In the shadow of negotiations over the so-called fiscal cliff, another deadline looms in Washington. States have until December fourteenth to decide whether they intend to create state-based health insurance markets. If states choose not to build their own or partner with others, then the federal government will step in. As states rush to create exchanges by 2014, they’re considering how best to develop health care comparison tools. Individuals and small businesses need ways to plan for unexpected expenses, find out which plans include their provider, and compare service quality. Diane and her guests talk about building customer-friendly health insurance exchanges.


  • Robert Krughoff Founder and president of Center for the Study of Services and Consumers' CHECKBOOK.
  • Julie Appleby Senior correspondent, Kaiser Health News.
  • Sonya Schwartz Program director, National Academy for State Health Policy.
  • William Custer Director of Center for Health Services Research at the J. Mack Robinson College of Business, Georgia State University.
  • Glen Shor Executive director, Massachusetts Commonwealth Health Connector.


  • 10:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. States are facing are facing a deadline next week to decide whether they intend to create state-based health insurance markets. One of the biggest challenges of running exchanges will be making them easy for consumers to use. Joining me in the studio to talk about how best to create consumer-oriented health insurance exchanges: Robert Krughoff of the Center for the Study of Services and Consumers' CHECKBOOK, Julie Appleby of Kaiser Health News and Sonya Schwartz with the National Academy for State Health Policy.

  • 10:07:40

    MS. DIANE REHMI know many of you will be looking for your own information. Give us a call, 800-433-8850. Send us your email to Follow us on Facebook or Twitter. We'll try to take as many of your questions as we can. Good morning all and thanks for being here.

  • 10:08:04

    MS. JULIE APPLEBYGood morning.

  • 10:08:05

    MS. SONYA SCHWARTZGood morning.

  • 10:08:05

    MR. ROBERT KRUGHOFFGood morning.

  • 10:08:07

    REHMJulie, I'll start with you. First, I think we ought to make clear that these exchanges are for the uninsured and for individuals who may not be getting insurance through their employers. Is that right?

  • 10:08:24

    APPLEBYRight. Right. These -- think of them a little bit like an online marketplace, and this is where individuals who buy their own insurance -- and there's about 18 million of them right now in this country who buy their own insurance -- will go to shop. And also for small businesses, those employers that have 50 of fewer workers will be using these sites where they're going to shop for coverage, find out if they qualify for a subsidy or if they qualify for Medicaid, which is the state and federal program for the poor.

  • 10:08:54

    APPLEBYThere's a couple other points about these that have become controversial, right, so they can be state-run, they can be federally run or they can be a combination of the two. And like everything else in the health care law, they've gotten caught up a little bit in the politics around the health care law.

  • 10:09:10

    REHMAnd the question is so far, which states have decided to participate, which have not? Are we talking about a majority-minority or what?

  • 10:09:25

    APPLEBYRight now, 17 states and the District of Columbia have decided that they're going to move ahead with their own exchanges. These generally tend to be Democratic-run states, supporters of the health care law. Although there are some states that don't like the health care law, but they're moving forward with it anyway because they want to maintain state control. So you got these 17 states and D.C. moving head.

  • 10:09:47

    APPLEBYThe rest of the states, some 30-plus states, are either not going to do it -- Maine and Louisiana, for example, said, no, we're not going to do it -- or they're undecided. They might partner with the federal government to do part of the exchange, or they might just let the federal government decide it altogether. And again, these tend to be the more Republican states.

  • 10:10:06

    APPLEBYThey've raised concerns about cost, about control, whether they have enough time left to put these together before they open. And, frankly, there's also a group of governors that just don't like the federal health law, so they see not participating in this as a way to show that they don't like the health care law.

  • 10:10:26

    REHMAnd, Sonya Schwartz, does it make sense for these states not to participate and then had the federal government move in?

  • 10:10:41

    SCHWARTZWell, Diane, you don't get a gold medal for participating. I mean, I think we're going to have three different models available, and what we really have to make sure is we get all three versions right: the state version, the federal version and the partnership. You know, this isn't a drop-dead date. By Dec. 14, states actually can file this blueprint and a letter of intent to do a state exchange.

  • 10:11:05

    SCHWARTZBut they can decide it anytime after that to change their minds and take, you know, the example of a neighbor state and say, we want to do it, too. The only issue there is that there's federal money to develop these exchanges, and there's a lot of work that goes into building them. It's kind of like VC money if you're a start-up company or something, and that money runs out at the end of 2014. So if you really do want to do it, it's best to make the investment now.

  • 10:11:29

    REHMSo, Robert Krughoff, what will a state's decision to drop out or not participate mean for its citizens?

  • 10:11:42

    KRUGHOFFWell, there will be an exchange regardless. So it's a question whether the federal government provides this exchange or whether the state provides the exchange. And the federal government may provide a perfectly good exchange. There are concerns that the federal government won't be as sensitive to the circumstances in each individual state, and that's why the states -- a lot of the states want to do it themselves.

  • 10:12:06

    KRUGHOFFBut from a citizen's standpoint, they're going to have a choice of health plans regardless. I think we're going to talk here a little bit about how helpful these exchanges will be in making that choice, and there'll be a lot of variation there, but there will be some kind of exchange.

