1 1 ILLINOIS DEPARTMENT OF PUBLIC HEALTH ADEQUATE HEALTH CARE TASK FORCE 2 WEDNESDAY, JANUARY 25, 2006 10:30 A.M. - 1:30 P.M. 3 4 IN RE THE MATTER OF: ) ) 5 ) ADEQUATE HEALTH CARE TASK FORCE ) 6 MEETING 7 RECORD OF PROCEEDINGS before THE 8 ADEQUATE HEALTH CARE TASK FORCE, at The Michael A. Bilandic Building, located at 160 North 9 LaSalle Street, Room N502, 5th Floor, Chicago, Illinois commencing at 10:30 a.m, on January 25, 10 2006, upon the meeting of the above-entitled cause. 11 12 PRESENT: 13 MR. DAVID CARVALHO, Deputy Director MR. DAVID KOEHLER, Speaker of The House 14 MS. ASHLEY WALTER, Policy Analyst MR. RANDY HALL, Intern 15 MR. WAYNE LERNER MR. CRAIG BACKS 16 MS. NIVA LUBIN-JOHNSON MS. CATHERINE BRESLER 17 MR. TIMOTHY M. CARRIGAN REP. ELIZABETH COULSON 18 MS. JAN DAKER MS. MARGARET A. DAVIS 19 MR. JIM DUFFETT MS. PAMELA D. MITROFF 20 MR. MIKE MURPHY MR. JOSEPH ORTHOEFER 21 MS. RUTH ROTHSTEIN MR. GREGORY S. SMITH 22 MR. KENNETH L. SMITHMIER MR. QUENTIN YOUNG 23 MR. PATRICK GALLAGHER MS. DIANNE RUCINSKI 24 MS. SHANNON LIGHTNER MR. RALPH SCHUBERT

2 1 MR. JOSEPH HYLAK-REINHOLTZ P R E S E N T 2 MR. CHRIS LIGONE 3 MS. ELENA BUTKUS MR. ARTHUR G. JONES 4 MS. STEPHANIE BECKER MR. JIM JORDAN 5 MR. RALPH DARVIN MS. SHANNON LIGHTNER 6 MR. BRUCE CAMPBELL MR. DON SCHUMACHER 7 MS. MELISSA BINGER MR. MARK JONES 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

3 1 MR. LERNER: Good morning. Happy New 2 Year. I'd like to call the meeting to order. As 3 we, typically, do, go around the room and 4 introduce yourselves and just give names, serial 5 numbers, and why we've decided to come to this 6 meeting. Elena? 7 MS. BUTKUS: Elena Butkus from the 8 Illinois Hospital Association sitting in for 9 Ken Robbins. 10 MR. ORTHOEFER: Joseph Orthoefer, 11 retired. 12 MR. LERNER: A doctor? 13 MR. ORTHOEFER: Yes; Public Health. 14 I'm a veterinarian. I'm not a physician. 15 MR. LERNER: Thank you. 16 MR. DUFFETT: Jim Duffett with the 17 Campaign for Better Health Care. 18 MS. DAVIS: Margaret Davis with the 19 Health Consortion of Illinois, 20 MS. DAKER: Jan Daker. I'm an 21 organizational development consultant, but I'm 22 here for the United Congregational Metro East -- 23 MS. ROTHSTEIN: Ruth Rothstein, retired. 24 MR. YOUNG: I'm Quentin Young. I'm

4 1 with the assistance for the National Health 2 Program. 3 MR. ROBERTS: Joel Roberts, Kay Witz and 4 Associates (phonetic). 5 MR. KAYLER: Dave Kayler, Peria Area 6 Labor Management (phonetic). 7 MR. LERNER: Wayne Lerner with The 8 Rehabilitation Institution of Chicago. 9 MR. CARVALHO: Dave Carvalho with the 10 Department of Public Health. I'm here with a 11 cold, so nobody shake my hand. 12 MR. SCHUBERT: Ralph Schubert, 13 Department of Human Services. 14 MR. HYLAK-REINHOLTZ: Joseph 15 Hylak-Reinholtz, Department of Health Care and 16 Family Services. 17 MR. BACKS: Craig Backs, Illinois State 18 Medical Society. 19 MR. GALLAGHER: Patrick Gallagher, 20 Illinois State Medical Society, filling in for 21 Tracy Printen. 22 MR. MOORE: Jim Moore, OSS Health Care 23 System. 24 MR. SMITH: Greg Smith, Group Marketing

5 1 Services. 2 MR. SMITHMIER: Kenneth Smithmier, 3 Decatur Memorial Hospital. 4 MS. WALTER: Ashley Walter, Illinois 5 Department of Public Health. 6 MS. RUCINSKI: Diane Rucinski, 7 Department of School of Public Health at the 8 University of Illinois. 9 MR. CAMPBELL: Bruce Campbell. I'm 10 here just as an observer. I saw that this 11 meeting was on the website. 12 MR. LERNER: Tell them what you do. 13 MR. CAMPBELL: I'm President of 14 Lutheran General Hospital. I'm here as an 15 observer and a citizen concerned. 16 MR. LERNER: Thank you very much. 17 MS. ASHBURN: Ashley Ashburn 18 (phonetic). I represent the individually insured 19 informally. 20 MS. BECKER: Stephanie Becker with 21 Health Disabilities. 22 MR. JORDAN: Jim Jordan, and I 23 represent Kramer Insurance. 24 MR. DARVIN: John Darvin. I'm an

6 1 employed benefits consultant in Illinois. 2 MS. LIGHTNER: Shannon Lightner with 3 the Office of The Governor. 4 MR. LERNER: Thank you, very much. I 5 think that's everybody. There may be a few more 6 people, who are coming in, and I'd like to call 7 the meeting to order. I'd like to remind 8 everybody that if we have pagers, PDA's, or cell 9 phones, please put them on off, mute, vibrate or 10 whatever rocks your boat. Let's try and keep 11 cooperate as we move forward. Also, for those of 12 us with various types of impairment, including 13 hearing, we need to make sure that everybody 14 speaks loudly as we make our presentation. Where 15 is Ashley? Do we have a quorum, yet? 16 MS. WALTER: I don't think so. I think 17 we're one short. 18 MR. LERNER: I'd like to hold on the 19 approval of the minutes from November 30th, until 20 we, actually, have a quorum, because we can't 21 vote. Okay? 22 Public hearing briefings, I don't 23 have a list with me, but there were a few. I'm 24 going to start it out by asking my good friend,

7 1 Margaret, to report on the ones that I know she 2 attended; and I ask anyone else who attended the 3 briefings to fill in and give us their 4 perspective. Margaret? 5 MS. DAVIS: Okay. At the Naperville 6 hearing, they had about 13 verbal testimonies. 7 What's striking about that, that's a very 8 high-end community, a lot of high-income 9 residents, but Edwardsville Hospital is reporting 10 a $50 million charity hit. 11 MR. LERNER: Five zero? 12 MS. DAVIS: Fifty zero;, and I thought 13 that, that was just astronomical for an area that 14 is about -- essentially, saying, it is really 15 high-income; and the hospitals are really 16 concerned about not carrying all of this burden 17 on their back and having it spread to maybe the 18 general revenue fund. There's organizations that 19 are trying to establish entrepreneurship, and 20 they're running into the fact, that, even when 21 trying to move women from welfare to work through 22 entrepreneurship opportunities, they're hitting 23 barriers of not having insurance for the women. 24 One of the gentlemen, who does not

8 1 seem to be a proponent of the Single Payer Plan, 2 he wants us to look at maybe -- because they're 3 not coming to the hearings, how could we get the 4 input from citizens, who don't believe in the 5 Single Payer Plan, because they don't seem to be 6 coming to the hearings and giving their voice. 7 MR. LERNER: Thank you. Was anybody 8 else attending the Naperville hearing, who is 9 here? David, any other perspective? 10 MR. KOEHLER: No. I think that pretty 11 well sums it up. I think regardless of City 12 influence in the community, obviously, people are 13 slipping through the cracks, and I think that's 14 what we're seeing to some degree in every hearing. 15 MR. LERNER: Okay. The next one after 16 Naperville was Aurora. 17 MR. KOEHLER: I was at Aurora, as well. 18 MR. LERNER: David, start it out. 19 MR. KOEHLER: The same type of thing, I 20 guess what I'm struck by is, again, the 21 individual stories. I don't think we're hearing 22 necessarily anything new, but hearing it and 23 seeing the emotion or the sincerity in which 24 people are testifying is making an impression

9 1 upon me, having health insurance and always have 2 had health insurance. I don't understand what 3 the fear is of not being covered, and I'm 4 starting to see that in the eyes and in the words 5 of people who are testifying. It doesn't seem to 6 make any difference as to whether they have a 7 college education. I mean, we've seen some 8 people who have been physicians, who have somehow 9 gotten caught outside the system with a 10 pre-existing condition or something, changing 11 jobs or whatever, so that's just an impression. 12 MR. LERNER: Any other comments? 13 MR. DUFFETT: Just a couple of other 14 things there, it looks like later maybe in the 15 agenda, not today, but somewhat to talk more 16 about the immigrant community. A growing number 17 of immigrants both documented and undocumented 18 are not being able to get access to care; and, 19 also, once again, I will say mental health 20 continues to be a major issue that continues to 21 be raised, people not being able to have access 22 to mental health. 23 MR. LERNER: Thank you. Any other 24 comments about Aurora? Okay. The one after

10 1 Aurora, see, I've got my cheat sheet, is Franklin 2 Park. Several of us were there. Margaret, do 3 you want to start it? 4 MS. DAVIS: I thought what was 5 interesting, the technologist, who was doing our 6 speaking equipment, got up and testified. He's a 7 businessman who's been a businessman for greater 8 than 25 years and never ever used health 9 insurance. It got so high he allowed it to 10 lapse, and as soon as he allowed it to lapse 11 that's when the disease set in, a blood clot to 12 the leg, and now he's paying through his nose. 13 He's really in debt as a result of this one 14 infraction, and he thought it was unfair having 15 paid 25 years into health insurance and now 16 having to pay out-of-pocket expenses for his 17 health. 18 The Legal Women Voters have been 19 showing up to most of the hearings, and I think 20 that this is a group that really has an opinion. 21 They seemed to be very well organized. They 22 always have good written testimony and their 23 consensus is to have comprehensive health 24 insurance. I just think that organizations like

11 1 that would be a good to maybe once we get our 2 idea of which groups we're trying to go to -- 3 what program we're trying to go to is 4 to funnel it through some of these national 5 organizations and get their opinion on it. 6 MR. LERNER: Jim? 7 MR. DUFFETT: A couple of additional 8 themes, I think preventive care, probably, 9 overlaps nearly at every hearing, and I think 10 more people understanding the importance of doing 11 preventive care, though, there will be a 12 front-end cost with not only the hope of at least 13 recouping some costs, but increased productivity 14 and increased G and P, which I think you 15 mentioned in the minutes in the November 16 meeting. 17 I think, also -- and, also, this 18 is at Skokie, too, as I, unfortunately, jumped 19 ahead, is the safety net providers. I think it 20 is quite fascinating hearing the testimony from 21 the different hospitals in terms of the increase 22 of charity care, and, also, the increase of 23 clientele that they're seeing there. 24 A number of safety net providers,

