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Interviews
Judi Hilman
Executive Director
Utah Health Policy Project
Interviewer
What is Utah Health Policy Project’s mission or goal?
Judi Hilman
The Utah Health Policy Project has been around for about 1 1/2 years. Our mission is to create quality, comprehensive, affordable health-care coverage for all Utahans as soon as possible, and we do that through research, policy advocacy and civic engagement activities. A starting point for our organization is the recognition that we're already spending enough money on health care. We're just not spending it the right way, and so we are calling for an ambitious or systemic solution for the uninsured that will get us to get back to some of the original purpose of insurance, which is to share risk. We should seek every efficiency through quality initiatives and making sure we are paying the lowest possible administrative overhead costs for health insurance (or health coverage). In our work we maintain that health care is not a commodity,
Interviewer
Why is that?
Judi Hilman
We prefer to see health care as a vital part of our social infrastructure. Utah policy makers and the public generally don't have a problem with investing in roads and transportation because we see that roads are a really important part of our infrastructure and we recognize that government should be paying for that--that's the most efficient way to deal with roads. Why don't we do that for healthcare? If we did I think we would find that our economy would boom and we would draw businesses to Utah to set up shop here because this would be one of the few places where we can afford to cover our workers, and that's also a good idea for economic reasons.
Interviewer
You say we’re already spending enough on healthcare. Explain that to me.
Judi Hilman
If you look at how much we spend compared to the next highest spending country, which is usually Germany, we spend at about a 9 to 5 ratio approximately... it varies. What we spend in terms of public dollars, taxpayer dollars, is... First of all 60% of our healthcare spending is public dollars; is the taxpayer money. That's kind of weird--if we think we have a private market, we absolutely don't to begin with! But take that 60% of public spending... all of that that we spend is more than the next highest spending country spends on their healthcare and they manage to cover everybody. Now we will say that we're not spending probably enough in the Medicaid and CHIP (areas that are inherently most cost effective) and on healthcare for the under-served and who you're looking at in your film--that you cannot argue. Utah ranks 48th in per capita public healthcare spending: somehow and mainly for philosophical reasons, we don't like Medicaid or CHIP. So when we say we're already spending enough money, we make an exception for Medicaid and CHIP and money for the community health centers. We can spend more there, but everything else is very wasteful spending.
Interviewer
It sounds like what you’re saying is we're spending enough money, more than enough money overall on healthcare, but we don't funnel it into public programs, is that accurate?
Judi Hilman
Yes, we're not spending enough on low-income people. I think we need to recognize that given what's going on in the private market and in the small group market, that low-income working people and working families are less and less likely to get affordable coverage through their employer, so we would say that while we're looking for bold financially sustainable solutions (and that's the purpose of our organization), while we're looking we should definitely take care of the low-hanging fruit--keep your children's health insurance program open, cover all of your kids, and use Medicaid and CHIP to cover those kids because those kids are just... they're falling out of a small group market. As small businesses are feeling that squeeze of rising healthcare costs who do they drop first? They drop the kids, tragically enough, and it's just idiotic not to cover children; they're cheap, they're healthy, and you're looking at a lifetime of productivity ahead of that child if you take care of their healthcare needs in an efficient way.
Interviewer
And how do we do in Utah in terms of taking care of our kids?
Judi Hilman
Well, I think it goes without saying that we need to keep our children's health insurance program fully funded. We need to make sure that we have good outreach and marketing going on around our Medicaid program. There was a survey done at the Health Department a few years ago that found that 86% of our uninsured children would qualify for the Children's Health Insurance Program or Medicaid were they to apply. So something else that we have working against our children and our working families is that we have this huge stigma that attaches to public programs. We need to get over that, because healthcare is that important, and for kids there should be no question and no hesitation about covering them however you can, and we would say do it in the most financially efficient way--that's Medicaid and CHIP.
Interviewer
You were talking earlier about we don't treat healthcare as an infrastructure as a basic fundamental necessity for our state. Why is that?
