want to start talking about something else feel
free to do so as well. We'll see you in 30 minutes.
All right, we're gonna wind down the conversation now and move to the
reporting phase. Everybody's been doing great work. I can see all those pads
they're being filled in. It was - a suggestion was made that we should
gather up all of this all these write-ups on the butcher paper and do a
summary report that we could share with our panelists and with the community at
large, we can post it on the web, to get a sense of of the room about some of these
issues. So we'll we'll work on that. I think that's a good good source of
information, a way of sharing with the community what we've discussed today. So
at this point I'm going to ask in no particular order for the for tables to
report back - those who wish to report back to the group or share some of the
thoughts that they've had - the conclusions, perspectives, questions, and
we do have mics around the room so if if you call your attention to me I will
direct them to you and give you a chance to share with the room. So...
Okay we've got one right there, mic over there.
Alright. - Okay, we had a question what is the role of the insurance companies in
setting fees for services, some of the keys topics that were discussed were
role of access to health care and how does that impact improving
SES. Fee for value movement was key, why isn't preventive care more
prioritized? There was discussion and conflict and policy driven by fee for
services versus preventive services, questions regarding health care rates
were set, policy prices versus coverage amount or amount of coverage. There were
some comments about people going abroad to countries that provide universal
health care. There was a lot of discussion about how fragmented the
system is in that it's very difficult to use. There was a focus on a need for more
preventative health care for mental health. There was a discussion on system
values economics more than patient health. There was some also discussion
government policy driven by politics thus can't expect to value citizens
health. The ACA forced the country to make some decisions about health care was
seen as a positive and the strain of having private providers ie profit
driven versus public needs for health. There was a discussion about kind of a
trade-off for universal care resulting in longer waits and reduced coverage
versus private care, fewer were covered but better better health care, better
assets. And then there was a discussion about looking at things from a system
system systemic from a society making decisions from a systemic place. The
discussion was you know if we have a shortage of doctors and the education
institutions should make a priority to provide more doctors and just making
decisions based from kind of a societal systemic point of view.
And then there was finally discussion about a lack in public health education
leading to more unhealthy lifestyles. - Okay thank you that was pretty thorough.
So I'm gonna ask the panelists to to try to jot down the salient questions that
you see emerging from these comments and then we'll address them at the end. And
and for the next person I call on let's try and focus on the most salient points
and summarize in one minute or so what your discussions were like. Okay, who's
next? All right, we'll go yeah okay go. - Okay so our first point and I will say
them in Spanish and then in English so we said ampliado especially that is
especially stossel cancer the twala's familias a poder para por toda la
familia normal individual item a poder para el costo access. So basically
what we had talked about is expand on specialist care better specialists care
and also family members can have accessible care not just the individual.
And also affordable care based on income. So those are the three main points that
we talked about on our table. - Any questions for the panel? - No. - Okay, thank you. Alright, next. - Okay, yeah, so I'm
just gonna mention just a few things from this group. One is this group or
some of the members of this group thought there's too much emphasis on
high tech solutions that even well-educated families can't figure out
the system or the bills. Let's see, just a general comment that the more inequality
in society the lower health health status for everyone. The general thought
that the outcome for catastrophic health care should not be based on our
socio-economic class which leads to the the question of whether or not our
capitalist system is incompatible with the human rights kind of kind of way of
looking at it. Most of the people at this at this table said it was not
incompatible, that other capitalist countries are figuring out how to do it,
although one of our one of our members of our table mentioned that instead of
looking at it as capitalism versus human rights it might be better described as a
human responsibility that everyone must support the system of care. And and we
said don't scrap it, mend it, except for one person. - Okay. - Okay, at our table there
was pretty much agreement that we should be discussing the single-payer option
that hasn't even been mentioned tonight. Historically has been approached but
avoided. That good primary preventing care will actually save money for
everybody and improve health. We need to talk efficiency and one of the issues
about rationing which sometimes comes up with values like the concern about
rationing we currently actually ration through affordability by class. So it's
already done. - Okay - And under insurance should also be discussed, it's a big
problem. Under insurance: people who have an insurance plan but it's not adequate.
