Interview by Rhonda Mullen PH: As an expert in health care financing, you've served at a number of universities - Harvard, the University of North Carolina, Tulane - as well as a member of President Clinton's Health Care Reform Task Force. For the past decade, your work has focused on the challenge of delivering health care to the uninsured. Can you briefly describe the scope of the problem of uninsured Americans today? KT: Today we have about 43 million people who have no health insurance. Among the population that is under age 65, that's almost one in five who have no health insurance. That's a very substantial number of people. In 1994, we had a national debate about covering the uninsured. Two things have happened since then: one, the economy has taken off, and, two, we decided not to have a universal insurance program. Since that time, we now have 5 million more people who don't have health insurance. The troubling thing about that is its occurrence during the best of all economic times. We've created 17 million jobs in the past five years. We have very low inflation. There is relatively low growth in the price of health in surance. And yet the number of uninsured continues to rise. I think the research on the uninsured has revealed clear trends. We know that they receive less care. They receive care in expensive settings - clinics and emergency rooms. When they do receive care, they get it later in the stage of illness so general ly problems that should have been picked up earlier are missed. They come in with more acute episodes of illness ranging from asthma to cardiovascular disease. This problem of the uninsured has a substantial public health impact, one that is worsening.

PH: Can you describe how your research and study approaches this problem of uninsured populations? KT: The first line of research evaluates some of the programs that try to provide more access to health care for the uninsured -- for example, public hospital systems or systems that provide monies direc tly to private hospitals with incentives to cover the uninsured. Another example is incremental programs that provide incentives to individuals to purchase insurance. We've evaluated those programs to see how well both government and private efforts work. Some of the innovations in providing insurance for the uninsured have been done in pockets throughout the country, for example in New York. Others are national in scope. We've worked on evaluations of the New York programs as well as Medicaid expansion s. We continue to work with the state of Louisiana on their design and evaluation of a program for the uninsured. It's also important to feed that research back into the policy process. I've been active in working with Congress and the administration in Washington, as well as state legislators in redesigning incremental efforts to provide health insurance for low- income populations.

PH: After the 104th Congress failed to adopt the sweeping recommendations by the Health Care Reform Task Force, you proposed incremental approaches to providing health care insurance for ma ny Americans. Do you still believe wholesale, massive change would be a better solution to the problem? KT: From a policy standpoint, comprehensive coverage makes more sense, but from a political standpoint, it is unlikely to happen. We have a political system that, by its very design, is inherently conser vative. It rarely takes on big, sweeping changes of any type, not just in the area of health care policy but also in making tax policy and social policy. Our country's diversity also favors more incremental changes. Having worked in the states of Louisian a and New York, I can tell you there are very few similarities in how the political systems in those states view the problem of the uninsured and how they view solutions to the problem. On the policy side of the consideration, having a system that is comprehensive makes more sense. The system we have now is not something anyone would sit down and ever design because it would be painful and wrong. It doesn't work for many. The biggest pocket of insurance we have is employment-based coverage. One-hundred-sixty-one million people have coverage either directly or indirectly through an employer. However, the nature of the work force is changing so dramatically that one even wonders whether the employer as a pooling entity or provider of insurance 15 to 20 years from now will make any sense. Currently, many people hold multiple jobs. Others are contingent workers, contract workers, or seasonal workers. Much of the growth in t he economy is fueled by people who have alternative work arrangements. Having a steady, stable job for five to ten years with a single employer still happens, but it is more infrequent than in the past. These types of transitions in the labor market make it more difficult to have employers as the pooling entity for providing insurance.

