Michigan Minds podcast: Fixing a broken health care system can help heal ailments, stem frustrations

Jeff Karoub:
Welcome to the Michigan Minds Podcast, where we explore the wealth of knowledge from faculty experts at the University of Michigan. I'm Jeff Karoub, a writer and public relations representative for the Michigan News Office. My guest today is Pamela Herd. She's the Carol Kohn Professor of Social Policy at the Ford School of Public Policy and a faculty associate at the Institute for Social Research's Population Studies Center. Her research focuses on inequality and how it intersects with health, aging, and policy. Glad to have you on Michigan Minds, Pam.

Pam Herd:
Thanks so much for having me.

Jeff Karoub:
I want to kick off with a question that's been all over the news for more than a month: the killing of a health care CEO on a Manhattan sidewalk. It has become, in the words of Philadelphia Inquirer columnist Will Bunch, "A stunning moment of clarity about the state of American society." I'd like to ask you what Will asked his readers. Why did it take an assassination to raise an issue that was ignored in a presidential campaign?

Pam Herd:
So let me preface this by saying that vigilante justice, which is one way to think about what happened, is never OK. The killing, the murder, assassination of the United Healthcare executive was not OK. But that said, people's reactions to it and the kind of depth of the anger that we heard from people in response is I think a pretty strong signal that something is fundamentally broken in how we deliver health care in the United States. And that's what it really tapped into. People are incredibly frustrated in the U.S. health care system. We spend enormous amounts of money paying for health care, both individually out of pocket as well as aggregately in terms of the federal and state budgets. And people just feel like they're not getting their money's worth. If you have any kind of illness, significant illness or any kind of disability, or you have a family member with a significant illness or disability, you really struggle just accessing basic health care services that were promised to you when you signed your health insurance contract and when you pay your premium every month and pay your co-pays.

In essence, people are struggling to access the sort of basic health care that they were promised. And it's really scary. There's a story going back a few years now that's actually about the Medicaid program which is not just a poverty-based program, but a program that covers millions of low-income and even middle-income Americans at this point. And the gist of what happened is that people in the state of Tennessee who were on the Medicaid program needed to show that they were still eligible for the program. And the way that Tennessee ran that process meant that they changed a bunch of the practices that people needed to engage in to keep their Medicaid coverage. And so a lot of people, for example, just didn't receive the renewal form though in the mail, and then even if they filled it out, if they didn't do it exactly right, Tennessee canceled the coverage.

And so there's these stories in the newspaper about moms showing up at a physician's office and realizing that their health insurance coverage had lapped. A story in particular of a little boy who showed up who had cancer and shows up at the doctor for his regular visit because his cancer's in remission and realizes that they can't access health insurance coverage. It takes them two years to get the coverage back. In the process, they ended up with a second mortgage on their home, and in fact, they were still eligible. They were eligible the whole time. That kind of encounter, whether it's that or whether it's someone with a private health insurance plan being told by their physician that they need a certain cancer treatment, and then the health insurance company tells them that they can't have it, even though it's very clear it should be covered and they spend three weeks, months fighting with them. Those kinds of interactions people are having all the time, and it's frustrating and it's scary and it's been getting worse over time, especially over the past five years.

We know private health insurers have been engaging in these practices more aggressively around just simply denying a lot of access to care that people are supposed to get. So people are overwhelmingly frustrated and they're scared and they're lashing out. And I think that's one way to look at the response to the assassination is that people are scared and frustrated and they're not seeing the government do what it's supposed to do in terms of regulating private health insurers as well as themselves in programs like Medicaid or Medicare to just do what people are asking them to do. And so I think that's where that anger and frustration is coming from and why we saw the response to the executive.

Jeff Karoub:
You helped lead the Better Government Lab, which is a collaborative research center at the University of Michigan's Ford School and Georgetown University's McCourt School of Public Policy. That lab, which like you is new to Michigan, aims to break down administrative walls and boost access to social safety net programs. Can you shed some light on how issues like barriers to health care inform or reflect on your work?

Pam Herd:
Sure. So the point of the Better Government Lab, which is a collaboration actually between both the University of Michigan and Georgetown University, is to improve access to government services by and large. And a lot of the work we've done has focused on improving access to different kinds of social welfare policies that people are eligible for and need but struggle to access and practice. So Medicaid for example, covers millions of Americans. … It's a huge program and has a large impact on population health, but a lot of those eligible to receive Medicaid coverage struggle in fact to do it because of complicated paperwork or confusing documentation or a failure of the government to even notify them, for example, once they're enrolled, that they need to actually continue to show that they're eligible for coverage. So there's a range of different kinds of administrative barriers that people run into that impede their access to that program. And then consequently their access to actual health care.

And so our lab is actually really focused on how do we help programs like Medicaid or the Supplemental Nutrition Assistance Program, which provides food assistance to millions of Americans, how do we ensure that those programs which are designed to improve health, designed to improve access to nutritious food, ensure that they're actually doing what they're supposed to be doing? So if the goal of that program, of Medicaid, is to improve access to health care coverage, but because we've designed complicated forms and unnecessary documentation requirements, people aren't actually accessing benefits that they're eligible for and need, there's kind of something broken there. And so our lab is really focused on working with the folks that implement these policies to fix what's broken.

Jeff Karoub:
What's the way forward with a complicated health care system and a restive polarized electorate? Can you see any clarity amid the political and societal chaos right now?