- Okay so I was a preschool teacher, we got this. First of all we have a question for the panel. We wanted to know if Medicare is more or less efficient in cost than -----
Okay, good. Well well we're taking the questions we'll respond at the end, yeah.
Okay. - We covered a lot of things that were already covered by other groups so I will just go into what was important for us.
We had an interesting discussion on whether or not healthcare is a basic human right. ----------
And we had a discussion about the mechanics of the ACA, and some other things that the panelists have already mentioned. -------------
Thank you. And there was general agreement that as a system it can be
improved but possibly not ditched all together. - Okay, thanks.
So our group talked a little bit about the differences in care for public
versus private health care and whether or not folks who are on Medical for
example receive the same quality health care as folks who have private insurance.
And so we talked a little bit about how to mitigate for some of the costs, our
group talked about rising premiums being one of the challenging things about the
ACA and we came up with something about the pharmaceutical intellectual property
being a solution to that. So having open markets could improve
drug costs. That was us. - Thank you. - So yeah, a mend it was what we said. - Hello, so
we had the same pretty much robust discussion and I looked covering a lot
of the same topics. One question that we developed was how will the executive
order impact the ACA? And so we don't know if that would be able to be
answered by the panel or maybe by congressman Panetta. And that's our
question. - Our group talked about South employment issues and enrollees. We
talked about the overall enrollment issues and the difficulty navigating the
medical system. We also talked about what they some people term is this concierge
medical service so it's sort of a self-paced service
and creating some problems. We talked about doctors, what they get paid and how
they're paid. And we talked about the current administration and the sabotage
that's going on. And so we believe that we should mend it and not end it and we
should end the administration. - That's a little far afield from the topic but
thank you. - Hi, I'll try to be quick about this. We
all felt that it's a basic right - health insurance coverage or health care. It's
fixable, the ACA is fixable. There was an agreement that eyes, teeth, brain, all of
its part of our body so all of it should be covered, meaning mental health, eye
care, dental care, that kind of thing. There should be preventive care
incentives for doctors to make sure their patients stay healthy rather than
caring for them once they're really really sick. Care and information prior
to a disease so that we're a well-educated healthy community and
country. Pre-existing conditions should obviously be included. We talked about
the single-payer plan. And Congress needs to have the exact same insurance
coverage that the rest of us have - no more special privileges.
So our group over here over here guys so
our group over here talked about ACA enhancements like education and bringing
like awareness to people who for like health care. And then we also talked
about access to like food, the healthy choices in food and how like not a lot
of there's such a like divided line between like we're all the healthy food
side and we're all the non healthy foods that if you get what I mean.
And then to improve like improve health behaviors, like if like they're gonna
smoke or they're gonna drink. And then prevent navigate patient navigating
enhancements. And we also addressed about the high premiums, how people have to
encounter. And then the limited access, like undocumented people and the
homeless. And then changes in plans so the cost goes up but the coverage
goes lower. And how like if like you're if you're on a fixed income that that your
income doesn't increase even if their cost goes higher. So that's where the is
why they're be making a bigger gap. - So thank you, yeah. We have just a few
more minutes for a few more and then we will turn to the panel. - Okay I'll go very
quickly. Cost of litigation, fear, and stress due to no insurance. Concerns and
holes in coverage. Access to care is important.
ACA addresses health care but not determinants of care and we all came to
a conclusion that we didn't know enough to know whether it's repairable or
fixable.