Judi Hilman
You know I'm kind of scratching my head everyday pondering that and trying to figure out why we don't. I think that one of our states, (and we think it's going to be Utah) needs to take a leap and do an experiment and see what if all of a sudden we made coverage affordable for small businesses and we stopped playing the actuarial games that we play to try to get as much money out of them as we can and cherry-pick the healthy, and keep the sick out of coverage and the social Darwinist fashion that we have. I think we should do an experiment for just two years or so, give them affordable coverage and I promise you our economy will boom and we will bring businesses to Utah, but somebody needs to take a risk. It should be a governor, and I think that's what we need to do. We need to at least try it and see what it does for our economy.
Interviewer
What would a solution look like?
Judi Hilman
You know I think there are a number of ways to do it. In the recent past we've made the case to allow small businesses to buy into the public employee health plan. The reason why we knocked on that door was because PEHP is incredibly efficient-- it has 3.4% administrative overhead costs, so quite a bit lower even than Medicaid and CHIP. It has a huge risk pool, and everybody who is in it--I think it's about 176,000 covered lives altogether--everybody who is in it, they combine their risk for the sake of all of their catastrophic costs... that's where most of your cost is, so we wanted small businesses to buy in there. Now policy-makers have not liked this idea for various reasons, one being that they think it's growing government. We say, wait a minute; we have to remember PEHP is a private, not-for-profit healthcare trust fund. It happens to have a lot of government employees enrolled in it, yes, but it's not government and it happens to be the right way to deliver health care. They have a lot of good experience and the icing on the cake, as far as I'm concerned, is you can get really high-quality coverage through PEHP. I want that for our small businesses. I want it for this small business. We can't afford the rates we're getting, you know. We all need it.
Interviewer
In another interview, you mentioned that you’ve had a hard time finding health care coverage even for your own organization. That's ironic that you're an advocate for healthcare coverage and healthcare access for people, and yet even you have trouble finding affordable insurance.
Judi Hilman
We had to fill out our health questionnaires and stuff, and right before I did that here I am taking a deep breath, "Oh no, what am I going to…?" So we're filling out our health questionnaires and we're going to get our quote from our broker and I called her up and I said, "How should I handle this so we can get a good deal? What shall I do?" And I was actually counseled to do whatever I could to hire a young, healthy male! And I... my heart nearly jumped out of my chest because I'm thinking I'm going to hire the best person for the job, and if it's a woman in her late 50's you know, with a condition, a thyroid condition or whatever, that's who I want to hire, you know. But anyway, just that idea that the Utah Health Policy Project is being told that, and I kind of paused when she said it and I said, "Do you realize who you are saying that to?" So anyway, that's how bad it is. I wonder if it's just a matter of routine. This confirmed what I suspected all along: that current healthcare financing arrangements are inherently social Darwinist--there is pressure to hire young, healthy people. There is something wrong with that I think in a society. It's very disturbing to me.
Interviewer
Who isn't getting access to healthcare right now? Who are the people who are left out?
Judi Hilman
Well I think there is growing awareness that when we're talking about the uninsured, the 420,000 uninsured in Utah, we're talking about working people. I think it's something like 91% of our uninsured right now are part of working families, so either the uninsured person him or herself works, or they're part of a family that's a worker, including the children. So what that says to us is that when you're looking for solutions, think about the workplace first, and small businesses. Utah's economy is dominated by small businesses. One of the reasons why Utah's uninsured rate over last year--the increase in Utah's uninsured rate was seven times the increase in the national uninsured rate--is because we have a preponderance of small businesses and they're the ones who are feeling the squeeze. So we've got to do something about it really fast. The other thing to note is that 60-70% of our uninsured are under 200% of the poverty level, so I think that means that if you're going to phase in your solution, and probably will have to do some phasing in, is think about the working poor first--they're the least likely to find something in the individual market or the small group market as time goes on, and so I think that's another important guideline for us.
Interviewer
And what does 200% of the poverty look like?
