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Health-Care Rollout: The View From Kansas

Q&A with Sandy Praeger, a Republican insurance commissioner in a state that’s refused to go along with the Affordable Care Act.

Oct. 30: This post has been updated to reflect quotes from video of today's hearing.

Most-often mentioned state at today’s House committee grilling of Health and Human Services Secretary Kathleen Sebelius? So far, it’s the secretary’s home state of Kansas.

“Madam Secretary, while you’re from Kansas, we're not in Kansas anymore. Some might say that we are actually in the Wizard of Oz land,” Rep. Joe Barton, R-Texas, said to Sebelius during one contentious exchange about her agency’s troubled rollout of

Rep. Frank Pallone, D-N.J., retorted: “I know we're not in Kansas, but I do believe increasingly we're in Oz because of what I see here.”

So, how is this all playing in Kansas?

We decided to check in with the state’s insurance commissioner, Sandy Praeger. Her state has forcefully decided not to take part in the Affordable Care Act, but Praeger, a Republican, has voiced support for health-care reform.

Praeger succeeded Sebelius as commissioner in 2003 when Sebelius became the state’s governor.  Praeger is a past president of the National Association of Insurance Commissioners and chairs the group’s health committee.

Here are highlights of our interview, edited for clarity and length.

Q. How do you think the rollout of the health insurance marketplaces is going? Is the media overhyping the problems?

A. Not very well. I think it’s just been unfortunate. It seems like from what I’m hearing that some of the last-minute changes that were requested by the administration have caused some of the problems, forcing people to sign up [for accounts on] and put their personal information in before they could shop. It’s been pretty rocky.

Q. Do you think they can be fixed in time for consumers to enroll in coverage beginning Jan. 1?

A. The Affordable Care Act does not depend entirely on the [] marketplace. All of the provisions are still there and people can still go to an agent and use a call center and sign up even though the federal exchange [has had problems]. I think there are still other ways for people to get signed up. It’s not as convenient as it was supposed to have been. That part of it is really problematic and hopefully it will get fixed so that people can get signed up by the first of the year.

Q. Have you spoken to insurance companies in your state about how it’s going?

A. They are getting enrollees, but they have not yet been willing to release numbers. It’s a competitive thing. They don’t want to look bad compared to their competitors. Especially during the open enrollment period they want people to sign up for their plan. If it looks like the other company is getting more enrollees, that could affect their marketing. Hopefully HHS is going to release [enrollment] numbers sometime in November.

Q. Is this a tale of a divided country in terms of success and failure? The 14 states that have chosen to run their own exchanges have seen reasonable success, while the 36 that left it to the federal government are most affected by’s problems.

A. I think it’s a clear example of how the law was intended. The states that are running their own exchanges — while there have been some technical glitches, which is going to happen with any new computer system rollout — it’s much easier to fix it at the state level. You don’t have as many people to deal with. You have state specific information. When conservative states pulled back and said, ‘We’re not going to do it,’ the reason for doing it is that they didn’t want the law to succeed. And this is a way of creating an impediment.

Think of the complexity of [the federal government] creating something for citizens in 36 states with different health plans. [If those states chose to run their own exchanges,] it would have been a smoother rollout, I think, based on the evidence we’ve seen with the states that have their own exchanges. While it has not been perfect, those states are moving ahead and getting enrollees. I think it is a case of a tale of two systems.

Q. Are you surprised that in some states, the number of people enrolling in the Medicaid expansion far outnumbers those signing up for private plans?

A. No not at all. The way the [marketplace] website is designed, if you’re eligible based on income for Medicaid, you’re immediately moved over to the Medicaid program, where the enrollment is much easier. If you’re going on the exchange to buy private insurance, you have to go through the process, you have to decide which one [plan] do I want. There are a lot more decisions that the individual has to make vs. Medicaid. If you’re put in the Medicaid program, those decisions are part of the Medicaid program. It’s much less complicated. In some states, it’s a huge expansion. In states like ours, where we didn’t expand [Medicaid], there’s very little eligibility.

Q. What advice would you give HHS to make the rollout smoother?

A. That’s tough. If the website is not going to be functioning in time to get people enrolled, then they really need to add more call centers and they need to beef up the call centers, and they need to increase the education and outreach efforts to let people know this is what you need to do.

Q. What about consumers. What advice would you give them?

A. I really recommend that they work with either an insurance agent or one of the navigators to understand the diff in the plans. Don’t just look for the lowest premium but look for coverage that’s going to be comprehensive enough to meet your needs. Low premiums can mean higher out-of-pocket costs. That’s a big decision. If it’s someone that knows they have health conditions, they should probably go for one that has a higher premium and then has lower out-of-pocket costs. The out-of-pocket costs are capped, but for an individual it’s a little bit over $6,000 and for a family $12,500. There’s still some significant out-of-pocket costs before the health plan covers everything.

I think I’ve heard somebody say this is not like a rock concert. The tickets are not going to sell out. You don’t have to do it right now. Famous last words. They can at least see what they’d be eligible for by going to our website and putting in basic family information and income information and it will tell them what the premium would be.

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