MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Whether you think of it as the Affordable Care Act, Obamacare or don't think much about it at all, change is coming soon to a health care system near you. Maryland has been hailed by many analysts and observers as a state that's been going all out to comply with the Affordable Care Act, with a goal of creating a health care exchange tailored to meet the needs of its population, while also planning for changes to Medicare and Medicaid programs within the state and dealing with the effects sequester cuts will have on the entire health care system.

MR. KOJO NNAMDIIf that sounds like a lot, it is. And here to help us get up -- here to help get us up to speed on it all is the man overseeing it. He is Joshua Sharfstein. He is the secretary of health and mental hygiene for the state of Maryland. He's also a medical doctor. Joshua Sharfstein, thank you for joining us.

DR. JOSHUA SHARFSTEINThanks for having me.

NNAMDIFeel free to join the conversation. Give us a call at 800-433-8850 if you have any questions or comments about the Maryland health benefit exchange or anything else having to do with Medicare or Medicaid. 800-433-8850. You can send email to kojo@wamu.org. Joshua Sharfstein, it's been about a year since we've spoke just after the Supreme Court upheld the Affordable Care Act. How far have you come since then in setting up the Maryland health benefit exchange? And please explain how it will work.

SHARFSTEINSure. We've come a long way. It's been quite a year, very busy. Right now, people can go online to marylandhealthconnection.gov. One of the things we've done is we've named our exchange Maryland Health Connection. Right now, we're looking -- we're planning very intensely for Oct. 1st, when that website will go from what it is now, just an information portal, to actually being a place people can go to sign up for insurance, both Medicaid, as well as private insurance, both for people who need extra health in the form of subsidies and for anyone.

SHARFSTEINAnd we're -- the coverage that is available on Oct. 1st will be kicking in on Jan. 1st. So we really have just a handful of days between now and then to get the system up and going.

NNAMDIAnd...

SHARFSTEINIn order to do it, there's a lot of work. We are working with organizations around the state. We have six major partners in different regions, with 50 or more organizations clustered around those partners as part of an agreement with them. There will be a P.R. campaign to tell people about the new options available to them. So we're seeing just a huge amount of preparation going into this fall.

NNAMDIWhat dates should Marylanders should circle on their calendars as the exchange gears up to go online Oct. 1st?

SHARFSTEINOct. 1 is the day where they can get started. The open enrollment period will be through March. People can go online now, though, at marylandhealthconnection.gov and sign up for updates, and probably sometime in August, we'll have our call center up and going to answer people's question.

NNAMDIWho qualifies for the health benefit exchange among the uninsured?

SHARFSTEINSo people -- adults who have incomes up to about 133 percent of the poverty line, maybe $20,000 for an individual, are able to receive Medicaid through the health benefit exchange, the Maryland Health Connection. Between 133 and 400 percent of poverty, which is may be up to about $80,000, people can qualify for subsidies so that they can finally afford coverage. And then children actually have a higher eligibility for Medicaid in Maryland, up to about 300 percent.

SHARFSTEINAnd then anybody, even if their income is higher or they're not a citizen, can still go online and purchase coverage but maybe not qualify for the subsidies.

NNAMDIMaryland has been hailed as a leader in terms of compliance with the Affordable Care Act, getting to work on an exchange even when the constitutionality was still in question. What advantage do you think getting a head start and doing this on your own terms has given you?

SHARFSTEINWell, you know, the governor and the lieutenant governor got started really early. The day after the law passed, they announced a planning effort that involved dozens of meetings, hundreds of public comments. And the one thing that really came through in Maryland was that people in Maryland wanted to control their own destiny, and they've realized the best way to do that will be to set up our own state-based exchange.

SHARFSTEINAnd so people left their preconceptions about the Affordable Care Act behind. This is a law that had passed. It provided a set of tools for states and let's try to get it to work as well as possible for Maryland. And I think that attitude, that sort of coming together has really served as well. There have been three steps in Maryland. The first was in 2011. We set up the governance of the process, the governance of the exchange.

SHARFSTEINAnd it's a public corporation. I'm the chair of the board, and there are other state employees who are on the board, but there's six people who aren't state employees, one who is the former head of the Maryland Retailers Association, another who's a legal aide attorney. So -- and that board in that first year convened a whole range of public meetings. We had six reports that we wrote with literally over 100 Marylanders actively involved that first year from a wide array of backgrounds, brokers, doctors, hospitals, insurers and others.

SHARFSTEINBased on that input, in the second year, the second step was setting up the policy structure for the exchange, and we did that in a second piece of legislation. The governor and lieutenant governor were critical, and the legislature was very interested in getting this right. And pretty much all the recommendations that we came up, with working with everyone in that first year, got put into law.

SHARFSTEINThe third year, we kind of tightened up a few things, and we put in place the funding. And I think by going step by step, we've been able to build support and show that we're really open to trying to figure out how to maximize the benefits and minimize the risks. I think people who have started late have had to do everything at once, and I think that's harder.

