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Rep. Ro Foege & Rep. Linda Upmeyer

posted on March 14, 2008

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Borg: Broadening the umbrella. Following up Governor Chet Culver's request Iowa legislators are extending health care to children who don't have health insurance. We're discussing the short and long-term implications with State Representatives Ro Foege and Linda Upmeyer on this edition of Iowa Press.

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Iowa Bankers Association -- for personal, business and commercial needs Iowa Banks help Iowans reach their financial goals. And by the Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. By Iowa's Private Colleges and Universities where faculty teach and students learn. Iowa's Private Colleges employ over 10,000 Iowans and enroll 25% of Iowa's higher education students. More information is available at thinkindependently.com.

On statewide Iowa Public Television this is the Friday, March 14th edition of Iowa Press. Here is Dean Borg.

Borg: Earlier this past week on a 97 to nothing vote the Iowa House of Representatives passed legislation setting a goal of bringing 40,000 more children under state provided healthcare. The target date is 2010. By 2013 the plan also extends Iowa's healthcare umbrella to uncovered or under covered adults. Governor Chet Culver's budget calls for it and the legislation comes from a special legislative task force focusing on getting agreements between Republicans and Democrats and the House and the Senate. Well, today we're getting insight from two state representatives, Mount Vernon Democrat Ro Foege and Garner Republican Linda Upmeyer. Welcome to Iowa Press.

Upmeyer: Good morning, thank you.

Borg: And across the table two people that you see at the statehouse every day, Radio Iowa News Director Kay Henderson and Associated Press Senior Political Writer Mike Glover.

Glover: Representative Foege let's start with you. Dean talked a little bit about some of the targets set in this bill and it's a complicated bill as you know. But I'd like you to take a step back. How will the ordinary Iowan feel the effects of this bill once Governor Culver signs it into law, which he will?

Foege: Well, we'll continue our effort to cover all children. Iowa is in a very fortunate ...

Glover: Back up Representative Foege -- how will the average Iowan feel the impact of this bill once it is signed into law? How will their life be different?

Foege: Well, I think that three percent of Iowa's children who aren't covered will be reaching out to those people and we will be covering those Iowa children. That is how it will impact families and children.

Glover: But isn't that the goal by 2010?

Foege: Yes, it is.

Glover: So, once this bill is signed into law in 2008 how will the average Iowan feel it?

Foege: Well, they'll feel it through outreach programs. We have outreach programs through schools and through organizations such as community empowerment groups and they will be reaching out to these families who have uninsured children.

Glover: Representative Upmeyer, the same question to you. Once this bill is signed into law, which I think we all know the Senate will pass it and the Governor will sign it, how will the average Iowan feel the change in their life from this bill?

Upmeyer: Individually it will be different but one of the things that I think some will notice immediately is they'll have improved portability of health insurance. That is part of this bill. So, if you were working for a company, you're a young entrepreneur and you want to take your health plan with you when you start your business you'll be able to do that within the 63 day window, of course, and there are circumstances, the cost may not be the same but nonetheless you'll have that opportunity. So, it provides more security in those instances.

Glover: But the young people won't you be able to stay on your parent's health insurance a little longer?

Upmeyer: Exactly, that was the next point. If you are 25 or still in college you'll be able to stay on your parent's health plan. This gives another opportunity for those folks just starting out to really kind of get a leg up. Things like the medical home, the expansion of any kind of programs that go out to children, that is going to take some time actually to get in place. But recall that 97% of the kids are covered. So, we're looking at 3% and about half of those are eligible for existing programs. So, some outreach of programs that already exist, already in place, we just need to find those kids, sign them up.

Borg: That happens right away?

Upmeyer: That happens immediately.

Henderson: Representative Foege, have we reached the point in Iowa where there is no longer a debate about whether healthcare is a right or a privilege?

Foege: I'm not sure that that argument has completely gone away but I think most people agree that all people should have healthcare. We know that we need to have a more rational system because right now we're all paying for healthcare, we just don't always pay for it through healthcare insurance. We pay for it when people go to emergency rooms, that increases our premiums, our healthcare premiums. So, we are all paying for it in one way or another.

Henderson: Representative Upmeyer, you are a Republican and your party has long argued that healthcare is not a right. Do you think though that there has been a sea change in attitudes among Iowans in this regard?