  • 10:12:23

    REHMSo, Julie, at this point, who are the most likely candidates for these exchanges?

  • 10:12:33

    APPLEBYMeaning which states or which individuals?

  • 10:12:34

    REHMNo. Which individuals?

  • 10:12:36

    APPLEBYThese are, again, the folks who buy their own insurance. If you have insurance at your job, it's probably not going to affect you at all because you're going to continue to get your coverage through your employer. Now, if you work for a very small company, your small employer may send you to the exchange where you will get a choice of plans in the exchange, but that's only, again, for very small employers.

  • 10:12:56

    REHMAnd, Sonya, what will an average consumer need from her state exchange to choose a plan? What kind of information?

  • 10:13:10

    SCHWARTZI think the first information a consumer needs is price, and that's not just what the premium costs, but it's what the premium costs after they get a federal subsidy. I think you probably know there are tax credits in the federal health reform law, and really, those look like a discount on your insurance plan month to month.

  • 10:13:28

    SCHWARTZSo you need to know not just what the whole premium is but how much you really owe after you get that discount. Then you need to know what the cost-sharing looks like in the plan. You're also going to want to know is my doctor in my network in this plan? You might want to know I take these three prescription drugs every year. Are they covered? There's a whole host of things you'd want to know.

  • 10:13:46

    REHMRobert Krughoff, it sounds as though it's going to be a complex decision for consumers.

  • 10:13:54

    KRUGHOFFWell, it is a complex decision, and in fact, there's a lot of research showing that consumers really dread having to make these kinds of decisions 'cause it is so complicated for them. Take the -- and, of course, the idea is that -- and the law says this will be a place where it's easy for consumers to choose among a large number of plans. Easy is something we still have to see. But take -- talking about the out-of-pocket cost, how much you're going to actually have to pay even though you have insurance, very complicated for people.

  • 10:14:27

    KRUGHOFFAnd one of our concerns, as you know, CHECKBOOK has been doing a health plan in comparison to and for federal employees for three decades plus, and one of our concerns is that on this out-of-pocket cost front, we're afraid that these exchanges are just going to give people what a number of existing exchanges out there in the world do now, which is a description of what the deductible is, what the co-insurance rate is, what the co-payments are, et cetera.

  • 10:14:53

    KRUGHOFFAnd then you're supposed to figure out, well, which is really better for me? But consumers can't figure out is a plan with a $200 deductible and a $10,000 out-of-pocket cost better than a plan with a $1,000 deductible but just a $4,000 maximum out-of-pocket cost? And how about differences in co-insurance rates, et cetera? They can't figure that out.

  • 10:15:14

    KRUGHOFFSo that's the kind of thing that we really want states to focus on, boiling this down to do a single-dollar amount figure as the best estimate of out-of-pocket cost for people like you, your family, your age, family size, health care characteristics, et cetera. And that can be done.

  • 10:15:32

    REHMWow. Big order, though, isn't it?

  • 10:15:34

    KRUGHOFFWell, I don't think it's that big an order, and we're actually pretty disappointed that the -- for them to do it themselves, they can't do it. Consumers can't.

  • 10:15:40


  • 10:15:41

    KRUGHOFFBut for the states to set up an exchange that actually boils this down into a single-dollar amount comparison, this plan, your best estimate of out-of-pocket cost is $4,000 next year, this plan, it's $8,000, it's not that hard to do that. That's actually what, as you know, we've been doing for federal employees for, you know, for many years, and it is possible to do. And we hope that'll spread around the country.

  • 10:16:04

    REHMJulie, how likely is that?

  • 10:16:06

    APPLEBYI think each state is deciding right now what their website is going to look like, what information they're going to include. It's going to vary state by state. We don't have any details yet on what the federal exchange is going to look like. And remember, the federal exchange is probably going to be running about 30 states. So we don't know what that one looks like. But what we do know is right now, starting already, plans have to give you a summary of benefits.

  • 10:16:28

    APPLEBYAnd this is an eight-page -- it's supposed to be a little bit more simplified, explaining what does this plan cover, what does it not cover, and it gives two examples. If you are having a baby, how much would this plan costs out of pocket and otherwise? And if you're managing diabetes, how much would this plan cost? So right now, you can ask for those and you can get them.

  • 10:16:47

    APPLEBYThese are going to also be available through plans you buy on these exchanges. Originally, they wanted to include, what if you're dealing with cancer because that's a very expensive thing, but that got left off initially and may come back later. But these eight-page summaries are supposed to help with a little bit of that.

  • 10:17:03

    REHMSo if you have, for example, a pre-existing condition, what happens then?

  • 10:17:13

    SCHWARTZThat's a great question. First of all, you know that the health care law made changes to insurance rules to protect consumers who have pre-existing conditions. So if you have one, you can get insurance now and -- but I think one thing we haven't talked about yet is that consumers, particularly those people who have pre-exiting condition, are probably going to need more help than just a website.

