Why Employers Aren't Rooting for Health Care Reform to Die

Is health care reform in danger?

Count the menaces. Rep. John Boehner and Tea Party victors have promised to repeal the Affordable Care Act. State lawyers are challenging the individual mandate. Republicans are looking to block funding. The administration is offering waivers to firms and insurance companies to provide inadequate coverage until the law goes into fuller effect in 2014. Everywhere you look, the law appears under assault.

To understand what American employers thought about health care reform, I spoke with Andrew Webber, President and CEO of the National Business Coalition on Health, a national, not-for-profit organization that represents public and private sector employers. Here is an edited transcript of our wide-ranging conversation.

Are you looking for this election to produce the repeal of health care reform?

I think there's an opportunity with the election to tweak some things. But I believe strongly that repeal is not going to happen.

Should the law be repealed?

Most of it, we expect to stay: expansion of coverage through the mandate, expanding Medicaid, state insurance exchanges, regulation of health insurance. But there are also big new compliance issues for employers. Could they eliminate the 1099 law and fix the 990? Sure. But our group is trying to spend our energies on system delivery reform based on value based purchasing.

What does that mean?

As employers, we provide health to 160 million Americans, when you include dependents. So the health care delivery system is based on employer provided insurance. The question is how do we as purchasers drive higher value, higher quality and get the delivery system to achieve better outcomes. Today's system is is too focused on acute care for illness. We pour in resources after people get very sick rather than invest in the management of chronic disease. We think this presents a huge opportunity for better health, better care, better costs.

The media spends a lot of time trying to get inside the heads of employers when we analyze public policy. You represent 53 employer-based health coalitions around the country. So tell me, what part of the health care bill do you care about most?

There are a lot of different requirement issues. We have to look at how comprehensive your benefits are. We have to make sure low-income workers aren't paying a certain percentage of their income. A portion of total compensation can't be required to go into health care. Children can stay on parents' plans until 26, and that needs to be reported. We see the excise tax [on expensive insurance plans] coming later in the decade. To be brutally honest, do they like a lot of new regulation? No, they're business people.

But I like the delivery system reforms. There's lots of language in the law about payment reform, becoming a value-based purchaser, hospitals moving to accountable care, exchanges, Medicare CMS reform, an innovation center funding demonstration projects, finding new ways to pay doctors and hospitals, Medicare sending market signals to providers, bundled payments to hospitals, community health innovation strategies, workplace health promotion, and prevention, investments in health information technology. If implemented right, this could be transformational.

How can employers help to make health care more affordable?

We've seen some employers say, "if you demonstrate healthy behavior, we will lower your premium." This is downstream, but I think in the future you'll have more employers say, if you're willing to abide by certain rules, like if you fill out a health risk assessment and meet with a health coach, develop a health care plan for yourself, we will reduce your premium share.

Some big companies have threatened to drop health care coverage altogether and the administration has offered them waivers saying "you don't have to follow the law until 2014." What do you think about that?

A lot of industries, especially low wage, have provided pretty skimpy benefits for employees that are technically illegal under the law.* So when McDonalds [one of those companies] threatened to drop health care, the administration gave them an exception to provide minimal care.

But I think it's just for this transition period When we get to 2014 and state insurances are set up, then there is an opportunity for individuals, employees in small companies and workers in certain industries with low wages to get on state health care exchanges. We'll see how that unfolds.

What worries you the most about health care going into law over the next decade?

Big picture, what worries me is the president said, "If you like your current coverage, we won't touch it." Individuals with jobs enjoy getting health insurance through their employer. But there is no question that with the new regulation, more employers are asking the question, "Are we going to stay in the game?" Maybe we're moving to a system and people get a voucher and they find insurance on the exchanges. That worries me.

Many economists seem to think that would be a good idea. They say the employer health subsidy inflates insurance prices by shielding consumers from real costs. They say if we bought health care they way we bought groceries, we would be better, more rational consumers, and that this is the only way to achieve value-based purchasing.

I'm not an economist. I think the tax subsidy provides some incentive from a pure economic sense to have more and more comprehensive health insurance. I think it probably makes sense that that issue be debated. But this is a voluntary employer based system, and I worry about consequences of that provision and other provisions, to the foundation of employer-based insurance.

To end where we began, did the fact that health reform was passed in a recession taint it permanently?

It's just unfortunate that this whole debate was had during a recession. My view is that historic social legislation becomes accepted over time. Now, there's a chance that this whole thing can crumble. But I don't see it. On the delivery reform issues, we had to do something. I'm hoping that, even if we start to peel back some of the insurance regulation to protect the employer-based system, we can all agree that there are good ideas here you should embrace whether you're a Republican or Democrat.

* Later he elaborated: "It's what we call a soft employer mandate.You must provide health insurance, not only that but ADEQUATE health insurance, otherwise there is a penalty. So it's buy or face a penalty [that is less than the cost of buying insurance]."