12 1 who, basically, know that, that's not the 2 solution by expanding the safety net, but, also, 3 knowing that even some programs out there that 4 people could sign-up for, but don't, those aren't 5 necessarily the solution either in terms of 6 there's so many people who fall in between the 7 cracks of those programs. I think in the last 8 few hearings I'm sensing a little more ideas of 9 generic policy, just how we not only need to 10 figure out how we get everybody in, but, also, we 11 need to look not just short-term but long-term as 12 this process unfolds. 13 MS. DAVIS: One of the things 14 at that particular hearing -- what was 15 it, Franklin Park, Representative Skip Saviano 16 was there. I raised a question about the 17 governor raiding all of the health care funds, 18 such as the nursing fund, the dentistry fund, the 19 medical fund, just taking the money out of the 20 funds and not using it to help promote the 21 profession. So that is an area, especially, with 22 me, with such a severe nursing shortage, we need 23 our money for marketing and the increase; and one 24 of the nurses from Rush testified about the need

13 1 for helping to increase the number of teachers 2 for nurses, that, they have such a backlog of 3 students who want to be nurses, but they don't 4 have the teachers. They don't have 5 the scholarship reimbursement. That's an area we 6 want to address. 7 MR. LERNER: Let me just add to that. 8 Susan Gordon from Children's Memorial talked 9 about physicians' statements that NACH put in. 10 That's the National Association of 11 Children's Hospitals. There are a series of 12 principles that she gave us as oral testimony, 13 and, then, she gave us the written testimony. 14 That's been entered into the record. Any of 15 these guidelines or principles are very helpful 16 as we will move down the road, eventually, to 17 re-evaluating models. As we've talked about 18 before, the basis under by which we evaluate the 19 models will be as equally as important as the 20 models themselves. It the principles that become 21 very helpful. 22 Just so everybody knows, we have a 23 direct connection to Springfield in case any of 24 the legislators want to tie in on our line. This

14 1 is your tax dollars at work, but at least the 2 legislators are here. There were a series of 3 conversations about certain populations. We 4 talked about mental health and the issues 5 relating to mental health. The nursing issue 6 that Margaret just talked about really had to 7 deal with adequate supply, during Representative 8 Saviano's commentary, making sure there is an 9 adequate supply of health care workers, 10 professionals, and etc, so, that, if we do, in 11 fact, expand access to services, who will be 12 there to take care of them? That backs into the 13 supply-and-demand issue, which backs into the 14 licensure issue, and that's how we started to 15 create that whole arrangement. 16 A lot of conversations 17 about safety net organizations -- nobody touches 18 the phone now without handwashing, very detailed 19 handwashing. In fact, I'll be changing my seat. 20 Anyway, there's a lot of these 21 conversations about special populations and 22 safety net organizations. I thought it was very, 23 very telling to have that conversation. It was a 24 good conversation. Again, I remind everybody

15 1 that all of those comments, all of the 2 conversations are transcribed and are available 3 publicly through our website. Elk Grove Village? 4 MR. ORTHOEFER: Yes. I can do the Elk 5 Grove Village one. I think the League of Voters 6 Realm Force, so much as the same thing they said 7 there as they've said at the other meetings. A 8 couple of things were notable to me, though. 9 There was a lady, who's running 10 against Henry Hyde, and I gave Ashley her name. 11 She was reciting that she, apparently, had to go 12 to one of the private hospitals, and, anyway, 13 they had a mix-up with her insurance, so they 14 were going to transfer her to Cook County until 15 she could get it straightened out, that, they 16 wouldn't care for her the next day. Even people 17 that do have insurance, apparently, these 18 mistakes occur. 19 The League, of course, mentioned 20 mental health, what they do, they have a 21 listing. I get their newsletter, and they have a 22 listing of points that I think are very 23 important. I don't recall all of them offhand. 24 Of course, the hospitals are all out saying how

16 1 much charity care they give. One of the 2 questions I have for hospitals, nobody was asked 3 the cost of this thing, what it is really costing 4 as far as charity care, but they add up the costs 5 as the ordinary price, and they say that's 6 charity. 7 MR. LERNER: As a sidebar just given to 8 me, the Attorney General's announcement yesterday 9 -- I guess it was yesterday, nobody allowed a 10 conversation about costs and charges and how you 11 add it up, so stay tuned. 12 MR. ORTHOEFER: Anyway, one of them 13 said they're giving $2 and-a-half million a month 14 or something like that, and the other one -- 15 there were two hospitals there, and the other one 16 is saying how much their charity was. They felt 17 it was important, of course. They were looking 18 for some kind of reimbursement for it, because 19 they had to cover that cost. The numbers of 20 people, I suppose about 25 people were there, and 21 9 or 10 did testify. I don't think there was 22 anything different than what was said there. 23 Basically, we're hearing the same thing from the 24 different groups, apparently.

17 1 MR. LERNER: Any other comments or 2 perspectives about Elk Grove Village? 3 MR. CARVALHO: If I could just go back 4 one moment to Franklin Park to clarify for the 5 record? First, Skip Saviano, S-A-V-I-A-N-O, is 6 the State Representative, and I believe Senator 7 Don Hurley (phonetic) was, also, there. 8 MR. LERNER: He did not talk? 9 MR. CARVALHO: He did not. 10 MR. ORTHOEFER: Can I add one other 11 thing? I think this was -- I shouldn't have 12 forgotten. One person testified, he said -- and 13 the people were there, and he said all of the 14 people here, he said, have health insurance. He 15 said, Where are the people that don't have 16 insurance? Where is their testimony in the 17 thing? I felt that was kind of biting, what 18 input are they having into it. 19 MR. LERNER: Thanks, Joe. I think at 20 the last hearing, in Skokie, there was quite a 21 good attendance and quite a number of people who 22 testified. Who wants to start out? 23 MS. DAVIS: I'll start. This notion of 24 hospitals and charity cases, I think that Mark

18 1 Kellitier (phonetic) from St. Francis Hospital 2 kind of put it in perspective. With all the 3 costs of the hospital, they're only experiencing 4 a 1 percent profit margin, and I thought that was 5 interesting, because you really want a bigger 6 profit margin than that, in order, to keep the 7 doors open. So this here notion of charity care 8 is really killing hospitals, as I see in my own 9 community of Bethany Hospital, Advocate having to 10 make decisions to make it a long-term care versus 11 an acute care facility. 12 The other area was people 13 referenced the Bernadine (phonetic) Amendment to 14 try to show that there is public support for 15 health -- comprehensive health care access for 16 all people, and, that, we shook Garner's support 17 from the public. Not only should we make a 18 recommendation, but we should be garnering an 19 advocacy piece, so that when we try to present it 20 to the legislators, we have the public in sync 21 with us. 22 Another area was, that, here a lot 23 of the elected officials sent representatives, 24 and they all had good things to say and a

19 1 commitment to be a part of the process; January 2 Schukowski (phoentic), and another one was Lou 3 Lange, and one other person -- 4 MR. DUFFETT: Schaumberg (phonetic). 5 MS. DAVIS: Schaumberg, okay. Let's 6 see, there was one more thing that I wanted to -- 7 MR. LERNER: Well, while you're 8 looking -- 9 MS. DAVIS: The religious community, I 10 mean, they were powerful. They just made you 11 feel like you better insure everybody, unless 12 you're going to experience the wrath of God. If 13 you're not for giving people the right of health 14 care, how can you call yourself a spiritual 15 person? It really made you think about the 16 admission of -- they were Christians, so their 17 person is Jesus, you know, but how he took care 18 of the less of the people, and, also, always 19 considered the least of the people, who had the 20 great needs and met their needs. They just 21 wanted to remind us that we have a moral 22 obligation to help people. 23 MR. LERNER: Jim, did you have something 24 to add?

20 1 MR. DUFFETT: At all of the hearings 2 that I've been at, and even without the hearings, 3 the fear that people have going without health 4 insurance, and there's something about the Skokie 5 meeting that I sensed intensified. Maybe it was 6 just an elderly woman that was talking about when 7 she was between 52 and 59. 8 MS. DAVIS: 58 and 60. 9 MR. DUFFETT: Just a couple of other 10 people relating to it, the guy from the social 11 workers talking about the I-Chip Program, that, 12 not only what a lifesaver it is, but it is so 13 costly that it is bankrupting him; a lot more 14 about quality of care, and, also, people wanting 15 to be sure that, you know, whatever combination 16 of private-public access that they get to some 17 form of a card, that, there has to be access. 18 We just can't dump these folks 19 with something and expect lower reimbursement 20 rates, which I'd say in the last few couple of 21 hearings, physicians and people from the 22 hospitals were, also, talking about we've got to 23 be sure whatever we come up with, the 24 reimbursement rates are there, so we can get the

21 1 providers to take people. 2 MR. LERNER: If I could just add to 3 that? There are a couple of other things that I 4 found interesting besides what Margaret and Jim 5 talked about. The President of Legal Women 6 Voters from Wilmett made a presentation, a very, 7 very similar presentation, against the series of 8 principles and issues against we could push as we 9 look at models. We had a lot of conversation 10 about Single Payer. Obviously, there were people 11 talking about the hospitals and clergy, as was 12 mentioned. 13 The other one was a fairly 14 extensive discussion about chronic conditions, 15 chronic conditions not being just 16 those conditions to go and do nursing homes, but 17 the whole idea of chronic disease management and 18 how you can think about that going forward and 19 how that has to be part of the overall package. 20 Anything else? 21 MS. DAVIS: One more thing was, that, 22 this here clinic, in Humboldt Park, did a piece 23 on the Telemundo Station, and just from a couple 24 minutes of the clip, they had 392 calls the next

22 1 day, because they were bilingual providers; 392 2 calls, and it was from all over the City, all 3 over many counties, and in Indiana, you know. 4 People were very, very sick looking for health 5 care with a culturally sensitive fashion, so 6 much, though, it just tied up their switchboard 7 and everything, so the need is great. 8 MR. LERNER: Okay. 9 MR. BACKS: I agree with the 10 impressions of the previous speakers. I just 11 want to add a couple of others. There was a 12 preponderance of discussion about the need for 13 fewer barriers, in general. I think the 14 impression I got was not just enough to provide 15 the providers, they need to be in areas that are 16 accessible to individuals, and that's going to 17 vary depending on the circumstances; and, that, 18 those are just as much of a barrier as the lack 19 of insurance. A lot of calls, obviously, for 20 Univer-South (phonetic). I was hoping that 21 somebody would give us the magic hands to finance 22 it, but I didn't hear that forthcoming. 23 One of the things that struck me 24 from the first speaker is, that, she did mention

23 1 how health insurance equals peace of mind and how 2 the lack of health insurance impacts on so many 3 other life decisions, and that's -- the first 4 woman -- my impression, this honestly sort of 5 varies, so why in the world would somebody 6 without health insurance stop driving and, 7 basically, stop living their life? What's the 8 matter with them? I started to think, people do 9 a lot of things as a result of lack of 10 insurance. They take jobs they don't want 11 necessarily, because it provides insurance for 12 them where another job you might be better at it 13 or be better suited. 14 It sort of runs up the dysfunction 15 of tying employment to insurance as not, 16 particularly, a good model to continue or build 17 upon, because -- another person who testified, 18 again, spoke of what happens when you lose your 19 job and how that impacts on your insurance or how 20 the loss of a marriage might impact on it. 21 There's so many seemingly unrelated life events 22 that affect health coverage, and there really is 23 no natural connection between the two. It is a 24 very artificial connection that developed many

24 1 years ago. It perpetuated for no apparent reason 2 that anybody can remember. We can remember it, 3 but it is not clear why we should continue it. 4 The religious community was well 5 represented. I would say, it was not necessarily 6 a broadly represented religious community. It 7 was one specific denomination that was 8 particularly represented, but I don't think 9 there's anything that they said that would be 10 necessarily argued with among others. The 11 religious hospitals are the backbone of the 12 charitable safety net, and so I think -- they 13 weren't outspoken, but they walked the walk. 14 Those are just additional perspectives that I 15 gathered from that being my first hearing, so I 16 can't compare it to others. 17 MR. LERNER: That's two very take-aways, 18 accessibility does not just mean access to a 19 health insurance card. If you don't speak the 20 language and if you don't understand the culture, 21 the hours are not consonant with the hours that 22 are needed by the family, and you have no 23 accessibility, so that issue is a broad basis of 24 accessibility that you brought up. It is a key.