Judi Hilman
I have a chart right here. Two-hundred percent of poverty, let's say for a family of three; mommy daddy and me, is about $34,000 a year--not very much money at all, so they're not going to find coverage. They're not going to be able to pay for care out of pocket either, and you're going to notice that with people that you talk to. So what that means is that they're going to forego preventative care. They're not going to have screenings. The women are not going to have their PAP smears and they're not going to get their mammograms when they're suppose to, and then you're asking for more costs down the road as some of these families are going to get caught and they're going to come down with something and it's going to be more expensive to treat.
Interviewer
Some of the uninsured are referred to as “the young immortals.” I’ve interviewed people who say that too many young men feel they don’t need coverage, so they don’t buy insurance. And there's a certain amount of personal responsibility lacking. What’s your view?
Judi Hilman
I think it's mostly a fantasy. In other words, I think there's a real strong appetite in Utah to have the problem go away if we just took responsibility both for our health and for our spending in healthcare, but a lot of that ideology I think is built on some false assumptions that people over-utilize healthcare. We have evidence suggesting that we're under-utilizing healthcare, especially preventative care, so I think we need to really try to reexamine those assumptions. I think it's been very unproductive. Yes, a lot of the younger, healthier workers are more likely to get jobs in the leisure field or in retail, for example, in restaurants where they're less likely to offer coverage. But there is no way they're going to be able to afford the premium that is offered them typically, and so they're going to play Russian roulette and they're going to go without. I did that in my twenties, o.k. and I got away with it. But the fact is that at that age, there is not enough extra money to cover premiums. If you want that person to put a career together for themselves, perhaps his or her money IS better spent on the future. I was uninsured for about five years, but look what I did during that time. I put myself through grad school and it was very worthwhile. I couldn't have done both (premiums AND grad school). So you want your young people to build careers or to be entrepreneurs to start a business, but they're not going to be able to take those risks and pony-up the premiums they're suppose to pay for whatever measly coverage is being offered, so I think we've got to cut it out with that expression (“young immortals") altogether.
Interviewer
You talk about people choosing to play Russian roulette with their health when they feel they can’t afford insurance. What other types of decisions do the uninsured make around their healthcare? Is there a sacrifice in lifestyle when you're uninsured?
Judi Hilman
Oh definitely, and I would love to talk to some parents of uninsured children because there you see parents holding the child back in the playground, not going on trips with their classmates because they're worried they're going to get hurt, and rightfully so. Things like... weird decisions that human beings, let alone children, should never have to make. The worst thing that happens is when they very often decide to go without care, to go without preventative care, and it's not a choice. They cannot afford it--they cannot afford that and food and if they're in school, the books, or to go to school at all. The math isn't there.
When I first started in this line of work I decided to just go out all over the state and interview uninsured families, and I can't tell you how many of these families, especially families of uninsured children would say I don't let my child play in such and such places where there could be more risk in the outdoors; skiing. Utah's all about skiing. So even young adults who want to go snowboarding or whatever, well maybe I shouldn't, well you know, they're right, they shouldn't! But let's face it, you're missing out on life, you're missing out on physical activity that could help you control costs down the road and be healthier, keep your cholesterol down. I mean it's not a sustainable arrangement.
Interviewer
I want to talk a little bit about the safety net that exists. What is the safety net or the concept of the safety net, and then I want to look at is it working?
Judi Hilman
I probably use the safety net more than anybody, I mean we get calls from people who are uninsured or underinsured increasingly, and they ask us, oh I’ve got a lump here, what do I do? We try to send them to a community health center. There is really high quality care at community health centers and I can't say enough about the need to fully support community health centers and make sure our Medicaid population, our CHIP… that we make sure that community health centers have the capacity to see all of those folks because that's good care. It's also very culturally competent care. But I have to say that Utah, compared to other states especially in the region, Utah does not put the resources into our safety net system that it needs. Now on the other side of things, our organization is really focused on bold solutions, so if you get carried away... we don't want people to think that the answer is just community health centers and that if you invest enough in community health centers and the like, that you don't have to get underneath the real problems of rising healthcare costs and the uninsured. You do! So I think that we need to have a very strategic approach to investment in our community health centers, for example, and whatever approach we have to making sure they have the capacity to serve, inch that along with different phases of implementing a bold solution.
