Kevin Counihan on the ACA: ‘Whatever happens, Trump is going to own this’
Kevin Counihan used to run the health insurance exchanges that serve most of the United States.
Now he’s a customer.
Counihan was the first chief executive of Connecticut’s exchange, Access Health CT, launching the coverage marketplace during the rollout of the Affordable Care Act. In August 2014, the Obama administration tapped him to lead HealthCare.gov, the once-troubled federal marketplace that served close to three dozen states.
Since he was a political appointee, Counihan left the job when President Donald Trump was inaugurated. And since he no longer gets insurance from an employer, he joined the millions of Americans buying coverage on the individual market; in his case, it’s through the Washington, D.C., exchange.
Counihan has been watching closely as Republicans in Congress work on plans to repeal and replace the health law. Many of those options include a broader use of health-savings accounts – which allow people with high-deductible health plans to save money on a tax-advantaged basis and spend it on health care expenses – and shifting the way Medicaid is funded from an open-ended system – in which the federal government reimburses states for whatever they spend – to one in which states get a set budget from which to provide coverage.
While visiting Connecticut last week, Counihan spoke to The Mirror about efforts to replace the Affordable Care Act, why the health law has gotten more popular since Obama left office, the need to address health care costs, how to keep insurance companies from fleeing exchanges, and what can be done to make it easier to buy coverage. (The interview took place before the leak of a proposed ACA repeal bill Friday.)
Counihan: It’s a really good question. I guess there seem to be these themes, [one of] which is moving from guaranteed coverage to guaranteed access. That seems to be a theme in each of these five bills that I’ve seen.
The second one is moving to a defined contribution approach, where there’s a fixed amount of money, whether that’s in the form of a contribution to an HSA [health savings account], whether that is in block-granting of Medicaid, or vouchers on Medicare. And those have extremely serious consequences with respect to expectations people have about coverage.
So it strikes me that looking at the philosophy behind so many of these current proposals, it feels like there’s a very strong sense of health care being an issue of personal responsibility as opposed to a right of citizenship. And that has a whole series of consequences with respect to how people procure [coverage] and stay insured.
Maybe conceptually this stuff can sound good, but I think practically implementing something like this is actually very challenging, and it’s going to be very disruptive.
CTMirror: Can you talk more about what “401k-ing” of health insurance looks like?
Counihan: [When employers moved from pensions to 401k plans for retirement benefits] it significantly changed how employees and employers perceived funding of those post-retirement benefits. In the past it was, for example, that your highest five years of income would be averaged out and then you’d get a percentage of that. This was now very different. It was pretty much, “We’re going to give you a certain amount of money, but you’re pretty much on your own.”
It feels like in looking at these concepts applied to the [health insurance] marketplace – to Medicaid and to Medicare – that that philosophy is similar, and it can make sense perhaps academically, but to really teach people how to manage their money for their retirement was very, very difficult. I’m not sure people still do it all that well, but they certainly do it a whole lot better than they did in the early and mid-80s.
They’re more sophisticated now, but buying health care’s not simple, and giving people money is fine, but when you’re already on a fixed income and so many people depend on Social Security, and then saying, “Well, any rise in health care, you’re going to have to fund,” is, I think, a disruption that I’m not sure many are used to or prepared for.
CTMirror: If you were given carte blanche to change the ACA or come up with a new system or tweak it in a way that you think would fix things, what would you do? What are the changes that you think you’d like to make?
Counihan: I think a lot of the changes I would’ve made, some of the regulatory changes, have actually been made.
I think moving to the verification of the special enrollment periods [to ensure people who sign up for coverage outside the annual open enrollment period have a valid reason for doing so] is actually consistent with what the industry wanted to do. We were implementing a program where 50 percent of them would already be verified. The concern that we had about those special enrollment period verifications is in fact that it actually may discourage healthier or younger people, because they would say, ‘You know what, it isn’t worth it for me to go through all this preparation of providing documents.’ That’s where the mandate was so important.
I would’ve funded the risk corridor program. I think many carriers came into the market believing that those dollars would be there, and the fact that they weren’t, or only a percentage was paid, I think is not right.
[Risk corridors was a temporary program intended to help insurers avoid extreme losses or gains, and included a mechanism for paying insurers that faced losses beyond a certain level. But the federal government has paid only a small fraction of the billions of dollars owed to insurance companies under the program.]
I would look at the grace period. And fundamentally, I would look to simplify. I think the law’s too complicated. I think there are ways to make it easier, and I’d standardize plans more. I’d just try to make it simpler and easier. That was the strategy and the philosophy that we had at Access Health, and I think we succeeded in some respects, and we didn’t succeed certainly everywhere, but we were very sensitive of the fact that this is not people’s only interest in life. And having so many confusing plan designs can actually get in the way.