25 1 The other is a greater hop, the 2 access to health insurance as an enabler or 3 hurdler getting on with the rest of your life, 4 not health insurance just because of how it is 5 paid for or where it comes from. It is just a 6 key ingredient in your life and how it could help 7 you or harm you going forward. I think that's a 8 very important point that, that wonderful woman 9 made, and we shouldn't forget. Any other 10 comments? 11 MR. BRESLER: Just briefly, I apologize 12 if they were covered already, I walked in late, 13 but a couple of impressions that I was having is 14 the use of the term "universal health care" and 15 how I really think that -- universal coverage, 16 you know, and how those are used anonymously; but 17 sometimes I think people are talking about 18 different things, and they talk about wanting to 19 get access to the physicians, wanting to have the 20 information that they need, in order, to find out 21 who can care for them and where the coverage is 22 going to come from; which ties into my second 23 point, which is, people need information about 24 what is already out there, what they can access

26 1 and how to access it, and I think that's really, 2 really important, because you hear a lot of these 3 people talking about the inability to access 4 health insurance coverage. 5 Well, as we've discussed so many 6 times, there are other programs, and I think 7 people just need the information to know how to 8 get a hold of that stuff, and, that, universal 9 health care doesn't equal universal health 10 insurance coverage necessarily. We just have to 11 keep those distinctions in mind as we go forward. 12 MR. LERNER: Thank you very much. 13 MS. MITROFF: I attended the Naperville 14 and Aurora hearings, and one of the things that I 15 picked up on, in addition to what Catherine was 16 just talking about, is the idea of personal 17 responsibility. Several physicians got up and 18 spoke about the need for people to understand, 19 that, there is a cost for the services that they 20 receive, and, that -- one of them said something 21 about if anyone could have a BMW, we'd all like 22 to have one, if someone else is paying for it. I 23 thought that was kind of interesting. 24 Backing into that kind of personal

27 1 responsibility, one woman spoke about the fact 2 that her son was a doctor and almost a lawyer, 3 and he couldn't understand how to get health 4 insurance. It sounds to me like he was a pretty 5 smart guy. So touching on what Catherine said, 6 maybe we need to somehow make sure that the 7 information is available, that, people understand 8 that there are avenues that could help them 9 navigate the system. 10 MR. LERNER: Thank you. 11 MR. KOEHLER: Just a couple of times, 12 it hasn't been mentioned a lot, but people who do 13 talk about it want to make sure that we are -- if 14 we are thinking about dental coverage and the 15 need for dental services as a part of the health 16 care system -- I know we talked about mental 17 health, but there are other things that, 18 certainly, relate to health care that we can't 19 use loose in our conversation. 20 MR. LERNER: Anything else? Lots of 21 action. I want to now go back. We had a couple 22 of people join us since we went around the 23 table. Actually, I don't think you introduced 24 yourself, did you?

28 1 MS. WALTER: I did, but I'm Ashley 2 Walter with the Illinois Department of Public 3 Health. 4 MR. LERNER: She's so important, she 5 should introduce herself several times. 6 MR. CARRIGAN: Tim Carrigan from the 7 University of Illinois Hospital. 8 MR. BRESLER: Catherine Bresler, 9 Trust-Mark Insurance Company. 10 MR. GAVIN: Ralph Gavin with the Health 11 Care Concession. 12 MR. LERNER: Going around the table, 13 Gentlemen, introduce yourselves. 14 MR. MURPHY: Paul Murphy, Employee 15 Benefits Consultant. 16 MR. SCHUMAKER: Don Schumaker. 17 MS. BINGER: Melissa Binger, Streizer 18 Center. 19 MR. LERNER: Around the table. 20 MS. MITROFF: Pam Mitroff, Pam Mitroff 21 Consulting. 22 MR. MURPHY: Mike Murphy with Wellpoint. 23 MR. JONES: Mark Jones. 24 MR. LERNER: Everybody, for reminder, if

29 1 you came in late, please turn your phone or PDA's 2 on vibrate or off. Obviously, we're having 3 someone transcribed all of our notes. You have 4 to speak loudly, so she could pick up all the 5 words that we are providing. With that, I think 6 we have a quorum. I'd like to ask for approval 7 of the minutes for November 30, 2005? 8 THE QUORUM: So Moved. 9 MR. LERNER: Second. Any additions or 10 corrections? All in favor please say aye? 11 THE QUORUM: Aye. 12 MR. LERNER: Any opposing? Any 13 extensions? David, do you want to tee-up the 14 presentation? 15 MR. KOEHLER: Yes. Thank you. Several 16 years ago, Dr. Rucinski had the job of giving any 17 details of the information. Several years ago, 18 the State asked Dr. Rucinski and her team to look 19 into the numbers in terms of the uninsured, and, 20 then, profile the uninsured and get an accurate 21 count and picture of the uninsured and 22 under-insured in Illinois. 23 A lot of policy was being 24 developed based on what data were available with

30 1 the understanding of the weaknesses in those 2 data; and while, as we said in prior meetings, 3 you know, knowing whether it is 11.275 versus 4 11.193 is not necessarily deriving any important 5 policy decisions; but having a sense of what is a 6 good snapshot of the uninsured in Illinois and in 7 adding data to or debunking certain thoughts 8 about who are the uninsured and where are the 9 uninsured, and how long are folks uninsured and 10 things like that, it would be useful to have a 11 policy determination. 12 As you may have, also, recalled 13 from prior meetings, the State received a grant 14 from PERSA (phonetic) Federal Agency a couple of 15 years ago onlooking into the uninsured and 16 strategies for dealing with the uninsured; and so 17 we asked Dr. Rucinski to come and make a 18 presentation this morning to you both on that 19 subject and for the further work that she's done 20 in this area since that time. So I'd like to 21 thank Dr. Rucinski, who is at the Illinois 22 University School of Public Health and a great 23 resource to the State agency that can help you on 24 the subject. Dr. Rucinski?

31 1 MS. RUCINSKI: Thanks very much, and, 2 David, thank you. I'm going to try and not get 3 in front of the light too much. I know people 4 have the notes in front of them, and I hope you 5 could see, if you'd prefer to look up this way, 6 but I am with the University of Illinois -- 7 Ashley, is there a clicker or -- 8 MS. WALTER: I could advance them for 9 you. Real quick, if there are extra copies of 10 the presentation along the back, can you please 11 send those around? Thank you. 12 MS. RUCINSKI: As we have as resources 13 through our tax dollars many sources of 14 information about health insurance, and the ones 15 that you're, probably, most familiar with come 16 from the current population surveys, which is, of 17 course, the data source that we use to measure 18 unemployment. That's the purpose of the survey. 19 It is a labor survey, so there's a supplement 20 where we start where we ask about health 21 insurance. That's the one that the Federal 22 Government uses to generate reports about changes 23 in insurance. It has several advantages that 24 make it a powerful instrument for doing that.

32 1 We have the Behavioral Risk Factor 2 Surveillance System. This is a State, Federal 3 partnership. It, also, collects health insurance 4 data among other things, other public health and 5 individual health behaviors. The survey of 6 income and program participation, the income -- 7 the survey of income and program participation is 8 a panel survey that gives us a good sense of the 9 dynamics of health insurance coverage and program 10 participation. As publicly funded programs, it 11 involves surveying the same people over time. 12 The National Health Interview 13 Survey is a telephone survey that is done, again, 14 another national survey. It gives us a good 15 sense of people's health insurance coverage and 16 utilization; Medical Expenditures Survey, which 17 is related to the National Health Interview 18 Survey, it involves surveys about expenditures, 19 as well, health insurance and what people 20 actually spend on health care. 21 Then, I, also, added the small 22 area of health insurance estimates. This uses 23 existing data to do statistical modeling, and it 24 gives health insurance estimates. If you go to

33 1 the website, a small area of health insurance 2 estimates program, again, using data that are 3 somewhat dated, you could get health insurance 4 estimates for counties in Illinois and for other 5 small areas. Again, it uses statistical 6 modeling. 7 Ashley, if you could go to the 8 next one? All of these health insurance data 9 services have strengths and weaknesses in scope, 10 and by that I mean what the population frame is. 11 This current population survey, again, is a 12 larger labor survey, and that is the scope of the 13 survey and what they do best. It does have an 14 affect and has been demonstrated to have an 15 affect on health insurance estimates. 16 For this group, I think the most 17 important thing to know is, that, up to 24 18 percent of the data are imputed. That means, 19 that, there are missing data points for health 20 insurance in the CPS, and they model what it 21 ought to be given a number of other factors; but 22 there have been some questions on how that 23 affects other estimates, such as, public survey 24 and participation rates is based on CPS.

34 1 The sample size is an important 2 variable. Again, the CPS Behavioral Risk Factor 3 Surveillance System, they all use data -- the 4 projections from the data don't allow us to make 5 good estimates for different regions. The 6 Behavioral Risk Factor Surveillance System 7 Survey, even though it focuses on Illinois and we 8 have our own data collection efforts going on -- 9 ongoing with it, it doesn't allow us to do really 10 precise estimates of what we consider to be the 11 five regions in the State of Illinois: Cook 12 County, Decolar (phonetic) County, Northwest 13 Central, and Southern Illinois does really well 14 with the whole state. 15 The content of the survey, again, 16 all of these surveys ask health insurance 17 questions a slightly different way. They have 18 different questions preceding the health 19 insurance questions, which sometimes implements 20 the estimates, the motive data collection, in 21 general. We find some of the best coverage in 22 terms of describing a representative sample from 23 in-person interviews, which is -- you might 24 expect they're very expensive approaches to data

35 1 collection. 2 Telephone surveys, we've had 3 decreasing response rates over time, and that can 4 affect our estimates, and, also, the analytical 5 approach, what I mentioned before with the small 6 area estimates and the ways of imputing data. 7 These all could affect our estimates of health 8 insurance. 9 Finally, for us what is important 10 is continuity. These sources, in general, are 11 continuous data collection efforts, and that is 12 something that we don't have in Illinois. With 13 the Behavioral Risk Factor Surveillance System, 14 it focuses on adults, so it doesn't tell us 15 anything about children, which is an important 16 population group to consider; but they do give us 17 a range of estimates and coupled with other data 18 sources, I think, can be useful in terms of 19 planning a policy. 20 One of the things that I know that 21 this group understands both from their 22 conversations with the public and studying this, 23 is, that, the uninsured is a dynamic population. 24 People move in and out of insurance coverage.

36 1 There's many people who are fortunate to have 2 health insurance coverage throughout their lives; 3 but, especially, when you start working with the 4 lower-income populations, they move in and out of 5 insurance coverage, so there's quite a bit of 6 churn. There are characteristics, though, that I 7 think could be used to form policy. When you use 8 these multiple methods, you could increase your 9 confidence that the policy will work under a 10 variety of settings, which I think we'll find as 11 we go on. 12 What I'm going to focus on, as I'm 13 going to focus on three studies that I've done 14 recently within the last 10 years for the State 15 of Illinois, specifically -- certainly, not all 16 of them, but the ones that I think draw on 17 different samples and tell us different things. 18 One is a population survey that 19 was conducted several years ago in preparation of 20 burling out what became the KidsCare Program, and 21 the purpose of the survey was to provide 22 estimates of the number of uninsured children in 23 the State of Illinois and the potential 24 eligibility and participation rates.

