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Interviews
David Sundwall
Executive Director
State of Utah Department of Health
Interviewer
So I’d like to start with basically looking at what is the role of the state in providing access to care for the medically underserved.
David Sundwall
Well it's my opinion the state has a very important role however we have to acknowledge in this state we have a conservative legislature and there's a range of opinion on how much responsibility the state should assume for health care or health insurance coverage. We already have a major role because we have Medicaid in our state which is a Federal/State partnership and that whole purpose is to provide health care and insurance coverage for the uninsured - economically disadvantaged primarily but also the disabled.
Interviewer
So what do you think we're doing as a state to address the needs at this point? I'm going to go through a couple of different populations but first let’s look at the uninsured.
David Sundwall
Okay well the uninsured, those are the people who aren't poor enough to qualify for Medicaid but can't afford regular insurance or don't have an employer who sponsors it. We do have some creative programs in Utah to address that. Number one is where we've received a lot of attention is what we call the Primary Care Network or PCN. This is what I call 'Medicaid Light' meaning it's not the full range of services but it's intended to provide basic primary care and preventive services for the near poor, those who like I say aren't poor enough for Medicaid but might be up to 200% of the Federal Poverty Level and these people can receive primary care coverage for prescriptions a month and ER coverage. Unfortunately it does not pay for hospitalization or specialty care. We have to seek volunteers among the specialists who will see our patients. But we've cared for almost 50,000 people in that category since that program was created in 2002 so it's something we can be proud of addressing the uninsured with a program that otherwise they would have had nothing.
Interviewer
And is that program affordable? I've talked with some people who even still can't quite afford that.
David Sundwall
Well there are co-payments, they're modest, it could be even five or ten dollars say for an office visit or three dollars for a prescription and I think it just makes sense to have people feel some financial pain or disincentive to getting just medical care. We've learned over the years that if medical care is free there tends to be an over utilization and a lot of it inappropriate so I'm not apologetic about there being a modest co-payment.
Interviewer
Is there a cost to PCN?
David Sundwall
Initially I think there is an enrollment fee. It's not high, it's around 50 dollars and while that is not nothing, we think it shows some personal responsibility or participation in healthcare.
Interviewer
There's been some f criticism of PCN because it is limited, because it is 'Medicaid Light' as you say.
David Sundwall
Absolutely, when I took this position with Governor Huntsman I had lived in Washington DC for 24 years and good friends of mine there were teasing me saying 'Oh you're going out to Utah where they're cutting back on Medicaid' and I said "I don't think so," but they perceive any program that doesn't provide the full range of services as not sufficient. I disagree; I think it's progressive and humane because we're covering people who would otherwise have nothing with some basic healthcare.
Interviewer
What else are we doing in terms in dealing with the uninsured? What other programs are out there?
David Sundwall
Well the Governor has a whole initiative on covering Utah citizens with health insurance. In fact when we discussed my assuming this position if he were successful in being elected, this was several months before Governor Huntsman was elected, he told me that it was a priority for him to work toward covering Utahans with health insurance. That was appealing to me. I thought that was a good thing to do because I see from a public health standpoint, having health insurance coverage is pretty well correlated with one's health. In other words, not having health insurance is not unhealthy and so from a public health standpoint that was a notable goal. Since he has assumed office and I have this position, we have a work group that is working to cover Utahan’s who are uninsured. What we've started with is children and we have succeeded this past legislative year in getting more funding for CHIP - that's the Children’s Health Insurance Program which will add 10 to 12,000 more children to the already 36,000 covered. So I'm very pleased and proud that we're moving in the right direction addressing the uninsured children in our state. The next legislature we hope to be able to get sufficient funding to cover them all of those who would qualify for CHIP, which is again under 200 percent of poverty. Furthermore we are trying to help small businesses. We got money from the legislature this year to design what we call the Utah Health Insurance Exchange, this would be a clearinghouse, a non-government entity in the private sector but which we think would help small businesses obtain affordable insurance or individuals in the event they don't have insurance or aren't employed.
Interviewer
Do you think that small businesses will still be able to afford insurance? Will that make their insurance affordable enough or are we going to have some sort of supplemental coverage for them?