NNAMDIOur guest is Joshua Sharfstein. He is the secretary of health and mental hygiene for the state of Maryland. We're discussing the coming changes to health care in that state and inviting your calls at 800-433-8850. Are you uninsured in Maryland, counting the days until the state's health insurance exchange becomes active, or are you dreading the impeding individual mandate?

NNAMDIGive us a call, 800-433-8850, or send email to kojo@wamu.org. Nationally, much of the focus on the Affordable Care Act was the mandate requiring people to buy health insurance, but you've been focusing more on making it affordable. Does a mandate help you to meet that goal, and what is it your plan for meeting that goal?

SHARFSTEINThe basic purpose of a mandate is to avoid the problem that people only seek to get insurance when they're sick, because if you do that, then the only people who have insurance are the people who are very expensive and the price becomes unaffordable. It'll be sort of like allowing people to get automobile insurance right at the point that they've had an accident. So there's a very strong logic in a mandate.

SHARFSTEINI think our initial focus right now is to really tell people what health insurance is about, explain that we think that there's gonna be an option that's going to fit their budget. And try to build as much of a interest in getting health insurance among as many people in Maryland as we can right off the bat. There are penalties. There are also exceptions to the penalties. And, you know, our goal is to try to encourage people to get insurance initially.

SHARFSTEINOne of the things that we've learned through some of the work that we've done is that people who are uninsured in Maryland, they want insurance. It's not that they've made a choice to put, you know, themselves and their families' finances at risk, they want insurance. But they may have been turned down in the past because they were sick or it was just too expensive. And they're feeling a little bit, you know, defensive about the fact that they're uninsured. And our initial goal is to get over that and really say it's a new day, that there are great options, and we want people to do it because it's the right thing to do.

NNAMDIAnd not just people in Maryland want insurance. People in other states want insurance and are still a little confused as to what will apply where. We've got an email question from Rita who says, "will Maryland's health exchange be available to residents in Virginia or only to Maryland residents?"

SHARFSTEINWell, it will only be available to Maryland residents, and I think that, you know, one of the things I read recently is that opponents of the Affordable Care Act have spent something in the order of $400 million, you know, and a lot of that information may have helped to -- or served to confuse people about what's actually gonna happen. And I think it's a big challenge nationally to really, you know, have people understand their options.

SHARFSTEINThe federal government is gonna set up a health insurance marketplace that will be available through healthcare.gov in a lot of states where there are not gonna be state-based exchanges like the Maryland Health Connection.

NNAMDIJust because a mandate is in place doesn't necessarily mean everyone will comply. How are you gonna be making people aware of the plans available and encouraging compliance?

SHARFSTEINSo it's a multipronged approach. So, for example, we're going to be doing some traditional advertising. We're also going to be doing some social media work, particularly among young people who may be uninsured. We have partners that we're calling connectors -- connector organizations. There are six major connector organizations in the state. In this region, Montgomery County Health Department is serving that role.

SHARFSTEINEach connector organization is getting funding, and they have an array of partners, and that could be local community organizations, it could be faith-based organizations, it could be local businesses or physicians groups that are partners, and they're gonna be getting support to be able to do direct outreach, particularly to communities that they know well. So in addition to all that, we're gonna have partners that are not directly related to their connector organizations that can go online to marylandhbe.com, which is our organizational website, download tool kits, videos, presentations.

SHARFSTEINWe want as much interest and enthusiasm as we can get. I think the insurers are gonna be advertising. I think the hospitals and medical systems, they're gonna have a big interest in seeing as many people insured as possible. And coming together as a state, I hope we're really able to make good use of the opportunities that are there in the law.

NNAMDIOn to Kate in Baltimore, Md. Kate, you're on the air. Go ahead, please.

KATEThank you so much for taking my call. I really appreciate it. I'm the mother of two young women who are -- have no insurance. One just graduated college, and her university insurance will run out shortly. And the other one has a year to go. And believe it or not, goes to a Maryland state school where no college insurance is offered, which is kind of a sad situation, I think, but any rate, I found out I couldn't get her on Medicaid -- she makes about three grand a year -- because she doesn't have any dependents. In other words, she's not a mother. So I thought that was interesting, and I was told that every state is not that way. Is that true?

NNAMDIWell, I'd also like to ask before I get a response from Joshua Sharfstein, how old is your daughter or your daughters?

KATEWell, one is almost 21, and the other one is 22. And it's the 20 -- almost 21-year-old who I applied for Medicaid for because her school doesn't offer an insurance policy. And those are very cheap. They have a high deductable, but they're much less expensive than, you know, going to Care First or Aetna and buying them a monthly plan.

NNAMDIOK. Here's Joshua Sharfstein.

SHARFSTEINWell, one thought would be whether they're able to be on your plan because under the Affordable Care Act, there are requirements that kids up to, I think, 25 or 26 can stay...

NNAMDITwenty-six.