37 1 The second was the population 2 survey of the uninsured under the State Planning 3 Grant. The last one I'm going to describe is the 4 population survey of caregivers that was 5 conducted for the Department of Public Aid with 6 us now, health care and family services, to 7 estimate the number of parents who -- not just 8 parents, but caregivers of children who were 9 currently enrolled in KidsCare at the time of the 10 survey to see if they had access to coverage 11 through their employers and to see what potential 12 interests they would have in enrolling in a 13 health insurance program that would be an 14 extension of KidsCare. 15 The population survey of 16 low-income family was to determine the 17 eligibility level, so it was a survey of families 18 with children. When we screened the households, 19 we asked, first, do you have children? Are there 20 children living in the household; and, then, we, 21 also, screened for income. This, again, was the 22 frame sampling frame, if you will. It is a 23 population survey, but within the population we 24 ask, first, do you have children in the

38 1 household. That to us constituted a family; and, 2 then, secondly, we screened for income, and we 3 screened for income by measuring -- by asking a 4 series of income questions and, then, determining 5 if they were at or below 250 percent of the 6 Federal Poverty Level. 7 The survey was a mixed-mode 8 survey. We conducted some of the interviews in 9 Cook County in-person and in the rest of the 10 state by telephone. We did this for cost 11 reasons, and we did the in-person component, 12 because there was a strong belief that people who 13 did not have health insurance often did not have 14 phones, so we conducted some of the interviews 15 in-person, but most of them by telephone. 16 We screened for low-income 17 families. The response rates for the telephone 18 component, it was around 55 percent; and for the 19 in-person component, it was within the 60 -- I 20 think, 67 percent. Ashley? 21 So what we estimated was, in 1998 22 to 1999, approximately, 18.4 percent of children 23 in low-income families below 250 percent of the 24 Poverty Level were uninsured. That was the

39 1 estimate we came up with. Just a 2 disproportionate percentage of them resided in 3 Cook County, which, I think, is not a surprise to 4 anyone in this room, and, that, the smallest 5 percentage of uninsured children resided in 6 Southern Illinois. We split the state into the 7 five regions that I'd mentioned before. 8 The families of insured and 9 uninsured children are working families, so 10 they -- in this slide we have the green 11 rectangle, which is families with uninsured -- 12 I'm sorry, with insured parents and children; 13 then, the families with uninsured parents and 14 children is blue; and, then, the yellow is family 15 with insured children and uninsured parents, so 16 those are families with at least one working 17 adult, but we do see the relationship between 18 employment and insurance. Ashley? 19 This has been found in any other 20 surveys. Latino children are the least likely to 21 have health insurance; and African-Americans are 22 disproportionately uninsured compared to their 23 population numbers; and Non-Hispanic, Whites are 24 disproportionately insured or they have

40 1 coverage. Ashley? 2 If we look at the income levels, 3 the uninsured, as we expect at the lower levels, 4 they're more than likely to have uninsured 5 children. As we move to higher levels, there are 6 more likely to be insured children. We, also, 7 found a relationship between the insurance and 8 the size of the employer. Uninsured parents with 9 uninsured children and uninsured parents with 10 insured children were twice as likely to work in 11 firms employing less than 50 people. We know 12 that there's a relationship between firm size and 13 the offering of coverage and the affordability of 14 coverage. 15 Next, I want to talk about the 16 population survey of the uninsured and newly 17 insured. Again, the purpose of this study was to 18 get a more in-depth picture of the uninsured and 19 newly insured in Illinois; and the idea behind 20 that was to understand in terms of comparison 21 what was it, specifically, about the newly 22 insured that we could find out that we could 23 apply to the uninsured, what allowed them to get 24 coverage in this. I think everyone in this room,

41 1 probably, suspects it is getting a different 2 job. It is the purpose of including the newly 3 insured in our screening. It was a random-digit 4 dial survey, which means it was a telephone 5 survey. We did no in-person interviews for 6 study for these purposes, again, for cost reason. 7 We did screen for people without 8 health insurance and people who have been without 9 coverage sometime within the last six months, and 10 it was funded by requests to the State Planning 11 Grant. The idea was that the Steering Committee 12 would be involved in data collection and 13 analysis. The Assembly for the uninsured would 14 use the data to do policy development and 15 consensus building. We would come up with some 16 ideas. Okay. 17 We did a survey of uninsured, 18 which I'm going to describe. We, also -- the 19 Planning Grant, who, also, expanded the 20 Behavioral Risk Factor Surveillance Survey added 21 cases for additional analysis. SIU, also, 22 engaged in a series of focus groups and formed 23 interviews around the State of Illinois to lead 24 to the policy discussion. We've conducted over

42 1 25,000 phone-call interviews to screen for people 2 to participate in the survey, the newly insured 3 and the uninsured. Our response rate was 52 4 percent, which at the time was good, but it just 5 shows you that response rates have been going 6 down. We've estimated that about 8.9 percent to 7 15.7 percent would be eligible to participate. 8 Remember, what we were looking at 9 is, we were looking at people who were either 10 uninsured or newly insured. We didn't contact 11 everyone. As I say, we only contacted about 52 12 percent of the people we wanted to interview, so 13 we put a range in there to say, that, in terms of 14 who is truly eligible in the State of Illinois 15 could be anywhere from about 9 percent to 16 16 percent uninsured or newly insured. We estimated 17 in the survey that 9.7 percent were uninsured. 18 This was lower than the current population survey 19 estimated during the same time period. I think 20 it was like 14.1 percent, so our estimates came 21 in lower than the CPS estimates. 22 This is consistent across many 23 states, who do their own state level surveys, and 24 there are a number of reasons for that; but I

43 1 think one of the most important reasons has to do 2 with the purpose of the CPS and the method of 3 data collection, so we came as other states in 4 with a slightly lower estimate of who was 5 uninsured in the state. 6 Again, we see the same pattern, 7 African-Americans and Latinos are 8 disproportionately uninsured, so -- and 9 Non-Hispanic, Whites, they constituted at the 10 time of the survey about 74 percent of the 11 population in Illinois, and the 55 percent of our 12 sample was uninsured, so considerably less. The 13 Latinos, they constitute 12 percent of the 14 population, but of our samples 16 percent of the 15 uninsured; African-Americans, 15 percent of the 16 population, 19 percent of the uninsured in our 17 sample. Again, we find a relationship between 18 insurance status and income. 19 Again, we talked to people who 20 were newly insured and the uninsured. Within our 21 survey, the uninsured are clustered at the 22 lower-income levels, less than 45 percent and -- 23 less than 133 percent. That's about 50 percent 24 of the uninsured within our survey compared to

44 1 about 32 percent for the newly insured. 2 As you move, you could see across 3 the chart, you see that relationship. The newly 4 insured were less likely to be without coverage 5 for longer periods of time; and so I think the 6 key take-away point of this chart is, if the 7 newly insured are in the pink and the uninsured 8 are in the blue, and if you look at this -- 9 especially, from 12 to 24 months, which is right 10 in the middle there, so that's over a year and 11 beyond. If you look at how this is growing up to 12 about 32 percent of the uninsured that we talked 13 to who had been without health insurance for over 14 60 months. This constitutes a chronic population 15 of uninsured, I think, by anyone's measure of 16 what a chronic uninsured person would look like. 17 Conversely, you, also, see that 18 there are some percentages of the uninsured that 19 have lacked coverage for less than six months for 20 under two years, so there is a chronic 21 population, but it by no means constitute the 22 mass of the uninsured. It is, probably, about a 23 third of the population. Again, this is 2001 24 data. Okay.

45 1 The uninsured were somewhat less 2 likely to be employed than the newly insured, but 3 not by much. The newly insureds were more likely 4 to be employed by a new employer than were the 5 uninsured, so, again, the story here is you 6 change employment, and you can get coverage or -- 7 sometimes maybe people are lucky to get a new job 8 that comes with coverage. There were a series of 9 questions on income and -- I'm sorry, on 10 occupations and industry to see where people who 11 were uninsured were working. 12 In terms of their sector of employment, 13 most of the uninsured worked in services. 14 Although, we see 15 percent working in the trades 15 -- and, historically, the trades have allowed for 16 coverage. It's part of the Union's package of 17 benefits, but we saw in our survey 15 percent 18 employed in the trades; and we did not ask about 19 Union membership in the survey, so we couldn't 20 break it out that way, but 15 percent of the 21 uninsured in our survey did work in the trades. 22 Next slide. 23 This was an interesting one for 24 me. They worked a cross-occupation, so people

46 1 self-reported their occupations, but we coded 2 them. They described what they did, and we coded 3 those occupations. We found that among the 4 uninsured in Illinois, 17.3 percent were managers 5 or professionals or technicians, which I think we 6 heard in some of the reports coming from the 7 community meetings that you've been having, that, 8 to be uninsured can happen to professionals and 9 technicians and managers, as well as, people 10 working and other occupations. 11 Sales, we see 12.7 percent were 12 uninsured just of our sample, which is less than 13 the managers and professionals, which I found 14 interesting; also, again, the laborers and 15 operators, 24 percent. One in 4 percent of our 16 sample were employed in jobs that, at least, 17 historically, had coverage in the past. 18 Less than half of the employers of 19 the uninsured offered coverage to workers in the 20 same position as the respondents. So what we'd 21 asked about -- if they didn't have coverage, we 22 asked, Well, does your employer offer coverage to 23 someone in the same position as you; and what we 24 found is, that, less than half of them worked in

47 1 jobs where they could get coverage through their 2 employer. Among those who did have employers 3 offering of coverage, we asked those who declined 4 their employer's coverage to tell us why they 5 declined, and for most of them there were 6 economic reasons. 7 The first was that they couldn't 8 afford the premiums, and the second was that they 9 believed that the premiums were not worth the 10 cost -- or that the coverage was not worth the 11 cost. Then some of the respondents hadn't worked 12 long enough, so they were planning on doing that, 13 but they just hadn't worked for the employer long 14 enough to purchase the coverage. Some thought 15 that the plans offered by the employer lacked 16 quality. Other reasons are related to the doctor 17 and -- but very small percentages reported that 18 they didn't need insurance or that they had 19 pre-existing conditions. 20 Just over 10 percent of the 21 uninsured had applied for health insurance 22 directly to an insurance company. Of that group, 23 only a small percentage were able to get 24 coverage. Most of them no longer had coverage,

48 1 because the premiums were too high or because at 2 that time of the survey had a pre-existing 3 condition and were denied coverage; but none of 4 them dropped their direct purchase policy, 5 because they were able to get other coverage. 6 Now, the question came up in part 7 of the Planning Grant on trying to figure out 8 different policy options, this issue of what will 9 people pay, what can people pay and discussions 10 of that. So what we did was, we asked the 11 question a couple of ways. We asked people what 12 they were willing to pay for a policy, and, then, 13 we, also, using an experiment of where we 14 randomly assigned different coverage -- different 15 premium amounts, we described a basic health 16 insurance policy that provided coverage for 17 office visits and in dental coverage and vision. 18 It was the basic package that the 19 Planning Group came up with. It was a little 20 wordy question, but we got the basic point across 21 that this was going to be a comprehensive plan, 22 and, then, we asked at different dollar levels. 23 Again, this survey was conducted in 2001, and as 24 you're looking at these numbers think about what

49 1 individual policies actually cost now, and 2 individual policies and -- I'm talking about an 3 individual person's purchase of a group policy, 4 say, through an employer or something like that 5 people were willing to pay when we asked them in 6 an open-ended question, the median response, $77 7 a month. So half of the people were willing to 8 pay a little more, half less, but the mean was 9 $92, and that's for an individual plan. Again, 10 those experimental amounts that we asked -- 11 MS. DAVIS: Can we ask a question? 12 MS. RUCINSKI: Yes. 13 MR. DUFFETT: The question I had, did 14 you break that down, also, by the economic income 15 level of these individuals? 16 MS. RUCINSKI: We did a regression 17 analysis. I have not put that in a slide. 18 MR. DUFFETT: Will you be able to send 19 that to us, because that's really important? We 20 often hear a family of four making $40,000, that, 21 they should be able to down $10,000 for family 22 coverage, but it is impossible for folks in that 23 income level. If you've got that, I'd be very 24 interested in seeing it.