So our table talked about a lot of the things that you've already discussed but
one of the things that was kind of unique is somebody brought up cultural
expectations and actually changing and educating society so that we don't have
an I want it now kind of attitude. Not necessarily for people who need it but
people who just want it and don't want to wait so we can be put on those lists
those wait lists. And also the I want attitude the coming in to a doctor's
office and thinking something's wrong with me give me something to fix it when
the doctor might not have something to immediately address it. - Okay we just had
a couple of questions that keep it short and sweet
Why are health care professionals not a part of the discussion and why is it in
the hands of politicians? Secondly, should there be a limit of how much profit
private insurance companies can make? - All right good evening everyone. So we are
going to really just echo a lot of what was said. One of the things that is most
striking is as we're talking about the uncertainty of our plans and what's
gonna happen next in the future everybody's worried about not only
themselves but it's clear that they're caring about everyone else and I think
that's a really important component that we think about as we go through this
battle for the ACA. One of the things that we talked about was the importance
of paying attention to some of our vulnerable populations such as the
elderly. Right now we've seen quite a few different attacks is kind of polarizing
but we'll say some challenges towards funding for our Medicaid and our
Medicare so these are things that are incredibly important. And it's really
important to think of who is getting treatment, who is getting insured and in
our community we've gotten over 85,000 individuals who have gotten insurance
that haven't had it in the past before, so it's really important that we keep
thinking about the importance of getting individuals the treatment that they need
and remember also the importance of mental health. - Okay, two more. - Okay
our group really talked about just comparison between our system and other
systems such as in Europe, Canada, and Norway. They also made mention about
healthcare on not being a for-profit type business. Question whether or not
CEOs are making too much money and whether the benefits are further if it's
for the benefit of the bigger the bigger whole or for just more personal benefits.
We also discussed preventative care whether that should be a bigger focus,
especially for medical programs during their training if somebody mentioned
there was only one or two courses during medical school whether that should be a
bigger focus. And really one of the questions that we had for the panel is
really just wanting their thoughts in regards to whether healthcare costs
should be based on income, either individual or family. - Okay, hi, so we also
touched on somebody else if you guys can touch on a single-payer system see what
your opinions on are that on that? Also how do we get to facts and not focus on
fake news? That has not been touched on yet, so what can we do and what can
everybody do to get real facts for our community? - Thank you and we're gonna - Do we have
time for one more? - One more? - Just two more tables here we kind of
echoed what everybody else was saying. One thing that came up that not a lot of
other people mentioned was the possibility of having federally funded
programs for students to go to school to be care providers and then have them pay
back by providing service and communities that might not have as much
access to health care. And then we had a question for
congressman Panetta - is does Congress have the power or the will to stop the
president from taking this executive order forward against the Affordable
Care Act? - Okay, so now we're going to turn to our panel and they've been taking
notes and yes so I'm sure some salient questions have emerged from this
feedback we've gotten and I'll let you address it. Which one wants to start?
There were so many disparate I think themes that were running through the
comments it's hard to know exactly where to start but I'll I'll just see if I can
hit four or five very very quick ones. The question of loan repayment for
individuals who go to school to get into one of the Health Sciences - today the
federal government has a plan in place that if you incur student loans for and
move into a healthcare system and work in a non for-profit health care system
after I think it's either six or seven years the remainder of your loan is
forgiven after six or seven years of payment. Yes, serving in an
underserved non-for-profit environment. I think the question about why
preventive care historically has not been paid for really relates to the
private insurance market in in in in markets where there are several payers.
Most insurance companies know they'll have someone on their plan for one or
two or three years and then they'll switch from UnitedHealthcare to aDNA to
Blue Cross to Blue Shield and historically the cynics have said that a
United doesn't want to pay for a preventive health care health care
because they're not going to reap the benefits of that preventive health care
which is is going to take years to to bear fruit, so it's been it really takes
a kind of a longer view and a more global view of the prevention and
unfortunately, you know, for-profit publicly traded
insurance companies take a quarterly view, a kind of a wall street view from
their expenses. The question about comparing us to different systems, in
fact we do have analogous systems to some of the European systems you talked
about. The VA system here is a federally funded system that has offers care
within a closed an employed group of providers - that's exactly the same as the
UK and the NHS. Medicare, which is a federally funded system which then pays
private providers to provide that service, is exactly is quite analogous to
what Canada has. So we have many countries represented in different in
different systems here. The question is to whether health care professionals why
they're not part of the debate that's taking place and that has been unfolding
in DC. I think if you go back to either the Washington Post or The Wall Street
Journal you and-and-and-and or the or the New York Times scratched The Wall
Street Journal sorry the New York Times or The Washington Post you will see that
the American Medical Association, the American Hospital Association, most
prominent nursing organizations, Public Health Organizations all came out very
very strongly in support of the ACA and against what were quite threatening
repeal and replace attempts over the last few months. Quite shocking that we
were essentially one vote away from potentially unwinding the entire thing.