CTMirror: Looking forward, it seems like right now there’s a lot of fear about what’s going to happen in the interim before a new plan potentially takes effect. What do you see as necessary to keep carriers involved? What do you think can be done? What needs to be done?
Counihan: I would do a few things.
The first thing I would do is I would convene a White House CEO summit the way the president has done with the auto industry and drug firms and the labor unions and others, to let them know about the president’s commitment to making this work.
The second thing I would do is probably name some type of health care czar or some type of responsible party in the White House to not only help drive policy but also drive accountability, because no matter what happens, the president is going to own this. It’s going to become Trumpcare, and one of the lessons learned I feel is that early engagement and being hands-on with this, both from a policy perspective and an operations perspective, is critical.
I think the third thing is to listen very carefully to key stakeholders. That would include providers, it would include the issuers, it would include enrollees, and really understanding what they think is working and what’s not.
The fourth is I would have a mantra of simplicity. I would basically say, ‘Look at, there are nine titles to the ACA.’ So much gets focused on Title I because that’s about the exchanges and expansion and such. But I think that one would want to learn from four years of experience and build upon that, particularly when the president has so much interest in trying to keep some of the key pillars of health reform.
The fifth is I think I would look at allowing states more flexibility with respect to understanding how policy plays out in their state and giving them more ability to tweak some of that policy based on their needs.
CTMirror: One thing I’ve heard floated as a possible option for Connecticut, where there is concern about keeping carriers on the exchange, is having a single individual market like some states have done, with no “on” or “off” exchange. What do you think about that?
Counihan: I think it makes the most sense.
CTMirror: Could you have a system where you get a subsidy for any qualifying health plan on an individual market?
Counihan: Yeah, you could. I think this is another example of areas to simplify.
Basically, people want to make sure they’ve got something that’s comprehensive, that covers their family, gives them peace of mind and is affordable.
I think providing more provider data is something that’s very important…this whole concept about turning patients into consumers sounds great, but there’s not really a lot of good information to actually do that. So one of the things I would advise under this whole HSA type of program is you want to make sure that there’s some really accurate data that people can use to make decisions by.
I’m not sure what the data is now, but when I was here, a colonscopy in Connecticut would range from $1,500 to $5,000 depending on location. People need to know that. That’s a huge spread in a fairly small state. That type of thing exists everywhere, but people don’t know what procedures cost and often the physicians don’t know because it’s all negotiated by a [physician hospital organization].
CTMirror: One thing I hear from people, whether they get their coverage through the exchange or through an employer or anywhere, is there’s a lot of frustration that, “In the last few years, my costs have gone up, my coverage has gotten worse.” And I wonder, looking big picture, what are the limits of what the ACA or its equivalent can do, and what are the other things that need to be addressed to get to a point where people don’t feel this squeeze with their health care?
Counihan: You’re getting really to the 800-pound gorilla, which is how do you control costs?
Insurance costs are obviously just a manifestation of health care costs, and health care costs are not showing any sign of abating. And prescription drug costs, particularly around specialty drugs, in some areas of the country, have had a 24 percent trend rate. So it’s a critical issue.
If you look at the federal exchange, roughly 85 percent of our enrollees are getting subsidies and a high percentage are getting cost-sharing reductions, so in many respects, they’re held harmless from some of these increases. But the 15 percent that aren’t are, in some states, bearing a big increase. In other states they’re not. It’s not uniformly high increases everywhere.
This is a much bigger challenge. Implementing the law, both in Connecticut and at HealthCare.gov, was really about access. It was really about gaining people coverage and giving them security. There were things that I think we’re doing to help control costs. There’s a PCP-plus program [a payment-reform program for primary care practices]. I think MACRA [a 2015 law that includes payment changes under Medicare] was another important move to help control costs. What the new leadership at [the federal Centers for Medicare and Medicaid Services] does with those programs, I think we have to see.
CTMirror: What’s next for you?
Counihan: I don’t know yet. It’s been a very strange experience to have a job end at noon on a day and suddenly start saying, ‘What am I going to do next?’
So I’ve been speaking a little bit. I was just in New Haven giving a talk at Yale, which was great fun. And so I’m just sort of kicking back and testing the waters and seeing what comes up.
CTMirror: Did you have to buy health insurance?
Counihan: You bet.
CTMirror: So did you go through the exchange?
Counihan: I did. That’s right. DC Health Link.
CTMirror: What are your thoughts, having done it now?
Counihan: I actually thought it was pretty simple. I kept asking myself if that’s just because I’ve been doing this too long, but I think one part that may have made it a little bit easier is that I did not need a subsidy, so I did not have to go through that verification process. But I thought the plan designs worked out pretty well. We were able to keep the same carrier that I had as a federal employee, and I was also lucky because the CEO is a friend of mine, so if anything goes wrong I’d probably give him a call. But I thought the experience was pretty good.