  • 10:17:32

    SCHWARTZI ran an online community for states who are trying to set up exchanges and work on health reform, and one of the things that comes up a lot on it is that states are estimating that somewhere between half and 75 percent of people buying insurance through exchanges are going to need in-person or phone assistance. So the website alone isn't going to do it for them. And someone who has just discovered a lump or, you know, has breast cancer is probably going to want to make a call and really look very carefully at the options.

  • 10:17:59

    REHMAnd the question is going to be, where is that call made to? Is there going to be a directory of phone numbers that people can call for that kind of telephone assistance?

  • 10:18:15

    SCHWARTZDefinitely. The federal law actually requires, in addition to a website, there has to be a call center operated. So whether it's a federal exchange or a state exchange, there'll be a number to call.

  • 10:18:24

    REHMSonya Schwartz, she's program director for the National Academy for State Health Policy. We're going to talk a little more, take your calls, work as many as we can into our conversation this morning. Stay with us.

  • 10:20:06

    REHMAnd welcome back. As we talk about state-based health insurance markets versus government-provided health insurance markets, joining us now from his office in Boston, Glen Shor. He is executive director of the Massachusetts Commonwealth Health Connector. Good morning to you, sir.

  • 10:20:33

    MR. GLEN SHORGood morning, Diane.

  • 10:20:34

    REHMTalk about how the Commonwealth Connector was actually developed.

  • 10:20:41

    SHORThe Massachusetts Health Connector was created as part of Massachusetts' groundbreaking health care reform law of 2006, a law which has helped us expand health insurance coverage to over 98 percent of our residents, including 99.8 percent of our children. The whole initiative has been a great success with more residents having primary care.

  • 10:21:02

    SHORMore businesses are offering coverage and more preventive care being received by our residents. The Health Connector is a important component of our state's health reform effort, making it even easier than ever before for people to find health insurance coverage that best suits their needs and their budgets.

  • 10:21:22

    REHMOK. So how do consumers in Massachusetts compare plans on your website?

  • 10:21:31

    SHORWell, purchasing health insurance can be very daunting to people. And at the Health Connector, we've taken a lot of the confusion out of shopping for health insurance principally by creating a website that allows people to generate real-time quotes in a very easy to understand format. Today, our health insurance plans are grouped by metallic tier. We have gold plans, silver plans and bronze plans.

  • 10:21:54

    SHORWhat differs are their premiums and their point of service cost sharing. Importantly, within each tier, we've created standard benefit packages, so people can make an apples to apples comparison between the options from different health insurers. For each tier, the plans have the same annual deductible, the same co-pays for a number of services in the same generic drug costs. We found that this helps people find a plan that satisfies their needs and meets their budgets.

  • 10:22:23

    REHMOK. Now, tell me whether simply one can go on that site and compare the cost of the plan for a single mother versus, say, a family of five.

  • 10:22:40

    SHORYeah. We can -- when you go on to our website, which is, if you're an individual or you're a family shopping for health insurance, you just have to provide some basic information about yourself, who -- how many people you have in your family, where you live, age, and then we will, in a real-time basis, generate quotes from a variety of that state's leading health insurers for a comprehensible number of health insurance benefit packages. And then you can choose.

  • 10:23:13

    REHMAnd what about the costs there in Massachusetts, have they gone up, gone down? What have you seen?

  • 10:23:23

    SHORFirst of all, you know, we're -- we are continuing to reform health care in Massachusetts in order to contain costs. Health reform in its own right -- our first phase of health reform has not been a budget buster. Some predicted it would be. But we've been very successful of controlling the cost of our coverage expansion initiative. But Massachusetts always recognize that coverage expansion was just phase one.

  • 10:23:46

    SHORPhase two was containing costs across the system by actually improving care. Under the governor's leadership, we recently enacted groundbreaking legislation in Massachusetts that will keep health care costs more in line with the growth of our state's economy and promote lowering cost by improving care.

  • 10:24:06

    REHMAnd do you have any advice for other states getting ready to do this?

  • 10:24:13

    SHORFirst of all, the most important thing that we should say to other states is be willing to experiment, be willing to innovate. If it doesn't work, pick yourself up and try something new. It's OK to treat this as a learning experience. And I think the principal reason we've had success in Massachusetts is even though in some instances or some places elsewhere health reform has been a political football, it's been a, in fact, a non-political, very serious policy endeavor in Massachusetts.

  • 10:24:42

    SHORA recent survey reported that two out of three Massachusetts adult support our state health reform because our leadership, the governor, the legislature, the business community, providers, insurers, brokers and others have come to the table and worked collaboratively because health care is one of the most important things in people's lives, and it shouldn't be treated as a political issue. It's a personal issue. It's an economic issue. And if other states approach this with the same perspective, and I know they can, they'll have great success, and we'll be eager to learn from them.

  • 10:25:14

    REHMAll right. And final question: Have costs gone up or down since you instituted this program?

  • 10:25:24

    SHORSome -- health care costs have gone up in Massachusetts. But they -- frankly, our -- we are no longer leading the list of states that are the most costly for health care. So that's something that's very positive, and recently, the growth in health care cost has actually slowed. Again, we treated this in phases. Health reform phase one, our law in 2006, was aimed at expanding coverage. Health reform phase two really crystallized in the enactment of recent groundbreaking legislation in Massachusetts is about containing cost. And we're going to contain cost by improving the quality of care.

