- Mahatma Gandhi famously observed it is health that is real wealth and not pieces of gold or silver.

True enough, as anyone who has lost his or her health would attest.

But there's also no disputing that gold and silver or their more prosaic counterpart government funding can make it easier for an individual or an entire community to avoid or recover from illness.

Hi, I'm Jon Schwantes and on this week's show we'll do a full workup on Hoosier's biggest health and healthcare challenges.

So, pop up here on the table, the discussion table that is, and we'll be right in.

Indiana lawmakers from the State House to your house and who said nobody makes house calls anymore.

(upbeat music) Dozens of studies have pointed to a link between health and wealth, often creating groups of haves and have not's, those who have access and those who don't.

Among other things well-to-do individuals often have greater access to nutritious food, safe, non-toxic surroundings, and preventive healthcare, including regular screenings.

On the other hand, those who are struggling financially have been known to ignore basic health needs and to put off seeking medical care until once manageable conditions turn into costly, full-blown emergencies.

Now, economic factors can have an equally profound impact on the wellbeing of entire populations, and that's where public health comes in.

Simply put public health is the science of protecting and improving the health of a community through the promotion of healthy lifestyles, the prevention of injuries and chronic disorders, and the detection and containment of infectious diseases.

Unfortunately, Indiana is one of the unhealthiest states in the nation as determined by metrics such as obesity, tobacco use, infant mortality, physical inactivity, and life expectancy.

It's probably no coincidence that until recently, Indiana also ranked toward the bottom of all states in per capita spending republic health.

For decades annual state funding hovered around $7 million.

Last year in the wake of the Covid pandemic, Indiana lawmakers, heeded governor Eric Holcomb's call for a renewed commitment to Hoosiers Health, allocating $75 million for our local health departments this year and $150 million next year.

So far, all but six of Indiana's 92 counties have opted into the so-called Health First Indiana Initiative.

The injection of new state funding promises to make Indiana something of a medical testing ground.

The question at hand, if money can't buy happiness, can it at least secure better health?

With March Madness looming, a lot of Hoosiers are paying extra attention to rankings.

But, here's one that should make us pretty darn mad and more than a little alarmed all year long.

According to a study released last fall by Forbes advisor, Indiana is number 10 from the bottom when it comes to accessibility, affordability, quality, and efficacy of healthcare.

And that's bad news indeed for a state that already has, as we just noted, one of the unhealthiest populations in the country.

How did we get here?

And more important, what can we do to fix the problem?

Joining me to discuss the issue are Democratic Senator Shelli Yoder of Bloomington, a member of the Senate's Health and Provider Services Committee, a senior lecturer at Indiana University's Kelley School of Business, and the one time director of a nonprofit focused on women's healthcare.

And former Republican senator and former state representative John Ruckelshaus of Indianapolis, vice president of governmental affairs for the Indiana State Medical Association.

And previously an executive with a healthcare benefits company and the head of a nonprofit dedicated to helping individuals who've suffered spinal cord injuries.

Thank you both and I will stipulate to regular viewers and listeners that's a much longer introduction than typical, but I wanted on an issue like this to point out that you approach this not just as policy makers dealing with dollars and cents and statistics, but as healthcare consumers in a very real sense yourselves and who people who've been touched dramatically by healthcare.

So that explains the introductions.

Alright, we're not very good in any of these rankings right now.

Cost or our own health attainment.

I mean, I don't know who to blame though in this quest to keep costs down and accessibility high.

So I'm gonna ask you both, who should we blame here?

Senator Yoder, we'll start with you.

- Well, I don't know how much we're going to get accomplished by blaming people, but I think it is important.

- Oh, but it makes, it's fun though.

- But I think it's really important to show the impact that it's having on Hoosiers lives from the $1 billion real error in fiscal oversight mismanagement to how it's impacting Hoosiers.

- This was Medicaid dollars.

- This was Medicaid.

- Just popped up in December.

- Yes, the Medicaid.

How did we miss a billion dollars when I would say we didn't miss it, we just didn't know about it.

So there's that and trying to find a way of really getting some solutions for Hoosiers working together to ease that burden of healthcare costs.

But you're right, we are also lagging behind when it comes to health outcomes.

And we have to get very serious about addressing those.

- So when we put up the villainous dart board and start, you know, pitching those darts, you're not gonna tell us whether we should put hospitals up there or physicians up there, or insurance companies up there, or Hoosiers themselves.

