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.