David Sundwall
Well we do have some kind of supplemental, again for the near poor to help them buy private insurance. In the event an individual is working and their employer offers some insurance but they don't make enough money to afford it, we have a new program called UPP - the Utah Premium Partnership, and what that is, we're using public monies to help people who are near poor but not poor enough to qualify for Medicaid to buy private insurance through the private sector through a match with their employer. So that's another creative thing that we've advertised and have funding for and encourage people to take advantage of.
Interviewer
How about small businesses? You've talked about having more affordable insurance packages for them, but Utah is very unique by the fact that we have a large percentage of small businesses and they really are struggling. Do you think that we'll be able to come up with a truly affordable package for them or do we need to supplement them in some way?
David Sundwall
Well we won’t know for sure how successful this health insurance exchange is until we try it. We're taking a page from other states like Massachusetts; there they call it the 'Connector'. The District of Columbia calls it the 'Exchange', there's about a dozen states that have such an entity and from their experience so far it is helping small businesses find an insurance product that they can afford and actually adjust how much they can afford to contribute. But in Utah it's a problem. We estimate of the around 300,000 still uninsured, over 100,000 at least are working in small businesses but don't have health insurance because their employer doesn't offer it. So we can put a real dent in the uninsured if we help small businesses obtain a more affordable insurance product. Another thing I like about this exchange is, if one were to obtain health insurance through this mechanism it would be portable. In other words, they'd take it with them; they don't have to stay stuck in a job they detest because they have to keep their benefits. Once they have the coverage they would carry that with them from job to job.
Interviewer
It just seems to me that the other states put state funding into giving some matching funds, or it seems they're putting a lot more state resources into those programs than maybe what Utah would be willing to do. What do you think about that?
David Sundwall
Well I think Utah's done a good job. I understand that some states are much more generous with their local tax revenues than Utah has been but you have to look at the rate of growth of Utah's expenditures for health care and it has been significant over time and our legislators are understandingly concerned about that so I think it's going to take a real cooperative effort between the Executive Branch (Governor Huntsman) and the Legislature on figuring out what's enough or appropriate for Utah to contribute to the uninsured. Like I said we have Medicaid, we have the CHIP program for children, we have UPP, the Utah Premium Partnership, the PCN...all these things I think are commendable and they're trying to be creative in looking at new ways. But that doesn't mean we've done enough. I think that you'll see us seeking the legislature's support for more and better ways to cover Utah's uninsured.
Interviewer
Where do we stand as a state compared to the Nation? What's our trend?
David Sundwall
Well it kind of depends on how you rank it. We here in the state of Utah are known for accurate record keeping and good data, in fact one article I read is titled 'Utah - Data Nerds' it was meant to be a compliment and in a humorous way point out that we are very focused on information. We calculate our uninsured rate using the methods that we've developed over time at about 12 percent. There are national rankings that put us near 16 percent. My answer to that difference is simply that it doesn't matter, it's too much. Whether it be 12 or 16 percent and furthermore we continue to increase. The last estimate we just did put us at having increased from 11.6 percent to 11.9, so it's modest but it's still going in the wrong direction.
Interviewer
Can you reiterate that information?
David Sundwall
The rate of Utah's uninsured is going up. It's been of concern to us because it clearly is going up annually even since Governor Huntsman took over, so our efforts to date aren't sufficient. Mind you it went up very modestly recently, about 0.3 percent, which we think reflects the better economy in this state. But still it's not going down, it's going up.
Interviewer
I’ve heard some people use the figure that the growth rate of uninsured is a giant problem. That in our state it has been 7 times the national average. Do you disagree with those numbers?
David Sundwall
Yes I disagree entirely, I think its hyperbole. I think that we do have a problem here. We have a growing state in numbers and in diversity and that poses challenges but gosh compared with say Texas with a 22 percent uninsured rate or California has 15 percent. We don't rank as high as surrounding states but that doesn't mean we can relax.
Interviewer
Can you touch upon what a safety net is?
David Sundwall
The safety net is efforts on the part of a number of health care providers to care for those without insurance or who are under-insured, in other words those in need of medical care who maybe couldn't afford it or who have other barriers to access be language or culture or remoteness because they live in a rural areas. So we're a pretty humane society, we don't just say 'well tough luck', we do a number of things to provide basic health care all throughout the state. They are primarily clinics that provide primary and preventative care services, some urgent care services and then facilitate people getting hospital care if necessary. That's we call our Safety Net.
