 Aloha and welcome to Ehana Kako. We're here every week on the Think Tech Hawaii Broadcast Network. I'm Kili Akeena, president of the Grassroot Institute. Well, everyone's involved in a national discussion now, and that is all about Obamacare or possibly Trumpcare. But today we're not going to focus so much upon the national issue, but something that's very important, defining what healthcare delivery is really all about. And what is its distribution? Do we have a shortage in certain areas? Do we have more than enough elsewhere? And exactly what are we talking about when it comes to healthcare? Well, there are people who are studying this in great detail, and they happen to be at the Dartmouth Institute for Health Policy. We have a project manager here with us who handles a program called the Health Care Openness and Access Project. It's a fabulous tool that has done a survey of all 50 states in terms of exactly how well they deliver healthcare. And so I'm delighted today to have joining us Jared Rhodes. And Jared, before we welcome you onto the program, I want to direct my viewers that we've got a terrific photograph of you here, but unfortunately Skype is not operating as well as we'd like to see it. Maybe the Russians have hacked us today. But we've got your voice with us today, and so Jared, welcome to the program. Aloha, and thank you very much for having me on. I'm pleased to be here. It was wonderful to be with you at a national healthcare policy discussion recently sponsored by the Cato Institute, and I was just fascinated by the tool you presented. Tell us a little bit about the organization you represent. Sure. Yeah, so I mean, I worked for Dartmouth, so that's the Dartmouth Institute for Health Policy and Clinical Practice, but this project was actually done in conjunction with Mercatus Center, which is another university-affiliated center, it's a policy center down in Virginia right around the DC area, and it is affiliated with George Mason University. So between the two institutions, this project was born. It's called the Healthcare Openness and Access Project. That's right. We're going to get into it a little bit more. But first of all, we've given our viewers fair warning that we're talking think tank talk, that you and I are policy wonks, and I want to give fair warning to our viewers today that we're going to deal with some technical things. But let me tell you this, everyone, it's well worth following, because Jared understands through his research exactly what healthcare delivery is in this country. So Jared, tell us a little bit about the HOAP project. Just briefly now, we're going to dive into it more in depth later on. Sure, yes. I mean, just as a really high-level overview, it's basically we did a bit of an inventory of the policies and regulations that are in effect at the state level. So we looked at each state. We came up with a bunch of measures, a bunch of areas that we wanted to look at, and what we're trying to do is decipher how open our states to provide, allowing patients to seek out care in the way that they feel is best, and at the same time, how open are they to allowing providers in hospitals and doctors and nurse practitioners and everybody on the sort of the producer side to delivering healthcare as well. Jared, I think that's an important conversation to be having now, because would you say that to some extent the national conversation kind of frames it as if healthcare is all about insurance, that it's all about a national program. But you're looking at a far more complex picture as to what really constitutes effective healthcare. That's exactly right, yeah. Really in the last, certainly through the Affordable Care Act era, the Obamacare era, we have really been focusing on insurance coverage. Do you have an insurance card? But the problem there is that they're just giving somebody an insurance card isn't the same as delivering healthcare to them. So somebody might be covered, but if you try to use that coverage, you may say that you have coverage, but if you try to find a new position to take you onto that panel, you might have a hard time accessing care. If you might think that you have coverage, but then when you go to use it at a hospital, you might find that you don't have what you think you do. In fact, wouldn't you agree that there are probably in every situation a myriad of laws, regulations at the state, county, federal level, as well as circumstances that have a great bearing on whether healthcare is delivered effectively. These things go well beyond the insurance program. Exactly, yeah. We've been talking about insurance at the federal level, this notion of this nationwide program, but so much really depends and is influenced at the state level. Knowing or at least having a sense that we might be in a scenario where we can never predict the future exactly and what's going to happen in Washington, what's going to happen with the formal character, would it be changed depending on who's in the office? Knowing that that is going to be a little bit of a murky situation for a while, we decided to take a step back and say, well, nobody's really looking at states maybe as much as they should, so let's take a look at what regulations and things are on the books at the state level and see how that could be used to, that could be a different place to look for change. I'm glad you mentioned that because such a focus has been placed upon national policy that we've talked largely in terms of broad strokes, but the reality is even prior to the Affordable Care Act, states were key players in determining healthcare outcomes and availability within the states. In our instance, Hawaii, for example, we had up to 90% coverage of all people in a public-private partnership before the Affordable Care Act and the remaining 10% were generally covered by charity and so it was a system that worked, there were five states that were actually examining Hawaii's healthcare system as a prototype for their own and then a sweeping law came into place, the Affordable Care Act, that's pronounced from a national frame of reference what should be done across the nation. What kind of problems did the Affordable Care Act create for individual