SHARFSTEIN...on their parents'...

KATEI don't have a plan.

SHARFSTEINWell, that's also something that, you know, obviously is important to address.

KATEBut -- well, I'm relieved to hear you say that it sounds as though at least the younger one will -- I can sign her up for this. And so I'm very relieved with that.

SHARFSTEINWell, and you too.

KATEAnd I'm happy that the state is going along with, you know, setting up an exchange. I think that's great.

SHARFSTEINYeah. Let me just tell you, and you as well, because for the first time, people can't be screened out or denied because of any health concerns that they may have had in the past. And in addition, you know, we hope that through the website, we'll have a much easier way to enroll, that will give choices to people, choices to your daughters, choices to you, to pick something that fits your budget. That's really what we're aiming for.

NNAMDIThank you very much for your call, Kate. You, too, can call us at 800-433-8850. If you live in a state that is adopting the federal health care exchange, how do you feel about that decision? And what are your thoughts on states' ability to opt out of that decision, 800-433-8850, if your state has decided not to adopt the federal health care exchange. 800-433-8850. In 2006, you told the Baltimore City Paper that the key question in public health is, compared to what? Do you continue to ask that question?

NNAMDIAnd if so, how does it play into the work you're doing with the Affordable Care Act? I know there has been a great deal of criticism of the Affordable Care Act. But in terms of Maryland, I guess one of the questions would be, compared to not having any health insurance?

SHARFSTEINOh, well, that's absolutely right. I continue to believe that that is a critical question in public health. And in a lot of different areas, I'm confronted with people who would say, well, my ideal world would be the following. And, you know, that's -- I may agree or I may disagree, but we're really confronted with an incredible opportunity whether or not it's written in a perfect way. I don't know anyone who thinks that the law is perfect. But it's an incredible opportunity.

SHARFSTEINAnd if we can get it to work as well as we can, we will be helping people get access to health care that they truly need, not just for themselves and their families but for their ability to work, their ability to contribute to society, their ability to feel dignity in their lives. It'll be a tremendous victory. So, you know, I view it as, you know, the alternative is us having a set of tools that we're not deciding to use.

SHARFSTEINAnd I'm really honored to be working in a state where there are just so many people, from the governor, the lieutenant governor, the attorney general, the state legislators, who've really encouraged us to use this law as best as we can.

NNAMDII guess I should have phrased my earlier question to the audience earlier. If you live in state that is implementing its own health insurance exchange, how do you feel about that as opposed to states that are adopting the federal health care exchange? Any advice for your counterparts in states now scrambling to set up exchanges in compliance with the law or those opting for the federally operated exchange such our neighbors in the commonwealth of Virginia?

SHARFSTEINWell, you know, we have very good discussions with people that are really apolitical. We'll share whatever information, advice, even computer code that we have. We learn from other states. You know, a lot of the challenges in health care are apolitical. While the Affordable Care Act, obviously, has its own kind of politics to it, the fundamental challenge in health care is to get better value, to improve health at lower cost.

SHARFSTEINAnd I'll go to meetings with Secretary Hazel in Virginia, where we all agree on 98 percent of what we're talking about, because we both want to see the citizens in our states be healthier, and we want to see it done in an affordable way.

NNAMDIGot to take a short break. If you have called, stay on the line. We will get to your call. We have still have lines open, 800-433-8850. If you have questions about other public health issues at play in Maryland, you can call that number also, or send email to kojo@wamu.org. Or send us a tweet, @kojoshow. I'm Kojo Nnamdi.

NNAMDIWelcome back. Our guest is Joshua Sharfstein. He is the secretary of health and mental hygiene for the State of Maryland. He is also a medical doctor. We are discussing changes coming to health care in Maryland under the Affordable Care Act and changes coming on to Medicaid and Medicare. Inviting your calls at 800-433-8850. Here is Gerald in Annapolis, Md. Gerald, you're on the air. Go ahead, please.

MR. GERALD LORNEGood afternoon, Dr. Sharfstein. This is Gerald Lorne (sp?) calling from Annapolis, and I'm very pleased to listen to you this afternoon. I feel that you're one of the few people in our state, perhaps in our country, who is a medical professional and is frankly very anxious and eager to make sure that the Affordable Health Care, as some people like to call it, Obamacare, works and reaches as many Americans as possible and brings better health to the country.

NNAMDIThank you very much for your call. Do you have any questions for Dr. Sharfstein?

LORNEI have no questions. I just want to make sure, Doctor, you keep doing what you're doing and make sure that it helps and you get the help from our citizens and we get this to be a success in Maryland.

SHARFSTEINThank you very much.

LORNEYou're welcome.

NNAMDIA committed Marylander. This is not, as they say, your first rodeo. You worked on the implementation of the Medicare Part D in Baltimore. How has that experience informed the work you're doing now?

