Spotlight: Health 2014

Still Defending Obamacare, Six Months Later

Kathleen Sebelius comments on the highs and lows of the beleaguered law.

(Emily Chaplin and Chris Council)

“Health care is like synchronized swimming,” Kathleen Sebelius said, looking out over the crowd before her with a wry smile. “There’s a lot of focus on the bathing caps, and that to me is the market, but what’s going on underneath the surface of the water is really much more dramatic.” This elegant metaphor was one of many interesting insights offered by the former Cabinet official, who sat down for an interview with Aspen Institute President and CEO Walter Isaacson at Spotlight: Health on Friday.  While technical glitches which plagued the rollout of the Affordable Care Act are believed to have contributed to her resignation this past spring, Sebelius made clear that she is ultimately proud to have shepherded such historic legislation.

To that end, she focused on cataloging the legislation's less scrutinized accomplishments: Allowing those under age 26 to stay on their parents’ health insurance; requiring insurance companies to cover individualsparticularly sick childrenwith pre-existing conditions; adding wellness and preventative care visits to Medicare coverage; and incentivizing the integration of technology into medical administration. On this last point, Sebelius noted with evident pride that more than half of the country’s practicing physicians have now made the switch to electronic medical records. (While a great accomplishment given the paltry early adaptation rate, we must pause here and ask why so many doctorsnearly half of those practicingare still dinosaurs).

Sebelius also waxed enthusiastic about the latitude that the Affordable Care Act gives to Medicare in experimenting with health policy design and then implementing successful results in larger and larger proportions. She reasoned that “if something works, you can take it to scale by simply turning up the dial,” whereas before ACA Medicare required an official three-year trial and Congressional approval. Sebelius believes that the new and nimbler system will result in dramatic progress. Sebelius said that she is particularly hopeful that as a result of cutting the red tape, successful experimentation will quickly upend the current “fee for service” payment model, which incentivizes quantity of treatment over quality.

But if she never wavered in her confidence in the ultimate value of Obamacare, Sebelius did admit to concern over the details of the marketplace exchanges, then and now. “The fear that I had from the beginning was that we wouldn’t potentially have a market,” she said. “[We] were asking . . . insurance companies to bid blind on who might come into this market, how many people, how successful it would be. They had to set rates that would be competitive, not knowing if the risk pool would be really adversely selective.”  

Though the Obama administration’s new favorite number8 millionhas set many of Sebelius’ initial anxieties about market demand to rest, she emphasized the need to remain vigilant in evaluating the economic health of the exchanges, citing the example of New Hampshire, where a single insurance company chose to take part at the beginning of the program. Now, with more companies joining the marketplace, the outlook is not so uncertain, a development that Sebelius touts as a victory for the free market.

Sebelius wasn’t only spreading good news. She portrayed Congressional gridlock and extreme partisanship as a major barrier to progress. “We had to use a blunt instrument to have a smoother runway for those who, for instance, had coverage and were transitioning into the program,” she said, skirting around the primary public criticism of the law. But the regulatory problem, she said, was compounded by the incessant squabbling on the Hill: “No one had the appetite to open up the Affordable Care Act and try to fix [these problems].”

Sebelius suggested that Congressional Republicans were never interested in compromise. “The House had one Republican vote [for the ACA] at the end of the day, in spite of three committees taking literally hundreds of Republican suggestions,” Sebelius said. Given the Republican failure to so much as come to the negotiating table—even after Democratic victories in the 2012 elections gave ACA a clear mandateSebelius said she could only conclude that the Republican stonewalling stemmed from a “personal” issue with President Obama. She declined to elaborate when pressed.

Sebelius’ staunch loyalty to the president, the Democratic party, and their most significant legislative legacy in decades may be obvious, but it seems apparent that shepherding the Affordable Care Act into realityand a harsh political one, at thathas taken its toll. Would she consider a run for state office in her native Kansas, where she served as governor before her federal service? Sebelius laughed joylessly before answering: “Not a chance.”