Originally Published in The Columbia Journalism Review on January 25, 2012
Jon Stewart welcomed Health and Human Services secretary Kathleen Sebelius to The Daily Show Monday night, and it was great to see that Madame Secretary had lightened up a bit from her oh-so somber appearances on the Sunday talk shows. There was a bit of jollity and friendly banter this time--but, then, Jon Stewart isn't David Gregory. Alas, it was the same slippery Sebelius, uttering her talking points, putting the best spin on health reform. Heck, that's what's she's supposed to do. And Stewart did what he's supposed to do--push back against her talking points to show how slippery the secretary is. The point/counterpoint made for good TV, even if a few crucial points got lost in the back and forth. Stewart's first question was logical: What has the health reform law done for Americans? The secretary responded that two and a half million young adults now had health insurance because they could stay on their parents' policies until they turn twenty-six--a positive outcome, all agree. Then Sebelius told Stewart fans that thousands of people all across the country were in life-saving situations now, because they could get insurance from the new state high-risk pools that will take everyone, including those on death's doorstep. The risk pools have not delivered such a positive outcome. The administration expected 375,000 people would sign up by the end of 2010; in October 2011, only 41,000 had enrolled. Why? The price of coverage is simply too high.
The interview didn't go there because Stewart wanted to tackle a subject everyone else in the media has virtually ignored--the Obama folks' decision to let the states determine the minimum benefit package for the coverage that Americans are supposed to buy in the state shopping services come 2014. This move opens the door for insurers to have maximum influence in state legislatures, where they are cozy with lawmakers, and to fashion the benefits packages to their liking. Stewart understood this, and asked why Sebelius would do that. Flexibility should be at the state level, she replied, adding "You want me to take it over, and I'm not going to."
Stewart noted the contradiction in the administration's position on state involvement in insurance, pointing out that it had opposed letting consumers shop across state lines because states offered different consumer protections. But why was it now okay for these same states to design the benefit packages? Madame Secretary was ready with an answer, and deftly bridged to her muddled message that every state now has consumer protections. Stewart said he was under the impression that only half the states had them, and Sebelius replied that not every state had "full authority yet." What authority was she talking about--bread and butter consumer rules or stopping over-the-top rate increases? Would states have authority to force down rates, or would they simply glance over the paper work when the insurance companies send it their way, as many states do. (Take Pennsylvania's new soft approach , for example.) Stewart continued to press on the contradiction, and finally the secretary made it clear she did not agree there was one.
She did say that some states had taken advantage of the feds' "financing stream" to beef up their insurance departments. I guess that was supposed to mean they'd get extra cash to hire more staff to eyeball those rate requests from insurers. When she used more in-the-loop Beltway speak, saying that insurers have to be on a "pathway to 80 cents" to describe the provision making insurers pay out in claims at least eighty cents of every dollar in premiums collected, Stewart noted that her remark suggested "We need to get you out on weekends to the movies. They're killin' you down there in Washington." Perhaps he's noticed the same wonk disconnect from the public that we have.
But much of the interview was dead serious, trying to tell viewers what they are up against. Stewart understood that letting states decide what the exact coverage could be within the ten coverage buckets the law requires--maternity, drug, mental health and so on--could leave people with good coverage or not-so-good coverage depending on where they live. He zoomed in on the often contentious relationship between the states and the feds over authority, and that led to a discussion of whether employers were likely to dump workers in the state shopping services, or the exchanges, and stop funding health insurance for them. Stewart asked several times whether employers would do that. It's a good question, with opinions differing depending on who's doing the opining. Stewart wanted Sebelius to opine. She was reluctant to say yes or no, but finally said no, reinforcing her PR message that the exchanges would would "stabilize" coverage for 180 million people with insurance from employers. In this discussion, a key point was missing, and one that Campaign Desk continues to point out . People who have employer coverage are generally stuck with that coverage even if they don't like it and want to look for something cheaper or better. They cannot shop in the exchanges and receive a government subsidy to help pay for their policies unless their share of the premium exceeds 9.5 percent of their gross income. That's a little-publicized part of the Affordable Care Act. Maybe The Daily Show can explore it later on.
Monday night's takeaway, though, was not about the possibility employers might dump workers in the exchanges. It was that the secretary's "flexibility" for the states might give them crappy, or shall we say less desirable, coverage if they live in the wrong state. As long as the coverage provides a minimum level of value, insurers have a lot of wiggle room to mix and match the premiums, the combinations of deductibles, number of doctor visits, and the coinsurance--the portion of the bill they will cover. Just imagine the choice and the headache someone will get figuring all that out. And just imagine the fun Stewart can have getting Sebelius to make all that clear.