state programs when it was implemented as a nationwide mandate? Well, I mean, certainly there's a big question of, to what extent should a state participate in the Medicaid expansion? Do you accept that money and knowing that it comes with the requirement of expanding those roles? That's a really tough question. Some people, they look at that and they figure, hey, it's in free money, you're getting some, you're north of 95% of the match, paid for from the federal coffers, but that decreases over time and so that it's tempting to do that now, but you have to think about really the long-term ramifications of that in a state budget and if you're trying to run a state, that's a harder decision than a lot of people gave it credit to and so that's why we saw some states really struggling with that decision, whether to expand Medicaid or not. Jared, in a few moments we're going to go to the actual tool that you are working on that measures health care delivery state by state and we're going to take a look at what it shows for Hawaii, but first, before getting down to that level, let's just look overall. What in your assessment were some of the strengths as well as perhaps some of the weaknesses of the Affordable Care Act known as Obamacare? What are some of the just major strokes with regard to that? Oh, well, that's certainly a bit of a can of worms, right? And I've actually been, I've been fortunate to duck out of some of the day-to-day kind of, you know... Let me narrow it. Let me... It will lose coverage for... Let me narrow it down for you. Yes. The election yourself. I'll narrow it down to you to make it very, very narrow and that is, in terms of health care delivery of the actual goods to the individuals who need it. How well do you think the Affordable Care Act has done across the nation? You know, it hasn't done anything for cost. You know, some people can argue that it, you know, it gave a lot of people coverage, but it never really addressed cost at all. And so that remains a problem and it's, you know, it's not terribly impressive to be honest. If you see, you know, you have these like three-legged stool, right, of cost and access. And when you have, when you focus on just one part of that, with, you know, while ignoring the sort of ramifications on the other parts of that, of those connected components, that doesn't really bode too well and it doesn't make it a long-term program that's very sustainable. And that's what we're seeing right now, you know, we have, we may have added 20 or 25 million people to the roles of coverage, but you have to ask what does that mean and what the coverage mean in that context and also what did it cost? And there's also this sort of forgotten person too of all these people whose coverage, whose insurance premiums went up as well because there are certainly victims, so to speak, of the affordable care act as well. We like to hear the nice stories and we like to see the nightly news that portrays the anecdote here or there with, there's somebody who had the pre-existing condition that now they can get the coverage for that whereas before they were excluded and that feels nice, but what it does is it really separates and starts to sever the idea of what insurance should be anymore. That's right. You know, the pre-existing condition is, you know, it's a tough nut to crack, but, you know, with high-risk pools, you know, there are ways to get, kind of get around it, but certainly in the long-term what you need is, you need a, if you're going to call it insurance at all, then you have to, it has to be created in some way that is priced based on actual risk, otherwise it really isn't insurance. We would actually be, we're kind of doing ourselves a disservice to even call it that anymore. Once it doesn't represent anything having to do with risk and once it's really just prepaid healthcare and even the things that you're covered for you, you know, those things more and more are being dictated to us as consumers and that's a real problem. Well, you talk about the nightly news as being the source of information about the quality of healthcare across the country and it becomes anecdotal rather than based upon research and what I like about your project at the Dartmouth Institute is that you take away the politics, you take away the perceptions that come through the media and instead you look at the hard data by identifying the actual variables that constitute healthcare delivery and measuring them and do so in a comparative way. But first, I was interested in some of the research that you've done here that shows that perhaps the reality doesn't fit with our political perceptions. For example, your research points out that the states that happen to be the bluest of blue states like, for example, Oregon may not necessarily have that much leeway and openness with respect to their administration of the Affordable Care Act or healthcare coverage, whereas states that are generally known to be red states like Georgia may not be as restrictive as people think. Could you comment a bit about this, about perceptions and politics in terms of what you've actually discovered through hard data? Right. I think that was interesting that, you know, we really didn't see a red state, blue state story play out here. I mean, I think that, I think the red state, blue state thing might be a little bit overdone anyway because the more we see national elections results roll in, the more we tend to understand it as an oral work, an urban rural divide, or a county by county kind of divide. But, you know, even all that said, you're right, we saw some blue states where, you know, typically maybe you associate blue states as being more command and control in certain ways, but that wasn't necessarily the case in the index that we did. There were certainly plenty of areas where blue states did fine. And then by the contrast there, if you're operating under the assumption that a red state's going to be all free market, well, you know, there are plenty of examples where there are some red states that really didn't do too well. And you mentioned Georgia. Georgia, you know, was 51st in our analysis. Of course, we included DC, so that's how we get 51. But, you