I recently had an interesting conversation with a lobbyist for the insurance industry.
We planned to talk about our narrow legislative issues to find any common ground. Predictably, we disagreed on some key points, but we agreed on a lot more. We agreed that it’s hard to get people across the health care system onto the same page and working through problems together. There’s no place in Connecticut for those conversations to happen.
People tend to care about health care and insurance when they’re at risk of losing it. More people are at risk because of COVID. Most observers agree that health care costs are unaffordable, displacing other important priorities, and that we aren’t getting our money’s worth. But we diverge as soon as we talk about the specific problems and whose fault they are.
There are three buckets of blame for unaffordable health care – insurance, public health, and providing care. All three buckets were under stress long before COVID, but the double-whammy of the pandemic and the recession have intensified the conflicts. Most of us can’t see beyond our own bucket.
The insurance bucket’s problems are rising premiums and rising consumer out-of-pocket costs. The stakeholders here are insurers, employers and the 2.4 million Connecticut residents who rely on commercial insurance coverage. It’s especially hard for the 423,000 state residents who buy individual coverage. Subsidies on the health insurance exchange are inadequate – if you can get them. This is what candidates heard on the campaign trail last year, and they need to respond.
There’s a lot of heat this legislative session devoted to rising premiums and the proposed solutions follow predictable paths. Those who blame insurers favor a public health insurance option to compete with private plans. Defenders of insurance favor reinsurance to even out the costs of expensive patients. Others want to directly increase subsidies on the exchange. The lobbyist and I agreed that all these proposals are missing the bigger point: For sustainable affordability we have to address the inputs that are driving costs up – drug prices and large health systems eliminating competition. But politics favors the easier fixes.
The second bucket is about what happens outside doctors’ offices but affects health such as housing, healthy food, safe neighborhoods and access to care. The stakeholders here are many – 1.4 million state Medicaid and Medicare members, 207,000 uninsured state residents, taxpayers, communities of color and social services. It’s harder to fix these problems because they require investments by communities while the savings go back into other buckets.
COVID has shone a bright light on inequities in our health care system. It has tested our underfunded, neglected public health system. We have a much better appreciation for the essential workers, often from Black and brown communities, whom we rely on for food, safety, shopping, and health care. There are legislative proposals to restore coverage for working HUSKY parents and new coverage for immigrants to address second bucket problems.
The last bucket concerns how health care is delivered. The problems in this bucket are doctors and nurses burning out because they can’t practice the way they should, patients with complicated problems who only get 12 minutes with their provider, and health systems who merge and get big to prosper. Stakeholders include providers, health systems, and seriously ill patients.
COVID hit the health care delivery system hard, especially hospitals and nursing homes. Providers put their own health at risk to care for us, despite unexplainable shortages of PPE and everything else they needed to heal patients. There has been some relief, but we need to strengthen the system for the future.
Unfortunately, most stakeholders have very little understanding of the challenges facing others. Many say, “If they’d just let me do my job, all would be well.” Insurers resent taking the blame for rising premiums driven by other industries. Providers believe that if they were given control over spending, they would do a better job deciding what patients need. Public health and community leaders have been starved for resources that could make entire populations healthier and avoid rising costs. They’re just talking past each other.
There are tables around the state where these conversations are supposed to happen, but most focus on just one problem in isolation. Connecticut conversations usually start with the end already decided, and the participants carefully chosen to support the predetermined outcome.
The most recent example of the tables that are supposed to be is the Office of Health Strategy’s Cost Cap project to control healthcare costs. It started with an unfortunate Executive Order that set specific outcomes ahead of the process and then convened carefully chosen committees to figure out how to implement the predetermined outcome. In committee deliberations, members noted that the Executive Order’s pre-set outcomes didn’t fit the goal, but were told by staff and consultants they couldn’t change them. Running conversations this way makes for smoother meetings but produces flawed policies that fail in the real world.
We can do better. We can find common ground and work together on shared goals. There are better models. We can develop trust in a thoughtful process that engages everyone. If an experienced industry lobbyist and a dedicated consumer advocate can find common ground in one phone call, we can all do it.
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