There already was plenty of uncertainty for Minnesota health insurers before the Nov. 8 election. The state’s individual market, which serves people who buy health insurance on their own, nearly collapsed last year. The election results bring the likelihood of federal legislation to repeal and replace the federal Affordable Care Act (ACA). Meanwhile, the state is considering proposals to stabilize the individual market, as well. The shifting sands raise a number of tough questions for Jim Schowalter, chief executive of the Minnesota Council of Health Plans, the St. Paul-based trade group for the state’s nonprofit health insurers.

Q: Do Minnesota health plans have any concerns with all the talk about “repeal and replace” for the Affordable Care Act at the federal level?

A: Of course. It’s confusing. It’s diverting. And at its core, it’s unclear whether Minnesotans are going to get the care they need.

It focuses our attention on the fight and away from the fundamental problem, which is: Care is expensive. It’s expensive for everyone whether you get care through your employer, a public program or you buy it on your own. Health insurance won’t be more affordable until health care is more affordable. That’s where we should focus.

Q: There’s been talk that Republicans in the U.S. Senate via reconciliation could eliminate the individual mandate, but not immediately change rules that block health insurers from denying coverage based on preexisting conditions. Is that a concern?

A: Individual mandates, public help in paying the premiums and a promise that everyone can purchase insurance on their own all work together. If one of those things is pulled out or two of those things are pulled, the math won’t work. ...

Mandate or not, if premiums are so expensive that people can’t afford them, or people are just confused by all the sound bites, they’re going to get frustrated and give up. And the result is the same thing then: There’s going to be really big medical bills from a few people who are still going to be seeking insurance, and there’s going to be fewer and fewer people who are going to be able to buy coverage on their own. ...

In Minnesota, about 1,600 people who buy insurance on their own have a combined medical bill of more than $400 million. There will be people who need expensive care next year, too. So whether at the federal level or at the state level, we’re going to need to make sure that we find ways to share that expense.

Q: It’s not clear exactly what form “repeal and replace” will take at the federal level. Given the uncertainty, are there actions that Minnesota lawmakers need to take in the meantime?

A: Our job here is to make sure that we take care of Minnesotans and get to some practical policy solutions, and that starts with not waiting. There are ideas on the table for 2017 and 2018, and they really need to be considered separately. People have already bought insurance for 2017, and it’s underway. Helping people who might still buy insurance, or have bought, that’s something that needs to be decided right away.


Q: You mean proposed rebates for those in the individual market who aren’t helped by federal tax credits?

A: Yes. We know that average premiums don’t mean that they’re affordable premiums. We’re more average in the cost of our premiums now, but the increase from last year is really hard on Minnesotans. And so, if we’re going to do something as a state policy, that is urgent.

2018 is its own problem to solve. ... By early spring, we’ll have to have some answers about what, if any, changes we’re going to do in Minnesota just to stabilize insurance. In the past we’ve had ways to help share high medical bills. We need to do it again, so people don’t get insurance through their jobs or have no options whatsoever.

Q: Is there a specific proposal from health insurers?

A: The health plans have worked on some outlines of a reinsurance program to help stabilize and share the cost of high medical bills. That language is available along with lots of other proposals at the Capitol. I think the key thing here is that we all work together on something that’s practical and effective, so that we preserve options for how people get their health care.


Q: Hospitals are concerned that a reversal of ACA coverage gains, primarily via Medicaid, could leave them with more uncompensated care costs. Would repeal of Medicaid expansion cause problems for Minnesota health plans?

A: One of the steps forward from the ACA was getting more people coverage. Initially people thought it was going to be by buying insurance on their own. It turned out that much of that progress was from expansion of our Medicaid program.

Right now, about 160,000 people are getting care under the expansion. I absolutely believe that losing coverage for that many people is a problem for all of us.


Q: How would you characterize the future for the state’s MinnesotaCare program, which is funded as a “basic health plan” under the ACA?

A: Uncertain. Minnesota has tried to do new things in the past and find new solutions to help people get care. I think the hard thing for all of us is not about one program or one question, it’s that it feels like we’re not able to dig deep into the important issues. We’re going to be working on big funding questions rather than questions of making better choices, delivering better care and addressing how to slow down rising health care costs.