SHARFSTEINWell, at the time, I was the health commissioner in Baltimore City. And -- so I wasn't working in the federal government. I wasn't even working at the state. But I was worried, if you remember, that was a big change, and a lot of patients, some very frail patients, were having their drug coverage switched over all on one day, just as I was starting as the health commissioner. And at the time, it was Mayor O'Malley, gave me some extra funds to try to set up a safety net system to help the people who were switching.

SHARFSTEINAnd we notified all the pharmacies, and 24 hours a day, they could call for assistance. And we gave some money to tide people over until whatever bureaucratic snafus were there got worked out. And I think I learned from that that, you know, these big transitions can offer a lot of coverage to people. But in the transition, you've got to really look out for the people who are most vulnerable.

SHARFSTEINAnd, you know, I do expect that even in Maryland, even where everybody's been trying to do everything right, we will have some bumps in the road. And I think our goal is to be able to be in a position to respond to them as quickly as possible, to fix problems as they come up, the attitude we've taken is we don't have all the answers. We may make some missteps, so we're gonna do our best to try to fix them as quickly as we can.

NNAMDIOn to the phones again. Ray in Salisbury, Md. Your turn, Ray.

RAYYeah. Hi. Look, I'm a small business guy. We got just over the 50 number of people that I should -- to get under whatever that level is. But anyway, let me give you a little bit of history. In fact, 15, 20 years ago, I worked with my health insurance company to get my people's health better. They -- and I worked with them. They sent vans down. We had everybody tested. Caught some people with high blood pressure. Caught some people with other things. Got everybody to quit smoking.

RAYAnd over a two to three-year period, my premiums went in half of what they were. My people were healthier. Everything was doing fine. Then Maryland passed some sort of law that said -- well, small business people, I guess, couldn't get insured. So they passed some sort of law, and all of a sudden, my premiums tripled the next year, and I couldn't figure out why. So I got a hold of the lady from California, I think, who was the mother of this, and I said, what did I do wrong here? She said, you didn't did anything wrong. Everything you did was right.

RAYBut the problem of it is that we put everybody together under one thing. And I said, so my premium is tripled. She said, that's right. So I am not a proponent of the government messing around with the healthcare. But, hey, we are what we are. The question is that how is this program -- I know it's gonna help a lot of people that are uninsured.

RAYHow is this program gonna help people that are insured and the businesses that help pay for this and the individuals who help pay for this. Some of the premiums are gonna have to be paid for them. Can you -- do you have any answer for that? And if you do, I'd sure like to hear to it.

NNAMDIRay, listen in, because we got an email from Lee in Frederick who says, "I'm in a plan with my employer which has less than 30 employees, and because of its size, is not able to negotiate a less expensive plan." That might be the satiation Ray finds himself from. "Will the exchange help my employer? If not, can I opt out with my employer and choose a plan on the network to get coverage on my own?"

SHARFSTEINSure. Well, I really appreciate both of those questions, and they're really two types of questions. One of which is, you know, nobody -- maybe it's a good idea to expand access to coverage. But what happens to the price? What happens to the price of coverage for people who are already insured? And that's a very important consideration, and I don't think the Affordable Care Act has all the answers for that. I do think that states have a lot of options.

SHARFSTEINAnd in Maryland, we're thinking very broadly about how we can, over the long term, curb the cost trends and reduce cost. I was out actually on the Eastern Shore with the National Federation of Independent Business Affiliate not too long ago, talking to small business owners about this. You know, Maryland has a very unique system of paying for health care.

SHARFSTEINWe're the only state that sets rates for hospitals, and that provides some very innovative tools to really change the trajectory of health care costs. And that's something that we're working on. Really, it's sort of in parallel with implementing the Affordable Care Act in the exchanges, but I think it's absolutely essential. If what we're doing is providing access to something that continues to grow out of control, in terms of costs, we won't be successful over the long term.

SHARFSTEINSo we've got to be thinking about getting better value in health care now as well. In terms of the exchange itself, I think that the -- there will be a small business side of the exchange. We've designed it to work very closely with the existing brokers who a lot of small business owners count on now for good advice, not only about health insurance, but about retirement and payroll and other things.

SHARFSTEINAnd people will be able -- it will serve the function of pooling buying power and will also provide access to tax credits for certain businesses and will provide the ability to allow employees to choose their own plans, which they are not allowed to do, if the employer wants them to. So I think that there may be some benefits. But over the long term, we won't do well as a state or really as a country unless we're able to get better control of health care costs. And that -- I think the Affordable Care Act is an important part, but it's not a magic solution, and we really have to think beyond that.

NNAMDISo the Affordable Care Act and the health benefit exchanges won't necessarily cause raised premiums to drop. But what you seem to be saying is that it will probably give both him and his employees more options.

SHARFSTEINI think that's true. Now in Maryland, there's about 7 percent hidden tax on every hospital bill. We all pay for the uninsured. As more people are getting insured through the Affordable Care Act, that tax will drop because there'll be less care provided for the uninsured. So every small business, every large business will get that benefit over time. So I do think that there are some direct benefits.