- I think Hoosiers themselves want answers.

They want relief in this area.

And what we need to identify are good solutions.

And I know the Democratic Senate Caucus, we have filed bills that would address this.

We've been sort of sounding the alarms of specifically the $1 billion Medicaid.

Oops, mismanagement of funds, lack of transparency.

We've been sort of sounding that alarm and we have not gotten anywhere as early as this session.

So, I know that Hoosiers, they want to know, "Okay, what are we going to do about it?"

And how we go about addressing it is going to again, impact Hoosiers directly.

So I think it's really important, the how and the why also important.

- John Ruckelshaus, you're not in office now, you don't have to be as diplomatic and as politically astute as your fellow panelist here, you represent 9,000 physicians, medical students.

I'm guessing they're not the problem in your eyes.

- Well, I think Senator Yoder, excuse me, did a very good job and you did a very good job Jon of framing this because when you look at healthcare, there's no greater issue in America than healthcare.

It touches every Hoosier, it touches every American.

It's 17, almost 18% of the gross domestic product, meaning 17 to 18 cents of every dollar is spent in healthcare.

I always look at this, that you can't point your finger at one particular individual, it's a circular firing squad, frankly.

And everybody has skin in the game.

Hoosiers have skin in the game by obesity, by smoking, by those issues that are lifestyle changes that we have to address.

We've got to get healthier as Hoosiers that helps drive this.

Physicians are coming to the table.

We're one of the lowest reimbursed in the United States, and we're trying, obviously to get more physicians into the marketplace and into the rural areas as well.

So, all hands on deck have to be a part of this.

And Senator Yoder is exactly right.

This is more than a Republican or a Democrat issue, this is a Hoosier issue.

- Well, and you point out the economic realities of this too, when people say, "Oh, the problem is high pharmacy costs.

Well, I'm mad at drug makers.

I'm mad at the people who develop and distribute medical implements."

And well, Indiana has more than a passing stake in those industries.

Certainly, 15 or 17% is the national, we probably even have more of our domestic product and output here tied up in that.

So, to your point, that circular firing squad probably is an apt metaphor.

So if we're addressing some of the health less than healthful habits of Hoosiers, and I include myself in that, I'm not pointing fingers.

Now, the Hospital Association did a study in the past year, said $3 billion we could save.

And that's direct cost, but also employer health premiums.

I mean that throws a lot of things in there.

Is that really, I mean, can Hoosiers really make that much of an impact just by curbing the smoking, eating better, trying to deal with their diabetes.

- We had a lot of discussions about this as we worked very hard on senate bill three last year in the Public health Commission that we wanted to engage with the state health department and local health departments partnering together.

And yes, it is expensive, the impact of heart disease, the impact of obesity, the impact of our high smoking rates, our high vaping rates in the state of Indiana.

They do have significant healthcare cost impact.

And we can address some of that there.

We also have to address the fact that I'm just very concerned about the priorities here 'cause we could address Medicaid, we could address the difficulty and access when we cannot attract healthcare providers and keep healthcare providers in this state by really having a serious conversation about passing a near ban on abortion care in this state.

It does nothing but hurt Hoosiers on a very unpopular policy and worsen each and every one of these areas that you've brought up.

- So you're saying that that alone is an issue that is driving up costs because physicians are fleeing the state that the care is not as affordable.

- Absolutely, it certainly isn't helping, it certainly is not going to help.

And I have been very vocal about this, that we could address each of these pockets by that one policy that is incredibly unpopular in Indiana and at least show Hoosiers that we are serious about putting aside these culture wars and letting Hoosiers decide the kind of care that they need with their physicians.

- You know, the health care oversight task force addressed a lot of issues that was not one of 'em.

But, you certainly bring that to the table and it's worthy of discussion as well.

You know, it's not for lack of legislation that these issues are out here.

I think about two years ago, I think about last year, there had been a commission that had looked at this, worked quite hard, collected a lot of input.

We had it yet another task force that met during the interim prior to this session.

But things just sort of, you know, there were caps proposed.

There were stringent bans on no compete provisions for physicians so they could maybe leave their current employers if they so chose and without having to move outta the state.

All kinds but everything sort of at the end got watered down.

Why did we have so much trouble as a state do you think John Ruckelshaus getting these bills across the line?

- Well, you're talking about a lot of stakeholders that are at the table and you have some big entities and I think we have to pull back and look again where we are at healthcare in America and in Indiana, it's consolidating.