PH: Can you talk about the incremental approaches for solving the problem of the uninsured that you proposed in your 1997 article in the Journal of the American Medical Association? Which of those approaches do you prefer? KT: I give several examples, some public approaches - expanding Medicaid - and some private - providing subsidies to encourage people to buy private health insurance. The fact is, we're doing both. I thi nk the US Congress and the states are proceeding along both of those lines. Two years ago, the federal government began the State Children's Health Insurance Program, which provides incentives to states to extend health insurance to low-income, uninsured children. Currently, there is a debate going on in the Congress as part of the tax reform discussion about how to give tax breaks to low- and moderate-income families, and how to tailor part of that strategy as a tax credit to individuals to buy health in surance. So, although that's a government subsidy, the idea is to encourage people to buy private health insurance. We're seeing Congress try a variety of incremental approaches. I think the question at the end of the day remains, are we getting more frag mented? Currently, you may have a situation where the child has Medicaid and the parents buy private health insurance using a tax credit. You wonder in terms of the continuity of care and the administrative complexity, whether that scenario makes a whole lot of sense.

PH: As we approach the new millennium, do you have a prognosis for how health care financing will work in the 21st century? Will we solve this problem of uninsured Americans? KT: The uninsured is not a major issue right now in Congress. In the debate about the budget surplus, four areas are receiving attention: Medicare, Social Security, tax relief, and paying down interest o n the national debt. From a public health perspective, particularly from the financial side, this issue is probably one of the most critical problems we face. We spend more money for health care as a percentage of our overall expenditures than any other country. Yet, we st ill have 43 million people who don't have health insurance. One way to try to keep the issue in the public and political eye is to continue to document it, to examine how well the solutions are working, or more often, not working.

PH: Can you describe some of your current research projects and discuss how those will dovetail with other research efforts under way at Emory? KT: We have a couple of ongoing projects that look at the financial changes that happen when hospitals convert from not-for-profit to for-profit status. In particular, in a national study, we're looking at changes in profitability, revenue, costs, and the provision of care to the uninsured. The uninsured is one of the key issues on hospital conversions: whether they maintain the same level of commitment to provide assistance to uninsured patients. The second project is an evaluation of the federal employees health benefit program. We've focused on that program because it is often used by legislators and administrators in Washington as a potential model for reforming Medicare. In terms of new projects, I've already supported several proposals by faculty in the department -- some focused on outcomes research and others on related topics, including clinical economics. I also hope to complete an empirical analysis of the multip le determinants of health and worker productivity. The idea is to quantify the broad range of factors that affect people's health, including lifestyle-related issues, socioeconomic status, access to health care, health insurance, and issues at the work pl ace such as stress. I'll examine how those factors interact to better or worsen health outcomes and how they affect the productivity of people at work.

PH: In addition to continuing your research, you'll be leading the Department of Health Policy and Management at the Rollins School of Public Health. Although you've only recently arrived, do you have goals you'd like to see the department accomplish? KT: Yes, I have educational, research, and growth goals for the department. On the educational side, we will be collaborating with Emory's Nell Hodgson Woodruff School of Nursing, which has a PhD program that we want to use as a model for building a similar program in our department. We also want to establish a new executive training program that will be available around the first of the year 2000. This program, designed for mid- to senior-level analysts in the pharmaceutical and hospital industries, will focus on medical health outcomes and managing change in health care organizations. It will combine a distance learning approach with on-campus participation. On the research side, we're going to concentrate on three areas. For the first, clinical economics and outcomes research, we already have a very good faculty base, including Kim Rask and Leslie Shaw, who hold joint appointments with the Emory School of Medicine; Adam Atherly, a new faculty member who concentrates on economics; and Ned Becker and Steve Culler, who have worked extensively in the Department of Medicine on the cost-effectiveness of treatments in cardiology. I believe clinical economics and outcomes research will be a center of research excellence for us. In addition, public health policy is an area I want to build. Our public health practice already focuses on management consulting with local health agencies, and I want to build on those relationships to develop auxiliary research programs. Health financing and insurance is the third area of focus, including Medicare reform issues, the uninsured, Medicaid, and financial and structural issues in the health care system. One issue of particular interest to Emory is how we finance graduate me dical education. We'll examine both the role of Medicare and the private health sector in meeting that challenge. Finally, we'll be addressing the size of the faculty. We're an undersized group, but our objective is to have our department grow on the policy side in proportion with expected growth in the rest of the medical center. We have a very ambitious growth s trategy for the next five to ten years, both in research holdings and in faculty.