Health Reform and Healthier Outcomes?

The Affordable Care Act marketplace opened up last week, but how might the health reform make us healthier? A group of experts discusses how insurance exchanges, accountability care organizations, and other aspects of the law may impact patient health.

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JOHN DANKOSKY, HOST:

The Affordable Care Act, or Obamacare, has been getting a lot of attention these days, even more than usual. The fight over the law triggered the partial government shutdown that we are still in. Even with that shutdown, federal and state insurance exchanges opened up and then some promptly crashed within a week. The insurance marketplace is one of the key features of Obamacare to help expand and improve healthcare coverage. But it's just one small part of this law. There are 10 different sections with hundreds of provisions that have been rolling out since 2010.

So with pages and pages of provisions, it's starting to look, well, like an insurance form. How can anyone make sense of it? My next guests are here to help us do exactly that. We're going to look at some of the less publicized aspects of the health care reform. How will they improve coverage? Can we cut costs? Will all this lead to actual improvements for our health?

We want to hear your questions and thoughts. What was your experience trying to sign up for the insurance exchanges? Do you have questions about what you are eligible for? You can give us a call. Our number is 1-800-989-8255. That's 1-800-989-TALK. If you're on Twitter you can Tweet us your questions by writing the @ followed by scifri. If you want more information about we'll be talking about this hour, just go to our website. It's ScienceFriday.com. You'll find some links to our topic.

Let me bring in our guests. Andrew Bindman is the director of the California Medicaid Research Institute and professor of medicine, health policy, epidemiology and biostatistics at the University of California, San Francisco. Welcome, Andrew.

ANDREW BINDMAN: Oh, thank you. It's a pleasure to be here today.

DANKOSKY: Rachel Garfield is senior researcher at Kaiser Family Foundation in Washington, D.C. Hello, Rachel.

RACHEL GARFIELD: Hi. Thanks for having me.

DANKOSKY: And Kavita Patel joins us - a fellow from the Ingleburg Center for Healthcare Reform at the Brookings Institution. Hello, Kavita.

KAVITA PATEL: Hi there. Thanks again.

DANKOSKY: Well, we want to get through an awful lot of questions from our listeners and we will have a few. But let's start, Rachel, with you and let's talk about the Medicaid expansion piece of this. One of the ways that ACA is going to be increasing coverage to people is by expanding that Medicaid. Of course this isn't happening in every state. Maybe you can talk first about how many more people will be eligible for Medicaid.

GARFIELD: Sure. So what the Medicaid expansion does is it tries to fill in some historical gaps in the program. The way that Medicaid has functioned up to this point is that you have to fit into a certain category to be covered. And for adults those categories are primarily being a parent, being an individual with a disability or being an elderly person. So what the law does is it expands eligibility to low-income adults who primarily don't have children and who are parents who were not eligible under the current law.

Up to - you know, millions and millions of people may be eligible for assistance who have been traditionally left out of the program. But, as you said, one of the key factors is going to be whether states actually implement the Medicaid expansion. With the Supreme Court ruling, states were basically left with the option of whether or not to do so. And as of right now about half the states have indicated that they're not going to do that.

DANKOSKY: You worked on the study that looked at Medicaid's impacts on actual health outcomes. What have you found about how Medicaid actually works for people?

GARFIELD: Well, when I did the study with my colleague, Julia Paradise, we tried to take a broad look at what does the body of literature say about how well Medicaid works for the people that it serves. And when you take a very broad look you see that on most measures of preventive care and primary care - so these are things like going to your doctor for your regular checkup, getting the screenings that you need - Medicaid works pretty well.

DANKOSKY: Well, and what we'll do is we'll leave it there and we'll come back in just a moment and find out more about Medicaid and some of the other provisions in the ACA, Obamacare, as people are calling it. We'll take your calls as well.

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DANKOSKY: This is SCIENCE FRIDAY. I'm John Dankosky. We're talking this hour about health care reform and we're taking your questions. Give us a call. Our number's 1-800-989-8255. That's 1-800-989-TALK. If you're on Twitter you can Tweet us at SciFri. Our guests are Andrew Bindman, who's from the University of California, San Francisco. Rachel Garfield is here from the Kaiser Family Foundation in Washington. Kavita Patel from the Brookings Institution.