  • 10:26:01

    REHMSo I -- final question. I would presume that no one outside of Massachusetts can get health insurance from Massachusetts. Is that correct?

  • 10:26:15

    SHORThat's correct. Our health insurance is for Massachusetts residents.

  • 10:26:18

    REHMAll right. Glen Shor, he is executive director of the Massachusetts Commonwealth Health Connector. Thanks so much for joining us.

  • 10:26:29

    SHORDiane, thanks for having me.

  • 10:26:30

    REHMAll right. And I'm going to take a call now. 800-433-8850. To Nantucket, Mass. Good morning, Randy. You're on the air.

  • 10:26:44

    RANDYGood morning, Diane. Thank you. I'm just calling in to comment that I am a satisfied customer of the...

  • 10:26:51

    REHMOh, dear. I'm afraid we lost that call. It sounds as though he was a satisfied customer for the Massachusetts health plan. Let's take another call in Southampton, N.Y., and to Jim. Good morning. You're on the air.

  • 10:27:15

    JIMHello. Good morning. Thank you very much for taking my call.

  • 10:27:17


  • 10:27:18

    JIMSlight -- might be slightly off topic but my situation is this: I'm self-employed. It's just my wife and myself, no children. We now have a catastrophic health care policy backed up by a health savings account. I'm just wondering if that policy is going to be still legal after Obamacare kicks in.

  • 10:27:37


  • 10:27:38

    JIMAnd, yeah, I haven't been able to find that information anywhere.

  • 10:27:40

    REHMOK. Julie.

  • 10:27:42

    APPLEBYYes. If you have a plan right now, you hang on to that plan. It's considered grandfathered, and you can keep that plan. You could also choose to go on your state's exchange and look around and see what else might be available.

  • 10:27:52

    REHMSo he can check on what New York is going to offer. Sonya.

  • 10:27:57

    SCHWARTZYeah. And the reason he might want to do that depending on his income is that then he might be able to get a subsidy from the federal government to keep his cost -- his premium cost down.

  • 10:28:06

    REHMDoes that make sense?

  • 10:28:06

    JIMYeah, we're small business...

  • 10:28:07


  • 10:28:08

    JIM...small business owner.

  • 10:28:09

    REHMSo maybe that makes sense for you, Jim.

  • 10:28:13

    JIMOK. Well, thank you very much.

  • 10:28:14

    REHMThanks for calling. Let's go now to Missouri City, Texas. Good morning, Blake.

  • 10:28:21

    BLAKEGood morning. Can you hear me?

  • 10:28:23

    REHMSure can. Go right ahead.

  • 10:28:24

    BLAKEOK. Great. Great. I'm going to make this as concise as I can. (unintelligible)...

  • 10:28:32

    REHMOK. Blake, I'm sorry. You're breaking up on us.

  • 10:28:37

    BLAKEOh, no. Can you hear me now?

  • 10:28:38

    REHMOK. I hope you're not on speaker.

  • 10:28:42

    BLAKENo, I'm not. I'm not. No.

  • 10:28:43

    REHMOK. Go ahead. OK.

  • 10:28:44

    BLAKEOK. OK. I'm really angry at both the federal government and the state of Texas because I lost my job, and I made -- I went through my 18 months of COBRA, and I never missed a payment. And when my COBRA ended, I got this letter of creditable coverage saying that my pre-existing condition -- I'm a chronic pain patient.

  • 10:29:04

    BLAKEI have an intrathecal pump, which it just needs refilling about every 50 days. And they said, oh, no, no. You'll be able to get insurance, you know, with this letter. Every health insurer that I applied to rejected me. So now I'm in the Texas Health Risk Pool, and my premiums are $867 a month, and I'm unemployed.

  • 10:29:27


  • 10:29:28

    BLAKEAnd it's horrible. I mean, those -- how can they say that this letter of creditable coverage was going to get me -- and they said they couldn't discriminate against me.

  • 10:29:38

    REHMSonya, what do you say to Blake?

  • 10:29:41

    SCHWARTZWell, what he's referring to is part of a federal law that passed in the '90s called the Health Insurance Portability and Accountability Act, which said that when someone exhausted COBRA, as long as they kept cover, they could go out, and there would either be -- like a state would designate a plan that they could participate in. And that's a horror story, and I wish I had known. I could have tried to help.

  • 10:30:03

    REHM$865 a month.

  • 10:30:06

    SCHWARTZYeah. Yeah. So the high-risk pool in Texas, I think, is that designated plan, and I think that's the issue.

  • 10:30:11

    REHMOK. So what's going to happen when the Affordable Care Act takes over, Julie?

  • 10:30:18

    APPLEBYWell, Blake is going to have to wait until 2014, but then in 2014, the law says that they cannot discriminate against people with pre-existing conditions. So he would have to be accepted by any insurer that's taking applicants. And the law also sets some new rules on how they can vary premiums, and they can vary premiums based on your age and where you live and your family size, but they can't vary them based on your health status.

  • 10:30:44

    APPLEBYSo he would have that option. And then there's also the subsidies that we've spoken about. Now, remember, the subsidies are sliding scale subsidies. They go up to 400 percent of poverty level, which this year is about $44,600 for an individual. It's around $92,000 for a family of four, and these are sliding scale subsidies to help people purchase coverage.