SHARFSTEINBut over the long term, I think that it's gonna require thinking about health care differently and really having the health care system pay for better value over the long term which I think is a trend that the Affordable Care Act is helping. But it's still gonna require everybody's efforts to really bend the cost curve.

NNAMDIRay, thank you very much for your call. Good luck to you.

RAYSure. Thanks.

NNAMDIOn now to Joanne in Ellicott City, Md. Joanne, your turn.

JOANNEOh, good afternoon. I'm calling because I am a person who has a preexisting condition. And years ago when Congress passed the HIPAA law, I was able to find a medical insurance policy because insurance companies were required to insure, I think, 10 percent of people with preexisting conditions. And it was my understanding that that was a one-time deal for me, so to speak. And since that time, my premiums have gone up every single year.

JOANNEAnd I'm wondering, am I allowed to shop around now to see if I can find coverage that perhaps may be equal to or even better than what I have now at lower premiums?

NNAMDIJoanne, I'm glad you brought that up because paying for health care is, as you probably know all too well, a process often mired in rigid regulations that can restrict doctors and restrict patients like Joanne's choices. How will the idea of flexibility play into these reforms and maybe be able to help someone like Joanne?

SHARFSTEINWell, I think what we're doing really is geared to help people like Joanne because starting October 1, you'll be able to go online or call our call center or reach out to one of the community agencies that's partnering with us and be able to be your own decision maker, look at a whole range of choices. We have more plans that are going to be participating in the exchange than are currently participating in the market.

SHARFSTEINAnd you'll be able to compare prices, you'll be able to compare quality scores, you'll be able to look at your budget at different levels and make a decision that's right for you. So you're gonna go to a lot more options, and really, it'll be up to you how to proceed. We wanna make that opportunity available to as many Marylanders as possible this fall.

NNAMDIJoanne, thank you very much for your call. Medicare is also a big part of this reform process. And Maryland currently gets a Medicare waiver that brings more federal money in. Can you explain that waiver for us and tell us whether that's about to change?

SHARFSTEINSure. So this relates to what I was saying before about the need to think more broadly about cost, even, you know, more broadly than just the coverage expansions of the Affordable Care Act. So Maryland is unique because we have an independent agency that sets the prices that each hospital may charge. Each hospital gets its own price structure, and every payer pays against the price structure, including Medicare, Medicaid, BlueCross, CareFirst, all the other private insurers. They pay against that cost structure that's set by this independent commission.

SHARFSTEINWhat we would -- and this has been a system that's worked very well in Maryland from a number of perspectives. What it does is it allows us to pull the uncompensated care for the uninsured and spread that over the system. So you don't have like one hospital that's overly burdened by having to -- or financially unsound because of care for the uninsured. It helps spread the educational payments. It helps reduce cost shifting between different payers. There are some strains in that system. And what we're thinking of doing and what we've been talking to the federal government about is modernizing it.

SHARFSTEINTaking this advantage that we have of being able -- or this system that we have of setting this commission that sets the prices, but orienting it to a challenge of getting better outcomes at lower cost. And let me give you a really concrete example. There are some innovations that are now going on right now that are kind of what we wanna promote even more in the future. But for example, there are 10 hospitals in Maryland that get a global budget across all payers set at the beginning of the year. It doesn't matter how many people come into the hospital.

SHARFSTEINIt doesn't matter how many MRIs they do. It doesn't matter how many ER visits. They know their budget at the beginning of the year. So instead of having to try to, you know, keep the numbers high to make money, this is a hospital that now wants to help people stay healthy and stay out of the hospital. So what are they doing? They're investing in home care. They're improving their partnerships with primary care. They're making better arrangements with long-term care facilities. They're working with community health.

SHARFSTEINThere's even a hospital in Maryland that has taken over the school health program in their county. And I talked to them, I said, you know, why would you wanna do that? I've never heard of a hospital doing that. And they said, well, we've noticed in our emergency room data there are too many kids coming in with asthma attacks. And so now, it used to be every time a child came in, we get paid. That'll be more money for us.

SHARFSTEINBut now, if we can keep them healthier by working on them in school, with their parents, they don't come to the emergency room, and we make money. That is the kind of thinking that will allow us to do a lot better in terms of the value we get out of the health care system.

NNAMDIOn to Anne in Kensington, Md. Anne, you're on the air. Go ahead please. Hi, Anne. Are you there? Anne?

ANNEHello?

NNAMDIThere you are.

ANNEHi. Thank you for taking my call. And I'm a retired federal public health expert. And I'm wondering how the Maryland Connector will ensure an outreach in partnership strategy reflecting the substance use in mental health coverage under the ACA. And how will Maryland work with SAMHSA's Behavioral Health Treatment Locator?

NNAMDIThere's a number of abbreviations there that our listeners might not be familiar with. But I'm pretty...

ANNEOK.

NNAMDI...sure Dr. Sharfstein is.