50 1 MS. RUCINSKI: Okay. The $10,000 -- we 2 did not ask about policies that were that 3 expensive. The maximum for family coverage, I 4 believe what we asked for was $400 a month. 5 MR. DUFFETT: I just wondered, somebody 6 making below 200 percent of poverty, how much did 7 they say they'd be willing to pay versus somebody 8 who is uninsured that was at 400 percent 9 poverty? I'd just be interested to kind of get 10 that idea of what people themselves were thinking 11 as they sit around the kitchen table and try to 12 budget their money. They pretty much have a good 13 idea of what type of disposal income is still 14 available. 15 MS. RUCINSKI: There's no question that 16 there's a relationship between income. 17 MR. DUFFETT: Right. 18 MS. RUCINSKI: Income is related to 19 one's willingness to pay disposal income, so it 20 is clearly there; but what was interesting to me 21 was the dollar amounts that people reported that 22 they would be willing to pay. 23 For the individual level coverage, 24 66 percent said that they would be willing to pay

51 1 $100 a month. Now, clearly there's a 2 34 percent, who would not be able to pay $100 a 3 month; 150, you see it starts going down to $250 4 for an individual level coverage. Only 34 5 percent said that they'd be able to pay that -- 6 willing to pay that. What are people willing to 7 pay for family coverage, about $100 a month was 8 the median response or $131 a month was the 9 mean. 10 Just for a comparison at the time 11 that we conducted the survey, I think that the 12 Kieser estimate for family coverage was $230 a 13 month. I'm pretty sure that, that was the 14 amount, that's employer group coverage, an 15 average across the firm size. This is $131, 16 which is the population of uninsured in 17 Illinois for family coverage. 18 MR. LERNER: The frame on this, one, 19 this is not one of you calling up the insurance 20 companies saying I want to be a sole-practitioner 21 and buy insurance, this is assuming some type of 22 subsidy that goes into that equation; is that 23 correct? 24 MS. RUCINSKI: This is just asking

52 1 people, what, if they were able to buy coverage 2 for their family. 3 MR. LERNER: Through an employer? 4 MS. RUCINSKI: We didn't say where it 5 would be from. 6 MR. LERNER: Is there an inherent 7 assumption -- let me rephrase my question. Is 8 there an inherent assumption, that, there's a 9 subsidy here or, that, you are buying this on the 10 retail market? 11 MS. RUCINSKI: No. I would say given 12 my interviews with people on how they understand 13 health insurance, I would say that people would 14 not make that assumption. 15 MR. LERNER: So they think that on a 16 retail market basis, this is the value -- it is a 17 value equation here? 18 MS. RUCINSKI: That was not the 19 question. The question was, What would you be 20 willing to pay? 21 MR. LERNER: Okay. 22 MS. RUCINSKI: I think that when we 23 say -- when we start asking questions about what 24 people understand about the costs of health care

53 1 and what insurance -- you know, what does the 2 employer -- we kick this around. Should we ask 3 respondents whether or not they knew what their 4 employer was -- I mean, what's the total cost of 5 your policy. People don't know that, and they 6 don't know that in part, because many employers 7 -- the only time you encounter that information 8 is during your open-enrollment, where some 9 employers will tell you exactly how much they're 10 contributing and how much you're contributing, 11 but you encounter that information one time a 12 year. 13 Sometimes it appears on -- I know, 14 our Walgreens, they'll tell us what our insurance 15 contributed, but that doesn't tell me what the 16 State of Illinois has contributed every month for 17 my families' coverage. Yes. 18 MR. HYLAK-REINHOLTZ: Was family size 19 considered in this? What is the definition of 20 family here? Three? Four? 21 MS. RUCINSKI: No. We asked them as a 22 respondent if they had a family, so we didn't 23 factor in family size. We just asked them -- we 24 described the plan and just given their

54 1 circumstances what would you be willing to pay 2 for family coverage. Yes. 3 MR. BACKS: I just want to be clear. I 4 understand, and I think it kind of duck-tails 5 with Dr. Lerner's question. The question was 6 what are you willing to pay or able to pay, 7 because I think they are two separate questions 8 in terms of understanding what this really 9 means. I think what Dr. Lerner mentioned, how 10 much do these people value health insurance? 11 They're willing to part with $100 a month for 12 family coverage, whether they consider it out of 13 their own pocket or the employer paid it. 14 I don't believe this -- I think we 15 need to dissolve ourself that employers pay for 16 health insurance. They take money that you would 17 otherwise get in compensation and put it into a 18 health insurance policy. Employees pay for their 19 health insurance, all be it, under different 20 taxation rules. 21 What this is saying in my mind is, 22 Craig Backs, what are you willing to part with to 23 have that case over there? Well, I already have 24 one very much like it, so maybe $5; but if I

55 1 didn't have it when I needed it badly, I'd might 2 be willing to pay 100. I think they're very 3 different questions. I sort of hear the words 4 willing and able interchangeably being thrown 5 back and forth, and that's why I want to be sure 6 that I understand. 7 MS. RUCINSKI: Yes. I can say we asked 8 the question about willingness to spend, but I, 9 also, think that we -- you know, we need to be 10 realistic about who we're talking about, and we 11 did have a slide that showed income levels of the 12 respondents who were uninsured; and I think that 13 when we say what are you willing to pay for 14 health insurance, the distinction for low income 15 people is not -- is a distinction that doesn't 16 make a difference. I mean, there is no -- if you 17 don't have disposable income, there's no 18 difference. It is an ability. It comes down to 19 -- I assume, we presuppose a disposable income, 20 because we have them; but for people at 133 21 percent of the Poverty Level, they do not have 22 disposable income. 23 MR. BACKS: I would suggests, that, 24 there might be some control questions of what

56 1 would you be willing to pay for other things that 2 they might, otherwise, involve themselves that 3 are beyond food and shelter. 4 MR. LERNER: We're going to lose our 5 schedule. Let me suggest to you this issue of 6 willing to pay and ability to pay, the use of 7 disposable income, the value of the equation that 8 goes into someone's decision process, given what 9 they think, we need to tee this one up, as well, 10 but the slide says willing to pay. 11 MS. RUCINSKI: That is true, it does. 12 MR. LERNER: Let's move it along. 13 MS. RUCINSKI: Ashley, can we go into 14 the next? Again, we see a similar relationship 15 here, but we increased the dollar amount in that 16 experimental question. We asked what people were 17 willing to pay for family coverage starting out 18 at $250 a month going to 300, 350, 400, and we 19 never break 50 percent. We're consistently below 20 50 percent of the population of uninsured in the 21 survey, the sample survey, of willing to pay that 22 amount. 23 We, also, asked about whether 24 or not people were aware of the I-Chip Program.

57 1 We found that only 11 percent of the uninsured, 2 in Illinois, had ever heard or read about I-Chip, 3 so it is not a well-known program among the 4 uninsured in the state. Among those who had 5 heard about I-Chip, we asked them why they had 6 not tried using it or -- 29 percent said that 7 they didn't think that they were eligible. A 8 fourth of them said that they couldn't afford the 9 premium, and 12 percent said that the coverage 10 was not sufficient. 11 For the Planning Grant's purposes, 12 we came up with set of -- after looking at the 13 data and reviewing it with the others in the data 14 group, we came up with some ideas. Increasing 15 access through employment based plans has the 16 potential to help some of the uninsured, because 17 the insurance was available through the 18 employer. Some of them elected not to have that 19 or could not get it for whatever reason. The 20 employers' sponsored coverage, however, continues 21 to erode, and we've seen that even recently. 22 There's been a further decline in the percentage 23 of employers who offer coverage. 24 Again, 40 percent of working

58 1 people do not have access through their employer 2 for coverage, and costs remain a significant 3 impediment to joining the employer's plan; 75 4 percent of the uninsured were uninsured for over 5 six months; 64 percent were uninsured for over 12 6 months. We're going to get to this notion of 7 chronic lack of coverage. The uninsured are 8 poorer than the insured in the survey, and this 9 is something that I think we've seen in data 10 sources over and over again. Okay. 11 Here is the data, this is from 12 the -- maybe it is Kieser or maybe it is the 13 other employee's benefit institute data, but it 14 was just published in health affairs this year. 15 The monthly premium for individuals, this group 16 coverage is $318 and $869 for families. The 17 direct purchase policies appear to be 18 unattainable. Increasing access -- then, the 19 other one, lifestyle choice does not appear to 20 play a significant role. What we mean by that 21 is, as we went through the data in the open-ended 22 responses and the answers to some of the 23 questions on why you're not using your employer's 24 coverage, we didn't come up with lifestyle-type

59 1 responses, such as, I prefer to spend my money on 2 other things, I don't need health insurance at 3 this time, so lifestyle appeared not to be a 4 choice based on our survey responses. The 5 awareness and participation in the public 6 programs -- and I'm talking about I-Chip, but, 7 also, knowledge and awareness of KidsCare 8 continued at that time to be low, and, again, 9 this is in 2001. Okay. 10 In 2002, I was asked by the 11 Department of Public Aid to focus on caregivers 12 of children enrolled in KidsCare to see what 13 their access to coverage was currently and their 14 potential interest in a program that would expand 15 coverage to the families. We knew antidontically 16 and from earlier survey work, especially during 17 the KidsCare survey and the survey for the State 18 Planning Grant, that people who did have children 19 enrolled in KidsCare would volunteer the 20 suggestion, that, they should offer coverage to 21 the parents of the caregivers. You've got 22 something for my child, but you've got nothing 23 for me; and I don't have health care, so it makes 24 it hard for me to take care of my child.

60 1 So the caregiver survey was 2 designed in part to get answers to some of those 3 questions. We, also, engaged in a secondary 4 analysis of the current population data to get, 5 again, the estimates on potential eligibility for 6 the program and the upper -- what I'll call "the 7 upper and lower boundaries". For the caregiver 8 survey, we used a list sample from DPA. This was 9 not a random-digit dial survey where we just 10 called people out of the phone book. This was 11 based on the children who were enrolled in the 12 program, as of July, I believe, of the previous 13 year, so we used that list survey, and the sample 14 included kids in share premium and rebate. 15 We had extremely low refusal 16 rates, but very high cooperation rates, 3 to 7 17 percent refused. The difference in that number 18 is what we call "a hard and soft refusal", but it 19 was very small; but for 17 percent of the sample, 20 we couldn't contact them, because their 21 telephones were no longer working, so we did miss 22 a part of the population of kids' caregivers -- 23 kids enrolled in KidsCare, because they no longer 24 had working numbers.