  • 10:31:04


  • 10:31:05

    SCHWARTZThere's one other thing. If you really have no income, there's the chance that Texas will decide to expand Medicaid, and you may end up being eligible for Medicaid, which would generally be low cost or no cost to you.

  • 10:31:17


  • 10:31:18

    KRUGHOFFWell, I think it's clear that things will be better for people who have pre-existing conditions, starting in 2014. That's going to be...

  • 10:31:26

    REHMBut what does he do between now and 2014?

  • 10:31:28

    KRUGHOFFOh, absolutely. It's a problem, except that at least he can get some coverage. This is very expensive coverage, but he's not denied coverage entirely.

  • 10:31:37

    REHMAll right. And here's an email from Bernadette. She's in Leesburg, Fla. and says, "One of my sons has to self-insure as a result of working under a 40-hour week. Heaven forbid that all the states should make it easy for him to choose his options in clear, understandable language. Why in the world wasn't it mandated by the president for all states to have a uniform policy? Isn't there enough for people to worry about in this economy without adding another burden to their lives?" Robert.

  • 10:32:24

    KRUGHOFFWell, I think there is an argument for having just one policy, and everybody gets the same thing. On the other hand, there are people who have really different preferences. They'd like to have a high-deductible plan, and they're willing to take a little more risk themselves, for instance. And there is a thought that if plans can vary their coverage, they may come up with ways that are more efficient that discourage excess health care prescribing by providers and so on.

  • 10:32:55

    KRUGHOFFSo that's the reason there is variation. But we believe, of course, that this can be -- that this decision can be made really very simple for people, and there are basically four things that we want to show people right away. One is that best estimate of out-of-pocket costs for somebody like you. Second is your risk. What's the worst case, or at least what's a -- how much we'd get for the out-of-pocket in a really bad year? Third thing is, is my doctor in the plan?

  • 10:33:24

    KRUGHOFFSo you can give them a list of one or two or three or however many doctors, and they will tell you, for each plan, yeah, my doctor's in there, not in there. And then, finally, there has to be some indication that this is a reasonable or a high-quality plan in terms of do the people in the plan actually get the service that they -- that they are -- they want? Do they get good care? Do they get -- are their claims paid and so on?

  • 10:33:47

    REHMRobert Krughoff. He's founder and president of the Center for the Study of Services and Consumers' CHECKBOOK. And you're listening to "The Diane Rehm Show." Certainly some would say that last email was an argument for universal health care, a single plan. We don't have it. We could have it in years to come, but who knows? Let's go to Indianapolis. Good morning, Pierre. You're on the air.

  • 10:34:26

    PIERREGood morning, Diane. Thank you. In Indianapolis, we have for people that don't have health insurance or whatever, the county hospital has a -- it's just called Wishard, but the name is changed to Eskenazi. But it has a Wishard Advantage plan where if you don't have a job or you're low income, you could go to the hospital, sign up and you would get health care. You could go to the clinics based off of what you -- you know, if you didn't have anything or if you make little money.

  • 10:35:00

    REHMRight, right.

  • 10:35:01

    PIERREAnd I'm thinking, how is this program going to affect programs like that? Because I tell you, when I fell out of work, I went and signed up, and I loved it. I could go around the corner to my local clinic. They saw me. Sometimes you could do walk-ins. And quite frankly, it was better than the primary care physician that I had when I had a health plan.

  • 10:35:26

    REHMAll right, Pierre. Sonya.

  • 10:35:29

    SCHWARTZWell, that's great to hear, and I think health reform goes ahead and supports programs like that. As Medicaid gets expanded, those kinds of clinics will be part of those networks, for the most part. As part of some of the rules about the network adequacy of plans that offer in the exchange, they have to use community clinics and support medical homes. So, yeah.

  • 10:35:49

    REHMBut you won't be able to simply walk into an emergency room. Isn't that true? Won't that be somewhat different, Robert?

  • 10:36:02

    KRUGHOFFWell, I think you -- if you -- are you talking about if you have health insurance?

  • 10:36:07


  • 10:36:07


  • 10:36:07

    REHMIf you have no health insurance.

  • 10:36:10

    KRUGHOFFWell, people who don't have health insurance, of course, now walk into emergency rooms...

  • 10:36:14


  • 10:36:14

    KRUGHOFF...and emergency rooms have to care for you. I don't think that's going to change, although you might then be stuck with a mammoth bill afterwards. And so that's the reason that we want to get people, one way or another, covered under a health insurance, whether it be Medicaid or whether it be one of these plans in an exchange.

  • 10:36:34

    REHMGo ahead, sir.

  • 10:36:35

    APPLEBYBut remember also, there are still going to be uninsured people at the end of the day. Even when this health law is fully implemented, there will be people who don't have insurance. The law, for example, does not allow undocumented immigrants to purchase coverage through the exchanges or to get subsidies, so many of them will remain uninsured. There will be people who choose not to buy coverage, and that's a big concern. And that's one of the things about these exchanges. The exchanges really have their work cut out for them to get people to enroll, and some may not.