The question as to the impact of the executive order and and sort of the
interpretation of it there were really two different actions by the president
in the last 10 days. One was an executive order that would
permit like individuals in a group to form a group - so a group of dentists,
group of accountants, a group of small self-insured people who are in the same
general trade or profession could be access insurance as a group. Which might
sound like a good thing, I know lots of small private practice Docs who have a
hard time buying insurance, or small accountants, or
small small businesses - name the business - the net impact of that is is again it
takes a relatively healthy population out of the exchanges and drives up it
creates increased adverse selection in what remains in the exchange and will
drive up costs for those in the exchange. Same is true for the the executive order
on short term health insurance. The not in the executive order but potentially
much more damaging is the the the the interest in getting rid of the
cost-sharing subsidies. These are subsidies that allow hard-working
individuals to be able to access insurance through the exchanges, through
essentially cost-sharing, the federal government helps insurance companies
offset the cost of co-pays co-insurance deductibles. And that's the only way
insurance companies are going to sell that insurance or they're it's going to
drive up the cost of the premium. If you know one month the feds are paying for
the cost-sharing reductions or subsidies that are covered and are called out in
the ACA and the next month they can't count on the federal government to
uphold their obligation to do so. So I think those those activities, those
actions are potentially quite detrimental to the ACA and the way - the
analogy I use is you build a vehicle and the vehicle may not work perfectly but
there are many moving parts of the vehicle that you need and if you take
out the carburetor you take out the steering wheel and you start to slowly
and mindfully pick apart the different moving parts of that vehicle at some
point it stops working. Thank you
Well Steve, you answered all the questions already so there's nothing left.
There is a there was a couple of questions regarding the having family
care, having more specialists in in communities, and and having gravitating
towards and not not just individual but the whole family, I think there was a
question back there. I think that's a great idea. I I remember when I was in
Victoria, Texas and one doctor took care of me and my mom and everybody knew the
whole family. If we can get to that kind of a family oriented team approach we
would we would probably benefit significantly in the primary care access
area. I had the fortunate experience to work for for profits and nonprofits and
we are very fortunate here in Monterey County, we have a nonprofit health plan,
we have three nonprofit public public and nonprofit organizations in this in
this county, and what that means is like for example we've went after diabetes
with a vengeance. All three of us. You will not see, or you will see very few,
for-profit hospitals going out of the four walls of the hospital
to try to get a handle on diabetes. So we believe what we're very fortunate in
this community by having four nonprofit public hospitals and a nonprofit health
plan in this community. Thank you.
Susan, can we hear from you Susan? - Stephanie. so I would just add on on to the points that
were raised. One was about the quality of the services available to medical
recipients and in the state of California. The vast majority of medical
recipients are enrolled in a medical managed care plan in our County. In
Monterey County we're under a County organized health system so we're the
sole health plan in Monterey County for Medicare beneficiaries and we have won
quality Awards across the state of California. Most recently we won the
highest quality award for plans our size in the state of California for the
services that our providers provide to our members. So quality is an area that
we pay a tremendous amount of attention to. And has been referenced, we're a
non-profit health plan, so our focus, as I mentioned before, ensuring that our
members have access to those quality services and that we're partnering with
our local providers to ensure innovation. And so there was a couple of other
concepts raised in terms of you know why isn't there more navigation for patients?
How do we ensure that if the primary care provider isn't available that
there's other resources available? And so I'm sitting on a panel with hospitals
that have partnered with our health plan to implement an ED navigators in
our hospitals, and so in 2018 our health plan will partner with the hospitals to
have navigators available in the emergency department to help our members
access the system. So it's not just about the medical care but are there other
services that they would need? And that's a local innovation that we've been able
to identify as a need here and then work with local partners to develop. And again
not focused on profit but what does the member need? And so sometimes these local
solutions are really an important step towards how do we make the health care
delivery system better? How do we ensure quality and be responsive to what people
are requesting? So I wanted to point that out about the medical system and in our
provider network to generally here. And then the other thing is just a note on
single-payer because I think this is a debate we're hearing a ton about. We know
other countries have these systems. There's many different models and I
would say you know in a very small way the county organized health system which
is a medical managed care model is a small model of that single payer system.