So you have fewer hospitals providing more services, fewer amount of physicians, nurses, et cetera.

There's a nursing shortage, we have a shortage of everything in the worker capacity.

The only thing we don't have a shortage is people running for office.

So the point is, is that there is a severe shortage around.

So, what happens is when you have these big players to try to come to the table, nobody wants to give.

So that's what we've been trying to work on.

I think the governor did a really good job last year.

Former Senator Luke Kinley spearheaded that and senate bill for and came through the Senate as a matter of fact.

And that is a good first step because that brings the healthcare down to the granular level.

It brings it down to the county level where it needs to be a one-on-one if we're gonna change Hoosiers.

One of the things we didn't talk about, and Senator Yoder, I think you were kind of alluding to this or trying to get there, is we need to take a look at the cigarette tax increase.

This is an initiative that is bipartisan, it passed the house multiple times.

It stalled in the Senate when I was there, we actually raised the tobacco age.

But if you wanna move the needle, that's the one quick policy piece that you could do.

Lemme give you a real world example.

- Some of the most zealous supporters actually have been Republican stalwarts, like the chamber and other entities that normally don't align with...

They don't depart from the the party lines.

- That's exactly right.

So I think probably not this session, but I think next session that clearly is gonna be on the table.

- Because what we could do with this $1 billion surprise mistake that points to so many things, you know, $1 billion Medicaid error.

I think we could say, instead of first starting with sort of pulling the rug out from underneath so many Hoosier families who are caring for the most medically complex children, these families who have come to rely on being able to be paid for caring for their child.

Now some people might say, "Well why should you get paid for caring for your child?"

I would push back and say, "If it was your child and you want the best quality care, Indiana should be able to pay parents to be able to not live in poverty, to be able to stay home and care for their medically complex child and be reimbursed for that."

Considering all of the shortcomings that we have, the lack of healthcare and lack of health providers that we have in the state of Indiana.

In order to address some of these issues of outcomes and this $1 billion Medicaid shortfall, I think it's a real mistake to start that fiscal fine tuning or fixing the mistake on the backs of some of our Hoosiers most medically complex.

- Well, you know, let's dive into a few of these issues 'cause you both have now brought several up and lemme go back if I may, just briefly to the notion of unhealthy Hoosiers, because both of you talked about Luke Kinley, the group and there were others, Susan Brooks and others.

I don't wanna leave anybody off that deserves credit for that, but Luke suggested, you know, half a billion dollars should be thrown at not thrown, invested in public health, it's been lagging for years.

I think we'd averaged as a state about $7 million a year.

We ended up about half 75,000,000 1st year, the biennium 150 second years.

So about half of the request, and I think most of the Indiana counties have signed up, there's a local match required, which is why I presume it's not all 92.

But, can we hope that that is going to have an impact or is that, I mean, will that move the needle in any significant way?

- I think it was a huge wake up call when you say no, no, no, no to public health investment for almost two decades and then realize the mistake that that was because of how far behind Indiana has fallen and that we've lost a life expectancy for your male working age individual in the state of Indiana.

The first time ever we've started to not track with the life expectancy of the United States, but are starting to go down.

Yes, it is a wake up call and an irresponsible approach to public health.

So my hope is every county will invest in partnering and the great thing that local communities can do local health departments and county commissioner, the executors of the counties, they can decide what are the biggest outcomes that we need to see improvements and partner and really fine tune how those dollars are gonna be spent.

That was the best thing I think that we did last year, is to really enable a partnership and a communication bridge at the local level to getting those dollars from the state to address unique needs in every county.

- And it may mean that the six counties that didn't sign up to this point have the op...

I mean they do have the opportunity whether they take the opportunity is another question.

John Ruckelshaus, let's say everything, this plan the investment in public health pays huge dividends.

Everybody starts training for marathons, everybody quits cold Turkey, we're gonna get healthy.

Still doesn't address the issues of the cost and accessibility of of hospital care and physician availability and so forth.

What's the one thing we can do as a state aside from getting healthier that would help address that issue?

- Well, just to circle back and finish up here, keep in mind with the governor's healthcare initiative that we had last year that was so important about that, 50% overnight of the 92 counties, excuse me, that we do have, half of the counties have a population of less than 50,000.

So they didn't have the tax base to do this.

So that's extremely important there.