  • 10:37:02

    REHMBut if they are not permitted to enroll...

  • 10:37:05

    APPLEBYSome people are not going to be permitted to enroll.

  • 10:37:07

    REHM...then they use existing clinics, and will those clinics be sufficiently financed?

  • 10:37:15

    APPLEBYThere is funding in the health law for these clinics. I think some people are worried that down the line, that that might fall victim to some politics as well and it get cut back, but at the moment, there is additional funding for them.

  • 10:37:25

    REHMJulie Appleby. She's senior correspondent with Kaiser Health News. Short break here. More of your questions when we come back.

  • 10:40:05

    REHMAnd as we consider these health care exchanges which will go into effect in 2014, joining us from his office in Atlanta is William Custer. He's director of the Center for Health Services Research at Georgia State University. Thanks so much for joining us, sir.

  • 10:40:33

    MR. WILLIAM CUSTERThank you for having me.

  • 10:40:34

    REHMAnd I gather that last month, Georgia Gov. Deal said that your state will not build its own health insurance exchange. What was his reasoning?

  • 10:40:49

    CUSTERWell, part of the issue for Georgia is that we have delayed even thinking about health reform weighing for both the Supreme Court decision last summer and the election this fall. So even if the governor and the legislature had been anxious to set up an exchange, we were so far behind in the planning process as a state that it would've been physically impossible to do all the arrangements necessary to set up a Georgia-specific exchange.

  • 10:41:24

    REHMBut I gather that the deadlines have been extended. Couldn't he still move forward on that kind of exchange?

  • 10:41:34

    CUSTERWell, not to do a Georgia-standalone exchange. Just -- the planning process isn't done. There's still the possibility as several states have already taken to partner with the federal government.

  • 10:41:47

    CUSTERThe Department of Health and Human Services has already gone ahead and done a lot of planning for creation of an exchange and have allowed some states to say that we can't -- they don't have the ability to do all the planning to help partner with the federal government in setting up the exchange with the notion that somewhere down the line in three or four years they would actually take over the operation of the exchange.

  • 10:42:14

    REHMOK. So what's it going to mean for Georgians in need of health care beginning in 2014?

  • 10:42:25

    CUSTERWell, the immediate problem for Georgians is that we just don't know what to see -- these exchanges are going to look like. We don't know what the consumer experience will be. The federal government has worked hard to set up a Web portal, but the idea behind the exchange as you probably already heard is that it's -- it was intended to be the one-stop shop for individuals seeking health insurance where they could discover their eligibility for Medicaid, for a subsidy within the exchange and look at the choices of plans available within the exchange.

  • 10:43:00

    CUSTERAnd that requires quite a bit of coordination between the exchange and the state government particularly the insurance department. And those linkages have not yet been developed -- how the plans will be certified, who can sell or help consumers navigate the choices. All of those things are still up in the air. So it's very difficult to predict what Georgians' choices will be in Jan. 1, 2014 because we just don't have enough idea of how these plans are going to actually operate here.

  • 10:43:35

    REHMAll right. I think Robert Krughoff has a question.

  • 10:43:41

    KRUGHOFFYes. I'm wondering what you're thinking -- as you say, we don't know what the consumer experience will be with the federal exchange, which I think is unfortunate that we don't have very good idea of that at this point. But are you thinking at all that Georgia might do something to help people with that experience? In other words, there's an awful lot of apparatus and mechanics that have to be set up for the overall exchange, you know, in terms of figuring out whether people are eligible, what their tax subsidy should be, et cetera.

  • 10:44:12

    KRUGHOFFAnd that may be too much to take on in this short time. But are you thinking about at least giving the people who would assist somebody on the ground level in the state of Georgia tools they can use to help these -- help ordinary consumers...

  • 10:44:29

    REHMOr telephone calls.

  • 10:44:31

    KRUGHOFFYeah. Or yes.

  • 10:44:32

    REHMYeah. Telephones help.

  • 10:44:32

    KRUGHOFFEither tools they can use or staff or, you know, church groups or whatever to help people work their way through these health plan decisions.

  • 10:44:41


  • 10:44:41

    KRUGHOFFThat doesn't seem to me to be so overwhelming, but the state even then will have to get behind it, it seems.

  • 10:44:47

    REHMSure. What about that, William Custer?

  • 10:44:49

    CUSTERWell, that's a very good point. The law sets up a program they call the navigator program intended to do exactly that -- to help consumers with these choices both from the types of information they have to bring and understanding the information they're giving in making those choices. Who those navigators are is not yet determined. The federal government has issued some very broad regulations on who they should be. The exchange may certify who they are, but it also will take some effort from the state.

  • 10:45:27

    CUSTERFor example, the broker committee who helps -- who does this for a segment of the population today would like to be navigators. Can they -- will they be licensed? And if they are, can they develop the expertise or be given the information to be that one-stop shop so individuals who actually turn out to be eligible for Medicaid could get that information?

  • 10:45:51

    CUSTERWe don't know right now who's going to certify those navigators and what role the state will be in. Just to keep going, you know, the state's insurance commissioner here and in other states access an ombudsman for complaints or issues with insurance companies. What role will they play for care or for coverage sold through the exchange is...