We are the one contractor in this county
that holds a contract with the state of
California to provide services and we do that in a really cost-effective way. And
we do that by ensuring utilization to appropriate services with a really big
focus on prevention. The savings that we're able to earn doesn't go into
anybody's pocket. We reinvest that into the community. So in the past two years
we've been operating a grant program where we are supporting physician
recruitment or supporting capacity building, clinic building, in each of our
three service areas and that's across the spectrum of the healthcare delivery
system. It's just not in medical care but we're also doing that in behavioral
health substance use and supportive housing. So when you focus on these local
solutions and you have good partnerships with good providers you can create
change in the community, and so I think that there are options out there. I might
be the one optimist in the group we were joking about that in the back before but
I think that there are opportunities here and so I just wanted to offer that.
A couple of comments - I think one specific to Medicaid and quality of care.
Keep in mind that and I agree with with Stephanie. Keep in mind that the number
one determinant of health in the US has nothing to do with health care, right? I
think as Dr. Packer mentioned the number one determinant of health has to do with
your with your socioeconomic status. And so again health is a very complex
problem. It's a purpose there's health care, but then there's housing, there's
all the other things that people require to to be successful. I think the, again
staying on that same theme, if you look at traditional measures of a health
system and health outcomes and try to measure success - so infant mortality
rates - those types of things, it doesn't really matter where your insurance is
coming from. the U.S. does historically poor compared to other industrialized
nations. So you know the public system is successful, the public system is
challenged by the of social determinants of health. The
private system is successful. However, I would argue that its focus largely
traditionally has been on on non primary care, right? It's been really been focused
on on on high-tech and specialty care and and I think the one characteristic
that without a doubt, with maybe the exception of Japan - or I think they have
actually have a fairly low and a number of primary care providers - but without a
doubt if you look at Canada and the UK and systems that really do better than
us, the one thing this uniform is they have a really broad ground foundation
they have a broad foundation of primary care providers. And and again I think
that's really the key to to providing effective care, regardless of who the
pair is, regardless who the pair is. We all know people who have had two MRIs
and three PET scans within the last year. I'm pretty certain that and that that
that there's probably limited data that suggests that actually makes people live
longer. Doesn't mean it's not important and somebody didn't want it and somebody
didn't get it done but it's a really hard conversation when you start talking
about curtailing your choice and driving down cost.
Well we're reaching the end of this this event and I want to thank all of you for
participating and for this great turnout and generating all of these ideas at
which we're going to compile and share with the community, and also to our
panelists. Our panelists have done a tremendous job,
all four of you, thank you very much.
so I can't help but draw some connections here before I turn over the
mic to congressman Panetta. You mentioned that socioeconomic status is one of the
greatest determinants of health levels, of health and community, and another
variable that is key in improving that socioeconomic status is education. And so
that's why we had Ray Bullock, the head of the health services for the county,
said that the single best health public health program they could think of was
education. And so I'm mentioning that because we will tackle that issue in our
third community forum that will take place in South County. We will deal with
the issue of education and before that the next one will be on immigration. So
we're not saying we're not shying away from the hot topics. But thank you once
again for really a tremendous contribution and let me turn it over now
to congressman Panetta for closing remarks. - Thank you Dr. Ochoa, I appreciate
that. And obviously thanks to our panelists and thanks to all of you for
being here to participate in this dialogue, something that is nice to see
here in our community because sometimes in Washington DC you don't see it too
often, especially when it comes to this issue of the ACA. So it's very important
that we are here to talk about this and it's very important for me as your
representative to hear this and hear your concerns, so thank you very much.
There obviously we've been dealing with the ACA - the Affordable Care Act in
Washington DC. We're just kind of let me set it up what its goal what else is
going on in Washington DC, I'm gonna give you a sense. By December we have to have
a budget. We have to raise the debt ceiling. We have to reauthorize C.H.I.P. -
Children's Health Insurance Program. We have to - exactly, it should be done -
we have to deal with the dreamers. We must deal with the dreamers. Exactly.