Interviewer
Does the safety net work?
Judi Hilman
It has got a lot of holes in it for sure. I've had uninsured folks trying to get into a community health center and having to... either they're not taking new patients at all or the wait is so many months that you're really talking about complications from whatever's going on, so that's a problem. I think we need to direct more of our traffic, our Medicaid and CHIP traffic into the community health centers and not so much in health clinics of Utah (low-income clinics run by the Department of Health)--that would be a good idea. Just because I think that if you really slow down and think about it, it's a really good idea to make sure that low-income people, uninsured people, at least that they have a medical home for their primary care and then we'll make sure that they're on a good schedule for all of their screenings and that they have a chart with all of their information and their history. That is really important. And who knows--we're looking for a systemic solution to the problem of uninsured. I am so excited about the quality of care at community health centers, that I would like for them to be part of the circle of service delivery. I myself have gone to a community health center for care because I know there is really good care there. There is no reason why they can't be a major provider in a future financially sustainable healthcare system.
Interviewer
I have insurance. I have access to care. My life is pretty good. Why should I care about this issue? Why should I care that people don't have access to care?
Judi Hilman
Well, you know if you're a young and reasonably healthy person, you would be less likely to notice the flaws in the current system, but they are there and eventually we're all going to need, you know, some care, and we're going to come up with little conditions, and little bumps and things here and there and then I think that if things go on the way they've been going, and lets say that we end up in a hospital, we're going to notice that we have a really hard time getting our bills paid, that we could, if we happened to be uninsured even for a brief period, we are at a huge risk for medical bankruptcy. The second largest cause of bankruptcy is medical debt. You'll notice a nursing shortage if you have a parent, for example, who is in the hospital for a period of time and we have the third worst nursing shortage in the country. So there's a lot of different holes and gaps, you know. In our vision of a well-functioning healthcare system, the different providers would cooperate together, so this facility could be really good at MRIs and this facility would be really good at certain types of heart transplants and so forth. But the competition model is not very conducive to efficiency in our healthcare system, so that's another area of waste that we have to go after.
Interviewer
Describe the impact of the uninsured on people with insurance. If I’m insured, I imagine I'm paying some cost down the line. And then what is the human cost, the societal cost?
Judi Hilman
Yes, of course you should care even If you are insured because approximately 17% of your premium dollar goes toward care for the uninsured. This is an implicit mandate we all pay while we delay real, systemic solutions. Besides the lack of quality and efficiency in current systems, this implicit mandate should be enough to really get underneath this problem. I know I was interviewing a small business owner the other day, someone who runs a business called The Closet Factory, and he was saying that because the children of his employees are now uninsured that the parents are missing more work because they've got to go and care for their children, so it has an impact on the broader community, and on the broader economy when even one family member is uninsured.
Interviewer
And the bottom line here too is what kind of suffering is happening out there?
Judi Hilman
Well, being uninsured is an actual cause of death in this country, you know the Institute of Medicine did a comprehensive study in 2003 that found that 18,000 deaths were associated directly with being uninsured, specifically being uninsured. But that's just the tip of the iceberg: what that number doesn't reflect is how many cancer deaths do we have that could have been prevented because so and so could have had coverage that would have given them the mammogram, that would have given them the breast exam in the office, the pap smear and so on? That's a very hard number to quantify. But let me tell you it exists, it really does.
Interviewer
Do you have people who basically just call you up with heartbreaking stories?
