Linda Berglin was not ready to rest on her laurels. By 2011, she had logged 38 years in the Minnesota Legislature, a time spent wielding her formidable knowledge of state budgets on behalf of poor and working people.
After she co-authored the Minnesota Care bill that expanded health insurance to the working poor in 1992, health care became Berglin’s specialty. On numerous occasions, sometimes as a lone voice, she successfully stood up against attempts to cut health care benefits or coverage.
But in the November 2010 elections, Republicans seized control of the Senate for the first time in nearly 40 years, putting Berglin in the minority party for the first time. Five months later, Congress passed the Affordable Care Act (ACA), paving the way for a large expansion of health care, initiated at the federal level but implemented by states and counties.
Subsequently, Berglin retired from the Senate to take a job that seemed tailor-made for her talents: Hennepin County health policy program manager. Today, the DFL controls both houses of the Legislature and the governor’s office, the ACA is on the verge of operation and Berglin has had a couple of years to establish herself at Hennepin County. It seemed like a good time for a conversation — held, as is Berglin’s custom, at Curran’s, the venerable south Minneapolis eatery.
Capitol Report: When you went to Hennepin County, I assume you knew exactly how it fit into the legislative equation and the state budget regarding health care.
Linda Berglin: I did, but you know reform on the ground is a bit of an unknown entity. And that was partly what excited me about this opportunity. You can create policy that helps encourage reform, but actually doing the reform isn’t automatically going to happen. You need dedicated people with vision and foresight and creativity and tenacity. So I am really enjoying my job, because I think we are getting some important work done at the ground level.
CR: Give me an example of something you have implemented at the hands-on level that is consistent with your duties.
Berglin: The problem of homeless people in the hospital. We have some very poor people, and homeless people or precariously housed people make up about a third of our population under Medicaid. And so we had people who were stuck in the hospital who couldn’t get out, jamming up the system and costing more because they couldn’t safely be discharged without someplace to go.
My suggestion was that we go talk to [the Minneapolis Public Housing Authority], and so a few of us met with [MPHA Executive Director] Cora [McCorvey], whom I have worked with in the past and who was curious about what kind of program would have me leave the Legislature. We told her about this county health initiative and how we are trying to bring in housing and social services and learn to blend physical and mental health, and outreach into the jails — the whole thing, which is especially important when you are trying to reach a low-income population.
See, we believe — and there is evidence to show this — that when people don’t have certain essential needs being met, they will try and get them through the health care system. And that drives up health care costs unnecessarily. So we explained that dilemma to Cora and together we came up with some transitional housing units where they could be discharged from the hospital and get their health care needs met there. While they are there, we are looking for permanent housing so the units can be available to the next group of people in the hospital with similar needs.
It was the first time MPHA had “rented” to another organization instead of to individuals. They got what I guess in health care terms would be called a waiver from [the U.S. Department of Housing and Urban Development] so they could use the units in this way without taking them off the system. To our knowledge, nobody has had a contract like this before and we are both excited about it, because we think it is really going to help some people who are not only homeless and poor but sick. The impression I got from folks at the MPHA is that HUD is looking at this as a possible national model.
CR: Is this type of interdisciplinary thing much different from when you worked at the Legislature?
Berglin: Going to work for the Hennepin Health program attracted me because I always believed in this type of a disparities model. It goes back to doing things that impact health care costs. We are trying to prove that changing behavior saves money with this population, and we are trying to prove it in a hurry because the expansion of Medicaid [under the ACA] will be happening here and in other parts of the country. It is important that Congress and administrators in these states look at this and not just feel like this whole thing will become a big black hole.
CR: So the ACA is a factor in this?
Berglin: Big time. First of all, it was part of that law that made the Medicaid expansion possible. Now we did early expansion of the Medicaid program with part of the population before I left the Legislature, and that’s the population that Hennepin Health is working with now. But the ACA is designed to provide health care smarter, eliminating some of the inefficiencies [in] partnership with other organizations, so that you lower health care costs in a way that delivers better outcomes. And those are the principles that drive this program.
CR: I imagine you agree with the consensus that Minnesota is way ahead of the curve on getting the ACA set up and ready to be operational.
Berglin: Well, the state has done the full expansion of Medicaid and we are poised to do the basic health plan, which will help that program grow. We already have a delivery system that has a lot of integration in it. The next step for us is to have a better product. But I don’t think it is a coincidence that Minnesota already has several pioneer ACOs that have been accepted by the federal government.
CR: What is an ACO?
Berglin: An accountable care organization. An ACO is accountable for the total cost of care and the total care of a population.
CR: Do you worry about the inevitable stories regarding premium increases and the forced carrying of insurance that will be aired when the ACA is up and running?