Upmeyer: Kathy, it's not just whether it's a right. I think people absolutely believe that everyone should have access to healthcare. It kind of moves to at what level and what places, personal responsibility. People need to pay attention to wellness, chronic disease management and I think people don't appreciate paying for people that just show up at the ER, have never given a moment's thought to their health in the past, show up in the ER or because it's inconvenient to make a doctor's appointment and your child is crying you show up at the ER at that moment. They want people to be thoughtful about how they access the healthcare and then think about who is paying for that, how it gets reimbursed, make the legislators in the state to come up with a plan that sort of creates a structure for us to do that in a much more thoughtful way.

Glover: Representative Foege, I'd like you to tackle a political question if you would. This is a state where the insurance and financial services industry is a big part of the economy of this state and a growing part of the economy of this state. How difficult is it for the legislature to deal with an issue like expanding healthcare coverage in a state where the insurance industry is an enormous power?

Foege: It's in their self-interest for us to be pushing for more people to be covered. They like the idea of having to sell more of their products. And we're doing it not in a mandated way. In the House bill we're not mandating that people have to buy insurance. We're doing this strictly on a voluntary basis and moving ahead as we have -- with the children's health insurance it's all be voluntary and we've been able to cover 97% of children in Iowa through voluntary efforts. We're going to continue those efforts because we think we can move to 100%.

Glover: Representative Upmeyer, same question to you but I'd like to phrase it a little differently. What role has the insurance industry played in the formation of this bill? Were they partners? Were they adversaries?

Upmeyer: Well, this bill really bubbled out of the product of the commission and they were at the table, there were representatives of the insurance industry just as the health industry, that was a very large commission that worked real hard on this. So, they were definitely at the table. Their ideas, their concerns, you know, their input was there. I have to tell you that I was very impressed frankly by not just them but other people on the commission sort of left their turf at the door. But the insurance industry gets beat up a lot for the premiums. I mean, what do you hear? My premiums are too high. That's what we always hear and they are, we all feel that. But part of the things we have to take responsibility for is the fact that the cost shifting that occurs by not funding Medicaid and the federal government not funding Medicare at a very equitable level in the state of Iowa that means that much of that cost gets shifted into the private insurance sector and we've been told that is about 10% of your insurance premium is because Medicaid and Medicare aren't paying, they're free.

Henderson: Representative Foege, help us out here. What percentage of Iowans are in the private insurance system? Aren't the majority of Iowans either covered by their job at a school which is a government or a state government or what is the percentage here?

Foege: Well, we have about 10% of Iowans rely on Medicaid and about 19% I think are reliant on Medicare. So, the rest of that group are really relying on private insurance. We only have 11% of the total population uninsured. And what one of the things we've found out in the work of the commission, 82% of those people who are uninsured are actually employed, some of them at two and three jobs. And that is the group that we need to help figure out how can the state facilitate with the employer and the employee them being covered so that it costs all of us less.

Henderson: Representative Upmeyer, Republican governors in Massachusetts, Mitt Romney when he was governor and Arnold Schwarzenegger who is currently the Governor of California have tried to tackle this at the state level. What influence, if any, did those efforts have on the efforts among you Iowans to strike a deal?

Upmeyer: We watched very closely what all the other states were doing and that was one of the things we did as part of the commission, just really study how those things were working out. Well, we've watched Massachusetts and that was a bold thing to do. And I think they have learned that they couldn't afford everything that they tried to approach and tackle immediately so they're stepping back and doing things differently. California's program is kind of deteriorating before it ever gets into an implementation phase. So, we have learned from that and to maybe start with some baby steps. If you notice the piece in the bill where it talks about the adults, dealing with adults we're calling for a plan. We want a plan how that might look and how those things might fit to be brought back to the general assembly. That is very different in moving forward ...

Borg: That's what I want to get into is the plan isn't developed yet but how do you envision it, Representative Foege, that is you have right now, you have private health insurance, you have Medicare for older adults, you have Medicaid for those at a certain lower income level, you have the Hawkeye program for children and you have Iowa Care which is the old indigent patient care program at Broadlawns Hospital and the University of Iowa and some other hospitals throughout the state. Yet some of those are state programs, others, Medicare, federal. Is the vision here to require people to have some form of health insurance, that is, force them to buy a policy if they don't qualify for the programs here that are government funded?