SHARFSTEINSure, no problem. Look, it's one of the great parts of the job. I think Maryland has a higher concentration of retired federal public health experts than any other state in the country. So I get a lot of extra help and advice along the way. It's a great question. Behavioral health is extraordinarily important.

SHARFSTEINAnd one of things that we're learning as we shift to value in health care, as opposed to just volume of services, is that people who have serious behavioral health problems, including mental illness and substance abuse are -- that can be very unhealthy, very sick and cost an awful lot of money. And paying attention to their behavioral health needs is great for them. They can regain control of their lives. They can get jobs. They can stay out of jail. They can be productive, and at the same time, really reduce the burden of excess health care cost. So it's a very important priority for us.

SHARFSTEINIn fact, Maryland probably invests more than any other state, I would guess, in terms of state funding particularly in a substance abuse system. So we've been working quite a bit right now to try to -- first of all, we -- there's been a major Medicaid expansion of benefits for behavioral health. And we've seen major improvements and access through that over the last couple of years under the governor and lieutenant governor. But as we're looking forward, we really wanna see the private health plans that people will be able to choose from on the exchange providing a strong set of behavioral health coverage.

SHARFSTEINAnd one of the things we're doing, we're calling mixers. Mixers are meetings between private insurers and Medicaid plans and providers who may previously have not been part of the network. It might be a substance abuse treatment program that has gotten a grant or they work with one payer. But now, all these new people may have insurance to pay for it, and we wanna introduce the plan on the one hand to the program on the other.

SHARFSTEINAnd so we're having these mixers across the state. Our goal is to really facilitate the ability of individuals to get these services and the ability of the programs to be paid for them through the benefits that are available under the law.

NNAMDIAnd thank you very much for your call. And since we're talking about phrases or acronyms that I didn't understand, a phrase you used in the break is plastic surgery compounding.

SHARFSTEINOh.

NNAMDIExactly what are we talking about here?

SHARFSTEINOK. Those are two phrases. So...

NNAMDIOh.

SHARFSTEIN...we've had a number of public...

NNAMDIPlastic surgery and compounding, yeah. (laugh)

SHARFSTEINRight, exactly. So, you know, this has been a very busy year in public health in Maryland, and there were a few very important laws passed in the general assembly, some terrific leadership by state senators and delegates, one of which expands our ability to regulate cosmetic surgical procedures. And what we found, there was a horrible situation where several people got very ill, and one actually died from plastic surgery, cosmetic surgery that had a bad outcome in Baltimore County.

SHARFSTEINAnd what we learned was that the regulatory structure was a bit like Swiss cheese. In fact, if people didn't bill insurance a certain way, then almost no licensing rules applied. And what the general assembly has done is given us authority to identify the higher risk procedures and apply licensing rules for the first time in Maryland to cosmetic surgical procedures. And we're -- we have just started that process. People can go to our website, dhmh.maryland.gov, and give us their input on which procedures they think we should cover. Compounding is...

NNAMDIYes.

SHARFSTEIN...an issue people may be familiar with from the, you know, horrible outbreak that happened. In fact, there's another one -- fortunately not, to our knowledge, in Maryland -- where people are mixing up medicines, and doctors have been injecting them. And it turns out that the medicines have had fungi in them, fungi, and people have gotten meningitis and very serious abscesses, and it's exposed a part of America's drug distribution system that is high risk.

SHARFSTEINAnd we had some very great leadership by Sen. Conway in the Senate and Delegate Hammond in the House to think through an approach in Maryland. And what we've done is created a -- you know, what's challenging nationally -- and this is challenging FDA quite a bit -- is that, you know, there are certain products that are fully FDA regulated, and there are certain products that your pharmacist might mix up right there.

SHARFSTEINBut what about the products that are in this middle gray area? They're made in big batches. They may be given in a clinic, and you'd have no idea that they weren't fully FDA regulated. What do you do? You might say, well, there shouldn't be any products like that. But it turns out the health care system depends, to a certain extent, on products in that gray area. The FDA right now is in front of Congress trying to get more authority over that gray area, and I completely support that.

SHARFSTEINBut in the meantime, what are states supposed to do? And what our law now says is that in that gray area, Maryland can grant a waiver. We can allow products into the state, but only when we know they're really meeting an important medical need, and only after we've done our due diligence that to the extent possible we can assure safety. So there's still gonna be risk there, but at least we'll be able to manage it better. And ultimately we hope that FDA gets the authority that it needs over those manufacturers.

NNAMDIAnd thank you very much for your call. We're gonna take a short break. When we come back, we'll continue our conversation with Joshua Sharfstein. He is the secretary of health and mental hygiene for the state of Maryland. If you'd like to join the conversation, you may wanna send us an email to kojo@wamu.org or send us a tweet, @kojoshow, if you have questions about other public health issues at play. Or you can call us, 800-433-8850. I'm Kojo Nnamdi.