We'll get to some of your calls in just a moment, but Rachel, let me let you finish your thought on Medicaid and what we know about how much it actually helps people. Because we're trying to get it to so many more people in America right now.

GARFIELD: Sure. So what we find when we look at the large body of literature that examines the impact that Medicaid has is that for measures of preventive and primary care, Medicaid does a good job of linking people up to services. People who have Medicaid fare very similarly to people who have private coverage. And this holds for both adults and kids. One of the challenges that we have in Medicaid is when it comes to specialty care. And there the findings are a little bit more mixed about what access to those types of services are.

And by specialty care we mean things like if you need to see an orthopedist or a cardiologist or you have some, you know, special medical condition. A lot of those challenges stem from provider participation in Medicaid, which has historically been limited for specialists. And so that's one area that the law will hopefully be able to improve things for people.

And when it comes to the quality of care that people are getting, this is a more recent field of research. But there is some literature emerging that the quality of care that people who are covered by Medicaid receive is very comparable to that which people who have private insurance receive.

DANKOSKY: And I know, Andrew Bindman, one of the things that has been not maybe proven but certainly looked at very closely is whether or not Medicaid is helping people get mental health care. This is something that's been shown in a study in Oregon that of all the things we don't know about Medicaid, we do know mental health care is improved.

BINDMAN: Yeah, you bring up an important point. In the state of Oregon they have done sort of an early experiment, if you will, of trying to expand Medicaid in that state. And they had an opportunity to rigorously evaluate that because their expansion was done in essence through a lottery where a number of uninsured people, some were able to get into Medicaid and some were on a wait list. And so they were able to compare those two groups.

And one of the things that was shown quite strongly was that the people who gained Medicaid coverage had a significant improvement in being screened for depression, getting treatment for depression and reported significant improvements in how they self assessed their health. And being able to address depression is a very important aspect, not only for how debilitating that disease is itself and how it could undermine your ability to work and function in different ways, but also your ability to care for other chronic conditions that you may have, as many chronic conditions require being able to take medications regularly and to do a number of things to self manage your disease. And those who suffer from depression are less able to do that.

So being able to address those important mental health issues should significantly contribute to improvements in health.

DANKOSKY: Now, Andrew, one of the other fears that people have about this big Medicaid expansion is that all the newly insured people are going to flood the system, that there won't be enough physicians to take care of everyone. What do you think about all of this? Do you think that we will have enough people to take care of all these people who are going to be getting health care coverage?

BINDMAN: Well, I think it is an important issue that we need to attend to. This law very much is about expanding coverage or access to health insurance. But as Rachel just brought up, we need to make sure that the insurance that people get, whether it is through Medicaid or through the exchange, will, in fact, allow them to access providers who can actually help to contribute to improving their care.

In that study that I mentioned in Oregon, it turned out that expanding Medicaid coverage there did absolutely contribute to those people who gained Medicaid coverage reporting that they were much more likely to have a regular source of care and so forth. So at least in that particular example, it was quite successful. But your question is a very important one.

One of the things we do know, for example, here in my state of California, where we're going to see the largest numbers of people gaining health insurance coverage are also the parts of our state where we have historically been underserved in terms of the number of physicians and health professionals available to help people. And so we may find that even if the numbers of providers that we have is close to the numbers we need for our population as a whole, that we do have a lot of issues of mal-distribution and where the demand might particularly grow.

DANKOSKY: Kavita Patel, do you think we need to change the workforce treating for people?

PATEL: I think what we need to do is actually try to change how we think about what each member of the workforce does. And I think the Affordable Care Act starts to put together pieces of that, like having doctors, nurses and allied health professionals as well as kind of this newer field of workers, community health workers, care coordinators who often don't have as much of the advanced health care education but are really deeply rooted in communities.

And we're finding that for skilled task alignment, we're having doctors and nurses do things that they honestly don't need to do.

DANKOSKY: We've got a lot of people who have questions about the ACA or Obamacare, so let's get to some of them. Dave is calling from Reno. Hi there, Dave. You're on SCIENCE FRIDAY.

DAVE: Hi.

DANKOSKY: Go ahead, you're on the air.

DAVE: Well, since I've been listening since I called in, I think Rachel might've touched on my question. I'm a firefighter and so I have insurance through my employer. But over the years we've been having to pay more towards that personally. And the return that we've been getting from it has been marginalized. So I'm wondering if, one, if that makes sense for us; do we qualify for the Affordable Care Act, somebody in my position.