Judi Hilman
We do. We get more of those calls as time goes on. It's funny because when I get those calls, since we don't really do direct service, we try to give them a good referral as soon as we can because you want that person to be available to help with advocacy, because boy they have the best case of all, but you know they need the operation. They need something right away, so we try to make the best referral we can and then we will say, by the way, your problem is really common and if you're interested in working on this with us you would be helping so many people by sharing your perspective and getting involved with us. And so, you know we've only been open for a year and a half, but part of why we're investing heavily in civic engagement and organizing activities is so that we can build the mechanism so that we can keep these folks engaged and make sure they get the care they need at the same time.
Interviewer
You spent a lot of time on Capitol Hill. Who are you a voice for up there? Why are you lobbying so hard?
Judi Hilman
Well, mostly the uninsured and Medicaid and CHIP clients, the medically under-served. We're finding that increasingly, we are also the voice of the small business owner. Businesses can't compete and deal with rising healthcare costs, and the voice of the small business owner is the voice that really resonates with our policy makers, so we're also trying to be that voice or help to project that voice, and also the middle-class, typically the under-insured individual--increasingly you don't know if your healthcare coverage is going to be there for you when you need it, and I find that a very shaky, very shaky prospect. So I think that we need to help consumers... the only reason why we're developing a quality initiative called Quality Watch, is that we want the typical middle-class consumer to get a handle on the quality of care that they can expect so that they can work with us too. They also have the ear of the policy maker before the poor person does, so to help them grasp well what kind of quality am I going to get? And you know what? You're going to find that it's not going to be very good quality probably as time goes on, so to help them stimulate the appetite for a sustainable solution.
Interviewer
We were talking about the legislature. How did that go? How did the session go?
Judi Hilman
Well it was our first session as a new organization, so with that I think we did very, very well, but the victories were limited to the Medicaid and CHIP and cost-containment areas. For instance, with our coalition partners we were able to restore Medicaid, dental and vision services. The Children's Health Insurance Program will be reopened in July. That's huge! We got a decent amount of funding into the Primary Care grants for the community health centers and the like. Those are all significant victories. A really delicious victory this year is our organization has decided to really focus on cost management and on the argument to reinvest whatever savings we capture through cost-containment strategies to reinvest those savings into the program--into Medicaid or into CHIP. This is the first time that that argument was successful. They listened to us. They implemented the Preferred Drug List, which is a way to manage how we buy drugs in Medicaid, and they're reinvesting the savings in the provider rates for Medicaid so we can make sure there is timely access to care. Those are great. We are a bit disappointed in our results on the systemic solutions part, but I can't say I'm surprised because I think it's going to take more of a slower drum beat to get some of those things moving along, and I think that this could be the year to really try something bold.
Interviewer
Why do you think more people aren’t speaking up and demanding change in our healthcare system?
Judi Hilman
For one reason or another I think that Utah is a culture where people are not as comfortable speaking up about a perceived injustice. This is an injustice, it's a social injustice, it's a very wasteful state of affairs. Another reason why I think people don't speak up is that I don't think that there's enough awareness of how things could be different. I almost wish that we could just allow everybody to live in another country for a month, something like that. I know it's a fantasy. But if you could, I mean I think you could see... it would really open your eyes. I lived in Germany one summer and I made some friends over there, and now the ones I keep up with they laugh when I tell them what my career is and what I'm working on. They can't believe there is a whole industry that is devoted to this problem! Not to say that they don't have problems in Germany, they do, but the core of the problem that we're working on, the financing of healthcare, is more or less resolved in Germany. We can't even imagine that in the United States.
When I was going around interviewing uninsured people all around the state, I saw that people were suffering in silence and they were doing that because either they're not used to speaking up about an injustice that they perceive--it's not really a culture for that so much--or maybe they're not aware of how things could be different.
Interviewer
What I've been hearing out there is we need more basic, affordable insurance packages. What do you have to say to that? Is that the way to go?