NNAMDIWelcome back. Our guest is Joshua Sharfstein. He is the secretary of health and mental hygiene for the state of Maryland. He's also a medical doctor. We'll go immediately back to the phones to Laura in Arlington, Va. Laura, you're on the air. Go ahead, please.

LAURAHi, Kojo. Thanks so much for taking my call. I actually live in Virginia, but I have employer-based health care, health insurance, and last December -- or November, they told us they were gutting our plan. We went from maybe not something you might call platinum coated, but definitely a good plan, to the same plan, but now with a $9,000 out-of-pocket maximum huge deductibles for -- in network and out of network and an HSA.

LAURAUnfortunately, the health savings account is maxed out at $6,400. So we are likely to actually end up having to pay all the way up to that $9,000 out-of-pocket, which effectively is like a huge pay cut on our single income for our family. And we have a special needs child who has regular therapy. It's not a -- she doesn't have major special needs, but my heart goes out to those people who do. Because of the way they gutted this plan, effectively we have no health insurance unless there's something catastrophic.

LAURAWe've already used up our health savings account just on therapy bills alone, waiting to meet the deductibles. And so I was a supporter of the health care -- of the Obamacare. But I'm wondering what excuses -- this is a major corporation, and it seems like they're using this as an excuse to gut their health care plan. We're paying the same premium. I think we save maybe $10 a month out of several hundred on this new plan, and it could potentially bankrupt us with the cost of living in Virginia.

LAURAEven though we have good salaries, you know, a good income situation in theory, in practice, it's really difficult. And I wish I could, you know, somehow be in Maryland to take advantage of this. But I guess I'm wondering, for those of us out there who do have employer-based health care plans, is there any hope for how this thing is going to pan out? Because it seems to me if other plans are going in this direction, then health insurance is becoming meaningless.

NNAMDIJoshua Sharfstein.

SHARFSTEINFirst of all, you know, I totally appreciate the challenge that you're facing, and I'm very, very sorry to hear about it. You know, we've been looking in Maryland at the rise of these high-deductible health plans, which are just like you said. At a certain point, you have to ask whether it's meaningful coverage if people have to pay so much before the coverage kicks in. And if they don't have that money, how do they wind up, you know, getting coverage at all?

SHARFSTEINOne of the solutions that we have been working towards to this problem, including in the private sector and the large employer market, is instead of a broad-based high-deductible health plan, to encourage employers to move towards something called value-based insurance design where there are certain types of services that are really necessary that would be lower copay even with the deductible and other services that -- for which there may not be good evidence for, might be -- cost more.

SHARFSTEINAnd I think that you're seeing a lot of movement in that direction in the private sector. And it's the one thing that can -- as costs go up, maybe make it a little bit easier for families to get the care that they really need. Overall, I think, you know, what the biggest challenge that, or one of the biggest challenges we're facing is the general trend in health care cost.

SHARFSTEINAnd like I said before, if we're not able to get control of that, things will get worse in -- for large employers, it will get worse for small employers, it will get worse for the exchanges. So even as we're expanding coverage in Maryland, we're really trying to think about how to realign incentives so that we can get better outcomes and lower costs.

SHARFSTEINObviously, I think there may be some other specific answers for you in Virginia. But I do think that you're pointing out a very serious challenge in why we need reform so badly in the United States.

NNAMDILaura, thank you for your call. In the aftermath of last year's Supreme Court ruling, some 13 states have chosen to opt out of the Medicaid expansion program with many citing the associated cost. Why is Maryland opting in?

SHARFSTEINSo it is -- first of all, in Maryland, there is wide recognition, I think, that expanding access to health care is not just important for the people who get health care but it makes them more productive and reflects well on Maryland. It respects the dignity of individuals and families, and at the same time, it makes the economy more productive. Maryland was expanding Medicaid before the Affordable Care Act kicked in. The governor and lieutenant governor led a major expansion effort.

SHARFSTEINSo I think from that perspective compared to other places, we've seen Medicaid as part of the solution, and so it's not surprising. But there was other factor. We had an independent group of economists look at the impact of the Medicaid expansion to Maryland. And, you know, in 100 percent of the people who are nearly eligible, 100 percent of their costs are paid by the federal government initially, and then it just dwindles down to 90 percent. It is a hugely advantageous deal for states.

SHARFSTEINIt overwhelmingly helps the state's economy even when you count in the fact that some people might sign up who are eligible now under different rules. And so counting all that, the UMBC -- University of Maryland Baltimore County economists, you know, they found just a huge advantage. So you combine the belief that health insurance is important, it helps our economy, it helps working parents, helps people stay employed and stay healthy with the fact that it helps to stay down the state budget, and that was a really easy call.

NNAMDIOn now to Anna in Bowie, Md. Anna, your turn.