know, so Oregon, a blue state doing a little bit better than maybe you'd think if this has a, you know, bar index has an element of freedom assessment to it. And, you know, a red state like Georgia doing worse. Same thing with Texas. You know, Texas doing, you know, not so well in certain areas. You know, because we didn't set out for this to be a political tool. This is definitely intended to, yeah, this is intended to be something that, you know, policymakers can reference as, you know, as a thing to get them. So I'm sorry, I'm going to cut that right there for a break. We need to jump to right away, Jared. But this is fascinating. And we'll pick up and actually take a look then at the data that you presented in terms of health care distribution from the Dartmouth Institute. I'm talking to Jared Rhodes. This is Kaili Akina. We'll be back on a Hanukkah goal in just a second. Don't go away. Hi, I'm Chris Leitham with The Economy and You. And I'd like to invite you each week to come watch my show each Wednesday at 3pm. I've got the Beagle sisters here with a healthy tip. We encourage you to enjoy the food you eat this holiday season and keep it local and healthy. Yeah. Eat the rainbow, eat the rainbow. And if you need any produce, come to the red barn on the North Shore. Aloha. My name is Josh Green. I serve a senator from the Big Island on the Kona side. And I'm also an emergency room physician. My program here on Think Tech is called Health Care in Hawaii. I'll have guests that should be interesting to you twice a month. We'll talk about issues that range from mental health care to drug addiction to our health care system and any challenges that we face here in Hawaii. We hope you'll join us again. Thanks for supporting Think Tech. Aloha and Happy New Year. It's 2017. Please keep up with me on Power Up Hawaii where Hawaii comes together to talk about a clean and just energy future. Please join me on Tuesdays at one o'clock. Mahalo. Welcome back to Ahana Tako here every week on the Think Tech Hawaii broadcast. My guest today is Jared Rose from the Dartmouth Institute of Public Policy talking about a terrific tool for actually measuring how well health care is distributed, the H-O-A-P. Now, before we go to that, I do want to say thanks to the Think Tech Hawaii team that is here. Jay Fidel and a wonderful group of employees and volunteers who are putting out 30, 35 or more hours of original content every week produced in Honolulu, Hawaii and broadcast across the world. And you can take a look at that always at ThinkTechHawaii.com. And you can visit my website, the grassrootinstitute.org. Well, now back to Jared Rhodes and again, I apologize that our Skype is not working well today. So we get a wonderful portrait of Jared here as he talks as one of our nation's true experts in looking at the actual data. Jared, the H-O-A-P or the Health Care Openness and Access Project looks at several categories or indices about how many are they? And what are a couple of sample categories? Sure. So there are there are 38 individual measures. So so that would be a certain example of an individual measure is how many, you know, certificate of need restrictions does a state have? Or does a state allow medical marijuana, for instance, you know, a yes, no or or in between some states have in between answers to those things, certain exemptions and such. So there are 38 individual kind of questions like that that you can think of. And then we found it helpful to instead of just talking about 38 completely different things to we explore them differently. But then we we combine some of them into categories where it makes sense. And so what we have is ultimately 10 categories. Sure. Now Hawaii is ranked in each category. And as I understand the index, there's an overall ranking, the rankings go from one to five, one being the lowest, five being the highest, kind of like an F all the way up to an A one to five. And in many categories, Hawaii ranks very well, four and five. And in many categories, Hawaii ranks very poorly, one and two. And even before we dive into the data itself, is this fairly common to see that when we actually define health care by specific standards, that we find states with lots of ones and twos and lots of fours and fives, and that really in general, there's no one single care care characterization of how a state is doing in terms of health care. That's exactly right. We, you know, when we we looked at these states in depth, and we found that states really all over the map, no pun intended, the there, you could be the leader in one area as a state, and then that's the very same state might be in the very bottom for the very next category. You know, even we're talking about Hawaii, you know, you Hawaii is number one in one of the categories, which looks at the corporate practice of medicine. In other words, how open is a state to allowing non doctors, organize medical services and deliver health care like that. And in other words, it's a category that's good to be open and it leads to a lot of innovation. And Hawaii actually did very well in that one. But then if you look to the very next category, something like insurance, where you're looking at, well, you know, how many, how many regulations, how many state mandated insurance benefits are there? How many, you know, what does it do for, does it mandates rate review, that sort of thing, you know, what kind of regulations and requirements does it levy upon insurance companies, who I think would would be better off if they could, if they could innovate their for their business models as well. And, you know, in that category, your Hawaii is 41st. So, you know, it can be, you know, a single state could be very good in one area, not so good in the other or anywhere between. And for our viewers who are from Hawaii or who have a particular interest in how Hawaii is doing, it's not really the case, isn't that Hawaii is the worst state for health care, nor is it the best state for health care? What index number did you assign to Hawaii if you have that in front of you there between one and five, just overall? Well, so overall, I mean, if you want to think of it as the, as the rank, you know, so first or 