So yes, rural hospitals have closed that are an alarming rate... - Yeah, lots of counties, I don't know what the number is now that don't have any hospitals at all.

- Correct.

So one of the things that we've been advocating for is graduate medical education.

So, Indiana has Indiana University has the largest medical school in the country.

So one of the things that we know if graduates of Indiana University, they do their fellowship and they do their residency trainings, 70% of them stay in the area that they do it.

The state could clearly look at subsidization and debt, student debt, medical students graduate with over $250,000 on average debt.

The state could help subsidize if the commitment is to stay in the rural areas and participate and take care of Hoosiers.

- And with IU being the largest medical school now by enrollment in the country, right?

If not the world, I guess that could have an impact.

- That's true.

I would agree with Jon on that point.

However, those numbers and that percentage was pre the abortion ban in the state of Indiana.

And we know that medical students who are graduating are looking closely at where their own licensing and profession is going to be at risk.

And those states that have put politicians inside of the examination room, those are the states that they are saying, "I don't wanna practice there.

I'm going to invest in my professional career and in my calling and my vocation and a state that doesn't put myself and my family at risk."

So I go back to, we could address this by repealing the abortion ban that we put in place in the state of Indiana.

- Again, an important issue, I'm guessing not one that typically shows up in discussions about healthcare cost containment.

But again, a very good legitimate point you bring up.

- It does show up, it is showing up and there is a reason why this topic gets excluded.

It's because we don't wanna talk about it.

You know, we had a a bill that it was a good bill, it was addressing prior authorization and it was a priority of the Republican party.

- You read my mind, I was gonna ask you since that's one bill that was a Republican priority in the Senate until it wasn't.

- And then it disappeared.

And in the committee hearing that we had on this bill, I asked the author of the bill who does get to be in that room deciding the care that you get, and the author of the bill said, "No one, not insurance.

They don't get to dictate the care that's needed for a physician to address the needs of a patient."

And I said, "Then why put politicians there?"

Which is what we did with passing that abortion care.

And then senate bill three, which was what the prior authorization bill was, disappeared.

- Authored by a physician, I believe.

- Correct.

- Senator Tyler Johnson.

- Right, so now again we can debate why it disappeared as you put it.

And I think clearly, fiscal impact was lurking, looming large here.

How much of a significant impact do you think that could have?

I mean, pre-authorization is a way of life for the insurance industry, certainly for our state is that the silver bullet?

- Oh, this is a major, major issue and it's all about patient safety and livelihood.

Because what we found out is that this is a notion, and this has been a tool that's been used by insurance companies probably 40, 50 years to "contain healthcare costs" and is an former employer.

I understand that paying the premiums for employees.

As an employee, I understand that too because we wanna keep healthcare costs down, but it's run amuck now with all the sophistication and algorithms and everything else.

Over 90% we're finding out of claims are being denied on the front end and then over 93% of 'em are being approved.

So there's a lot of shell game patient delays and people are up in arms.

And this is what our physicians are telling us, this is what Hoosiers are telling senators and representatives.

There were three bills that were introduced in the house this year on this issue about two bills in the Senate that were introduced.

It will be back in some form.

(Crosstalk) - 'Cause it was offered last year, didn't prevail and again this year.

- Well, lemme say this, I'm gonna actually push back a little bit, Jon, on the notion that send this prior authorization bill disappeared because of the fiscal.

We already knew, the super majority knew that they were not opening this budget.

This was the last day that we could hear from Republicans and what their priorities are going to be.

Session had already started.

They absolutely knew about their priorities.

You cannot tell me that the fiscal note on this, which came back, it didn't show a price tag that all of a sudden it was another surprise.

We get a billion dollar mistake that is costing, that's going to cost Hoosiers significantly in December and then we're gonna have another surprise fiscally.

So I just wanna push back a little bit and say that bill disappeared because of the fiscal impact because they absolutely knew.

I think it's because they realized that they had stepped in it.

And if you wanna talk about trying to control... - No doubt it's a controversial bill.

- But I mean there is a huge impact even from that the Medicaid standpoint, which also deals with pre-authorization for... Before we run out time.

- Yeah.

- And I know you're passionate about this so I hate to move on, but we've got a lot of territory to cover in a short amount of time.

So, we've addressed Hoosiers who are not very healthy.

We've talked about insurance companies, are they the bad guys?

Hospitals?

Some economists say it is that lack of competition.