61 1 We used, again, these two data 2 sources, and I'm jumping back to the CPS. We 3 used the Public Aid files, and what we tried to 4 come up with is, we tried to come up with 5 estimates of the upper boundary of families that 6 are at or below 250 percent of the Federal 7 Poverty Level, so this is just to give a sense of 8 who is out there. We came up with 738,000 9 families, 809,000 individuals at or below 200 10 percent of the Poverty Level; and, then, we, 11 also, estimated for 185 percent of the Poverty 12 Level, and that came out, as you see, a slightly 13 lower percentage. 14 MS. BUTKUS: Outside of non-citizens, 15 and this is what -- 16 MR. LERNER: Elena, we can't hear you. 17 MS. BUTKUS: What strikes me in this 18 presentation is, that, half of the Illinois 19 uninsured are pretty poor; and so my question is, 20 Outside of non-citizens, why are these people not 21 eligible or taking up Illinois Medicaid? 22 MS. RUCINSKI: That's a complex 23 question, and I think that what -- based on the 24 work that I've done asking people who are clearly

62 1 eligible for Medicaid or KidsCare, why they don't 2 enroll their children, it is they do not believe 3 that they are eligible for the coverage. They 4 don't think of themselves as poor. You see the 5 same thing with earned income tax credit. They 6 don't think they're eligible, because the person 7 who is poor is that person I've got my -- you 8 know, it is amazing to me what people think of as 9 poor, so they think -- at least the people that 10 I've talked with one-on-one and looked at 11 survey data where we've asked people, why -- your 12 children are eligible, have you heard about 13 Medicaid, have you heard about KidsCare; if they 14 have, we say, Well, why haven't you applied, and 15 for many of them they don't know about the 16 program. That's why they didn't -- or if they do 17 know about the program, they don't know they're 18 eligible. 19 I think we do a very good job in 20 reaching people who are already touched by public 21 programs. We don't do a very good job reaching 22 people who don't touch public programs and that 23 aren't in the system in some other way. We go 24 through public panels. We do outreach, and we

63 1 hit the same people over and over again. We do 2 health fairs, and we get the same people. We 3 don't go for the low-hanging crew. We don't 4 really try to give outreach in the areas that are 5 unfamiliar to us. 6 MR. CARVALHO: In one of the hearings, 7 one of the participants cautioned us about 8 enrolling health insurance through Public Aid, 9 you know, because he felt that many people do not 10 want to be associated, you know. I don't want to 11 be on Public Aid. I don't want to be a recipient 12 of public poor dollars, you know, so he cautioned 13 us about any program should not enroll through 14 Public Aid. 15 MR. LERNER: I don't want to get into it 16 in any detail, but that gets you into the whole 17 issue of individual mandates and what -- the 18 freedom we give people. We're going to have some 19 healthy discussions later on in our process as we 20 start to roll this down. I would suggest to you, 21 Catherine Bresler talked about this just the last 22 time, as we started to roll out the commentary 23 from the briefings and from the hearings, access 24 to information and knowledge is not necessarily

64 1 power, unless you do something with it, right? 2 We, actually, could be better off by hiring a 3 bunch of Amundsmen to get out there and help 4 people to be aware of what programs exists. We 5 heard this before when Ann Marie Murphy was 6 talking a couple of meetings ago, and, then, 7 looking at her expenditure dollars, and, then, 8 looking at who's falling through the cracks 9 rather than assuming, de facto, that everybody 10 sitting out there not having access or 11 eligibility to these programs. I understand 12 image issues. I'm not drawing a conclusion. I'm 13 just suggesting to you, that, we truly have a 14 patchwork quilt here. We need to step back and 15 take a look at these facts very carefully as we 16 look at these economic and political models that 17 we're going to bring forth. 18 MR. BACKS: Just one comment, I don't 19 think necessarily the lack of signing up for a 20 form of coverage does not stop someone from 21 accessing the health care system when they 22 finally decide that they need it. 23 MR. LERNER: That's correct. 24 MR. BACKS: It may be at a very

65 1 inopportune time to improve their health, and 2 that's the most expensive point in their illness. 3 MR. LERNER: I think the whole issue 4 about willingness to pay is somewhat -- let me be 5 cynical for a moment, is somewhat modeled by the 6 fact that we do have safety nets in your society, 7 and people know that in God-forbid situations 8 there are places to pick and go. There's a place 9 to root, but this is a part of that conversation. 10 MR. CARVALHO: What, also, might be 11 responsiveness to Elena's question, I still 12 remember when you made this presentation almost 13 six years ago from the first survey, which is, 14 the take-up rate for Medicaid varied dramatically 15 by region. I don't remember exactly, but I 16 vaguely recall that in Cook County, that, the 17 take-up rate for Medicaid -- the take-up rate 18 meaning people who are eligible and enrolled was 19 north of 75 percent; and, then, in DuPage it was 20 south of 25 percent; and in much of the state you 21 saw that dramatical variation. Do you recall? 22 MS. RUCINSKI: I don't recall the 23 take-up rates offhand, but I do know that they 24 were higher in Cook County. I do think,

66 1 Margaret, that the perception -- I think it is 2 one of the reasons why the State named the 3 program KidsCare, instead of Medicaid Plus or 4 Medicaid Extra or something like that because of 5 the perceptions both in terms of the public of 6 what people believe, physicians believe. 7 That's the other thing that in my 8 one-on-one interviews with moms came up again and 9 again, is, they think it is fine coverage, but 10 she can't get -- you know, she thinks the doctor 11 looks down on her children, because they are 12 enrolled in Public Aid, that, the disrespect came 13 up again and again because -- I don't know how 14 you'd change that. I don't know if it is, you 15 know, something that's changeable by changing the 16 reimbursement, but that came up again and again, 17 I would prefer to pay a sliding fee than have my 18 children disrespected, so that came up, as well. 19 MR. LERNER: Can I have just one other 20 -- I'm sorry, but having done a little bit of 21 work in New York State, where they poor a ton of 22 money from Medicaid into nursing homes and 23 hospitals, particularly, long-term care, Medicaid 24 is not looked down on in that state. In fact,

67 1 those patients are wanted by everybody, because 2 of the payment rates for doctors, hospitals and 3 nursing homes are reasonable. We have a cultural 4 problem here that is somewhat embedded in the way 5 this policy has been promulgated over all of 6 these years and how we get paid. I'm right there 7 with you thinking about how all of this stuff 8 fits together. Go ahead. 9 MS. RUCINSKI: Okay. Again, looking at 10 the relationship between the percent -- the 11 Poverty Level as expressed by the Federal Poverty 12 Guidelines, the 393,000, with the adjusted income 13 of less than 200 percent, we find, again, there's 14 a clustering of the uninsured in the lower-income 15 categories; and as you move to the -- I guess, 16 your right, we see a tapering off; in terms of 17 the demographics for the caregivers, the 18 Non-Hispanic, White constituted about 44 percent 19 of the caregivers and kids enrolled in KidsCare; 20 37 percent were African-American; 13 percent were 21 Latino; and 6.4 percent, other. 22 Then, here is one of the -- again, 23 the key relationship between employment and 24 coverage. For caregivers coverage was only --

68 1 individual level coverage was available to 72 2 percent of the caregivers, so there was still a 3 large percentage of the caregivers who did not 4 have access through their employers. These are 5 employee caregivers, so caregivers who are 6 employed outside of the home. Only 72 percent 7 had coverage available through their employer, 8 and, that, only 63.9 percent had family coverage 9 available through their employer. 10 In terms of enrollment, 67 percent 11 of the employed caregivers were enrolled in their 12 plans, so there was still a percentage of them 13 who lacked coverage. 14 MS. MITROFF: When you use the 15 term "employed", did you check for whether they 16 were part-time or full-time employed, how many 17 hours a week? 18 MS. RUCINSKI: Yes. 19 MS. MITROFF: Are you using a full-time 20 contract -- 21 MS. RUCINSKI: I believe for this one, 22 we considered full-time employment anything over 23 32 hours a week. Again, we asked in that same 24 experimental format, we described the policy

69 1 which was un-named at that time when we didn't 2 use it, What would you be willing to pay if you 3 could enroll in KidsCare for families? It would 4 be family coverage, and you'd have the same 5 benefits as the child in your care. We asked at 6 three different levels that had been specified by 7 DPA. We found even as you go along to the left, 8 as you move from $10 to $20.00 a month for 9 premiums, also, 90 percent were willing to pay 10 $10 a month; 87 or almost 88 percent were willing 11 to pay $15 a month; and 84 percent -- I'm sorry, 12 83.4 percent were willing to pay $20.00 a month, 13 which I thought was significant, so you do have 14 some dropping off of willingness to pay; but you 15 can -- if you have premiums -- again, these are 16 caregivers of people whose children are currently 17 enrolled in KidsCare, so they were income 18 eligible for the program, but to have premium 19 levels at that amount still had very high 20 expressions of willingness to pay. 21 MR. LERNER: Could we turn the lights 22 back on for a second? I want to thank you for an 23 outstanding presentation. I think it is exactly 24 what the Task Force is looking for and gives us

70 1 the kind of grounding that we needed to get into 2 some further discussion. Let me ask you a 3 question and you respond to the Task Force. Our 4 charge says, that, we're to recommend a plan -- 5 implementation of a plan that provides access to 6 a full range of preventive, acute, and long-term 7 health care services maintained in a group of 8 body of health care services, Illinois' resident 9 and meets other criteria. What recommendations, 10 what advice would you give us as you look at that 11 information? You've been doing it for a number 12 of years now, and you understand our chart. What 13 are the take-aways that you would provide to us, 14 as we think about modeling where we might find 15 plans? What advice would you give us? 16 MS. RUCINSKI: That's a really easy 17 question to answer. I thought about this on the 18 training coming down, not exactly that question, 19 but the question I wanted to answer is the one I 20 will -- which is, that, I think that the 21 diversity of the uninsured population, you know, 22 I'm just going from the population data. I'm not 23 going from your experience with markets and, you 24 know, groups and Couhling (phonetic) and all of

71 1 that. I think that whatever this group comes up 2 with, you have to go back to that question of 3 access to insurance and have an understanding of 4 how to use the system, because the more complex 5 the program is, the more difficult it is to 6 access and to enfranchise yourself. You are 7 going to lose the population group that is 8 suffering the greatest health disparities. 9 I spoke two weeks ago at a 10 conference on health disparities in Washington, 11 and I came away depressed, because we've been 12 doing this for a long time trying to eliminate 13 health disparities and we still see them over and 14 over again. The level of understanding that 15 people have and to learn how to use health 16 insurance coverage and to learn how to do 17 prevention, it is huge. It is enormous, and it 18 is very difficult to do when you're trying to 19 figure out how you're going to get to work. I 20 mean, it just -- to talk -- I work in West Town 21 with the West Town Latino United on a project. 22 They're, actually, doing a community survey to 23 see what access to health care is in their area 24 and if they can improve it. I was struck by the

72 1 their descriptions of going to Fantus (phonetic) 2 for care and how difficult it was for them to 3 with their children in tow take two buses to get 4 to Fantus to wait for nine hours to see a 5 doctor. It just -- you know, whatever you do, it 6 has to be simple, and it has to recognize that 7 the people sitting around this table have 8 histories of insurance. They know how to work 9 with institutions. They know how to keep a paper 10 trail, and the people who I think are the most 11 vulnerable, and the people that we saw over and 12 over again in those slides, I mean, we're just 13 talking numbers. They are people without access 14 to those institutional skills that would make 15 something complex, difficult. 16 I understand the issue of mandates 17 and -- you know, the concerns people have about 18 Single Payer or, you know, limited choice; but I, 19 also, know that there have been some very 20 powerful experiments in economics about randomly 21 assign -- or assigning people to contribution 22 levels for their 401's and how participation 23 rates go up. So those are, I guess, the two 24 things that I would say, that, whatever you do,

73 1 you either have to make it simple or you have to 2 have a dedicated group doing outreach and a group 3 that's willing to go beyond your standard 4 partners. 5 MR. LERNER: Absolutely. I really 6 thank you for those take-aways. We've got some 7 freedom in the agenda, and I want to open it up 8 with some questions and comments now for a few 9 minutes. 10 MR. BACKS: I'm just going to throw 11 something out. What strikes me is, that, if we 12 look strictly at the health care system 13 providers, the insurance system and government 14 financing, those are all pieces of the pie that 15 we've been looking at over and over again; but I 16 think it is going to require us to, actually, go 17 clearly way outside that box and look at the 18 education system, because why is it that these 19 people -- I don't mean that in a pejorative 20 term. I mean, we're talking about this 21 population, that, over and over again you go to 22 them, but they don't take advantage of the things 23 that are available to them. Why is it that, that 24 happens, and it seems to me that it is something

