I never intended to have a career in public service, one that involved running for elected office 8 times. I don’t like being the center of attention. My wedding day felt awkward. But here I am now retired after almost 30 years as an elected official both at the local and state level.

I am so grateful for the many opportunities that I have had over those years to work with an amazing array of people from all walks of life with interests and issues as varied as they were. If I were to sum up in a few words the most valuable part of this experience for me, it would be this: being able to say that through collaboration and cooperation we made a difference. Sometimes it is a small difference when, at the city level, we could respond to the need to place a stop sign to protect children as they walked from their neighborhood to their school. I still think about the debate over those signs as I stop at several of those locations. We did traffic counts and looked at the enrollment data for the schools to determine that the signs were justified. But I really think we placed those signs because we had grieving parents in two separate incidents where children were killed trying to cross the busy streets.

Other decisions have had more far reaching results, but one thing remained consistent across the board: tough policy choices should always be made through listening and collaboration as well as the use of good, reliable data. Let me just run through a few of the important decisions and policy changes that I was able to work on over my tenure in office and share how we were able to arrive at each outcome.

Making Decisions Through Collaboration, Personal Stories, and Good Data:

When I took office as a City Commissioner in Lawrence, Kansas in 1985, the debate over second-hand smoke was prominent at the local and state level. We were getting more and more pressure to enact indoor smoking bans in public buildings. After hearing from a lot of folks and doing our own research to justify our decision, we did pass the ban on smoking in city buildings just prior to the state legislature enacting the same requirement statewide. It was a small step toward getting rid of smoking in all public spaces, like bars and restaurants, which would eventually happen, but making that first important policy decision paved the way for more comprehensive controls. 

At the local level, there really is a lot of attention on issues and with only 5 people making decisions, lots of pressure too, on everything from zoning, to speed limits, master planning, sewer line back-ups into basements (those folks can really bend your ear!). When I was elected to the state House of Representatives in 1990, I was one of 125 members, and the issues weren’t as immediate nor, as only one of a larger group, were my decisions under a microscope as they had been at the local level. That isn’t to say we didn’t have some important decisions that received a lot of public scrutiny. We changed the way schools are financed based on a court decision that the funding was out of compliance with our state constitution, which emphasizes that education needs to be equally accessible to all students. That change is now being challenged and the financing of schools is once again front and center with the court, our legislators, and governor.

We passed legislation to provide for school breakfast programs (Kansas ranked 49th out of 50 states in providing breakfast to students). We tried to pass laws requiring riders of motorcycles to wear helmets (still don’t have that requirement in state law). We worked on numerous bills relating to health and health insurance issues: mental health parity, patient protection laws, portability of coverage, and review of health plan decisions.

Debate for most, if not all, of these decisions required proponents and opponents to be well-versed in their positions and ready to defend them with good data, but sometimes personal stories can be even more persuasive. For example, we passed an insurance mandate that prostate cancer screening had to be a covered benefit in plans sold in Kansas, and one of the main reasons it passed, at least in the Kansas Senate, is that two of our members had been diagnosed and treated for prostate cancer.

We had a session-long debate on mental health parity. We needed good data, personal stories, and professional advice and input to counter the stigma about mental illness, especially depression. The common health belief seemed to be that treatment really didn’t help and was too expensive to be included in insurance the same way other illnesses were covered. During that same period of time, the Mid-America Business Coalition on Health—a group comprised of human resource professionals from the biggest employers in the Kansas City area—conducted a review of their claims data for their employees to determine how to better manage costs and outcomes. They really thought they would find that cardio-vascular illnesses would be identified as the category with the greatest expenditures, and they were surprised when depression was the culprit. They evaluated the co-morbidities and lost productivity and realized that if their employees didn’t receive the appropriate care for depression, the long-term cost to the employer increased. Based on their findings, they implemented changes to ensure that depression was diagnosed and properly treated.

Their experience helped to make the case for changes in our requirements for the treatment of several types of mental illness, including depression. The law on the books at the time had a lifetime cap on outpatient treatment for mental illness of $7,500. And the limit on inpatient treatment was 30 days annually. So once the outpatient limit was reached, the only recourse was to be admitted to an inpatient hospital for treatment. So we looked at other states to determine their requirements, and Texas provided a good comparison. They had recently made changes to their mandates and substituted dollar limits for day limits. For outpatient and inpatient, the day limits were 60 days. I tried to push for the same limit in Kansas but realized that making that big of a change would be hard to get passed. So we went for halfway between our current 30-day inpatient annual limit and the Texas 60-day limit and settled on 45 days for both. The changes were heavily opposed by the health insurers, but in the end, the current lifetime limit of $7,500 and 30-day for inpatient treatment really couldn’t be justified. Interestingly, the leader of the changes in Texas was a legislator who had been treated for depression and was a great example of how intervention can make a difference. 

This policy decision was a good example of the saying, “half a loaf is better than no loaf.” Day limits are still not parity with other services, but at the time, we were making progress (this was 2000). And fortunately, the Affordable Care Act made additional improvements.