Interviewer
I want to look at where the Safety Net works, but also where people are falling through the gaps in the net. So first of all, do you think the safety net in Utah is unique?
David Sundwall
Well I'm not sure it's unique but the first time I'm aware of since I became the Director of the Department of Health, I've attempted to identify it to get a clear idea of where these clinics are and what these clinics do. So I hired an outstanding doctor from the University to come head that division of Health Systems Improvement, Doctor Marc Babitz. Under his leadership they have identified where these clinics are, the range of services, the kinds of people they're seeing, so we now can illustrate for people where they are. I'm impressed that we have 26 agencies running clinics or health care facilities in 47 locations throughout the state of Utah. So there's a tremendous opportunity for people, if they're aware of it, to get health care even if they can't afford it.
Interviewer
Who is falling through that safety net?
David Sundwall
Well I think that the people who are falling through are people who are unaware of this. Some remote rural areas where there simply isn't a population to sustain a clinic or access so there are people through either distance or through language which is increasingly a problem in Utah with our having 80 plus languages now spoken in Salt Lake County because of this being a magnet for immigrants from other countries. So there are barriers that are cultural, language, distance and poverty will always remain a barrier to access to appropriate care.
Interviewer
We have been talking with people who are single men, single women basically who feel like they can't get on Medicaid and they feel like the system isn't supporting them. Do you think that there are particular groups that just fall through these cracks?
David Sundwall
Yes, Medicaid is traditionally been for women with children or for the elderly, the disabled and the adult single people were not categorically able to participate in Medicaid. That's why I think, in defense of our PCN program, that's a good idea because there's no such discrimination on gender or age or anything and they can participate in that. But I guess I don't see real discrimination in categories, for example when the HIV epidemic became apparent in this country, there was this obvious gap between single young men not being able to qualify for Medicaid just by virtue of category where that gap was filled in part by new funding, through the Federal Government, through the Ryan White program that would provide both HIV care or support with medications and what have you. So as a society I find it fascinating, I've been in health policy now for most of my adult life and we fill in the gaps of this imperfect system by - I kind of think of it as the analogy of the little Dutch boy with his finger in the dyke, we have lot's of leaks but when a leak becomes apparent we try and plug it with either a categorical program from the Federal Government or the State level, so as a country and society we're pretty good at trying to care for these problems when they become apparent.
Interviewer
I’ve heard from people who are frustrated in trying to get care. For example, I was talking to a woman yesterday who had colon cancer, her kids were older, she was unmarried, she tried to get Medicaid help, and she couldn't. She actually works for a doctor, she doesn't make enough to buy insurance on her own-- he doesn't offer insurance. She suspected she had cancer, but didn’t get treatment for close to a year, because she couldn’t find a doctor to help her. Finally, she had her surgery, but now she has 47,000 dollars worth of medical bills. Six years after her surgery, she still hasn’t gone for a colonoscopy to see if her cancer has returned because she can't afford it. What do you say to people like that?
David Sundwall
Well there are those individuals who are probably not fit in a category of currently existing programs which begs for this concept of a universal coverage and that is appealing on many levels because it would be more fair and more just and cover everybody and I think that is the debate that's on the forefront of the national policy agenda. I'm confident that in this next presidential campaign you will again hear 'National Health Reform' as a top agenda item and it's because of cases like this. But I'm a little perplexed by that case you just mentioned in that in Utah we have something called HIP - the Health Insurance Pool, so people without insurance who have a pre-existing health condition that makes them uninsurable like colon cancer would qualify. They could be covered. Now mind you, it's not free, they've still got to come up with the money. If she's making too much to qualify for Medicaid but has some income she could be covered by our Health Insurance Pool.
Interviewer
I think she actually looked into that and it was still too expensive. Switching gears, do you think that too much is being left up to the states at this point? Do you think that the Federal Government has not been responsible?
David Sundwall
Well for the current period of time I think it is up to the states so I'm looking forward to the next level of debate when we have new leadership nationally. But right now states are very dynamic. Someone said 'states are the laboratory of democracy' and that's kind of exciting. We see our governor moving ahead with some creative ideas on covering the uninsured. We see it in neighboring states, so yes, I think it's up to states in the near term and it remains to be seen if the Federal Government is going to assume more responsibility.