Judi Hilman
You know I think that that's a sign. There's a sign that the folks who are interested in maintaining the status quo are panicking and if we are at this crossroads right now where we could bite the bullet and go to something more innovative and more sustainable that will get us comprehensive, quality care, or the only other way to maintain the status quo in the private market business model is to dumb down the benefit package and do these health savings accounts and other kinds of garbage, and I hope we don't go that route--it's very short-sighted, it has a satisfying feel to it for the so-called young immortals because they're going to eat those solutions up like hot cakes. But let me tell you, with those kinds of solutions, you're asking for trouble, o.k. Those kinds of solutions--Utah's Medicaid program has embarked on that type of solution for a part of the Medicaid population called the Primary Care Network. We decided in 2001-2002 that the working poor only deserved access to prevention or into primary care, so that's what they get. They get the Primary Care Network. What a policy like that forgets is that the working poor are human beings, and human beings get sick, and so you do well to make sure that they have access to the catastrophic coverage and the hospital care and so forth. By the same token, if we're saying let's do health savings accounts, what do those do but discourage the use of preventative care? Of course it's going to be cheap in the short run--those products are going to be cheap or it's going to end up giving a tax break to the wealthy--it's just another tax shelter I think for wealthy people, but it's very short-sighted. You don't want people going without preventative care.
Interviewer
Isn't it better to give them some care than no care at all?
Judi Hilman
You know, as a temporary measure, I would have been o.k. with the Primary Care Network as an experiment if we put a time limit on it. But what happened in the Governor's Uninsured Task Force last year... I remember going to a couple of those meetings and asking very quietly, "So we're looking at the problem of the uninsured. Is the Primary Care Network a part of that problem, or is the problem solved for them, and we're looking at other groups?" And basically I was told oh that group is taken care of. I'm thinking, wait, wait, wait a minute. All they have is primary care! What happens if they get sick? They said; oh no, no we've got bigger problems to deal with. So is this idea that a little something is better than nothing, you know? We think to the contrary. We think we can, if we take a deep breath and really re-examine how we're financing healthcare and how we're spreading risk, that we can afford a quality comprehensive package for everybody. And in the long run it is worth it, trust me.
Interviewer
Do you really think that will ever happen? Why do you even think it's possible?
Judi Hilman
I'll tell you why I think it's possible. I think we're fortunate in that this is the land of fiscal responsibility so, you know, really innovative, state-wide proposals like the Massachusetts plan, they can do something like that in Massachusetts but they're going to mandate individuals and small businesses to cover people and that's how they think they're going to solve a big part of the problem. Well, to rule that out, they're talking about spending at least about 1.6 billion dollars. There is no appetite to spend that kind of money here. Now their reasons for not spending the money on healthcare might be a little different than my reasons right now, so we're working on that. We're going to try to bring those two reasons together. We would say we don't need to spend much more money on healthcare because we just need to reallocate our current spending and we need to spread risk, and we need to lower our administrative costs and seek other efficiencies. What we need to do, is we need to have the financially sustainable visionaries like us... we need to back into the fiscal responsibility policy makers and realize that we have a lot in common. We shouldn't have to spend that much more on covering our uninsured in Utah, and we can still have the same quality that we think we have right now, or hopefully better. We should be able to do that and not cost the taxpayer that much more money over the long run. We're also blessed, I think, in a sense that you want to spend whatever Massachusetts is spending, you want to spend that in Utah. You can't. Look at what you need to keep up with our growth in our population for public ed. The school age population is growing at such a rate and we're not paying our teachers, so we've got a huge need to fund public ed. You can't dump more money into this inefficient healthcare financing system and pay for the exorbitant needs that we have right now in our public education system. The money's just not there.
Interviewer
So our policy makers, are they on the right track? It seems like the Governor and legislators I've been talking to are really looking for basic health care packages. It seems like that's the road they're willing to take.