And the second part of the question is, there are many fire fighters that qualify for what's called a presumptive condition. If they have some type of disease down the road, it's presumed that it came from their profession. And I'm wondering if under the Affordable Care Act if that still is maintained.

DANKOSKY: So two good questions, one about presumptive conditions. Maybe, Kavita, you want to tackle his first question. Is he eligible for new insurance under the ACA?

PATEL: So depending on - so the short answer is yes. And what I would encourage - I didn't hear where the caller, what state he was from.

DANKOSKY: He's in Nevada.

PATEL: In Nevada, sorry. So depending on - and Nevada certainly, it's one of the states that has opened up one of their own exchanges and even despite technical glitches has been able to have applications enrolled and processed. So what I would recommend doing, because one of the things that gets complicated is how to verify income, eligibility, etcetera.

And given just - what I would say to you about - and following on to the second question is that a preexisting condition such as one that you and some of your colleagues have had will not be counted against you as you enroll in these new plans. That's exactly what the Affordable Care Act did.

DANKOSKY: Any other thoughts on Dave's questions before we let him go, from anybody else? We'll move on. We'll move on to Richard in Tucson. Hi there, Richard. You're on SCIENCE FRIDAY. We're taking questions about Obamacare today. Go ahead, Richard. Richard, are you there? We'll put Richard on hold and we'll try for the next call here. Rich is calling from Alabama. Hello, Rich. What's your question?

RICH: Hi. I have an extremely small business. I'm the only employee and I carry Blue Cross health insurance and was notified by Blue Cross that due to the Affordable Health Care Act, my insurance premium will increase 50 percent effective January the 1st for the same or similar coverage. And so I have tried for the past several days, both by email, Internet and phone to qualify on the United Healthcare or the HealthCare.gov website. And it is, of course, fraught with problems.

But I have been told that I will not qualify for a subsidy or tax credit. And based on the table that the website gives, when I enter my criteria, I do qualify. I need to have qualified information that I feel comfortable using in order to make the decision. How do I find out for sure whether or not I qualify for a subsidy or tax credit?

DANKOSKY: Well, thank you for your question. Andrew, you have an answer for him?

BINDMAN: Well, you know, I think what the caller brings up is something that has been highlighted certainly in some of the early news stories, that there's been a tremendous amount of interest and pent up demand and so forth of being able to get onto these exchanges and to learn about them and to be able to purchase health insurance. Particularly, of course, being uninsured and having the opportunity to gain coverage this way is a tremendous opportunity available under this law.

Having said that, we're also hearing of course about that that demand is causing websites to freeze up and for there to be, sort of, long lines to work through that. I think, you know, the good news here is that there's a long lead-in time that we're talking about insurance coverage that will start in January so we're certainly - I am hopeful that some of the challenges of getting through will start to dissipate with time.

There are phone numbers listed in addition to being able to use the website to try to get some of those kinds of questions addressed and so I think, like a lot of things, when there's a lot of excitement at first there's going to be a long line but I think with time much of that should hopefully work itself out.

DANKOSKY: We want to try to get through some of the things that aren't as much in the news that are part of this law, especially about improving some delivery systems for healthcare. One of the most talked about is Accountable Care Organizations, or ACOs. Andrew, what exactly are these? Are they kind of like the old HMOs?

BINDMAN: So ACOs, Accountable Care Organizations, is a new kind of organization that is now, at present, in the marketplace in certain parts of the country. This is basically bringing together different providers for the purpose of taking care of a populations. So in that way they sound sort of similar to the way managed care sounded in the 1990s. I think there are some significant changes with this concept as it was first developed in the '90s.

One is that much more attention in ACOs than was the case in managed care of paying those organizations fairly based on the illness level of the population that they're taking care of. In the managed care era there was sort of a payment on a per person basis but it didn't fairly account for how sick the people were who were signing up for one organization or another, and as a result there was a lot of motivation on the part of different managed care organizations to try to selectively get the healthiest population.

So that the amount of money relative to taking care of them was profitable. Under ACOs they'll be a much better way of accounting for the illness of the population and making sure that those organizations that take care of sicker patients are in fact given the resources to be able to do that, but are still going to be judged in terms of whether they used those resources efficiently - and therefore, it would have the opportunity to share in savings over what would be the projected amount that they would spend on them.