  • 10:46:15

    REHMYou know, I have actually heard about these navigators or brokers. Aren't they fairly expensive in and of themselves?

  • 10:46:30

    CUSTERWell, it really depends upon who they are and what they do.

  • 10:46:35


  • 10:46:35

    CUSTERIf they're simply a phone call -- and there is a call center as part of the law that's supposed to be a part of the exchanges that's above and beyond what the navigators are. But, really, we need to design who they are, what their training needs to be, what their licensing needs to be in order to perform these functions. And we have not yet gotten guidance from the federal government on that, and there has been no movement at the state level to implement that part of the program.

  • 10:47:02

    REHMWilliam Custer, he's director of the Center for Health Services Research at Georgia State University. Thanks for being with us.

  • 10:47:13

    CUSTERThank you.

  • 10:47:14

    REHMOK. And let's go now to Raleigh, NC. Good morning, Chris. You're on the air.

  • 10:47:23

    CHRISYes. Good morning. I am a sole proprietor, own my own business. I pretty much own my own business since I got to college. I'm a photographer. And I've been paying into Blue Cross Blue Shield my own health insurance premiums. They were quite reasonable when I was younger, but now they're double the cost of my mortgage. If I didn't reduce or if I didn't, you know, go my -- what is it -- went from a $500 deductible to a $2,500 deductible.

  • 10:47:53

    CHRISIf I kept the $500 deductible, I'd be at over $1,000 a month now. I bumped it up to $2,500, which lowered my rate temporarily, but now it's, again, you know, close to what I pay for, like, my home mortgage.

  • 10:48:08


  • 10:48:09

    CHRISAnd at the same time that's happening, OK, the fees that I get to charge for what I do have not kept pace with the cost of health care. What I used to be able to charge $500 to do for half a day, they only want to pay me $150. So I'm trying to find out how mandated coverage is better than universal single payer.

  • 10:48:32

    CHRISI'd much rather be paying 9 percent of my income -- or I'd rather see this country pay 9 percent of GDP and have everybody be covered than to be paying what I'm paying right now and see 20 or 30 million people still go without coverage and the rest of us who have it have to figure out, are we going to live in our cars?

  • 10:48:49

    REHMRight. Well, Chris, I'm afraid you're going to have to ask your member of Congress about that because the Congress did not vote to go forward with universal coverage for everyone that an awful lot of people in this country would have like to have seen. It did not happen. So where is he, Sonya?

  • 10:49:18

    SCHWARTZOh, I'm thinking about his situation. In North Carolina, just one note, is I think that your state is looking at a partnership exchange right now. But for your particular situation, there's one piece of health reform that will protect you a little bit from cost increases, which is that now every state decides kind of how they rate health insurance. And under the federal law, the oldest person in a planned insurance can only cost up to three times as much as the youngest persons.

  • 10:49:45

    SCHWARTZSo if your premium for the youngest person is $3,000 a year, for the oldest, it's $9,000 a year. But that's still a lot. Remember, though, that depending on your income, Congress decided to cover people up to 400 percent of the federal poverty level. So I'm thinking for -- are you single?

  • 10:50:02

    CHRISYes, I am.

  • 10:50:02

    SCHWARTZI guess we don't you. I think that that's about $60,000 a year. I'm just thinking through. So depending on your income, the subsidies, if you buy on the exchange, may be able to help keep that premium down and keep it. The other thing is the subsidy is tied to a percentage of your income every year, so it'll keep pace with your income.

  • 10:50:23

    REHMSo what does he have to do, Robert Krughoff? Living in Raleigh, N.C., what are his best options?

  • 10:50:35

    KRUGHOFFWell, of course, once the exchange, whether it be federal or state, comes in place, he certainly wants to go to that exchange and see and make these plans compete for his business in a sense. He needs to see -- be able easily to see which are cheaper, which are more expensive, which have high quality, which have good doctors, et cetera. Beyond that, I think it is a painful fact that the cost of health care has gone up dramatically and is continuing to go up dramatically.

  • 10:51:03

    KRUGHOFFI think there are lot of aspects of the reform law that have nothing to do with the exchange -- exchanges that are targeted on trying to get rid of unnecessary procedures that sometimes are driven by the fee-for-service system, for instance, and other things to make the cost of the health -- of health care go down or at least be more contained long term. But it is a big problem for the -- for America is the very high cost of health care. And unfortunately, he's feeling the pinch.

  • 10:51:35


  • 10:51:36

    APPLEBYAnd some of the proponents of exchanges say that they think that by having these prices out there, by having insurers competing in a public manner, it's transparent, you're able to see how much each of them are charging, that this might slow the growth of premiums. We don't know if that's going to actually play out or not, but that's one of the theories.

  • 10:51:52

    REHMAll right. To Union, Ky. Hi there, Mitch.

  • 10:51:57

    MITCHGood morning.

  • 10:51:58

    REHMMorning, sir.

  • 10:52:00

    MITCHI'm curious, if everyone is so concerned with getting health care cost down, why we still can't buy insurance across state lines through either an exchange or some other manner and why do we continue to allow these gigantic medical monopolies that seems to be driving up health care cost more than anything.