74 1 that we can't fix at this table? It fully 2 involves attitudes, education, language barriers, 3 and transportation issues and just sort of the 4 general skills of activities of daily living that 5 are some of the biggest barriers to getting the 6 benefits of the system. 7 I know you mentioned the lifestyle 8 choices, but the priorities that are chosen, the 9 decisions that are made about when to start a 10 family and when not to start, education versus 11 employment, all of those things -- I don't think 12 we could discuss and solve this problem without 13 talking about those elephants in the room. 14 MR. CARRIGAN: How many people around 15 the table are picking up on that point? I saw an 16 important article in the New York Times a week or 17 so ago on Diabetes in New York, the Diabetes 18 epidemic in New York City. We need to give a 19 copy of it to everybody. I'm not promoting one 20 newspaper or another, but if you just read this 21 article and you think about our charges and you 22 think about chronic health care conditions, and, 23 then, you think about conditions of ethnicity, 24 culture, language, and the whole definition of

75 1 accessibility, lifestyle choices, I mean, it is 2 scary, so I'm just picking right up on that. 3 MS. ROTHSTEIN: People are scared, 4 too. There's a lot of fear out there. 5 MR. LERNER: I think picking up on both 6 of your comments, one of the things that we're 7 going to have to debate later on is not just 8 which model makes economic sense or which model 9 makes political sense or which model gorges the 10 ox more or less. It has to do with how we 11 execute on the model that we're talking about, so 12 that when everyone try and do good things, 13 something good happens. If you can't deliver the 14 services, because people can't get there, they 15 can't talk or they can't communicate, it is not 16 going to do us any good. 17 MR. ORTHOEFER: I had a comment. The 18 thing that worries me and I've picked up just 19 from undertones of things being said, that, it is 20 easy to blame the victim, and that's what goes 21 on. What is wrong with the system or what can be 22 done to improve the system, I don't think we're 23 ever going to get to a place where we've got 24 everybody covered, at least, under the way health

76 1 care is delivered in this country, but it sure 2 can be improved. There's no question about it. 3 It is not the victim's fault in most cases. 4 MR. LERNER: That is right. Other 5 comments? 6 MR. BACKS: I have to clarify, if 7 anything that I said or the way I said it implied 8 that there was a plain victim issue, I apologize, 9 but I don't think that's -- I know that's, 10 certainly, not what I meant to say. I think you 11 have problems outside the health care system that 12 have allowed -- that needs to be addressed, as 13 well, education and understanding as to these 14 choices. If we don't talk about those things and 15 just keep putting the same -- more resources into 16 the same models or just around the edges, I think 17 we're wasting a large percentage of our time. We 18 could do some good, but much more good if we 19 address the issues. I did not mean to imply a 20 judgment of anybody's character. 21 MR. LERNER: I don't think there's a 22 blame game here. I think what we're doing is 23 recognizing the complexity of the system and the 24 complexity of the individual and family structure

77 1 and how it all comes to go. Jim? 2 MR. DUFFETT: I have a couple of 3 things. I know it's been a while, several years 4 ago, I worked at several hospitals on cultural 5 competency. It's, probably, been about two years 6 that maybe we revisit it, and I'm just very 7 impressed with what some of the efforts that have 8 been done to be able to deal with some of these 9 issues that you've raised. I don't know what we 10 do with transportation, whether there's a laundry 11 list that's out there to say -- as you've said, 12 too, we have many people that transportation is a 13 very big issue. How do they get to where they 14 need to go; but for Diane, I mean, if there's 15 other interesting slides or information, and that 16 stuff that you've presented can be broken down 17 and sent to us, I mean, I'd love to see the 18 deeper detail of that, especially, again, when we 19 get into the issue of what are people willing to 20 pay and how we are all analyzing that word; that, 21 again, someone making 40,000, a family of four, 22 pretty much maybe has a good handle on how much 23 other disposable income they have, and they may 24 say, Gee, I'm willing to pay just $50. I don't

78 1 think if they make that comment that they're 2 dissing (phonetic) the system and they don't feel 3 like there's enough skin in the system, that's a 4 nice word, that, people want to use it, like -- 5 that's all I have. While somebody who was 6 uninsured may be making $80,000 a year, may say, 7 Gee, I have 200 Bucks a month or 300 Bucks that 8 maybe I could pay, but I can't get insurance 9 because of maybe a pre-existing condition or 10 something. 11 I mean, I'd be fascinated to see 12 the deeper detail on the income levels that you 13 have; because I think as you said, Mr. Chairman, 14 too, as we're looking at some of these folks and 15 what we can do to get people who are eligible for 16 Medicaid, you've said this several times, 17 Catherine and him, too, I think there's a chunk 18 of those folks -- that, there's parts out there 19 already that people should -- we have to figure 20 out how we move them into it, and, then, it look 21 like you were saying, Chairman, of the -- but 22 there's other people who may just be able to pay 23 $100 Bucks. We have to figure out how we'll come 24 up with the other money to be able to do it.

79 1 MR. LERNER: Joe? 2 MR. ORTHOEFER: My thought on the thing 3 is, somehow or another we should be looking at 4 the whole system, because, in fact, we're already 5 paying double of what most other places are 6 paying for health care in this country. When you 7 do that, I know how difficult it is going to be, 8 because it means -- I don't see new money coming 9 in, so you talk about new money all you want, but 10 I don't think it is there. It means, you're 11 going to have to shift resources around some, in 12 order, to do that. 13 Once you start doing that, we all 14 know there's going to be winners and losers, and 15 the losers are going to raise bloody hell; but 16 nevertheless, I think we really need to look at 17 the plan or look at a plan and do some 18 comparisons of -- let's look at some other 19 systems, which have compared to what we presently 20 have and see what can be done or other people 21 have done and maybe have been successful at it. 22 I know Ashley passed out the thing today on the 23 part payer thing, I have some experience with 24 that, but nevertheless, I'd be interested in

80 1 hearing -- 2 MR. LERNER: We'll get to that. Ken? 3 MR. SMITHMIER: You made a good point a 4 minute ago about not getting into the blame game, 5 whether it is the person in the system or the 6 system itself. I think that's exactly right. I 7 think getting away from blame, though, of what we 8 have to -- it will be hard for us, but as a state 9 or as a country have to get to is. I never hear 10 any conversation about an individual's 11 responsibility for what they have done to affect 12 their own health. I give talks to my own 13 community. I had them just a couple of weeks 14 ago. Usually, it is these retired people. They 15 have time to eat and listen to somebody talk, and 16 I always ask them do you believe that people's 17 choices contribute to the cost of health care and 18 their need for this drug and that drug; well, 19 yes. Do you feel that you're doing everything 20 that you could do? No. Who do you think should 21 be held accountable for it? Well, they hate it 22 when I ask that question. I always put them on 23 the spot. 24 I'm not saying that every person's

81 1 choice is -- you know, as they all change to the 2 good, we fix everything in health care, that's 3 not the case; but we all know there's a 4 tremendous amount that we are increasingly doing 5 to ourselves; and the literature dealt with it, 6 but nobody ever wants to pay for that, whether it 7 is their smoking or their eating or their lack of 8 exercise or whatever it may be. 9 MR. LERNER: That's, actually, on our 10 schedule at the end of August, and it is 11 reminiscenced all throughout the article on 12 Diabetes. Jan was next. 13 MS. DAKER: I'm going to piggyback with 14 that. Diane, also, said it, if we don't look at 15 the root cause and make that a huge part of our 16 overall plan, so that they don't need the medical 17 facilities, we will be able to afford it. I 18 think that should be huge. We keep kind of 19 flopping over it. Diane said use prevention, and 20 we all went, Oh, yeah, yeah, but we don't really 21 take time to do that. We just go, Oh, how are 22 we going to pay for it after -- 23 MR. LERNER: Yes. 24 MR. YOUNG: First of all, I want to

82 1 praise -- pardon my voice. Somebody in one word 2 said simplicity, itself, and, then, I think 3 Medicare Part D is inflicted on people you're not 4 going to blame in asking them for immediate 5 assistance. 6 The other point I want to make, 7 because I don't think there's any room for 8 pessimism, if there's any part of a person's 9 endeavor where success follows logical planning, 10 it is in health. We've doubled the 11 life-expectancy of our species in the last 150 12 years, and it came from just extensive 13 application of what we knew. There's no reason 14 we can't take that same good sense and achieve 15 equivalent gains. 16 MR. LERNER: David? 17 MR. KOEHLER: I would ask, if we do 18 nothing else, if we could take a complex system 19 and make it a little simpler, we would have done 20 something. I guess I look at myself in that. I 21 mean, we used to be an indemnity plan. I 22 couldn't figure out the deductible and copays, 23 and I'm a college educated person. 24 I went to a HMO, because I want to

83 1 pay 15 Bucks when I go to the doctor. That's 2 it. I live in a neighborhood that's very poor. 3 Often, our area's first access is St. Francis 4 Hospital's emergency room, because it is simple. 5 People know what they need to have when they need 6 it, and that's, basically, the system, so if you 7 look at every level -- I mean, if you look -- I'm 8 not a physician, but I can imagine what 9 physician offices go through when they have how 10 many different forms to fill out or how many 11 different PPO networks, the same thing with the 12 hospital. We've just gone way off the edge with 13 the complexity of this. 14 Just one other comment, I think 15 that the person's responsibility, also, has to be 16 taken into the corporate world, too. The first 17 thing I would do is band prescription drugs from 18 being advertised on TV, because we represent in 19 our labor management -- 20 MR. SMITHMIER: I vote for that, too. 21 MR. KOEHLER: We represent about 60,000 22 covered lines under the prescription pharmacy 23 plan with our health care consortion. The top 10 24 drugs is the little purple pill, and it is all

84 1 the way down the list. Lipitor is Number 1. 2 MR. LERNER: We're getting way off hill 3 here. I would like Diane to have the last word. 4 MS. RUCINSKI: I heard the comment 5 about that universal coverage or complete 6 coverage was, probably, not possible. I would 7 just like you to look at Minnesota and look -- 8 Minnesota is different from Illinois in many 9 respects, but they have some of the highest 10 coverage rates in the nation; and one of the ways 11 they do it is, they take advantage of something 12 that we all know, that, if you include healthy 13 and sick people into a system, and you insure 14 them and you focus on prevention, it can work. 15 So they in their State survey found at one point 16 that they only had 3 percent uninsured. 17 Now, 3 percent uninsured to me is 18 noise. That is sampling variance, so they have 19 almost complete coverage in that state. We have 20 many things in Illinois that make it difficult to 21 compare, but they did have very high coverage 22 levels or they're publicly funded programs went 23 to high levels; because, again, as you go through 24 and as you look at the trend data for employment

85 1 based plans, those so-called marginal occupations 2 or the occupations where there's increased 3 competition or lower returns or whatever, they're 4 shedding their coverage. So we're going to have 5 more and more people who don't have the employers 6 to go to for coverage and who are going to need 7 someone else. When you raise that Poverty Level 8 rate, you make the system just not for poor 9 people. Since no one wants to be poor, it 10 becomes a middle class system. 11 The other thing, I guess, I would 12 say about personal responsibility is that, 13 systematic personal actions that occur over time 14 within the same group is structural. 15 MR. LERNER: Is what? 16 MS. RUCINSKI: Is structural; if you 17 look at the same choices, you know, the same 18 lifestyle choices that are going on -- I look at, 19 again -- 20 MS. DAVIS: Like, in Harlem, they don't 21 have grocery stores. 22 MS. RUCINSKI: Right. In West Town, a 23 little village, Pilsen, to hear the moms talk 24 about how when they were in Mexico, they say to