Judi Hilman
I think we're going to have to do our homework over the next year and really dig down and learn what are the consequences of having all these basic healthcare packages? We can start by studying the Primary Care Network experiment on the working poor through Medicaid. We can uncover the long-term consequences of that. What kind of preventative care are people foregoing? And you can model the long-term cost impacts of that. It's not very easy, but you can. We need to start asking more structural questions on the implications of a basic health plan. What does that do to the healthcare safety net? What does that do to the rest of our healthcare costs? What does that do in terms of our end-of-life care costs? I do think that we also need to take a really hard look at some of our expenses at the end of life. I think that there is an irrational basis underneath a lot of our decisions or passive decisions about what we pay for at the end of life, and to me that's a really exciting conversation that needs to happen, and it's a conversation that is ultimately about our own attitudes about our own mortality and morbidity. That conversation I think has to happen I think before we reign in some of those costs. It's going to be an awkward conversation, but really important if we're going to come up with a really financially sustainable way to cover healthcare.
Interviewer
It sounds like we're all going to have to make some uncomfortable decisions.
Judi Hilman
Yes, but I can't think of a healthier line of thinking for people to think about their mortality and their morbidity in a healthier way.
Interviewer
This is going to be tough because it's complicated, but in a summarizing statement what's causing the problem of our rising healthcare costs and the rising number of the uninsured?
Judi Hilman
First we need to go after the actuarial gamesmanship that characterizes our small group market, the social Darwinism that underpins decisions around small group coverage. I think we need to really take a hard look at that and about whether that way of financing healthcare is consistent with our values as a community, as a God-fearing community if you will. We're not sharing risk as a community and that's the first thing we have to change. We need to get back to the original purpose of insurance, which you might remember way, way back when was about sharing risk; its' very simple: you buy insurance so that if you get sick down the road a healthier person is paying their premium so that you can afford your care, and that's how it all comes together. Well small businesses are not part of that anymore, so that's got to change and that's a big leap, yes, it's a big leap we're asking everybody to make. Another area of waste is we allow for unbelievable administrative waste. The average administrative overhead in the private market in Utah is between 15% and 20%. The amount of their costs that goes toward patient care, that's called the medical loss ratio, ironically enough. There is a lot of dollars that go into denying claims, and all of the administrative staff that you need to figure out how to deny claims, o.k., again, not the purpose of insurance. I think we need to look at programs like Medicaid and CHIP and the PEHP, Public Employee Health Plan, and figure out how is it that they are able to have... PEHP has a 3/4% administrative overhead cost, CHIP and Medicaid about 5%. That's great. Now what are the factors that give you such an efficient administration? Well, you have economies of scale. You have a lot of covered lives that they're managing at once, so they can build one apparatus to take care of that. . You can do that and be a private nonprofit if you want. We think that healthcare is one of those things, it's not a market commodity, but if we can start to look at healthcare like we do roads right now as a vital part of our social infrastructure, as the key to our economic viability and the ability of small businesses to compete in a global economy, then we will make that leap.
Interviewer
Aren't you talking just more government?
Judi Hilman
No, absolutely not. But it does make sense to have government oversight of these decisions. You know, when you're getting all of your roads built and your highways built, you know, your roads and your whole network of the roads and the resources that go into it are managed by government and they're paid for by the taxpayer, and that doesn't bother us. Why is traveling in your car all over the freeway… why is that somehow seen as more valuable as getting healthcare? I don't get it.
Interviewer
Why is this a political issue, and should it be?
Judi Hilman
Well I think it gets to the core of sort of how we look at the role of government and the role of the individual and the personal, all of the values and the contested ideologies in Utah are in play with this question that your documentary is raising. So I think that's why, we are opening up a whole can of worms here, and to me that's what makes it so worthwhile and so interesting to work on is how fascinating is that to really ask those questions about what is the role of government? Where does the role of government stop, and where does the role of the safety net or the charity sector, or the individual begin? Yes we're engaging all of those questions, and I hope we answer those questions the right way.
Interviewer
Do you think that healthcare should be a right?
