FAIR Health Board Access Interview with Chiquita Brooks-LaSure

October 18, 2018

Having recently joined the FAIR Health Board of Directors, Chiquita Brooks-LaSure, MPP, brings a unique viewpoint as a widely respected expert in health policy. Currently the managing director of Manatt Health at Manatt, Phelps & Phillips, LLP, in Washington, DC, Ms. Brooks-LaSure played a significant role in leading the development of marketplace and private insurance policy during the passage and implementation of the Affordable Care Act. Notably, from 2012 to 2014, she served as the director of coverage policy in the Office of Health Reform and then as the deputy director of policy and regulation in the Center for Consumer Information and Insurance Oversight at the US Department of Health and Human Services. The author of numerous publications on Medicare, Medicaid and the state marketplaces, Ms. Brooks-LaSure spoke with FAIR Health Access about healthcare policy and reform in the public and private insurance spheres.

FAIR Health: What influenced your decision to pursue a career in health policy?

Chiquita Brooks-LaSure: I had been interested in medicine, but much more interested in a number of issues related to policy and social justice. When I was studying public policy as a graduate student at Georgetown University, I took a class with Judy Feder and became very interested in health policy. As I learned about the complexity of healthcare in that class, I became interested in pursuing a career in health policy with the government, particularly in the Office of Management and Budget (OMB). When both of those aligned—i.e., getting a job that focused on health policy at the OMB—it seemed like a perfect fit. Once you get involved in health policy, you realize it’s a field where you can spend decades and still discover new issues to learn about. It is so complex, and there are so many different lenses, that you can be an expert in Medicaid and still have plenty to learn about the Medicare program. Likewise, you can know what is happening at the state level but not so much at the federal level, and vice versa. Once I started on the health policy path, I knew that it was the path for me.

FH: Several states are pursuing reinsurance (1332) waivers from the Centers for Medicare & Medicaid Services.
a) When is it advisable for a state to pursue such a waiver?
b) To what extent might such waivers affect coverage and marketplace stabilization, particularly in light of the elimination of the individual mandate?
c) What additional solutions might states consider for increasing coverage?

CB-L: Reinsurance is a policy that has proven to be effective at lowering individual market premiums in a way that’s incredibly fair to people with preexisting conditions and to people who are healthy. In my opinion, most states, if not all states, should consider applying for a 1332 reinsurance waiver. The biggest issue for a state is being able to come up with the funding for a waiver, but it is a policy that is beneficial for everyone.

Right now in the marketplace and the individual market some people are being subsidized, are getting tax credits and are not experiencing the premium increases directly; however, some people are paying for their premiums and those premiums are increasing. So reinsurance really helps the unsubsidized, which in turn helps everyone by encouraging those individuals to stay in the market. This is even more important given the elimination of the individual mandate.

Reinsurance is one very effective way to reduce premiums in the individual market, but there is a range of other options that states might want to think about to make coverage more affordable. While reinsurance focuses on premiums, cost sharing also is a factor that may be keeping people from buying coverage. Some of the deductibles in the individual market are too high for people who don’t have cost-sharing reductions, so states might consider providing subsidies to individuals and updating tax credits to offset costs. Some states also are starting to think about Medicaid buy-ins as a way to create other options for individuals.

FH: With states beginning to pursue changes to their Medicaid programs (e.g., community engagement as a requirement of eligibility), to what extent might the program undergo a fundamental transformation in the next few years? How might these trends lead to a larger shift down the road in how the federal government plays a role in Medicaid, how states administer their programs and eligibility requirements in general?

CB-L: The Medicaid program has evolved over the decades. When it was first created, it was more closely linked to the welfare program, and over time it has been much more closely linked to health insurance coverage. Many of us think about Medicaid as one type of coverage along with other models: commercial coverage, the Medicare program and the individual market and marketplace coverage. Medicaid programs are continuing to provide an array of broader services—they may have been providing these before, but we are seeing them pay a lot more attention to these issues.

There are competing views right now about the role of the Medicaid program. On the one hand, there is a continued interest in looking at individuals more holistically and comprehensively. That is true with their healthcare needs and true about things broader than their healthcare needs—that’s a good thing for individuals and could potentially be more cost-effective. At the same time, some are pushing to limit the program. Some states are considering work requirements and we are seeing a return to language about Medicaid being available only for certain individuals. I think of that as a rolling back from thinking more holistically about how Medicaid fits in the big picture.

FH: The national healthcare debate has largely focused on controlling costs and increasing coverage. What other issues should be given greater attention in the public forum?

CB-L: Both of these issues are important goals for obvious reasons, but in trying to control costs and increase coverage, we need to make sure that we are actually increasing access to services and creating a better care delivery system, and not controlling costs in a way that will lead to poorer health outcomes. We need to continue to find the answers to what is happening in our system: There are clearly enough dollars going into this system to take care of people in a better way. More attention needs to be paid to that disconnect. We spend a lot on healthcare—are we getting the outcomes that we should be getting? Can we control costs in a way that also leads to better health outcomes? That is what we need to focus on.

FH: FAIR Health has continued to lead as a source of independent and objective price and utilization information. How do you see FAIR Health’s role in the healthcare sector and the value of claims data in addressing the system’s current challenges? Looking to the future, how would you predict FAIR Health’s role will evolve particularly as the role of cost transparency continues to figure into the national conversation on costs?

CB-L: Price and utilization data are so important for many of the questions that are being asked in today’s healthcare policy debate. Almost all of the critical issues that our policy makers are grappling with require data, and FAIR Health’s role is key to answering so many of these questions.

Cost transparency is a huge issue right now, and is continuing to grow for a number of reasons. FAIR Health’s evolving role will continue to be important in helping policy makers at the federal and state levels, the industry, and advocates understand what kind of questions can be answered by the data and therefore have the ability to answer even more questions. Understanding better how prices are evolving for a range of healthcare services and for drugs is key to understanding how we are going to improve our healthcare system.