Interviewer
Each year as a state we struggle with Dental and Vision and health funding. Where do we stand now and where are we going?
David Sundwall
Well there's been a lot of change in this last legislature. Dental and Vision services are surprisingly optional in Medicaid and a lot of people are wondering why they are optional when if you think of yourself, you'd hardly think that eye care or dental care would be something you'd say, well I don't think that's important I won't bother with that. Especially when you consider is pretty important to being employable and oral health affects our entire health. But they are optional and surprisingly only around 20 states, less than half, of Medicaid programs cover them. Utah used to, so in the lean years they cut back on those services at the state and it caused quite an uproar because people were used to them. Governor Huntsman has always supported them. He proposed them in each of his budgets since I've been here that we would have adult dental and vision services. Last year of course there was a flap because he went back and asked them in a special session for coverage when it wasn't covered in the legislative session and resulted in it being covered primarily from a private donation. This year again they were covered by the legislature. Unfortunately it's one time funding; it's not permanent so we'll have that discussion again next year. The good news is on access to oral health care, however, thanks to some champions in the legislature, specifically Dr. Allen Christensen and Pediatric Dentists from Ogden, the Medicaid reimbursement rate was enhanced significantly and I think you'll find more dentists accepting Medicaid patients and therefore improving access to oral health.
Interviewer
What other challenges do you think we're facing right now as a state in terms of access to care?
David Sundwall
Well there's a lot of challenges that have nothing to do with insurance. For example, we rank pretty low in immunization rates and I can't imagine anything being more important in public health than having your populous adequately immunized according to current guidelines from CDC. We rank about 39th at the last ranking according to the Federal Government and that's way lower than we'd like to be but it's moved up from 49th so we've made some progress recently. But immunization rates are a challenge and we're focusing on that, especially for children and preschoolers. We need to get that rate up. The second thing I think we need to be concerned about and are trying to do something about is the obesity pandemic. I don't know if you'd call it an epidemic or pandemic but Utah ranks in the lower half of the nation surprisingly on the rate of obesity. But we're growing fatter quicker than other states and this a real concern because of the costs of the health related consequences of obesity whether it be diabetes or hypertension or degenerative joint disease.
Interviewer
Do you think that there's a personal responsibility role, in terms of access, that perhaps people aren't picking up?
David Sundwall
Yes, I think there is. In fact there are many out of our uninsured, in fact the largest segment of our uninsured are young men between 18 and 35 - that's the largest if you do the demographics, that's the category - we think that part of that is choice. Even people that can afford it are choosing not to have insurance; they'd rather use their excess funds for other things. So that's why we're considering, not recommending yet, but we're considering having a requirement that people in our state have health insurance. Massachusetts has done this, California is considering it and it is a matter not of heavy-handed government to me but more like common sense regulation. If we require a seatbelt to be worn or we require people pay child support, why wouldn't we require you to have health insurance. Because when you don't and if you get sick or have an injury, the costs of that are really picked up by society through taxes or uncompensated care in hospitals. So yes, I think personal responsibility is really important and something that we might need to have an open discussion about - do we require such?
Interviewer
On the other hand what's the State's role if we do something like that? You can't just say go out and buy this.
David Sundwall
There will always be a states role. I need to be clear that as we work towards more health insurance coverage, I think the safety net we talked about will always be necessary because there are clinics who serve the indigent populations or the migrant populations or the culturally different populations who are much better served in such. So I see the public programs as a complimentary parallel system of care not competing with the private sector. In fact I don't know many doctors who are concerned anymore about our public clinics taking business away from them. They're happy to have them there. So there will always be a public role which I think is complimentary to our predominantly private health care system.
Interviewer
I want to get back to maybe painting a picture so people understand who are the uninsured? Who are we talking about?
David Sundwall
Well we've done a breakdown of who they are and they're surprisingly primarily young. We have an estimate of about 280,000 in total but of those, a good percentage are on public programs so we consider them part of the uninsured that have been addressed. But if you do a snapshot, it would be a young white male with a high school education who is working and surprisingly it's not a minority who's uneducated and disadvantaged economically (while they're part of the mix) the predominate number would be that young male. That's why we're considering talking with our Board of Regents in the state and seeing if we can't have as a condition of matriculation in universities having health insurance. BYU already requires that and it seems to work well there. The University of Utah and Utah State...if we had such a requirement that would also cut it by 25,000 young adults, the number of uninsured. That's how many are matriculated in these higher institutions. So we're going to go where the money is and try to look at the populations that are uninsured and see what we can do to get them covered.
