Q&A with Paul Starr, Part 2: How to watchdog health reform’s rollout

The American Prospect's co-editor Paul Starr spoke with Antidote last week about the magazine's special report on health reform. The magazine's ongoing analysis of the health reform battle has been the subject of a lot of buzz in outlets such as The Hill, Kaiser Health News and Truthout.

The first part of our interview ran last Friday. The second part is below. It has been edited for space and clarity. 

Q: As you have pointed out in this issue, health care reform is going to play out a little differently in each state. What should reporters be doing now to catch reform developments as they occur? Who should they cultivate as sources? What documents should they FOIA?

A: They should be working hard at the state level. There are commissions being formed in the executive branches and legislative branches. Proposals are moving along. Many states are moving to carry out the law. And at the other end are the states that are resisting. Even in some of those states, there are people within the administrative agencies who are preparing to roll out reform, and they would be good to know.

Q: Isn't this what happened with the stimulus package too, though? Some governors pledged to refuse the money and then stuck their hands out?

A: I think the ideological resistance is a lot stronger than in the case of the stimulus.

Q: What should people be looking for in terms of this idea of malicious compliance that you discuss in this issue of the magazine?

A: I think there are a whole series of possible dangers at the state level. One possibility is that, even though there are requirements for states to reduce barriers to enrollment, there are a variety of ways that states can formally seem to comply but in practice set up new barriers for enrollment or ways of getting people dis-enrolled when the time comes. So there are going to be things buried deep in the bureaucracy that reporters should be looking at. Medicaid and CHiP will be two of the main programs that will continue and to be expanded under this reform. Will there be enough staff to handle the additional enrollment? The states are going to get fully reimbursed for people who are newly eligible, but they don't get 100% reimbursed for people who were previously eligible but are now signing up because of the individual mandate. Many states may drag their feet in respect to those groups.

Q: What might states do to game the system to make it look like everyone is brand new?

A: There are provisions that are aimed at preventing exactly that kind of manipulation. But if you check with people who are working on the ground level with this, you will find that states are very clever at evading those kinds of controls. Where they have a conservative Republican governor or they just want to keep down their expenditures, reporters should pay close attention to what happens.

Q: How do reporters watchdog the creation of these insurance exchanges to see if they are, indeed, going to cherry-pick for patients or exclude well established types of care?

A: The danger is not that the exchanges will cherry-pick. The role of the exchanges will be to prevent that. But one thing to look at will be the marketing practices of the insurers and whether they are trying to circumvent the purpose of the law, which is that insurers should no longer be trying to cherry-pick the healthy, but take everyone and deliver the best value for the money. The exchanges will have risk-adjusted payments. Plans that take enrollees who are older or sicker should have those costs compensated for. This is aimed at protecting plans that have higher-risk populations.

Q: How transparent will all of this be?

A: That's an interesting question. This depends on the regulations. The federal regulators right now are preoccupied with the provisions that go into effect relatively soon. The exchanges don't go into effect until 2014. That's still a bit away.

Q: In the same vein, how can we find out whether insurance companies are saying that they are spending 80% of their premium money on care when they are really spending an average of 80% across many different plans, some of which may have much higher profit margins? And what about figuring out whether a CEO's salary is being included in "care management"?

A: The insurance companies are going to have to report that. That will be in the office that Jay Angoff runs at HHS. The Office of Consumer Information and Insurance Oversight. They are planning to report that information on the new website that HHS has created.

Q: You say in this issue that the exchanges will help winnow out the least efficient plans, but wouldn't that have happened already in the free market that we have now?

A: The market today rewards cherry-picking. It rewards insurers that are good at enrolling only healthy people and avoid sick people. More competition in health insurance doesn't have any effect on reducing costs. The people who thinkthat competition is the solution to everything are ignoring the way health insurance has worked in this country for a very long time.Competition will help only if the structure of the market changes, so that they are truly competing for all patients, not just the healthy ones.

Q: You also talk about how insurers have reduced health costs in some cases. What do you think are some untold stories about how insurance companies have put checks on costs?

A: If you have the whole debate that we had about health maintenance organizations, there were unquestionably examples of high quality HMOs that did successfully control costs and deliver good health care. Group Health is one of those. But unfortunately, we saw the emergence of a lot of low-quality commercial HMOs that ruined the whole reputation of the industry.

Q: Prevention is going to get more funding with health reform. To a lot of people, prevention doesn't mean lifestyle changes as much as it means more tests and screening. But, as you pointed out in your piece on preventive care, screenings aren't always effective and can actually lead to other problems. How can reporters do a better job of explaining preventive care to readers?

A: There are incentives in the law against smoking. Insurers can set higher rates for smokers. There is a financial incentive there. On the question of screenings and tests, the legislation provides support for scientific research and evaluation to decide which are the effective tests and which are not. That was the issue we were talking about in relation to mammography. We need authoritative, scientifically based decisions on what works and what doesn't work. We do have a long established process of scientific evaluation. It is true that, as new research comes out, findings will change and something we all thought was effective will turn out not to be. That's the very nature of science. One of the things this legislation does is create a financial incentive for pharmaceutical companies and medical equipment makers and so forth to orient themselves more toward the preventive side than they were in the past. Traditional health insurance hasn't really covered prevention at all. On the whole, this is a very good thing.

Q: One of the pieces talks about the political talking points that are driving so much of the opposition to reform. How can this be highlighted more in reporting on reform and other topics, so readers know when policymakers or public figures are speaking from the same script?

A: They all read the memo from Frank Luntz and all use the phrase that Luntz recommended. It's more traceable now than it used to be. The trouble is, of course, everyone in politics is trained to be on message. And so there is inevitably a conflict between the politician's determination to stay on message and the reporter's mission to get people to speak the truth.

Q: Exactly, so how do you push past the talking points?

A: Just keep pressing them to defend their positions.