Foege: We want to find a way for us to do this in a voluntary way. The state may be the facilitator just like it's a facilitator of the children's health insurance program which we call Hawkeye. The state actually buys a product and it's a private insurance product for Hawkeye. And so one of the thoughts is -- we haven't totally flushed this out -- but one of the thoughts is could we buy some other products, could the state facilitate buying other products and having an employer and employee go together and buy that product off the shelf maybe with a small subsidy from the state? Because, again, 82% of the uninsured in Iowa are employed and most employers that I know, some of the small restaurants that we know of, for instance, they would like to provide insurance for their wait staff, the wait staff would like to have coverage and maybe they need a little bit of boost from the state.

Borg: Representative Upmeyer, build on that. Do you see some of the ones that I've listed here possibly going away?

Upmeyer: Well, I think they either go away or they change, Iowa Cares I think specifically. That program did what it was designed to do the day we designed it. I think it's time that we go back and look at that and see if there's any opportunity there that we can use that kind of structure in a way that benefits some of those same issues on a little different scale around the state because having Des Moines and Iowa City be the only points of care doesn't make it seem very accessible to me.

Glover: Representative Upmeyer, it seems to me as we go down the road, it's not dealt with in this bill, but if you go down the road and begin looking at trying to expand healthcare to other people who don't have it you're going to be faced with an essential question which is the state is either going to have to require people to have healthcare or to accept a certain number of people are going to be uninsured. What is your view on that?

Upmeyer: I think you accept that a certain number of people aren't insured. Here's why -- it's not only people that choose I am not going to participate in that kind of program and I'm just not going to. We also have a number of people in this state who whether they suffer from mental illness or other kinds of problems don't make that their priority choice every morning when they get out of bed whether they're going to buy health insurance. There are other things on their mind. So, I think we either become sort of an operation where you're constantly monitoring that people have these things or don't or you accept that there are always going to be a small population that don't. I think you'll go back then again why? Is it because, simply, very specifically because they can't afford it? Then I think we have to really look at that question, why can't people afford it, and is the appropriate thing for the state to have some kind of graduated subsidy over time that if I'm starting out and I need a little subsidy to have health insurance is it in the best interest of Iowans to help provide a subsidy like that, that will probably go away in a few years?

Glover: Representative Foege, same question to you. And are you willing to accept that there will always be a percentage of Iowans who don't have healthcare?

Foege: I think there will be a small percentage of Iowans who will avoid getting healthcare. I think with education and promotion of these products I think that we can insure more and more of those people who are currently uninsured. Iowa has some of the least uninsured people of any state in the union and we're tied with Vermont for having the best record of insuring our children. And I think we can continue to build on that.

Glover: Then what's the big deal?

Foege: What is the big deal?

Glover: If we have the highest number of covered people in the nation, we're tied for the fewest uninsured why are we making this such a big deal?

Foege: Because we need to continue to do better. It's called continuous improvement. We want everybody to have healthcare because it does impact what happens in schools ...

Glover: I'd like to talk about a little inconsistency. You just said you'd like everybody to have healthcare and right before that you said you're going to accept that there will be a certain number of people without coverage. Which is it?

Foege: We are going to continue our efforts to make sure that everybody is insured, we'll do it on a voluntary basis. I think that is more the culture of Iowa and what Iowans will accept that they're not very accepting of a mandate at this point. There may be a day, some day we may see that but I don't see that in the near future that we'll mandate it. I just don't think it's part of the Iowa culture.

Henderson: Representative Upmeyer, Chet Culver had a news conference a few weeks ago during which he said, you know, the state shouldn't go whole hog on this, we should wait until, in his words, Barack Obama is inaugurated because Obama is out there promising healthcare reform. As a Republican do you think that if John McCain becomes president this will be an issue at the federal level and that you have made the right move here to go slow?

Upmeyer: I think our move is correct for a couple of reasons. There are really two issues here. One is coverage and one is health. They are different topics and no matter what the president does, whoever that president might be, I think we are absolutely right to focus on health and that is really what the majority of this bill is about. It's about wellness, it's about chronic disease prevention and management, it's about an information system. That means here in Des Moines my records are accessible even though I get my primary healthcare in the Garner, Mason City area. Those are the kinds of things, it's allowing people to use section 125 in the tax code, small businesses can buy their insurance the same way as a big business can and deduct it above the line. Those are all things we can do here today that help us in the future promoting wellness, promoting coverage, it doesn't matter how the president moves forward.