And then the other really significant change compared to managed care, an Accountable Care Organization also has built in metrics of what they need to do in terms of quality of care for their population to be able to share in those savings. One of the things that was a great fear with managed care that patients feared was, gee, if they're only paying a fixed amount to providers, how do I know that my doctors or providers won't skimp on the care for me.

And by building in metrics of what these organizations have to do in terms of demonstrating high quality care for their population, this should guard against those fears that the organization won't be doing its best to meet those quality standards.

DANKOSKY: I'm John Dankosky and this is SCIENCE FRIDAY from NPR. Kavita Patel, I'm wondering what you think about doctors in ACOs. Are they buying into this idea?

PATEL: Well, we know that up to about 10 percent of the country is in some form of an ACO or an Accountable Care of organization, as we're describing it. So you might say, oh, 10 percent, that's not a lot. But considering three years ago that was zero pretty much, that could be - you know, I would think that this is a sign of a trend that's here to stay.

And from a kind of doctor's perspective, doctors I think, like almost everybody is, they're asking questions about what does this actually mean for me. And I think what we're finding, much like the Affordable Care Act when we explain and talk about what an Accountable Care Organization is, oh, you can have more time with patients that need your time.

And you can manage patients for a population over the course of the time period, you know, not limited to the 10 minutes you get in a visit with them, but over the course of however long they're your patient. And also, at the same time, being held accountable for a budget for that patient. Then you start to get doctors who say, oh, OK, that's of interest to me.

I still think the majority of physicians in the country, and there has been some survey research that's validated this, are confused by it and don't really understand what it means, but the Affordable Care Act has really placed an emphasis on system reforms like an Accountable Care Organization. So, again, I think they're here to stay.

DANKOSKY: Let's get back to more questions that our listeners have. Randy is calling from Arlington. Randy, Arlington, Texas; Arlington, Virginia? Where are you?

RANDY: I'm in Arlington, Virginia.

DANKOSKY: OK. What's your question?

RANDY: I'm a graduate student and my wife works full time in the District of Columbia and so we've both been very interested, living on only one person's income, whether or not we're going to have any savings under the healthcare plan. My question - well, a comment and then a question. My comment is that, you know, as a person in my mid-20s who knows how to run websites I really don't understand why there's been such a problem with the websites.

I was about create an account but then after getting an account I couldn't log in and then call - there was a comment earlier that there were numbers to call, which is great, which I did call, but they don't help with technical assistance. They gave me a number to talk to, like, a counselor in Virginia that could help me through the phone.

And when I called that number it wasn't the correct number and they gave me another number which was only a number to a voicemail and they said they'd call me back within four to five business days.

DANKOSKY: It didn't sound like this - yeah. This didn't sound like it went very well for you, Randy.

(LAUGHTER)

RANDY: No. It did not go very well at all.

DANKOSKY: Well, what's your question for our panel?

RANDY: So that's been my experience. My question is I have not been able to find any information as to the healthcare.gov marketplace plans and what happens if you are to be moving from one state to another, and whether or not that triggers an open enrollment allowment(ph) so that you can change plans if you have to travel outside the network.

DANKOSKY: A great question, Randy. Rachel Garfield, do you want to take a crack at that?

GARFIELD: Sure. So the marketplaces are state-based marketplaces. So you will sign up for coverage through your state. Now, as many people know, some states are not running their own marketplaces so in those states the federal government is essentially running the marketplace. And so that's why Randy in Virginia had to go through the healthcare.gov website in order to access his plan options for his state.

In other states, the state is running its own system and so you would go through a separate system. So, for example, if you moved to Maryland, you would go through the Maryland exchange, which is - that state is running its own exchange - and sign up for coverage through that state's own exchange.

DANKOSKY: So it does matter what state you're in and of course if the federal healthcare site isn't working, it's not going to help you very much at all. Hopefully, we'll get some questions answered from our callers at 800-989-8255 or 99-TALK as we talk about the ACA, affordable care in America. We'll be right back after this short break.

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DANKOSKY: This is SCIENCE FRIDAY from NPR.

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DANKOSKY: This is SCIENCE FRIDAY. I'm John Dankosky. We're talking this hour about health reform and its actual health outcomes. My guests are Andrew Bindman, director of the California Medicaid Research Institute and professor of medicine, health policy, epidemiology, and biostatistics at the University of California, San Francisco. Rachel Garfield is senior researcher at Kaiser Family Foundation in Washington, D.C. and Kavita Patel is a fellow at the Engelberg Center for Healthcare Reform at the Brookings Institution.