Judi Hilman
Well I don't think that it becomes a right just by declaring it, so it's just not a right. But I think that it might as well be a right. If it could just be a right then we could solve a lot of problems, but I think that's one really stubborn ideology in Utah. I don't think it's going to be a right in Utah. I know that our policy makers and Utah taxpayers really value our economy and they want Utah to be, you know, the strongest economy in the country, and that's wonderful. And I think that there is a growing awareness that access to quality, affordable health coverage is absolutely key if you really want to have a strong economy, so if we can connect those two areas of government or problem-solving in government, then I think we can get something meaningful done.
Interviewer
It seems to me that a lot of the solutions, even the safety net to some degree, that we keep putting band aids on this issue. Are we doing that?
Judi Hilman
Are we doing that? Oh we're putting band aids on every little corner. The analogy we like to use is we're poking. When you poke one side of the balloon it pops out somewhere else. And let me tell you that all of those band-aids make up a lot of scar tissue, and that's what we're dealing with now. It's also really expensive to keep putting band aids on things and especially when you're talking about a problem that's really along the scale of a systemic infection. Band aids just don't do the trick, and there is no point to them, frankly anymore. So yes I think that it's not, what we're doing is not sustainable. One of the reasons why I think a lot of these issues are coming to a head right now is that you've got the aging superhighway, the baby boomers are approaching retirement, and I believe the first group of retirees comes next year. So what that means is these healthcare costs that we're not able to manage are just going to explode exponentially and we're just... The group that makes up the big costs is just going to explode, so your costs--think about how they're going to expand beyond our capacity to pay for them, or pay for them at the same time as we always want tax cuts whenever we have a surplus, o.k. You want tax cuts, fine. But you can't have the tax cuts and continue to pay these price tags we pay every year for Medicaid, case-load growth and so forth, and we're not going to be able to afford what we need now because we have a lot of kids--what we need now in public ed. The money is just not going to be there, so this will come to a head. I just hope we solve it the right way. We have, I don't know if it's a Hobson's choice, but we have a Hobson's choice sort-of where we can go the road of an innovative, systemic solution that will get us quality, comprehensive health care and a full benefit package, and we will be able to sustain our financing--our investment for years to come, or we can dumb down the benefit package and have these light, basic health plans like you can get at a Wal-Mart and so forth, and that's the choice that we're facing right now, and I think we know which way we need to go.
Interviewer
Let’s go back to the beginning, why are we in a crisis now?
Judi Hilman
Well some of our policy makers are saying that we can't afford the Medicaid cost growth right now, o.k.? Well for state governments right now, they are really feeling the pain of rising healthcare costs and they feel like the only way that they can control that is to take it on Medicaid, and so there is a lot of appetite to cut Medicaid and so forth, when the real problem is rising healthcare costs in the rest of the system. All of that pain that we're feeling right now--small businesses cutting off family coverage because they just can't hold onto the whole family and they can't keep up with double-digit inflation in the premium….Everything we're feeling now is going to be exponentially worse as the baby boomers approach retirement. That starts next year.
Interviewer
How do we stand nationally, or internationally?
Judi Hilman
We're sinking. Now I think we're down to 37th in health status overall. Part of your health status is access to health care, so part of our uninsured problem is feeding into our low ranking, but I have to say that some of it is lifestyle, some of it is we're the fattest... I think we're the fattest country in the world--that's not helping with our health status and our health ranking. Now those issues--I mention them like they're in a side, but they're not. Those questions of our lifestyle--of how we take care of ourselves, what are we eating? Those questions should also be at the core of how we design a smoother functioning, a better healthcare delivery system. There is no reason why your healthcare benefit and your financing strategy can't include incentives to manage your health and get a better grasp on your own health risks and health behavior.
The factors that go into that ranking are infant mortality, infant birth weight, mortality itself, access to healthcare, smoking, obesity--the typical health indicators.
We rank 37th and yet we spend an awful lot of money. Sixteen percent of the GDP at least count, the next highest spending country was 9%, if I recall.
Interviewer
So what are we buying with our money?
Judi Hilman
Not a lot, and certainly not the kinds of coverage you expect most human beings to have--too many people go without, 442,000 in Utah and what is it now, 46 million in the nation. It's just crazy.