86 1 me, I looked like you, and now I look like this, 2 and it is because I eat donuts. I go to 3 McDonald's. My kids won't eat Mexican food 4 anymore. They have changed their lifestyles, and 5 it is because they can't get access to the foods 6 that they eat. The schools don't serve the foods 7 that would make it a seamless system of going 8 from the healthy Mexican food at home to school 9 lunch. It is individual behavior that tends to 10 be the same among a group. There's a structural 11 factor in there, I believe, in personal 12 responsibility; but I, also, think that structure 13 makes certain choices easier than others. I 14 think, that, when you come up with your plan that 15 structure needs to lead people to prevention 16 rather than to not using the system. 17 MR. LERNER: Why don't you join me in 18 thanking Diane. I would suggest that we take a 19 10-minute break. I got 20 after 12:00. We'll 20 get back here at 12:30, and we'll roll through 21 the administrative side of the agenda. Thank you. 22 (A break was taken.) 23 MR. LERNER: We're going to get 24 started. If you see anybody out in the hallway,

87 1 who may want to vote on something -- if you've 2 seen David Carvalho that would be good, because 3 he's first up on the agenda. I'd like to call 4 the meeting back to order. David is not here. 5 MS. WALTER: I could do the rest and 6 let him -- 7 MR. LERNER: Okay. 8 MS. WALTER: Just a couple of quick 9 things, when you came in there should have been a 10 CD at your seat. If you didn't get one, see me. 11 Those are video recordings from the health forum 12 back in December. They're, also, available on 13 the website, so anyone could go ahead and 14 download those and view them, if you'd like. We 15 just offered to do that instead of any sort of 16 meeting minutes or whatever. It will be easier 17 to go back through and provide an opportunity to 18 those of you who couldn't make it to partake in 19 that opportunity. 20 MR. LERNER: I'm very disappointed. I 21 thought that was a DVD from the Stones 22 concert this week. 23 MS. WALTER: I'm sorry. I just want to 24 thank everyone, because I think overall it was a

88 1 big success, and I think a lot of learning 2 happened and it got some ideas flowing, so thank 3 you for coming out for that and for making that 4 possible. 5 On that note, we have another 6 similar event that we are planning, and you 7 should have two handouts that you've received 8 regarding this. The top sheet is just the brief 9 agenda. I don't know if Joe wants to say 10 anything, because he's helped me coordinate all 11 the speakers. 12 MS. JOHNSON: I don't have it. 13 MS. WALTER: I'll get it to you in one 14 second. 15 MS. JOHNSON: Thank you. Can I make a 16 suggestion? I'm sorry, I was late. I was taking 17 care of my day-job patients. If persons are 18 members of the Task Force and they picked up some 19 things, maybe they need to make it available to 20 those of us who didn't get -- there are a couple 21 of us over here who didn't get -- 22 MS. ROTHSTEIN: Ashley, are we talking 23 about Friday, the 21st? 24 MS. WALTER: Yes. I don't know if it's

89 1 been determined if it is going to be a half-a-day 2 or a full day at this point, but the title of 3 this is "The Private Sector Options for 4 Increasing Access to Care". As you could see, 5 we've lined up four speakers to come in and talk 6 about different points. There will be a 7 presentation on the background of the health 8 insurance market in Illinois. We'll, also, have 9 a presentation on the "Share Program". There's, 10 actually, a handout regarding that, that should 11 be with this agenda, so that if you'd like to 12 read this ahead of time or make yourself familiar 13 with the program, you can do that. 14 The third presentation will be 15 about consumerism in health care, and, then, 16 we'll wrap up the day with a presentation on what 17 other states have done in the private sector to 18 expand access to care. 19 MS. JOHNSON: Is this all-day or 20 half-a-day? 21 MS. WALTER: I just said we're not 22 sure, yet. We're still working out the details. 23 My guess is, it will likely be a half-a-day or a 24 three-quarter day.

90 1 MS. JOHNSON: Okay. 2 MR. LERNER: Do you have a suggestion? 3 MS. JOHNSON: Can we go in the morning? 4 MR. LERNER: I'm sorry? 5 MS. JOHNSON: Can we do it in the 6 morning? 7 MS. WALTER: You would prefer the 8 afternoon, if we -- 9 MS. JOHNSON: No. I prefer the morning. 10 MS. WALTER: Okay. 11 MR. LERNER: I would suggest, that, if 12 we could keep these things to a half-a-day or a 13 working lunch, that, we could do it that way; 14 that way, people coming from out of town could 15 get here and get going. 16 MS. WALTER: Especially on a Friday. 17 MS. JOHNSON: In May, we start the 18 all-day meetings, also. 19 MR. LERNER: Right. 20 MS. JOHNSON: Thank you. 21 MS. WALTER: Note taken. I think 22 that's all I had, as far as technical assistance. 23 MR. LERNER: Any questions? 24 MR. ROBERTS: Ashley, just one update?

91 1 MS. ASHLEY: Yes. 2 MR. ROBERTS: There, also, will be a 3 forum there for discussion that we'd like to 4 offer an opportunity just to open up and utilize 5 these speakers, since we have them that period of 6 time to bring their experience to get in here, a 7 nice opportunity to ask them questions. 8 MS. WALTER: Thanks, Joe. 9 MR. LERNER: Ashley, would you go to the 10 update on the Online Community -- 11 MS. WALTER: I could do the 12 presentation plan. The next item David was going 13 to present, I could do that. 14 MR. LERNER: Sure. 15 MS. WALTER: It is just very brief. In 16 the email that I sent out prior to the meeting, 17 you should have gotten an updated presentation 18 plan. You've seen different versions of this 19 earlier. It was just to let you know of some of 20 the things that have been made. They've been 21 very minor, as far as switching organizations to 22 different dates given the topic of their 23 presentations and feedback we've received from 24 them.

92 1 It is, also, just, again, another 2 plea, if you know of any organizations, 3 individuals that would like to come and present, 4 please, pass them along or have them contact me. 5 MR. LERNER: I just want to, again, 6 bring a heads-up here, if you look at that 7 schedule and remember what our goal was, we're 8 going to be doing and learning at the same time, 9 because, obviously, we've got to be embedding the 10 models and discussing the models at the same time 11 that we're still going to be getting 12 presentations here. We're going to be doing 13 realtime learning in action. Any questions or 14 comments? 15 MS. WALTER: The next item was the 16 Online Community, and that is up and running, so 17 if I've received all of the necessary forms from 18 you, you should have received two emails from me, 19 one that had your user name and password and 20 another that contained instructions for accessing 21 the site. If you haven't received that email 22 from me, it means that you have not submitted 23 both of the forms. I have extras with me here 24 today, if you'd like to fill those out. Things

93 1 are up, and they continue to go up, and my emails 2 telling you what has been posted will start 3 soon. I'm still catching up from the holidays 4 and my little break. 5 Other than that, I have some I.D. 6 cards, I.D. cards for some of you that did send 7 me your photos. If you don't have an I.D. card, 8 I don't have your photo, except for there are a 9 hand-full of you that I.D's are still being made 10 for. If you could send me a digital picture of 11 yourself, so I could have the I.D. created for 12 you, it will be helpful. It will help you bypass 13 security downstairs for the meeting. You use 14 this as proof for your State rate at a hotel, if 15 they ever require it. 16 If for some reason you don't have 17 a digital picture of yourself and you'd like us 18 to take one of you, let me know, and I could 19 bring our Department's camera to the next meeting 20 and snap a photo of you. 21 MR. LERNER: While we're waiting for 22 David to come back on the RFP -- there he is. 23 Here is David. We're done with the agenda for 24 the RFP.

94 1 MR. CARVALHO: We are? I was hoping to 2 learn a lot today. 3 MR. LERNER: You'll read the 4 transcript. 5 MR. CARVALHO: Actually, the reason why 6 I was late, we'd encountered a glitch at CMS. I 7 thought I was going to be able to say today, 8 that, the RFP is on the street. It should be 9 shortly; and just the last meeting, I really 10 don't want to go into the details, because it is 11 being transcribed, we'll adjust the timeline in 12 sufficient a way that we could continue to 13 provide the Task Force with the services 14 required, but at this point I'd just like to say 15 I apologize for the delay. 16 MR. LERNER: It will be on the street 17 about when? 18 MR. CARVALHO: Within the next week. 19 MR. LERNER: And the due date within the 20 next week? 21 MR. CARVALHO: Right; by the end of 22 next week, so the due date will be about four 23 weeks after that. We'll have two or three weeks 24 to review it, and we should be able to identify

95 1 it, then, for your services at the end of March. 2 MS. JOHNSON: So you're working with it 3 on the street, like, February 1st, the decision, 4 March 1st? 5 MR. LERNER: I don't know if you heard 6 what he said, but he said, we, probably, would 7 have identified a consulting firm by the middle 8 to the end of March. That's the date now that 9 we're looking at. What that means is, the 10 Steering Committee will, obviously, talk about 11 this after the meeting, what does that do to the 12 timeline, what kind of pressure do we have to put 13 the consultants under, what pressure does that 14 put on us to identify models to work with the 15 staff, on-and-on, just like the rest of our 16 lives, just shorten some time available to get 17 together. The end of the race is still the end 18 of the race, so we know what we're going after. 19 Questions? 20 We've covered the RFP, technical 21 assistance, presentation plan, Online Community, 22 I.D. cards. Any new or old business? 23 MS. JOHNSON: I'm sure I missed 24 approval of the minutes, but there -- approval of

96 1 the minutes, but there needs to be a change. I 2 was present for the last meeting. 3 MR. LERNER: Dr. Lubin-Johnson was not 4 only present the last time, she's present this 5 time. We'll make sure we got it clarified. 6 MS. JOHNSON: Thank you. Was there any 7 discussion about changing the rotation for the 8 February or March meeting with the 9 legislature being in session? We had mentioned 10 that the last time, the possibility of changing 11 one of those. 12 MR. LERNER: Well, what we've decided to 13 do is, we set up a hotline for the legislature to 14 call in. 15 MR. CARVALHO: None of them -- 16 MS. LUBIN-JOHNSON: Okay. 17 MR. LERNER: The last meeting, that's 18 what we agreed to and we were talking -- 19 MS. JOHNSON: I thought there was still 20 some discussion about changing the location, but 21 that's fine. This is how it stands in terms of 22 location, okay. 23 MR. LERNER: Any other issues, new or 24 old business? Jan?

97 1 MS. DAKER: Just a question, is the All 2 Kids' enrollment on the website? 3 MR. HYLAK-REINHOLTZ: Yes. There 4 should be something on the website, 5 pre-registration, not enrollment, but 6 pre-registration. 7 MS. DAKER: Thank you. 8 MR. LERNER: May I have a motion to 9 adjourn? 10 THE QUORUM: So moved. 11 MR. LERNER: Second. You're out of 12 here. Thank you very much. 13 --- 14 (WHICH WERE ALL THE PROCEEDINGS HAD 15 ON THE ABOVE-MENTIONED DATE IN THE 16 ABOVE-MENTIONED MATTER.) 17 18 19 20 21 22 23 24

98 1 STATE OF ILLINOIS ) 2 ) SS: 3 COUNTY OF COOK ) 4 5 I, CHERLYANA SIMS, a Certified 6 Shorthand Reporter, doing business in the County 7 of Cook and State of Illinois, do hereby certify 8 that I reported in machine shorthand the 9 statement in the above-entitled cause. 10 I further certify that the 11 foregoing is a true and correct transcript of 12 said statement as appears from the stenographic 13 notes so taken and transcribed by me, this 14 20th Day of February, 2006. 15 16 _____________________________ 17 CHERLYANA SIMS 18 Cook County, Illinois 19 20 21 22 23 24

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