We have several major hospital groups, you know, and in the past they have had non-competes.

They can't do it for primary care physicians now, but they can still have non-competes for everybody else.

How do you John Ruckelshaus make sure that hospitals are in line with reasonable costs without putting more of them out of business because a lot of them are, I mean they run it in the red a lot.

I mean there's not a one size fits all.

Yeah, they're huge surpluses for some, but not for all.

- Right, we still need strong hospitals.

We still need strong fiscal hospitals, financially responsible.

No question about it, we need that.

But one of the things that we've been working on for physicians is more of an independent practice.

If you look at House Bill 1004 from last year, for the first time the Indiana General Assembly gave a $20,000 tax credit for physicians that would go out on their own and have independent practice.

So I think if we could decouple physicians than they have more independent practice so that they can actually consumers and and their patients are true consumers of healthcare.

- 'Cause they offer testing in their labs and so forth that maybe would compete with, especially if the non-compete goes away as not for primary care.

- Correct.

So more independent physician practices long-term I think will go a long way.

And you wanna say, I presume the primary care ban be extended.

- Correct.

- I mean the ban, the non-compete... - Correct.

- Final word, yeah.

- I would say part of the physicians are the nurses.

I mean, if you are ever gonna talk about how this impacts healthcare is the burnout and the high turnover in the nursing profession.

And I am meeting more retired nurses than I'm meeting nurses who are actually providing the care probably because they're working so hard day in and day out providing care for Hoosiers.

And we need to address what they're asking for.

And that is, you know, some workplace balance being respected in their profession and making sure that we are doing everything that we can to address that high turnover and burnout that nurses are...

There's an outcry on what they're facing today.

- All right, I'll tell you, we gotta leave it there.

But we covered a lot of territory and in fact in deference to this healthy Hoosier kick, I feel like I gotta work out, just trying to keep up with you two today.

But thank you for your insights.

- Meet you in the gym.

- And your passion on these very critically important subject that really does affect all of us.

Again, my guests have been Democratic Senator Shelli Yoder of Bloomington and former Republican Senator John Ruckelshaus of Indianapolis, now vice president of Governmental Affairs for the Indiana State Medical Association.

Indiana has a love-hate relationship with technology.

We love it when it simplifies our lives, but not so much when it displaces workers or empowers criminals on the next "Indiana Lawmakers."

And time now for our weekly conversation with "Indiana Lawmakers" commentator, Ed Feigenbaum, publisher of the newsletter, "Indiana Legislative Insight," part of Hannah News Service.

Ed, hard to believe we're at the halfway point.

Fill us in, surprises?

- I think the biggest surprise is that we've got five members of the legislature running for Congress.

I don't think anybody expected that at the beginning of the year with all the congressional resignations and people wanting to move on up the food chain.

But, we also have, I think have seen some surprises with legislation.

I don't know that anybody would've predicted that a wetlands bill would've been the first one through both chambers and on its way to the governor.

But when you look at the healthcare things that we were talking about earlier in the round table, that prior authorization bill in particular, I think that was the one big surprise this year that that hasn't gone further.

That didn't go through the senate in the first half of the session... - Because usually when a bill has a single digit attached to it, it is a leadership bill... - And it was... - And that's gonna be on rails.

- Certainly.

And it was a senate majority caucus agenda item as a priority.

And I think, you know, yes, the cost was a little bit more than they thought it would be.

And there were some questions about whether it might even be higher.

I think you'll still see something along those lines.

I think John Ruckelshaus alluded to that with some more attention to this at the end of the session, I think what you'll see is more reporting, insurance companies required to report when and why they turn things down that may lead to something next session like you've got in Texas with that gold card where good providers, providers who have shown a record of doing things well will be able to do things without prior authorization going forward.

But that's still, you know, another session away.

And then it would take a long time to implement a program like that administratively.

- So essentially everything that cost containment measure we've seen this year and last year will be back in some way, shape, or form.

- Oh no doubt and it'll be a budget session so they won't have an excuse not to do it.

- Alright, very good Ed, as always, appreciate your insight.

- Thank you Jon.

- Well, that concludes another edition of "Indiana" Lawmakers.

I'm Jon Schwantes and on behalf of commentator Ed Feigenbaum, WFYI Public Media and Indiana's Other Public Broadcasting Stations, I thank you for joining us and I invite you to visit wfyi.org for more State House news.

Until next week, take care.

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