Being Cautious of Unreliable Information:

Throughout my legislative experience, we were also able to get things done because, at the end of the day, good data and information made a difference, and we were willing to work together to find a common or middle ground. Unfortunately, too often today there is a media frenzy around some policy issues that make it difficult to get beyond the misinformation to have an informed debate. I am concerned that we are losing the ability to rely on research and informed decision-making in the political debate. Case in point: the debate around the importance of childhood vaccinations.

Unfortunately, we now have a controversy over whether childhood immunizations are needed. The Kansas City Star on February 11, 2015 did a reader poll, and I was amazed at the results. On the question of whether children should not be allowed to attend public schools unless they are vaccinated 57% did not agree while 32% did. On another statement: “The anti-vaccine crowd places their personal freedom above the good of others, thereby threatening public health,” 59% strongly disagreed while 33% strongly agreed. Another statement raises concerns about how research can support important requirements like vaccinations: “Studies that say vaccines are safe and do not cause autism are flawed, sometimes because they are supported by large pharmaceutical companies.” The response, 62% agreed or strongly agreed and 38% disagreed or strongly disagreed. It is hard to get past these kind of entrenched beliefs so that reputable studies can have an impact.  

Some years ago, we had a study that appeared to demonstrate that women who had undergone abortions were more likely to develop breast cancer. That study, while discredited, has been used in statehouses—and still is—to justify the restrictions on abortion as protection for the woman from developing breast cancer. When we can’t trust the research to help us make informed decisions or just chose to ignore it because it doesn’t suit our agenda, I wonder where we are headed. Now more than ever, in this age of instant media, sensationalized news, and pseudo-news shows, we need research that is objective and authoritative. Laws are being passed by lawmakers who don’t know what to believe. Kansas just passed the most restrictive abortion regulation in the country, followed by Oklahoma, which could potentially place a woman’s life in jeopardy and used non-medical terms to sensationalize the discussion, making it difficult for even thoughtful legislators to do the right thing. This will most certainly play out in court, costing unnecessary public dollars to defend a law motivated by a narrow political agenda and not public well-being.

Making and Committing to the Decision:

Whether it’s through personal stories and experiences or good data, eventually, you must take the information available and commit to the right decision, regardless of the consequences. However, no one ever promised that doing the right thing would always be easy, which brings me back to my first term in office as a City Commissioner. 

The same year we took action on public smoking, we also had a tragic suicide of a young coed from the University of Kansas. She was being treated for depression, and one day, she decided she just couldn’t cope anymore. She went into a local gun shop, bought a handgun and ammunition, walked a few blocks to a nearby public park, and used that newly-purchased weapon to end her life. One of my fellow Commissioners (there were 5 in all) brought the incident to our public meeting and requested that we look at enacting a waiting period for the purchase of guns. His point was that if she couldn’t have obtained possession of the gun at the time of purchase, she might have been helped and could still be alive today. It made sense to me. So we had an ordinance drafted and, a few weeks later, scheduled the debate. 

It was during this time that we started getting threats at our homes, one of our Commissioners had his tires slashed (he had suggested that maybe we should regulate knives too), and our local police started patrolling the neighborhoods where we each lived. The week before the debate and vote on the ordinance, our local paper started calling each of us to see what we intended to do and how we planned to vote. Two said they were for the ordinance, two said they were opposed, and I said I wanted to wait to hear the pros and cons at the meeting before deciding. I thought I should keep an open mind, but honestly, after the threats and intimidation, I was pretty sure I would vote to enact. Being identified as the swing vote days before the meeting was not a good thing. I received more threatening calls and was told that if I supported the waiting period, my political career would be over. The NRA-influenced opposition said they would see to it that I would never again be elected to public office. And they did openly oppose me each of my next 7 elections. I always received an “F” on their scorecard that was sent out to voters. 

From that early-in-my-career experience, I discovered the importance of standing up to fierce opposition and doing the right thing. Had I lost subsequent bids for elective office because of that vote, I would do it again. What I learned is that if you are afraid of losing an election, maybe you shouldn’t be running. If you fear losing, then at some point you will compromise your values, and that can be a slippery slope that will make subsequent tough decisions even tougher.

Sandy Praeger was elected Insurance Commissioner three times in 2002, 2006, and 2010. She retired from office in January, 2015. While commissioner, she was active with the National Association of Insurance Commissioners and served as its president in 2008. She had several opportunities to provide the state perspective on the health reform bills that were being debated in Congress, including the current Affordable Care Act that passed in March 2010. Prior to becoming insurance commissioner, Praeger served in the Kansas House and Senate. In the Senate, she chaired the Public Health and Welfare Committee and the Insurance Committee. Her career in politics began at the local level where she served on the Lawrence City Commission and one term as Mayor.

For more than a century, our country has tried to pass some form of health coverage for all Americans. Presidents from Teddy Roosevelt, to Nixon, Clinton, and now President Obama have recognized the importance of providing affordable health care so that families aren’t forced to declare bankruptcy because they accessed needed medical services and then couldn’t afford to pay for them. The Affordable Care Act was a very politically-charged piece of legislation, passing with no Republican votes, even though I know Republicans, especially in the U.S. Senate, who would have been willing to vote for something had the opportunity for compromise been afforded them.

