State health insurance exchanges opened across the country on October 1st, but how much do you know about what’s going on? Dr. PG Forest, newly appointed Director of IPS, and MPP alum Ernest Le, Outreach Consultant for Healthy Howard, were asked to share their perspectives about the exchange. They each listed three elements of the health insurance exchange that every health policy student should know.
Dr. Pierre-Gerlier Forest, director of the Johns Hopkins Institute for Health and Social Policy:
1. Read about what’s going on. First and importantly, I think everyone should read the New England Journal of Medicine article entitled “Only the Beginning – What’s Next at the Health Insurance Exchanges?” (13: 369; Sept 26, 2013). I have found this to be one of the most helpful papers published on the creation of health insurance exchanges. It is co-authored by Henry Aaron, who I consider among the very best social policy experts and writers in the U.S. I am truly amazed by how clearly and insightfully he writes. This paper is important because Aaron and Lucia give you everything you need to know about what’s going on in just three pages.
2. This is a perfect opportunity to learn. I’m intellectually excited about health insurance exchanges because I see it as a fantastic occasion to learn. Insurance exchanges are among the most sophisticated social technology of our time. To be at Johns Hopkins at this time means that we get to witness implementation at its best and see important social and health transformations. In paying attention to implementation, we can see where the needs are, how people behave, and where problems truly hide. For example, are the problems we currently see political or technological?
Some of the implementation occurring, however, is not always intuitive. Kentucky, for example, decided to implement health insurance exchanges independently by using pieces of bureaucracy already existing within their state. This is like piecing together a car from used parts: clever, but we won’t know if it works until several years down the road. Vermont also implemented health insurance in a different way. In the long term, the state would like to build a made-in-USA system as close as possible to single payer, and decisions that are made now could either facilitate or delay the achievement of this overarching goal. Decision makers are making very interesting choices and it’s all happening under our very eyes. What an incredible time to learn!
3. State level policymaking is just as important as federal decision-making. In America, experts tend to pay attention to national and city level policymaking while neglecting state level actions. We have a lot to learn from paying more attention to state governments because their choices will impact an incredible number of people. States are taking interesting steps in implementing health insurance exchanges and we need to heed their decisions. (This may be my Canadian bias where we focus on what goes on in each province, not just national policies.)
Ernest Le, Outreach Consultant for Healthy Howard:
1. Policy is not just about passing the right laws. In fact, the passage of a law is only the beginning because implementation matters just as much. Different states have taken different approaches to implementing the ACA ranging from outright hostility to full-throated support, and I believe in the months and years to come, we will clearly see a difference among the states in health outcomes and cost savings.
2. Most people are not paying attention to policy even though it can profoundly affect their lives. You can see this clearly in the work that I do. My job title is "Outreach Consultant" which means I do all the things that are involved in informing people about the ACA and how they can enroll in its benefits. Even in places where most people support the ACA politically, I've seen a lot of misunderstanding and ignorance about the law. Public policy students should understand that even if they manage to do some good in the world, most of the people whose lives they touch will never know it. Maryland will consider it a huge success if they enroll even a third of all the uninsured people in the state, and nobody thinks we will get 100% of the people who are eligible for benefits under the ACA.
3. Policy is imperfect and must always be improved. I'm not referring to the hiccups associated with the launch of the ACA. There is a laundry list of things even the biggest supporters of the law would like to change. You could argue for example that the tax penalty for not having insurance is not big enough. A lot of people would like offer coverage under the ACA to undocumented immigrants since they also place a burden on the American medical system when they get sick. Assuming the ACA doesn't get repealed wholesale, the challenge in the coming years will be to identify the ways it needs to be changed.