One of my longtime patients came in and said, "I need all of the medicines I can get right now because I’ve been laid off and I am losing my insurance at the end of the month. I have no idea when I’ll have insurance again."
The Affordable Care Act, the central piece of legislation driving health care reform, calls for the development of health insurance exchanges (HIE) throughout the country. The spirit of the law mandating HIEs is that insurers comply with consumer protections and benefit requirements and compete in a fair and cost-efficient manner. Although HIEs do not themselves provide insurance, they are meant to be the conduit for the expansion of insurance coverage to more Americans. Under federal law, HIEs must be fully certified and operational by Jan. 1, 2014.
HIEs essentially enable individuals to shop for insurance coverage online in a manner analogous to using Expedia to book a trip. Depending on income and other factors, costs are covered through paid premiums, tax credits or subsidies.
The federal government gave states the choice to create their own HIEs or to opt out and use the federal program. Hawaii, like many other states, chose to create its own: the Hawaii Health Insurance Exchange, also known as the Connector. Last year Senate Bill 1348 passed, enabling official formation of the Connector. An interim board of directors was selected, and the board hired an executive director.
The board comprises representatives from the following sectors: government, health insurers, health care provider groups, hospitals, labor, Native Hawaiian health, federally qualified health centers, business, health information and consumers.
Of particular note is that the health insurance plans and the government have the greatest number of representatives on the board. This month the governor submitted his nominations for the permanent board of directors, and it should be noted that he proposes to remove hospital representation from the board and increase the number of health insurance plans represented to four: HMSA, Kaiser, Ohana Health Plan and Hawaii Dental Service. The majority of other sectors are now represented by only a single seat or organization.
SB 2085 and HB 2114 seek to prevent organizations that have a direct financial interest or benefit from serving as voting members of the Connector board due to conflicts of interest. The bill was submitted with the view that despite conflict-of-interest rules, health plans can’t be expected to act in the best interest of consumers or the state when they have financial interests tied to their actions.
Advocates of these bills say that the ability of health plans to vote on which plans are offered to consumers is like the electric company sitting on the Public Utilities Commission and voting on its own rate increases.
Proponents of the bills also cite recommendations by the U.S. Department of Health and Human Services that health plans be used in an advisory capacity only. They claim that as voting members of the board, health insurance plans have direct conflicts of interest because they will be financial beneficiaries of the exchange. Given that anywhere between 50,000 and 100,000 people in Hawaii are uninsured, there are literally millions of dollars at stake. Twenty-one states have language prohibiting inclusion of health plans on insurance exchange boards, and an additional six states are considering such language.
In contrast, some argue that everyone has a financial stake in the Connector, so all but the government should be disqualified. Health insurance plans also argue that they are responsible stewards and have contributed much to making the Connector a useful instrument. They say that health insurance plans have the knowledge and experience to help develop a complex infrastructure and technical expertise on plan design and financial risk modeling that is critical to the process.
The parties behind these bills affirm that they allow for health plans to provide their valuable technical expertise without voting on matters that financially affect them.
Hawaii needs the expertise of our health plans to ensure that the Connector fulfills its mission to facilitate the expansion of insurance coverage to more people in Hawaii. The Connector must become a trustworthy source of information and serve the health care needs of the community. While all parties have a financial stake in its structure and should provide useful input, Hawaii must guard against undue influence and conflict of interest.
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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