ANNAHi. I'm live in Bowie as you said, and I am on the Maryland health insurance plan. And I'm right now actually leaving the physical therapy clinic, where I do physical therapy, so you can hear me. The situation I'm in is that we're transitioning in Maryland off of the support for Maryland health insurance plan plus onto not having that, or, and going over to whatever other options there are out there. My concern is that my cost is gonna go up. But I'm using a PPO.

ANNAAnd I can't even afford the monthly payment for that. My aunt's paying for me. And I'm very worried that as of the end of our support, when Maryland stops paying into the health insurance in that plus program for us poor people, then I'm not gonna be able to afford my insurance anymore. And I'm gonna have to do whatever I can to have a huge, huge giant deductible in order to have the, you know, required insurance and not be able to use it. So do you have any answers for me?

NNAMDIAnd, Anna, thank your call. I think we have the same question from Libby in Colesville, Md. Libby, your turn.

LIBBYYes. Hello. My daughter is 28. She has Crohn's disease, so she was turned down for insurance, but she was able to get her insurance through the Maryland health insurance program for which we are very thankful. And I am also wondering what happens with her plan if that's still gonna be available after the Affordable Care Act kicks in.

NNAMDIJoshua Sharfstein.

SHARFSTEINSure. So the Maryland health insurance plan is the high-risk pool that exists in Maryland. Maryland has had one of the most generous high-risk pools historically, and it's been added to by some federal funds that will be sunsetting as 2014 gets closer. This has basically been the last ditch, last opportunity for insurance, for people who are turned down on the individual market. And it's been very expensive for -- to be able to subsidize and almost getting to the point of unaffordable.

SHARFSTEINSo now that people who have preexisting conditions can't be denied, it makes sense for them to participate in the market, in the exchange market. And if they're low income, just like the first caller, they would be eligible for some subsidies. And, in fact, it's likely for most individuals who are now getting -- if not all actually -- who are now getting subsidies at the health insurance that they can get, on the other side, may be less expensive than what they're getting now.

SHARFSTEINI can tell you that I know that there is definitely anxiety because people who had been turned down for health insurance, and they finally got into the high-risk pool, are very nervous about any changes. And I totally understand that. We will have a team of people who will be working directly with them to make sure that it's a smoother transition as possible.

SHARFSTEINBut ultimately, what we're doing is trying to actually, you know, provide a more stable, lasting solution to the health care system than just, you know, waiting for people to be turned down and then getting them into kind of a last measure insurance plan because during that period, it is enormously stressful, and people can get sicker and sicker and sicker. We want people to be able to get and afford coverage earlier and be able to stay healthy.

NNAMDILibby, thank you very much for your call. Good luck to you. Hard as it may be to believe, there are other public health issues you've been working on including a ban on crib bumpers and parts of a so-called patient safety packet of bills that made it through the Maryland General Assembly recently. What changes are coming on those fronts?

SHARFSTEINSo actually, it wasn't through legislation but rather through regulation that we have adapted that starting this Friday, the sale of baby bumper pads in Maryland will be banned. That followed about a two-year process where we had experts weighing in. And one of the things that we learned was that these pads, like in the inside of the crib, can suffocate babies, can reduce the airflow, can potentially contribute to the development of sudden infant death and really provide very minimal, if any, benefit.

SHARFSTEINAnd so when you look at the potential for a very serious risk -- and, well, you know, we heard from medical examiners talking about autopsy cases and experts in the field against, you know, a benefit that may not be there at all, the state moved forward to ban their sale. And it's something that we've been talking about for a while. We've certainly been advising, and it's not just our recommendation, it's CDC's recommendation, the National Institutes of Health and the American Academy of Pediatrics.

SHARFSTEINBabies sleep best and safest when they're alone on their back and in a crib without pillows, stuffed animals or crib bumper pads. And by following that message, we've actually seen a decline in infant mortality in Maryland.

NNAMDII was about to ask, have you been seeing results from that?

SHARFSTEINYeah. So from, you know, the ban is about to take effect, but the message has really been out there, particularly in the city of Baltimore where I was health commissioner. I remember when we had 20 babies a year dying in unsafe sleep conditions. And that number has really dropped. There has been a terrific public education campaign that has featured moms who lost their babies, looking right the camera. And it's really made a big difference. And we're hoping to avoid mixed messages and have a strong effort on safe sleep.

NNAMDII'm afraid we're almost out of time, but we've had the pleasure of having two guests in our studio this hour, two young gentlemen by the name of Sam and Isaac, who, it is my understanding, have led an exemplary life...

NNAMDI...and have been behaving really well in the studio. It's my understanding that they are here in order to make sure that you really do work for a living. You know these young men?

SHARFSTEINYou know, I do know them. I really appreciate your openness to hosting them and showing them around the control room. It's summer vacation, and they didn't get -- they get to see what their dad does today.

NNAMDIThey are, in fact, Joshua Sharfstein's sons. Joshua Sharfstein is the secretary of health and mental hygiene for the state of Maryland. He's also a medical doctor. Thank you so much for joining us.

SHARFSTEINThanks for having me.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.