We now have to deal with the Iran decertification. And then we want they
want to deal with tax reform. This is governing by flurry and not governing by
focus. And I believe Congress needs focus. And I believe that has been an issue as
to why the ACA is where it is in Congress. But I have to tell you though,
in my limited time there in Washington DC, what I have seen is it's not just
this flurry of activity that back there. It's this partisanship when it comes to
certain issues, especially the ACA. Now look I am a firm believer in the ACA.
20 million people across this nation, 5 million people in California, the
uninsurance rate has dropped from 17% to 9% in California. Here on the Central
Coast, because of the ACA, the uninsurance rate has dropped from 21% to 9%, created
6,500 jobs. It must be repaired. It cannot be repealed because what we're seeing
and what I heard throughout the campaign and what I hear today is yes it can be very
expensive. I'll never forget talking to an emergency room doctor who said to me,
he said, "Jimmy you know what I love the ACA. Let me tell you why. Because all
people are coming to see me in the emergency room. They're not going to see
the regular care doctors." I'll never forget that. And that's why we need to
repair it. Because it's done so much good but there are areas where we can fix it.
But in the meantime we have to deal with this efforts by the majority party in
Washington DC to repeal it. Very partisan. I'll never forget talking to a
representative named Joe Barton, guy who served with my father,
that's how long he's been around. And he was telling me about the process of how
the ACA was introduced to him. He was the ranking member on Energy and Commerce
Committee and the chairman at the time - Democratic Chairman Henry Waxman -reached
out to him and said, "I want to talk to you before we drop our bill on the ACA."
And Barton said, "you bet." They set up one meeting - it got canceled by Waxman. They
set up another meeting - it got canceled by Waxman. They set up a third meeting
and right before that third meeting the Democrats dropped the bill. The way Joe
Barton, Republican from Texas, was telling me that story you could feel the
bitterness coming out of him and that is why you're having this AHCA. We had the
AHCA be pushed through in Congress, that for that took two times before it then got
to the Senate, and then came the better Care Reconciliation Act which then
fortunately, and I mean this, I thank a Republican Senator, John McCain, gave it
the thumbs down. And what I would ask all of you to do is read the speech he gave
before he gave that thumbs down because it was in that speech where he talked
about such quotes like, "basically our deliberations are not here in our Senate
at this point are not overburdened by greatness.
Due to the extreme partisanship on both sides it appears that we are conspiring
in our decline. we need to get back to regular order, having hearings, bipartisan
hearings. We need to get back to trusting one another
and it's okay to do something less satisfying than winning. And that three
yards and a cloud of dust is just fine as long as we are moving the ball
forward." Very good poignant marks from a very very
important speech. But unfortunately what happens? A month later we get the Graham
Cassidy bill, something that would completely destroy the ACA. But once
again, fortunately there were people like you who spoke to senators across this
country and it was rejected. What do we have now? We have a fulfillment of a
campaign promise by President Trump. And he has taken upon himself, as you heard
Dr. Packer say, to pick away at the ACA, and doing it by one stop stopping the
payments of the cost-sharing reduction subsidies. This is something worth three
and five people on the ACA rely on these CSRSes. They're available to people who
earn twelve thousand to thirty thousand a year,
so clearly stopping that would hurt the most vulnerable - the people who need
health care the most, the lower-income and middle class. The second thing he did
is create these alternative health insurance system. This is the executive
order he sent down that would extend these short-term health care policies,
and two it would expand these association health care plans that you heard Dr. Packer
talk about. Now it sounds good. These sound good, especially if you're
part of these associations associations. The problem is is that they're not
comprehensive and they're a lot cheaper. So what's gonna happen? you're gonna get
younger, healthier people to go to those plans, pay less into these insurance
companies. Insurance companies are going to then have to care for predominantly
sicker, older, more expensive patients. Insurance companies are then going to
raise the rates. In fact the CBO - Congressional Budget Office - nonpartisan
CBO said that because of these actions that the president took, premiums will be
raised by 20 % in 2018. Premiums will be raised by 25 % by
2020. The government's going to end up paying for the CRSes
and then what's gonna happen? Then they're gonna have to provide tax credits, that's
gonna go right to our deficit. A hundred and ninety four billion is gonna be
added to our deficit because of these two actions if they're carried out. Like
I said, this is something where it comes down to, you know, you break it you own it.