  • 10:52:23

    REHMAll right. Julie, the buying across state lines.

  • 10:52:27

    APPLEBYBuying across state lines is often discussed as one way to lower cost. Whether that actually turns out to be the case or not is questionable. It's...

  • 10:52:37

    REHMIt's under consideration, isn't it?

  • 10:52:39

    APPLEBYIt's under...

  • 10:52:40


  • 10:52:40

    APPLEBYStates can set up multi-state exchanges if they want to, so you would be able to pull together and be able to buy in different states.

  • 10:52:47

    REHMI see.

  • 10:52:47

    APPLEBYSome of the opponents of just simply buying across state lines worry that if that were to happen, that people would flock to states with the least amount of regulation, the lowest coverage and that type of thing. But that's not under consideration, just -- but multi-state type exchanges are a possibility.

  • 10:53:01

    REHMAll right. To -- I hope that answers it, Mitch. What about the question of these gigantic institutions driving up costs, Robert?

  • 10:53:16

    KRUGHOFFI assume he's talking about providers, hospitals and so on.

  • 10:53:18

    REHMYes, exactly.

  • 10:53:20

    KRUGHOFFAnd I think there are some cases where this -- there is an awful lot of monopoly power or monopoly-like power, let's say. And those can be a problem, a big problem, and that's something that has to be looked at very hard. And then, of course, the incentives that providers -- any provider has to provide care -- more care than might be necessary and the unfortunate lack of knowledge that consumers have in reassessing whether they really need that care, all those things drive cost as well.

  • 10:53:55

    REHMAnd you're listening to "The Diane Rehm Show." Let's go to Sarasota, Fla. Harvey, good morning.

  • 10:54:05

    HARVEYGood morning, Diane. Thank you for taking my call.

  • 10:54:07


  • 10:54:08

    HARVEYI have so many things to say but I'm going to try to keep it short. The very first thing is the comparison with Medicare Part D is what I see here where the confusion of that particular insurance policy was so difficult. People had to end up with trying to discuss why they were in a doughnut hole and what, in fact, was a doughnut hole. You're running into a very similar thing. First of all, the semantics.

  • 10:54:33

    HARVEYThe decision to use the word exchanges is probably the worst thing that anybody ever made because I don't think anybody knows we're exchanging what for what. So I think that they should have come up with affordable health care choice, with the health care network or the gentleman from the Massachusetts, health care connector.

  • 10:54:49


  • 10:54:51

    SCHWARTZActually, I'm glad you brought that up. States are working on their names for their exchanges. They're not going to be called the California health insurance exchange. In fact, California's is called Covered California. In Colorado, it's Get Covered Colorado. In Washington, it's the Washington Health Plan Finder. It's Cover Oregon, and it's the Maryland Health Connection. That's what we know so far. We don't know what the names will look like in the federal-exchange states yet. But those are some -- gives you an example of some of the state's names.

  • 10:55:16

    APPLEBYCalifornia flirted with the idea of calling it the avocado.

  • 10:55:19

    SCHWARTZYes, it's true. One of the board members brought an avocado to the meeting as an example. They didn't win, though.

  • 10:55:25

    REHMI mean, talk about ridiculous how complex it is. And Harvey is so right that these terms really confuse people.

  • 10:55:38

    KRUGHOFFBut California is way out ahead of many states in terms of really -- well, first of all, getting the whole thing up and running. But from the standpoint that we look at it, from really thinking very hard about how to make these health plan choices simple, not only to name their exchange a friendly name, but to actually give people the information that boils it down so you can really make good comparisons.

  • 10:56:01

    REHMWhat happens to Medicare Part D with all of this health talk?

  • 10:56:08

    APPLEBYMedicare Part D, I think, stays the same as it is. You'll still go on the site, right.

  • 10:56:10

    REHMJust exactly the same. But as confusing as ever to people, Sonya? No, you don't think so?

  • 10:56:20

    SCHWARTZIt stays the same. I think, I mean, I think things -- people have learned a little bit about it. They definitely still need help when they're enrolling in plans at Medicare Part D.

  • 10:56:28

    APPLEBYI think that we learned a lot from the rollout of that. It was pretty rocky at first and it did straighten out. I think the number of plans was overwhelming to people. And this may be the same way in some states. Now, California, we're just talking about California. One of the things that states that decide to do their own exchange get to decide, one of the differences, is that they can decide whether they're going to take every insurer that qualifies or are they going to be more selective and negotiate and pick only certain insurers.

  • 10:56:52

    APPLEBYAnd California has decided to do that model. They're going to limit the number. They're going to just pick certain ones. So there might be fewer choices there, but it might be a little more understandable.

  • 10:57:01

    REHMClearly, this is going to take a while to roll itself out so people can have better understanding. I thank you for helping us in this first stage, Robert Krughoff, Julie Appleby, Sonya Schwartz. And thanks to our listeners for your questions, always so important. Thanks for listening. I'm Diane Rehm.

  • 10:57:31

    ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Susan Nabors, Rebecca Kaufman, Lisa Dunn and Jill Colgan. The engineer is Erin Stamper. Natalie Yuravlivker answers the phones.

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