Nothing has changed, yet we're walking on eggshells: 6 questions with former COO of the Massachusetts Health Connector

Established in 2006, the Massachusetts Health Connecter was the nation's first health exchange. It was created as the cornerstone of the state's 2006 healthcare reform law, which helped reduce Massachusetts' uninsured rates to the lowest in the U.S. and later became the model for the ACA.

Rosemarie Day served as the COO of the Massachusetts Health Connector during its implementation, building a never-before-seen model to sell insurance and enhance health coverage. She has also held several senior level fiscal positions in the Massachusetts government, including Assistant Secretary for Administration and Finance under former Gov. Mitt Romney. Now, Ms. Day consults with private and public organizations across the nation to implement health strategies.

Here, Ms. Day discusses marketplace trends and key takeaways from establishing the nation's first health exchange, shares her thoughts on regulatory priorities and explains where hospital administrators should shift their focus.

Note: Responses have been edited for length and clarity.

Question: What are a few key takeaways from your role at the Massachusetts Health Connector?

Rosemarie Day: From an external perspective, we knew this online marketplace had to be a model businesses would accept. We have a big healthcare industry in Massachusetts … including insurers and providers … and we couldn't do a reform law or create this platform if it didn't involve them being at the table and agreeing. Internally, it was challenging to build something from scratch that had never been done. To do that [in] a public sector was even more rare and more challenging since we don't have venture capitalists. Especially at this time, the online platforms for where you sold things were platforms like Travelocity, Amazon and eBay… but there wasn't the model to do that with health insurance. We were in uncharted territory, and we were trying to bring together the public and private sector. Building a hybrid team that would work together was challenging. I brought together folks that were creative and innovative but also had lot of experience in their respective fields. I brought in insurance experts, subsidized program experts, government experts and younger tech savvy folks. These various entities don't work together [often] — they stay in their zones. This was a hybrid organization … We needed people's experience… but we also needed people to not get stuck in their experience and respect the things they didn't know and learn about them instead.

Q: What trends are you seeing in the marketplace?

RD: There's so much attention on the ACA marketplace and all of the uncertainties surrounding how they are going to operate and how it's going to work under the Trump administration. The buzz around the [ACA marketplace] has increased this feeling of uncertainty more broadly than is potentially warranted, especially since it is a much smaller subset of the insurance market. It got so much attention because of repeal and replace efforts all throughout 2017 — so one of the trends is uncertainty. People think these huge premium increases may hit them. There could be a ripple effect, but it would be delayed. Nothing has actually changed yet, but there's this feeling of walking on eggshells.

If you go to broader market … half in the U.S. are insured through employers … and the pain points for those insurers and that market have been fairly consistent. They are feeling the steady rise of healthcare costs. Maybe they haven't been spiking as much recently, but the increases still exceed the rate of inflation. They are worrying about how to … absorb [the costs] without shifting the cost onto employees.

Q: Amid the uncertainty, what can and should payers and providers prioritize?

RD: Across all policies, we are looking at having less money on the table for healthcare, not more. Whichever way you come at it … through tax cut legislation or another attempt of ACA repeal ... it's pulling back, scaling back ... so the healthcare industry has to look at ways to do more with less. Trying to establish better coordinated care and approach things in a smarter way — that's what payers and providers from their perspective spheres should be challenging themselves to do. And, they should prioritize coming together to collaborate on care more readily instead of just being across the table from each another bargaining, negotiating and arguing over rates.

Q: What would you expect to see if Alexander-Murray gets passed?

RD: It's too late for Alexander-Murray to help right now … if it gets passed it will help for the following year. It would restore the level of subsidy that people can count on. That said, the way the math works ... even without the cost sharing reduction, there are still a fair amount of subsidies on the table that people can tap into through the premium tax credits. For the people without subsidies, roughly 20 percent buying through exchange marketplace… would feel sharp premium increases this year and it would be good news for people for that to be reduced next year under [Alexander-Murray] … In summary, it is too late for this year, but it could help next year for out-of-pocket premiums. The more powerful piece of Alexander-Murray, in my opinion is the state flexibility piece. That's where we could see a lot of benefit. Different states wish to approach their healthcare systems differently … and look solve the ACA conundrums the way they want instead of waiting for a federal solution. Of course, this wouldn't happen over night, but the bill could help bring costs down and test interesting approaches in smaller areas first.

Q: What regulatory priority do you think should come next?

RD: One priority, a defensive priority, I think should be at the forefront is continuing to protect folks with preexisting conditions. There were some proposals on the table that undermined that. In terms of proactive priorities, I'd go back to ensuring value over volume … continuing to feed and get experiments going so we achieve better ACO-type solutions, more bundled payments and things that are good for costs and health outcomes. Pushing those ideas forward and having federal authority to catalyze it, would be my pick for a priority.

Q: Do you have any closing thoughts on healthcare delivery?

RD: In this country we are so proud of how we do things but our health outcomes are nowhere near as good as other developed nations. We should challenge ourselves to question why that is. We need to learn how to do things better… we need to look beyond our own boarders sometimes to figure out some of those answers and we need to not be too proud to do that. Sometimes we fall victim to thinking we know it all.

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