As the Republican-elected Insurance Commissioner in Kansas, I had numerous opportunities to comment on the law. While far from perfect, I felt the ACA moved us in the right direction, so I consistently spoke in favor of implementation, while at the same time recognizing that as the law matures there will be needed changes to be made. I was criticized by many of our Republican legislators for supporting the ACA, but to me, the alternative of repealing it and doing nothing to address the access to care for Americans was simply not an option. 

The recent United States Supreme Court case demonstrated one of the law’s imperfections that, in Congress’ haste to pass it, was overlooked. Chief Justice Roberts himself, in writing for the Court, acknowledged that the ACA, “contains more than a few examples of inartful drafting.” However, in a 6-to-3 decision, the Supreme Court looked at the intent of the entire law and upheld the crucial piece that provides health insurance subsidies to all qualifying Americans. As Justice Roberts wrote, “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former and avoids the latter.”

When the Court’s decision was released, I do think that many in the current Congress had to have breathed a sigh of relief, because, had the subsidies been denied in the states with a federal exchange, chaos in the marketplace would have ensued. Here’s why: Unless some delay in the implementation had been included, within 25 days, those citizens in federal exchanges would have seen their health insurance premiums increase dramatically, most likely causing many to drop their coverage and stop paying premiums altogether. Those companies that priced their products based on receiving the subsidy for their enrollees would have seen a big loss in revenue. The only enrollees likely to keep their coverage would have been those folks who know they need coverage no matter the cost, i.e. older, sicker enrollees. Absent some quick fix, those states would have experienced what is called in insurance vernacular a “death spiral” where only the sick stay with coverage, more claims have to be paid, premiums have to increase to pay the increased claims, more drop coverage, and soon the insurance policies are unsustainable.

I would hope, now that the challenges to the law have been settled, that Congress would accept that the Affordable Care Act is here to stay and move on to making the necessary adjustments that could and should be addressed through the legislative process. 

One such criticism of the law that could be re-visited is the way age is treated. The ACA says insurance has to be priced based on an age rating of 3:1. In other words, an older person cannot be charged more than 3 times what a younger, healthier person is charged. This causes many younger folks today to pay more than they might have paid before the ACA. Congress could change the age rating rule to one that is wider, perhaps 5 or 6:1. This could still protect older citizens under the age of 65 from very high costs, because they still cannot be rated based on their health status, but it would also help offset the higher premium costs that younger folks could be paying under the current system. On behalf of our National Association of Insurance Commissioners, I offered this change during one of the Senate hearings on the ACA in July of 2009, but it was not included.

I also would hope that Congress and the administration could continue to work on making improvements to the delivery system in order to support policies that reward quality of health care over quantity. For example, health care providers need to be rewarded for reducing hospital readmissions and for improving outcomes, and several pilot projects are demonstrating that this works. When this happens, the insurance companies have fewer claims to pay, and those savings can be shared with the providers that are helping to create the savings. The ACA includes other pilot projects that reward better coordination of care, which can also reduce costs and improve outcomes for patients. Congress needs to look at the results of those pilot projects and find ways to incentivize the delivery system to take advantage of those positive results. 

It is long past time for Congress to put politics aside and begin to find ways to compromise and solve problems. This will take leadership that is willing to step up and do the right thing and explain to their constituents why it is the right thing. As a nation, we could no longer accept a status quo where too many of our citizens went without needed health care because they couldn’t afford it and couldn’t even afford the insurance that could help provide the needed health care services, especially preventive services for chronic conditions. The ACA begins the process of dealing with our ailing health care system. Now, as a nation, we must address the expense of our health care system which is, per person, double what other countries pay for health care for their citizens. Those countries, by the way, have a much better health ranking for their citizens than we do in our county. So we are paying double and not getting anywhere close to the result of better health for our citizens that other countries enjoy. We need our leaders to step up and begin to look for solutions and not be driven by political ideology that produces a stalemate where nothing is accomplished.

As the necessary changes are proposed, they will meet resistance and will need to be justified. Research, data, controlled studies, medical education, and training will all need to be used to explain what works, what doesn’t, and how to appropriately rein in costs while improving outcomes.

The end goal is to have a health care system that is affordable, accountable, efficient, and effective that has the support of the providers, patients, politicians, and the public. Without that, support for the necessary changes will be hard to come by and we will continue to nibble around the edges. 

Sandy Praeger was elected Insurance Commissioner three times in 2002, 2006, and 2010. She retired from office in January, 2015. While commissioner, she was active with the National Association of Insurance Commissioners and served as its president in 2008. She had several opportunities to provide the state perspective on the health reform bills that were being debated in Congress, including the current Affordable Care Act that passed in March 2010. Prior to becoming insurance commissioner, Praeger served in the Kansas House and Senate. In the Senate she chaired the Public Health and Welfare Committee and the Insurance Committee. Her career in politics began at the local level where she served on the Lawrence City Commission and one term as Mayor.