51st, because we included DC, you were actually 29th, which is, you know, pretty close to the middle. Pretty much in the middle of the country. Now, you were talking a bit about the first index, and that is the corporate index, and I thought that was rather interesting, because you simply measured the data, but you haven't interpreted it from any political sense. And I can imagine that when we look at these numbers, people could fall on either side in terms of saying it's a good number or a bad number, but you pointed out that compared to the rest of the nation, Hawaii is right at the very top with four sets of 5.0, which is a letter A right at the top in terms of how business has control over medicine. For example, the state allows corporate practice of medicine, in other words, businesses to own medicine, that's 5.0, allows businesses to employ licensed health care professionals, that's 5.0, allows non-licensed individuals to own or operate medical practices or medical entities, 5.0, or allows licensed individuals to split fees with non-licensed individuals, that's 5.0. My first question is, is this rather uncommon across the nation, this level of corporate control over medicine as a professional practice? Yeah, so you know, Hawaii really stands out. I mean, there are there are a number of states, so it ties for first in this one, so there are other states that also got fines across the board, but not many, and so it does stand out as a good thing for Hawaii. Now on one hand, those who believe in free market economies and free enterprise might rejoice that it's possible to own medical practices, but those who look a little deeper and see that these are generally held by large associations affiliated with the government might not be so happy about that, so what is the general implication of such a concentration of medical practice in corporate entities? Well yeah, and I just want to jump in and say that that for for anybody who, you know, I do want to kind of reach across the aisle, so to speak, and say, you know, look if you if you're looking at our index like this, and you see something like what you just talked about with the, you know, like the corporate practice of medicine doctrine, if you are, you know, into into policy, and if you kind of disagree with one of those things, or if you think the scale should be flipped because we're calling something good that you think is bad, or, you know, vice versa, you would have it the other way, we also posted on our website which is notatus.org slash H-O-A-P, we posted the spreadsheet, a very simple kind of Excel spreadsheet, where you can go in and actually change those, and you know, just kind of flip the orientation on them, because that has the raw scores in it, and if you wanted to see, you know, well how does that change the state ranking, you know, so it can be overwritten, because, you know, and we did that because we want to, we want to be open to the people in the research community and the policy community, so that's the kind of thing, you know, maybe you don't agree with that particular category, or maybe, for instance, another one that could be potentially controversial is the whole medical marijuana thing, if you were really opposed to medical marijuana, you think it's a bad thing that a state is open to it, or you could go and flip that around, and you could, you could see what, you know, what effect that has on your numbers, so that's one feature of the tool as well. Certainly. Now you talk about direct primary care as one of your indices, and at the very outset, I understand that to be an alternate form of financing medical care, could you define that a bit, and tell us a little bit about how Hawaii stands in this one, where we're not really quite there at the top in terms of your measures. Sure, so direct primary care, it's a different form of primary care that is basically a monthly subscription, and this exists in a growing number of states, it's a relatively new thing, although really if you think about it, it's kind of a, kind of just a new take on an old idea that had been crowded out. It's where you pay, just kind of like a monthly subscription, and it's very, it's very affordable, or something on the order of usually $45 to $75. We're not talking about concierge care for the celebrities, where it's a, you know, $10,000 a month retainer fee, but what we're talking about is that it's a relatively affordable, you know, probably less than your cable TV bill, in order to have what is generally offered as a pretty unlimited access to a primary care physician in your community. And these, these direct primary care practices, the physicians practice there, often will have all sorts of things that they can do on the spot. They will, they will help you. Certainly. They will do some, in many states, you can do, you can dispense a prescription straight from from your practice. If the state allows that, then that's something that they'll do, which is a huge benefit and well worth the $50, because they will give you, they will pass along their discounts. But all the regular office hours and office visits, a lot of times people will do little tests and you can get blood tests done on the spot and you can get other, other labs done that at very, very, usually it's actually included in that $40 to $50 monthly fee. Well, you're going to have to, we're going to have to leave this as a little sampler of your work because this has been so fascinating. We've come to the end of the hour and I just would like you to give the website, if you would, at which people can actually dig in and take a look at this, these and other measures. What is the website? Absolutely. It's markadis.org slash cope as an H-O-A-T. One of the indices indicates that we're fairly low in terms of some of the occupational regulations. For example, we don't allow midwives as other states do or we don't have reciprocal exchange of medical licenses with other states to the extent other states do. Given all of that, Jared, I think we're going to be looking at a lot of information. I want to thank you so much for taking the time today. Keep up the good work to give them the objective information. Jared Rose. Absolutely. Thank you very much.