We're going to get to some more of your phone calls at 800-989-8255. You can also tweet us at scifri today. But we want to talk a bit about how we're going evaluate whether or not people are actually healthier at the end of all this. So Rachel Garfield, what exactly are you doing at Kaiser Family Foundation? What are you learning and what are you going to hope to learn over the course of the next few years about whether or not the ACA is making people, you know, healthier?

GARFIELD: This is really a long-term project to find out what the impact of the ACA is. The first thing we're going to be looking at is are people getting coverage. And that is the most immediate goal and, as one of the other panelists mentioned, the primary goal of the law: are people insured? And so over the next year we're going to be tracking what insurance coverage is looking like, finding out how the enrollment process is going for people, and looking at what types of coverage people are getting.

The next step that we're also going to be doing over the next year is trying to assess how is this coverage translating into access to care. So asking people about how their utilization of care has changed, are they more likely to go to a doctor, have they had some unmet need for care, and seeing what impact coverage has had on that.

And then the last thing, and that's really the long-term thing, is trying to measure some impact on health. Most of the affect that insurance has on health takes a long time to show up. If you think about it, health insurance can give you access to a screening, say, for cancer, that will catch a cancer early on and prevent that cancer from showing up.

But those kinds of outcomes, even at the population level, take several years to show up in the data that we're able to analyze.

DANKOSKY: So Kavita Patel, what are some of the challenges you see in trying to get at this question of whether or not this is going to make us a healthier country? What are the things we need to be looking at here?

PATEL: So I think that some of the challenges Rachel touched on - just kind of the time lag. It could take, you know, just an ounce of prevention is a pound of cure. But how long does it take to see that pound of cure? And we have in our time this, you know, instant gratification need. Like, OK, well we started on January 1st of 2014; shouldn't health be better right away?

And I think that's a very natural kind of reflex. I think on top of that another challenge also is the way we share information about our health. Only about half of the doctors in the country are using electronic health records. So in my practice I have electronic health records, but once a patient leaves my system, even if what I'm doing in my system is making them healthier, it's hard to share that information with someone else.

I think that will be something that, as a result of the Affordable Care Act, we can work on with time. But when we talk about science and outcomes, we have to have the data to match the patients to determine what those outcomes are. So I think we have some, you know, just time issues that are challenges.

And then we have some infrastructural issues that we're getting better at but will certainly not be perfect anywhere, you know, any time soon.1

DANKOSKY: Andrew, how about you? Obviously, at the end of the day what we want is people to be healthier. Coverage is important. Access to healthcare is very, very important but if it doesn't result in better health for Americans it probably all doesn't matter quite so much. What do you think we need to get there?

BINDMAN: Well, I think there are some things in this law that will help us in that regard. So, in addition to the idea of getting more people covered, which is an enormous step and an enormous barrier to people getting the benefits of healthcare today because we have so many people who are uninsured, they are late in coming in for care, for problems, that could be treated earlier and could make their lives much better.

But there are other aspects of this law as well. So, for example, something we haven't talked so much about today is the fact that the Affordable Care Act now eliminates any kinds of copayments for people covered by Medicare or through these private plans that will be sold through the exchanges or marketplaces, that individuals will no longer have a financial barrier to prevent them from getting preventive services like cancer screening and so forth, to ensure that they get the benefits of that.

We touched earlier as well about the fact that there is, through health plan reform as part of this law, there's now a requirement that health insurance plans will include benefits like for mental health services and for other kinds of behavioral health needs that will again contribute and should contribute toward improving people's health.

So health insurance is a financial barrier for care but it also - this law does a great deal to really standardize what we mean about health insurance and what it actually covers for people that could translate into real health improvements.

GARFIELD: And one thing I'll add there is while it will take some time for the specific effects of the ACA to show up on health, there is a long history of research showing that health insurance does make a difference in people's health. That we have been looking at over the past, you know, 50 years showing that when people have these financial barriers removed, as Andy was saying, there are improvements in health and in mortalities.

So we expect to see that difference; it's just going to take a long time to show up.

DANKOSKY: Some more people...

BINDMAN: Yeah, to...