Henderson: Representative Foege, you started out wanting something much broader. Did you scale back knowing that this may be debated on the federal level and you should wait until the feds decide what to do in this regard?

Foege: Well, first of all I think we started out, let's get all the information and then what is sustainable and doable and that was kind of my mantra during that whole process. What is sustainable and doable? We were hoping to get 51 votes and we got 97 and so we really worked hard to have everybody included. I believe that something will happen at the federal level. We couldn't wait for them to do it, Iowa had to move ahead but whoever becomes president it's such a big factor in our country that the federal government I'm convinced will do something. What we've done with the work of this commission is we've prepared ourselves to be a recipient of that. The federal government will say just like they did when the SCHIP program came down states, you're the laboratory to make this work and we made it work and they'll ask us to do the same thing in healthcare. We're in a position to really move forward with that when the federal government makes a move.

Glover: Representative Upmeyer, the bill calls for all children to be covered in the state by 2010, all adults by 2013. It includes no funding to make that happen. When you step in and try to fund it how much will that cost? How much will it cost to cover every child in the state by 2010, every adult in the state by 2013?

Upmeyer: Well, first of all, I would argue that the bill kind of calls for a plan and, again, I think we're not going to get every single individual covered. But all that aside, the Lewin Group came in and modeled sort of the Jack Hatch's dream bell and that price tag was $550 million. I think that was a conservative estimate. The Senate bill as I understand it has been referred to appropriations. So, I'm guessing there will be a fiscal note on that bill eventually. This bill will be less, arguably, and by virtue of the fact that we asked for a plan show us how you do it and then we'll decide which pieces we can do and how we would move forward with it. Then we decide I think how much we can spend, how much Iowans are willing to spend and what the priorities are and I think that is the key. This has a lot of money in it, potentially, and so deciding on the priorities are going to be very important.

Glover: And Representative Foege, we're heading into an election season and the question I asked of Representative Upmeyer I think is irrelevant when should you go to voters and say okay, we're going to expand healthcare to cover all kids by 2010, all adults by 2013 and here's what it's going to cost? Do you want to do it? What kind of a number are you going to put on that? I know you're not running again.

Foege: It's going to cost about -- to cover all children -- about another $25 million in addition to what we're currently spending. And one of the things that we do in Iowa somebody has referred to as creeping incrementalism and we kind of sneak up on some of these issues and we'll put a certain amount in this year, like the power fund, for instance, we're doing this over a period of four or five years and some of our other big projects that we do. That's probably the way we'll approach healthcare. The $550 million that was referred to by the Lewin Group, that included a lot of other things that aren't in this bill. And that didn't include talking about shared responsibilities. We've always talked in the commission and in other areas that we are sharing this responsibility, the state may be a facilitator of how do you bring employers and employees together along with some state money.

Borg: We're out of time. Thanks so much for sharing your insights with us today. We look forward to hearing the details.

Foege: We will too.

Borg: Well, on our next edition of Iowa Press Iowa political journalists are providing insights on the current legislative session and the campaigns leading to November's general election. And we'll be back to our usual Iowa Press schedule, that's 7:30 Friday night and 11:30 Sunday morning. Saying that we're back to normal schedules next week, well that means this is Festival 2008's final weekend and that means that if you haven't already renewed your pledge to Friends of Iowa Public Television time is getting short and your continuing support means that we aren't caught short without the money it takes for the programming that we all enjoy on Iowa Public Television. We can't take it for granted that someone else is picking up our share of the load and I know you feel the same. Thanks for your loyalty. I'm Dean Borg and thanks for joining us today.

Archive editions of Iowa Press can be accessed on the World Wide Web. Audio and video streaming is available as are transcripts at www.iptv.org.

Funding for Iowa Press was provided by Friends, the Iowa Public Television Foundation. The Iowa Bankers Association -- for personal, business and commercial needs Iowa Banks help Iowans reach their financial goals. And by the Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. By Iowa's Private Colleges and Universities where faculty teach and students learn. Iowa's Private Colleges employ over 10,000 Iowans and enroll 25% of Iowa's higher education students. More information is available at thinkindependently.com.


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