Pam Herd:
That's a really big question because the U.S. health care system is incredibly complicated, more so than most other wealthy countries, kind of analogous to the U.S. And one of the consequences of all that complexity, of the fact that we get health insurance through our employers or through the government through programs like Medicaid and Medicare, or after the passage of Obamacare through these kind of more regulated health insurance markets, it's a really, really complicated system and it's complicated for people to really navigate that system as well. And so I do think one of the more low-hanging fruits that could be addressed is using regulations to reduce some of that complexity for people and reduce the kind of negative interactions that people have with their health insurance companies. Honestly, whether that's government via Medicaid, or whether that's your employer-based plan, we can make it easier for people to navigate.

So to go back to the denial of services for people in health insurance plans, for example, we should be doing a much better job. The government should be doing a much better job of regulating private health insurers to make sure that they're not gratuitously denying people access to health insurance coverage and requiring people to go through, to file appeals and to spend 20 hours on the phone arguing with a health insurance company, either physicians on behalf of patients or patients themselves to access services that they're supposed to be provided. Like the anger that swelled up and that we saw after the killing of the UnitedHealthcare executive really reflects just that anger that both the government and the private sector are not doing their jobs properly. And so that's something beyond much more expansive political solutions like broader expansion of health insurance coverage or single-payer systems. That's just like basic regulatory effects to make companies, to make the government just deliver what they promised to deliver in their contracts is something that should be happening and that we're certainly capable of doing.

Jeff Karoub:
Bipartisan, nonpartisan-it shouldn't matter, in other words.

Pam Herd:
Yeah, exactly. In many ways, a lot of these are regulatory fixes. And what I think is sort of interesting about it is whether you are a Republican or a Democrat or regardless of your ideology, I think most of us can agree on if I sign a contract with my health insurer and they say they're going to provide coverage for my cancer treatment when I've been paying my premiums, I've been paying my co-pays, I think we can all kind of agree they should have to do that. And they shouldn't be like randomly denying people coverage and deliberately making it hard to kind of pad their bottom lines. And that's what they've been doing, and there's a lot of evidence that they've been doing that. So again, I think regardless of your political ideology, most of us would agree that's not OK, and we have tools to fix it too.

Jeff Karoub:
To wrap up, can you talk a little about your journey to Michigan and what kinds of things you and the Better Government Lab might have in store for this year, 2025, and beyond?

Pam Herd:
In many ways, I moved here at the beginning of the fall, but I've long actually considered the University of Michigan kind of another home. Twenty years ago, I did a Robert Wood Johnson Foundation postdoc here. And really it was here that I developed an interest in all the things that I love doing now in terms of both research and teaching. So it felt a little bit like coming back home. So delightful to be here.

In terms of moving forward, we're really excited (about) some collaborations that the Better Government Lab is engaged in. We recently received funding from the Gates Foundation to do a wide variety of projects that focus on what I mentioned earlier, which is effectively just trying to fix the delivery of benefits and social welfare programs to ensure just that they're doing what we promise that they do, that we ensure that for people eligible for those programs, that they're delivering proper food and nutrition to children, that they're providing health insurance coverage that we've promised to provide people. It's just basically about keeping promises that we've made to people, and that's really what the Government Lab is focused on doing.

Jeff Karoub:
Can you give me an example of some work that you're doing with the Better Government Lab?

Pam Herd:
Yeah. So one of the programs that we do a lot of work with or in regards to is the Supplemental Nutrition Assistance Program, which a lot of folks would be familiar with is referenced as food stamps.

Jeff Karoub:
Right or SNAP.

Pam Herd:
Or SNAP. And that is a program that provides support for people to buy food. One out of every two children will actually end up relying on SNAP benefits during their childhood to effectively eat. But one of the problems with the SNAP program is that a lot of people who are eligible for SNAP and need SNAP either don't get on it when they should, or actually sometimes they get kicked off it when they're on it and should still be on it. And it's really what I was mentioning earlier about just people really struggling to fulfill basic kinds of bureaucratic or administrative processes. And one really simple example is that SNAP oftentimes requires people to complete an interview. So when you apply for benefits or frequently if you're trying to renew your benefit eligibility typically on an annual basis, need to do an interview with a caseworker. And kind of completing that interview ends up actually being something that ends up getting a lot of eligible people kicked off. Why? Seems really straightforward. How hard is it to complete an hour interview with a caseworker?

Well, the problem seems to be around the scheduling of the interview. So in a lot of states what happens is that the state would mail out a letter and say, "You need to complete this interview at X time and X date." But most people on SNAP have young children and they're also working and they're working in jobs like at say, a Starbucks where you have no control over your work schedule and you can't take an hour out of your work day to go complete an interview. That's a huge barrier. And so one of the projects that we worked on is a project, this is a collaboration with Code for America, which is a nonprofit group that helps states fix these kinds of glitches in programs like SNAP. And what we did was evaluate an effort that the state of Colorado did to make sure that people could complete those interviews.

So what they did is instead of just simply saying, "You have to complete the interview on this date, and you only have a 30-day window to complete it." Instead, they said they mailed out an interview date and time, but what they also did was say, "But if this doesn't work for you, you can actually just call up and either schedule a different time or just do the interview when you call." And that very small difference, what seems like a small difference had a huge impact, and that what we saw was not only did we see a substantial increase in the rate of people completing those interviews. We also saw a substantial increase in people actually getting onto the program who are supposed to be on the program, who are eligible for those benefits and need those benefits. It's just one really simple example about the kind of work that the Better Government Lab engages in to try to improve access to these benefits and services.

Jeff Karoub:
That's great, Pam. And thank you for listening to this episode of Michigan Minds produced by Michigan News, a division of the University's Office of the Vice President for Communications.