DANKOSKY: Go ahead. Quickly, if you would, yeah.

BINDMAN: I was just going to say what's fascinating about this, to build on Rachel's point, is much of our knowledge about the value of health insurance for years was determined on the basis of, sadly, people losing their health insurance and how their health declined. What's very exciting in the context of the Affordable Care Act is that this will be a large social experiment in which we are helping people gain insurance.

And we should see the flip side, the actual improvements, in the health. One other small thing, from just a methodologic thing is that, unfortunately, because some states are not implementing all aspects of this law, as Kavita talked about earlier, this will create in a peculiar way some natural experiments to allow us to understand how the benefits of gaining insurance in some states and what happens to similar individuals in other states.

So while I would not personally recommend this as a policy strategy, it does open up some evaluation opportunities.

DANKOSKY: Let's go to Cathy(ph) who's calling from Massachusetts. You've had healthcare statewide in Massachusetts for some time now. Cathy, what's your question?

CATHY: Yeah. So you'd think that I had all this down. But I'm disabled and in addition to Medicare I also have insurance through my former employer. But my former employer was self-insured and therefore exempt from some of the Massachusetts requirements up till now.

So at the moment, just for premiums, not counting copays or prescriptions or whatever, my premiums between the two are about 15 percent of my income. And I'm trying to figure out what counts as a household. I live with one of my siblings but I can't control their money. I can only control my disability pay. And I'm trying to figure out, does his income count towards whether I can get a subsidy or not?

DANKOSKY: Who on our panel wants to tackle Cathy's very difficult question.

GARFIELD: I'll tackle it, but in a very broad sense. The rules for whose income counts towards your eligibility will vary between whether you're looking at whether you're eligible for these marketplace subsidies or Medicaid. But in the most general sense, what they're looking at is how do you file your taxes and who is claimed as a dependent on your taxes.

So that's going to be, perhaps, one of the ways to think about whether their income is going to count towards you or your income will count towards them. But the only way to really decide how that judgment is going to be made is to go ahead through that application process.

DANKOSKY: Cathy...

CATHY: OK.

DANKOSKY: Go ahead.

CATHY: It sounds like it's worth it and I'm very glad mental health is going to be covered, because before this the allowance for mental health was minimal. And for anyone with a chronic condition, as I'm sure you guys have mentioned, it's imperative.

DANKOSKY: Well, Cathy, thank you so much for that. And as we run a little bit low on time here, Kavita Patel, I know you said earlier that we sometimes live in an instant gratification society. We - it's going to take us a while to learn how all this is going to work. Massachusetts has been at this for a while. Have we learned anything from the Massachusetts model of statewide healthcare that maybe the rest of the country can learn from now as we look ahead to the ACA rolling out fully?

PATEL: Yeah. We have - real briefly. We've learned three things. One, that having access to healthcare can improve outcomes. Two, we've learned that there are - that in certain cases in certain parts of Massachusetts ER visits actually went up. So we know there's some kind of pent up demand that people had not been getting healthcare, then they got health insurance and then they needed to get to the doctor and had a little bit more urgent need and so they went to the emergency rooms.

Which resulted in a little bit of a strain on the system. And then the third thing is that we know that people initially were also picking the lowest cost plans but didn't realize - and I think this speaks to something the whole country can learn from - didn't realize that when you pick something that might be the lowest cost that generally comes along with some increased out of pocket co-pays and less generous benefits.

And so we saw people who made decisions based on, oh, I'll just find the cheapest plan because I'm not sick or what I need, and what I think this should do is open up a more national dialogue about, OK, what kind of healthcare costs could I anticipate, even if I'm feeling fine right now, and looking at the different structures of those benefits on the marketplace.

DANKOSKY: Kavita Patel is a fellow at the Engleberg Center for Healthcare Reform at the Brookings Institution. Thank you so much for joining us.

PATEL: Thank you.

DANKOSKY: Thanks also to Rachel Garfield, senior researcher at Kaiser Family Foundation in Washington, D.C. Thank you, Rachel.

GARFIELD: Thank you for having me.

DANKOSKY: And thank you to Andrew Bindman who is director of the California Medicaid Research Institute, professor of medicine, health policy, epidemiology, and biostatistics at the University of California, San Francisco. Thank you so much, sir.

BINDMAN: Oh, thanks. Great to be with you today.

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