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.