In Capitol Hill’s shadow, health reform gets underway

September 25, 2012

If you want to know what health reform in action looks like, here's what you should picture: a nondescript conference room, on the fourth floor of a government building, with about four dozen people sitting in rows of red chairs and one fluorescent light that keeps flickering on and off. No hope, change or death panels to speak of. 


The Sept. 24, 2012 meeting of the District of Columbia Health Benefits Exchange Authority (Sarah Kliff | The Washington Post)

This is a public meeting of the District of Columbia Health Benefits Exchange Authority, which convened at 5:30 p.m. on Monday, about a half-mile from the Capitol Hill buildings where legislators wrote the law. It wasn't exactly a must-attend event. About four rows of chairs, way in the back, were left empty.

But this is actually a pretty important place. It’s where government officials decide what the Obama administration's signature legislative achievement will look like for residents of the nation’s capitol.

As a resident myself —and an admitted health policy nerd— it seemed worth understanding how my representatives were deciding what health benefits my insurance plan will cover and what my insurance market will look like come 2014.

As far as health exchange boards go, the District’s has some serious health policy star power, a product of the many think-tanks and universities in its jurisdiction. The Brookings Institute’s Henry Aaron sits on the board, as do health policy professors from Georgetown and George Washington universities. As one meeting attendee remarked to me, “It’s kind of cool to think that we really have the best of the best.”

“Cool” wasn’t necessarily an adjective that came to mind during the 80-minute meeting that took place squarely in the weeds of health policy. 

It started with the first agenda item: Deciding what set of essential health benefits the District of Columbia will require all insurance carriers to cover. Even in one of the most Democratic-leaning districts in the country, there’s was not exactly enthusiasm for this new piece of federal regulation.

“This is mandated by the law,” District of Columbia insurance commissioner Bill White noted. “This is not something anyone here decided to do.”

Still, they did have to set an essential benefit package - and heard from a few local voices on how to do it. Peter Rosenstein is the executive director of the American Academy of Orthotists and Prosthetists and urged more comprehensive coverage for orthotics and prosthetic devices for both children and adults.

“One role you all have is determining levels of coverage,” Rosenstein said. “Have you considered things like prostheses for a child who loses their legs in an accident or cancer? If your child is 3-years-old when he loses his legs, he’ll need six prostheses by the age of 21.”

Another consumer health advocate commended the board on including a pediatric vision benefit (which also is required by the federal law). But the one who followed contended that the one pair of glasses-per-year provision didn’t go far enough, pointing out that “often times kids have glasses and lose them. If they’re limited to one, a child might have to go a whole year without them if a parent can’t afford a replacement.”

These are just two among a multitude of decisions, on everything from orthotics to optometrics, that the exchange board will have to decide as it figures out its essential benefit package. It’s not exactly the most exciting of debates, but it's important in shaping the medical care that local residents will have access to.

Next up on the agenda was the District of Columbia health insurance exchange, the new marketplace where residents will be able to use federal subsidies to purchase insurance coverage.

The District of Columbia has been one of the more aggressive implementers of President Obama's signature health-care legislation (the politics of the District make it an easier sell than in, say, neighboring Virginia). It is among only a handful of states that have committed to running their own health insurance exchange, rather than ceding the task to the federal government.

Even with widespread support, the District still has a to-do list that stretches 11 PowerPoint slides long. They have to decide whether all insurance plans will be sold through the insurance exchange, or if there will still be an outside market.

Processes need to be put in place to vet insurance plans to make sure they meet new federal mandates. A communications plan must be put in place, so that District residents actually know about the new marketplace. There’s also the not-so-small matter of hiring an executive director. These are big decisions that will shape how residents buy insurance  here just 15 months from now.

All of it is supposed to be done by Jan. 1, 2013, but officials here recognize, despite their commitment, it's just not possible. Even the most stalwart of Obamacare supporters just simply have too much work to meet that deadline, and will instead seek "conditional approval": They will lay out what they plan to do for the federal government, rather than have it done.

“No state is going to be able to be fully certified on Jan. 1,” said Bonnie Norton, D.C’s acting director of health reform.. “When they passed the ACA, they were highly optimistic about the timeline for states to implement exchanges.

As Norton went through her presentation her microphone kept going fuzzy with interference, interrupting her presentation and causing audio-visual specialists to intervene.

It got noisy enough that, at one point, board member Henry Aaron quipped “I hope your processes go better than this.”

Many of those at the sparsely attended-meeting smiled in agreement.

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