Berglin: Well, they have done that from the beginning. Before people even knew how it was going to roll out, they were criticizing it. But I think people are going to be surprised. You know there has never been that much competition in the individual market and this is really forcing that. The level of premium that gets subsidized [under ACA] is from the two lowest-bidding health plans in an exchange. So if it is higher than that, people will have to pay out of pocket, and for that population, money is an issue.
I think it is going to create a lot more competition in the individual market for this population and it is going to force carriers to really examine what their costs are and try to get contracts with the most efficient providers. I think you’ll see a lot more limited networks as a result of this. But I think it is a trade-off people are going to have to accept. If they want a lower price, they are going to have to accept limits.
CR: Is it inevitable that even as costs go down, the average citizen is going to be asked to bear more of the cost of health care?
Berglin: That is a disturbing trend. But it also has something to do with the economy. When the economy is down like it has been, what employers have to do to attract good employees isn’t as much. And now that the economy is improving a little bit, I think the competition is going to force employers to maybe be more careful about how much they want to shift costs on to their employees.
CR: You mentioned your work with the homeless. What are some of the other things Hennepin Health is doing that fit in with this Medicaid expansion under the ACA?
Berglin: We’re working on a sobering center. A large number of people in Hennepin County are in the emergency room primarily for inebriation. That’s costly. Right now we try to get them out the front door, because if they start detoxing in the hospital they have to go to a hospital bed. But if we set up a sobering center for those who don’t have injuries — because if they are injured, they do belong in the emergency room — then we can start to have a conversation as they are sobering about using the health care services, and we would hope many of those services would be treatment.
We are also working on a model that is integrating behavioral health and primary care, called “psych consult.” You have psychologists or mental health social workers in your primary care clinics working with the primary care doctors. But then they have the ability to consult with a psychiatrist on cases that are not moving forward. They have a regular established consult time and the opinion in other parts of the country is that this can work for 90 percent of the people with mental health issues.
We are also working on something called the employment project, which is one of my favorites. We have invested money to bring an employment specialist right into the hospital [Hennepin County Medical Center] to work with some of our behavioral health clients to get them employment. And our feeling is, and it has been borne out by some of the literature, that a job fosters good mental health. In addition to helping people’s mental health, obviously, it helps with reducing poverty — which we think is the cause of some of the health problems.
CR: Where are you at in terms of results and feedback overall? I would imagine the county is more of a bureaucracy than the Legislature, and you have more people you need to please.
Berglin: Annually, we renegotiate a contract with the Department of Human Services, and it was originally a two-year pilot — we are now in our second year. But the department has indicated that it would intend to have ongoing contracts with us in the future. We are expected to live within the limits of the premiums that our contract allows us. If we want to make investments, we have to do it through savings in coverage.
CR: And you have managed to live within that constraint?
Berglin: [Laughs] So far. Because we are in our second year, we have more outcomes that are helping us. We have some earnings from last year that were modest. We have already reduced inpatient admissions and emergency care visits significantly. Considering where our project is at, there is so much further we can go. We have a population that, for much of their lives, they didn’t have regular health care — they had emergency care. Because they didn’t feel like they had full health insurance, they’d use the system over their lifetime a lot differently than we wished they would. So we are not only changing the health care system, but we are changing the behavior and the expectations around the clients.
I think it is important to say that we have had bipartisan support for this at the county level. We have had to work with some of the Republican commissioners, but in the end, we have gotten support. I think it appeals to them that we are working to reduce costs and to help our clients become more self-sufficient. Because we have a safety-net hospital, we are going to be paying for them one way or another. So they get excited when we talk about delivering services smarter, and having these employment projects that try and get people back to work. So at the county level, some bipartisan common sense prevails, whereas at the national level, I just haven’t seen that. I am glad for that.
CR: You are 68 now. Can see yourself working five years from now?
Berglin: I don’t know, that’s a long time. There are things I am working on I would like to see come to fruition, but I know on a lot of things, I’m not going to be along for the full ride.
CR: Is this your last job?
Berglin: Yes. Well, you never say never, right?
The Berglin File
Name: Linda Berglin
Job: Hennepin County health policy program manager
Born in: Oakland, Calif., but moved to Minneapolis as a child and graduated from Roosevelt High School.
Lives in: The south Minneapolis political district that she represented as a member of the Legislature for
Education: B.F.A , Minneapolis College of Art and Design (MCAD)
Family: Married to Glenn Sampson. They have one adult child, Maria.
Hobbies: Quilted artwork and organic gardening.
Interesting factoid: Berglin’s interest and compassion around the issue of health care is rooted in having a rare disease of the nervous system that plagued her throughout her high school years and into college, often keeping her in bed. Despite this hardship, she graduated from high school on time.