Interviewer
Just how porous is the safety net?
David Sundwall
Oh it's leaky. I wouldn't pretend to say it's a nice net that you could bounce up and down on. It's leaky. I think geographically if varies and the map should illustrate where some of the holes are. Rural areas of course are always at risk because of not having a critical mass and I think there is not sufficient public awareness about the available services. But furthermore, I must tell you that I get a little heat from the safety net providers when I brag about the good things they do because they say, wait a minute, we're backed up three months. So while I'm proud that we as a state have this network of clinics and free care or reduced care and can take care of people when they really need it. It's straining and we got some more funding from the legislature this year so we can fund some more of these clinics but don't get me wrong, it's not a tight safety net. It's pretty porous.
Interviewer
The community health clinics in incorporated Salt Lake, they actually are faced with the possibility of even closing their doors because of the lack of funding and I think the national average given to community health clinics is about three times what we donate. Do you see that as a big gap?
David Sundwall
Yes I do. I think that since I've been here we've succeeded every year in getting more funding for primary care and I don't want to take the credit for that, it's with the Governors support and some strong voices in the community like Pamela Atkinson, so we're moving up. I think the state acknowledges, most of the legislature, that these public or community health centers are filling a very important need. By the way, they get a lot more Federal money than they get State money, it's just been recently that we've kind of stepped up and decided that we need to give some state money. We could do much better. We have done some estimates of what it would take to make this safety net not leaky, but really cared for the uninsured in our state, but that would really be tens of millions of dollars and we're not there yet and I'm not sure if that would become considered an appropriate state role, but I hope it's on the agenda because these clinics really care for the most needy among us. We're getting there but we're not there yet by a long shot.
Interviewer
Where do you think that we're going to be going as a state and as a nation in terms of dealing with these issues?
David Sundwall
As a state I'm optimistic because of Governor Huntsman's leadership and because of the recent legislature I think acknowledging that the Department of Health has an important role and our budget was good. It was increased in some categories. I think people appreciate that we're trying to do the right thing. I also think in this state we need to start figuring out how to work in better cooperation with our local health departments because they have an important role and many of them are under funded by their communities so if we figure out how to partner better we'll be able to serve the interests of citizens throughout the state not just in the urban populations. Nationally, I'm very interested in what's coming up because I see all the signs pointing towards a real serious debate about the role of the Federal Government in health care. Now some people are anxious that they're going to - because of the costs and complexity - adopt a single pay or national/universal system which will be contrary to traditions in our country. Meaning it would take away some freedom of choice and it might make it less convenient like in other nations where they have universal coverage, but I don't think you can stop the debate because our health outcomes in this country are just embarrassing when compared with most other nations who do have a government program. I'm not advocating for a Federal Government program but we better look straight in the mirror and say "if we're spending over two trillion dollars on health care but our measures of health fall quite a bit behind other countries, we've got to figure out how to spend our money more effectively or do it differently". So I think its kind of exciting times in health care, certainly front-and-center.
Interviewer
Previously, we talked about the rhetoric where some people use the term “private marketplace” in relation to healthcare; you said that term drives you crazy. Why is that?
David Sundwall
I object to when people say we shouldn't do legislation related to health care because we don't want to interfere with the private market because we don't have a private market, we haven't had for some time. If you take the sum of Medicare which is the insurance for the elderly, Medicaid for the poor and disabled and add to that the tax write-off that businesses get for buying health insurance for their employee's - that's over 65 percent of the cost of health care. There's nothing ‘free market’ about that. It's tax subsidies or direct payment of public dollars for insurance. So it's not a private sector system already. I think we have in the public (meaning State and Federal Government) a very vested interest in making sure we're getting the biggest bang for our buck, therefore we better be responsible in requiring that these funds be spent well or directing them to programs that are proving effective, not just spending whatever doctors or hospitals bill us for.
Interviewer
That's pretty radical.
David Sundwall
Well it's the truth.
Interviewer
Do you think health care is a right?