The Pottery Barn theory. And let me tell you we talked about how beneficial it is
here in covered here in California. And this little memo that came out today by
Covered California, it basically says consumers who are eligible for
cost-sharing reductions they will also continue to receive them because of what
we've done here in this blue state. And I'm sorry to be partisan about it, but as
you've seen a lot of these steps are because it's a very partisan
issue. The thing is if you read the New York Times today you're gonna see a
front page article - it'll probably be in tomorrow's paper actually - that talked
about how the ACA has benefited this small town called Mountain Home town the
Mountain Home in Arkansas in Baxter County where it's created a number of
jobs and being and provided great health care for a number of people who normally
wouldn't have it. Once again, you break it you own it. And that's
what's gonna happen. But in the meantime in the meantime I
can tell you and to answer your question yes Congress does have the power to stop
this. It's that second part of that question that you asked - does it have the
will? It has to have the will and I can tell you that there are discussions on
both sides of the aisle that are showing the backbone of Congress, are
showing that Congress is doing what it's supposed to do, are showing living up to
what John McCain said. Coming to the table and talking about the issues. In
the Senate you have patty Murray, Democrat from Washington, Lamar Alexander
from tenant Republican from Tennessee. Having hearings in the health education
labor and pension committee where they're actually talking about how they
can shore up the individual market, how they can make permanent the cost savings
reduction subsidies, and how they can make states more give them a little more
flexibility in implementing the ACA. And I can tell you in the House of
Representatives we have been talking about it. Now I'll be frank, in the
Democratic Party, the Democratic Party just kind of sat back. Democratic leadership
sat back and let the Republicans kind of go down with the ACA. a wise strategy but
as a new kind of aggressive member I wanted to do something else
because I got questions from many of you, when are the Democrats going to put up
their own plan to repair the individual market? When's that gonna happen? And I
didn't hear anything from leadership. So I joined this group called the Problem
Solvers - a purely bipartisan caucus. Twenty-three Democrats, twenty-three
Republicans. And we actually are came to the table and put forward five
principles to just shore up the individual market because we knew
that that's what was needed at the time. And those principles consist of making
the cost-sharing reduction subsidies permanent and putting under
congressional purview. Having reinsurance for insurance companies. Talking about
the employer mandate and maybe upping the number. Getting rid of the medical
device tax, and once again making it making incentives for states to be more
innovative in their implementation of the ACA. We've had discussions with
Murray and Alexander and they're using our principles in their hearings. That
wasn't legislation but I can tell you it was something where one of the person
that I was on the the Working Committee with, he was a congress member. Been there
twelve years, and he turned to me and he said, "Jimmy in my 12 years we've never
done something like this. I've never done something something like this." But it's
showing basically that there is a will in Congress that that is listening to
you, that understands that we have to shore up the individual market and we're
actually at the table talking about it. Now yes, don't get me wrong, I believe
that we one day we will get to universal health care, but in the minority we're
not going to get it up to 2018, I can tell you right now. But I can tell you
that that's why we're taking steps to reach across the aisle and make sure
that the individual mandate is shored up. We're talking to each other. That's why
these types of events are so important, because you're talking to each other and
we're hearing what you're saying. And so that's why I stand here, absolutely
humbled to be in front of this crowd that actually took the time out on a
beautiful Monday night at 7:30 p.m. to still be here, a packed room, because you
understand how important the ACA is. Not just to this community, not just to the
Central Coast, but to our country, and I can tell you I hear you loud and clear,
and that's the message I'm going to send back to Washington DC. Thank you.
Thank You, Congressman Panetta for those stimulating remarks and and keep up the good
work in Congress. And now we're going to break and we're going to have some
refreshments for you and we can socialize. Thank you for coming.
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