CTMirror: Is it easy for you to pick a plan?
Counihan: No. It really wasn’t.
I think that’s something else that I think we all need to look at. We tried to offer some new decision support tools on HealthCare.gov a year ago, but they were kind of basic stuff. It was a provider search, a hospital search, a pharmacy search. But there’s an exchange in The Netherlands that does a really good job of asking about six or eight basic questions, and then based on that, they recommend some plans.
That kind of thing I think would be helpful. I think there was always a concern that if we implemented something like that, we’d be viewed as actually being a consultant or consulting to them, and then we’d have all kinds of ramifications to that. But people find buying health insurance confusing, and I think the more tools that people can get to basically say, ‘What are my needs, what are my family’s needs?’ and how that algorithm translates that into a plan, I think people would welcome.
CTMirror: There’s been a lot of talk about the young invincibles, the young healthy people needed to help balance the insurance risk pool. Do you think there’s been a change in their calculus? Compared to where things were three or four years ago, do you think in that age group there’s any kind of different expectation, or will it always be a challenge to get them signed up?
Counihan: What’s always been a challenge in particular has been young men. Less with young women.
I think part of this is just having it baked into the culture so that there’s an expectation that at a certain age, you get insurance.
One of the benefits of having that provision of staying on your [parents’] plans to age 26 is there are roughly 3 million young people that are on their parents’ plans. So when people say we can’t get young people on the plan, it’s actually not necessarily true. There are a lot of people covered, but they’re covered through their parents’ coverage. And then typically by a certain age they are employed, and often then can get coverage through their employer, so they don’t find that gap.
For folks that aren’t covered say at 21 or 22 or things of that sort, I think it is a challenge right now. There are ways to try to mitigate that, but I suspect that’ll be a challenge for a while.
CTMirror: What do you make of the fact that the ACA has gotten more popular since Obama left office?
Counihan: I think it’s a couple of things. I think one is the fact that people don’t necessarily realize what they have until it’s gone… I think that there’s a piece of people not thinking that some of these things would actually go away and some of these campaign promises wouldn’t be delivered on, and they’re surprised at it.
I think the second is the fact that people are calling it the Affordable Care Act now more than Obamacare. The Affordable Care Act always polled 10 percent more favorably than Obamacare. But what’s a little interesting and depressing at the same time is the fact that recent polling has showed that a third of the country did not realize it was the same thing.
Every open enrollment I would be out on the road and visiting different states, and I remember being in the South last year and talking to insurance brokers, and they typically said that they would ask their clients whether they wanted affordable health care or Obamacare. And almost invariably, people said, “I don’t want Obamacare, but I’d love the Affordable Care,’” without realizing it was the same.
So I think a lot of it is just this fear of it going away. The second is now people are depending on it more and more, and the third is that there’s not been surfaced any replacement ideas yet.
CTMirror: Any predictions of where we’ll be in a year?
Counihan: I don’t know. It’s really tough.
There seems to be so much rhetoric around repeal and replace. I think the big issue is going to be reconciling between the House and the Senate. So the House has got three key factions to it and they’ll figure out something. But getting the Senate to agree to that, I think it’d be tough.
There are re-elections coming up in ’18. Much of the House is gerrymandered or they’ve got little risk of losing an election. That’s not true in the Senate. So the senators always have to be a little bit more moderate than the folks in the House can be, and I think they’re very concerned about disruption.
If you look at the town hall meetings going on nationally, much of that is about the ACA and fear about it going away. So that plays into some sense about whether or not repair may be a better option than repeal.
CTMirror: To what extent is repair vs. repeal and replace a semantic or marketing difference more than a substantive difference?
Counihan: It’s hard to say. It’s going to depend on the detail. Certainly if you look at how the politics are playing out, people don’t like the ‘repair’ word because it sounds like they’re keeping the status quo, which they made all this commitment they’re going to eliminate.
But if the president has already committed to saying, “We’re going to be covering everybody with better coverage at cheaper prices,” that’s already an ambitious goal. Then you want to keep the key benefits of no pre-existing condition exclusion, kids on to 26, no lifetime caps, women not being charged more than men. All these kinds of things back you into a corner of what you can do.
So to me, I would think that the rational thing of course is to try to get people from both parties together and saying, ‘Let’s look at the data. Let’s look at the evidence, what’s worked and what hasn’t, and let’s build on that.’
This idea about tearing down and building up again is very disruptive, not just to beneficiaries but also to the insurance companies. So I guess we’ll have to see.
This Q&A has been edited for length and clarity.
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