David Sundwall
That's a troublesome question for me I guess because I spent almost a quarter of a century in National Health Policy in Washington D.C. where advocates for rights in various categories earnestly made their case. They wanted a Federal guarantee for a right. I think health care is a responsibility of individuals, of employers, of families. If you made it a right I worry that it would get caught up in the legal system and we would spend enormous sums challenging claims that rights have been violated. In other words we would legalize the health care system more than it already has this kind of a troublesome relationship with the legal system with malpractice. But I'm against making health care a right as a law. I think that we as a society ought to agree that it should be available to everybody and I think we've shown that we think that's right and correct but that we ought to keep it not tangled up in laws and regulations.
Interviewer
What do you have to say to people we've been talking with in this documentary who just can't quite get the help that they need and they're suffering? What do you say to them?
David Sundwall
I think that they need to get informed or get people to help them get the care when they need it. Let's not overstate this, we do not as a state or a society cast people in the gutter. We don't say, you're not worth care. We do enormous amounts to get people integrated in the system. If they're really suffering and they really need care I think they can get it through case management, whether that be a Medical Social worker or a Eligibility Worker in our Medicaid program or a Doctor or a Nurse - we're basically attuned to helping people. That doesn't mean everyone gets help when they need it but I don't think there is any need for people to suffer unnecessarily over time.
Interviewer
What about the rest of us, the majority of us actually are insured or we have some access to care, why should we care about this issue?
David Sundwall
Well that's part of the problem. That's a really good question because I find that kind of part of the uphill battle. If you acknowledge that we have say 15 percent uninsured in Utah (that's more than we calculate) but what if it's that many? Then that means 85 percent are insured and that's a strong majority who aren't worrying about this everyday. So I think the only way to make progress on a policy basis is by making the case for the economic reasons because to have people insured is good for the economy - we don't so much uncompensated care or write-offs, but also the public health thing, that they're healthier and it's the right thing to do. Governor Huntsman was in an interview with me once and I was so pleased and touched when he was talking about CHIP expansion and we were getting some pushback from the legislature and he just said in a very straight forward manner "this isn’t' just the right thing to do, it's a moral obligation". I think he believes that and I certainly think as a compassionate society we would want people to have access to appropriate health care at the right time.
Interviewer
Is there anything that you'd like to add?
David Sundwall
Just that it's an exciting time to be in health care and I'm honored to work with Governor Huntsman. I'm not on his campaign committee; this has nothing to do with that, I just think he's a progressive man. I'll tell you what's been fun for me at this stage of my professional career is after a couple of decades in Washington the last five or six years was just partisan stalemate. It was so troublesome because it was always those damned Democrats or those awful Republicans and most of us were not very interested in the partisan politics or that kind of gridlock - to come back to Governor Huntsman where he see's a problem that he'd like to solve, it's very refreshing! It's kind of fun for me to work in an environment where we're pulling together to get things accomplished, not worrying who's getting the credit.
Interviewer
I have a question to follow up to that - this seems to be viewed as a political issue. Is it?
David Sundwall
If you say, is it a political issue? if you're talking partisan, I don't think it should be. Historically to be honest the Democrats have the confidence of the public to address health issues, they think that's been their kind of agenda item more than Republicans. Republicans have in my view, unfortunately for too long had the public statements about it being a private sector issue and to keep government out of it, like I've already mentioned, that's silly because we already are into it in a big way. Way over our waist deep. So now we have a vested interest and because it's taxpayers dollars we're spending I think we better get serious about how we're spending them. I wouldn't care if you were a Republican or a Democrat. I know Republicans, which I consider myself a good Republicans, very interested in economy and the efficiency of government and my dollars being spent well and in health care I don't think they are necessarily. So I don't look at it as a political issue, I look at it as a social issue.
Interviewer
What is the cost to society of having large numbers of people uninsured?
David Sundwall
It's hard to get your arms around it. I think there are some people who have tried to put a dollar figure on the uninsured. I prefer to look at it in health terms and one figure that I find very sobering (generated by the Institute of Medicine, a very credible group in Washington) is that if you don't have health insurance it can be equated with having Type II Diabetes. In other words it's an illness burden. We estimate that about 18,000 people a year die from Type II Diabetes that's not appropriately treated or from the complications of it, so the burden to society is certainly economic but it's also a health burden - loss productivity and premature death, so it's a costly problem.
