Two Weeks Notice: Asking the President the Right Health Care Questions

“The president who is supposedly trying to sabotage the Affordable Care Act (ACA) has proven better at managing it than the president who wrote the law.”                 -HHS Secretary Alex Azar, September 27, 2018, explaining the 2019 premium reduction and return of insurers to ACA markets, and marking the Trump’s administration’s first formal acknowledgement of improved ACA markets.

It is professional courtesy in our culture to provide advance notice of two weeks before resigning from a full-time employed position. This is intended to provide the organization and the remaining employees the benefit of a smooth transition of responsibilities. In my general experience, two weeks is a compressed time to transition knowledge from a fully productive employee unless some serious cross-training has already occurred. It requires a singular focus without the affordability of distractions; it is crucial that the departing employee is asked the important questions within those two weeks. It is not uncommon for a “two weeks notice” announcement to catch managers and colleagues off guard and invoke some sense of panic.

My career experience with employee transitions left me surprised by the sanguine reaction to a Sunday morning television segment last week. In an interview that aired last week on Fox News Sunday, President Trump sat down with Chris Wallace on a White House patio outside the Oval Office. It was a wide-ranging interview, but my professional interest was related to the health care policy conversation where we are enduringly lacking pertinent information regarding the president’s past and future policy action and associated rationale. Don’t miss this…we retrospectively see (the infinitesimal few of us who are empirically looking) the implications of his policy and we hear repeated commentary about what he is “trying to do” (almost exclusively from his detractors), but there is a disturbing misalignment between the two which demands more professional accountability from those well-compensated to "gather information and present the information in an accurate, honest and fair way to the general public in order that the public can be informed." It's not intuitively clear, but the consequence of not publicly resolving this misalignment is poorly implemented policy and real harm to health care consumers.

The resulting blank sheet of notes about the president’s health care policy after such interviews is not due to a lack of opportunity to ask questions or his unwillingness to answer them; it is because the wrong questions are repeatedly asked and predictably answered the same way. This may have contributed to a crucial answer to a usually unimportant question (hence no time planned for follow up) being consequentially underappreciated last Sunday. My ambitious intention with this article is that we collectively learn to ask the president the right questions with a sincere purpose of necessarily informing the public, and the president only gave us two weeks to be prepared.

Separating the Action from the Talk

I always listen with direct purpose when the president speaks about health policy, perhaps with a more nuanced ear than my fellow citizens. I will explain. The president is usually asked questions about things that are beyond his control, but he does not seem to mind and cordially answers them with perhaps more liberty and less precision than actual decisions under his purview. Specifically, he is repetitively asked the same questions about potential developments in the legislative and judicial branches of the federal government. The questioning is peculiar not only because he leads the executive branch, but because virtually all the health-related activity since he assumed office (and all foreseeable future activity) have been executive branch administrative actions, and such policies have monumentally reshaped ACA (aka Obamacare) marketplaces.

His first Executive Order Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal was signed merely hours after he was sworn into office, substantively and symbolically denoting health care policy as a high administration priority. It called for greater state flexibility to implement health care programs and advised federal agencies to “delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”

As noted in 2017, President Trump began promoting flexibility leading to significant state variations; “the federal executive branch under President Trump has the power to modify the law through new regulations...The range of potential regulatory action and enforcement discretion is significant. The ACA delegates responsibility to the executive branch to interpret and implement numerous key provisions of the ACA. While it is not yet clear how this administration will use this responsibility, early executive actions and statements of senior officials suggest they will reduce regulatory burdens on insurers and give them more flexibility to design benefits, conduct marketing, and set prices. The effect of such changes on consumers, health plans, and other stakeholders will depend to a great degree on how states respond. States have historically been, and remain, the primary actors in insurance regulation. While the ACA sets a number of minimum standards for insurers, and federal oversight has provided a critical backstop for state insurance regulation, the majority of states have exercised their authority to interpret and enforce federal insurance laws.”

There is a lot to unpack here and there has been significant action in this arena. Every state has responded differently to the administration's actions, and there is an abundance of newsworthy topics and analyses to productively fill interview time regarding both the rationale of administration actions and the downstream implications of particular state responses. Suffice it to say, state decisions in response to President Trump's policies have impacted local market success. Outside of actuarial research, there is underwhelming public discussion regarding federal ACA policy and associated state reactions, and virtually no descriptive public commentary from the Trump administration. Why doesn't anyone ever ask the president what he is doing? Would hearing him speak about actual policy rather than muse about Congress and the Supreme Court change the national conversation and improve our collective understanding?

In April 2019, a colleague and I were astounded by the nationwide diversion in results and the number of states/insurers not effectively complying with new regulations. In investigative conversations, we gained revealing insight. We learned that the market perception of many stakeholders with technical responsibilities aligned better with the misguided public discussion than technical reality. We concluded that "new state flexibility allows ACA markets to thrive, but a nationwide view suggests that few states and their local insurers fully understand the new mechanics". 

Responses from states, insurers, and consumers to federal regulatory action is really where ACA market improvements are occurring (not through symbolic and distracting partisan federal proposals), but reactions have been very uneven and administration/state activity warrants our attention more than federal legislation that will not pass and court rulings that will not occur. Prior to the 2016 election, innovative state opportunities were already expected to be at the forefront. President Trump's policies have led to more state activity and variance, yet the public sphere discussion over the last three years has mostly been wasted on hypothetical federal legislation. This needs to change; it has led to a diminished understanding of President Trump's policy action, and consequently ineffective and unbalanced implementation.

Overall, local market responses are weaker than expected and this is largely attributable to poor market understanding and hesitancy to invest time and resources amidst unending repeal gossip and a temporal expectation of the current ACA environment. The media obsession with 'ACA repeal' over 'improving ACA markets' is largely to blame here and we have spent several years neglecting 'real news' to promote 'an unlikely narrative'. The upside is that several states are now taking direct steps to improve markets in 2021; public discussion of the Trump administration's actions would encourage other states to think about innovation. The downside is that some states remain unaware of new opportunities, some are understandably postponing non-COVID initiatives until next year, and others are more keen on political retaliation than market improvement.

If we need a historical timeline of massive federal legislation related to social insurance assistance benefits to help guide our expectations and focus, we passed Social Security in 1935, Medicare/Medicaid in 1965, and the ACA in 2010. Like the preceding landmark legislative accomplishments, the significance of the ACA's provisions and the regulations that have followed warrant a complete understanding of the current market infrastructure before amending or rewriting the law; at the current pace, we are decades away from ACA comprehension; let's not "replace the bill until we find out what's in it".

Election year campaigning does not help our cause either. Perhaps is an effort to deflect attention from perceived ACA gaps, Joe Biden's campaign, with President Obama's support, has recently adopted former Senator Tom Harkin's conception of the ACA as a "starter home" that requires frequent legislative adjustments to properly function. Recurring narratives from varied sources which hint at imminent federal legislation are a distraction that freezes stakeholders and prevents them from taking decisive and appropriate action as they delay initiatives in anticipation of disruptive federal law. They have told me this going on several years now. We need a prudent media to help reframe the national conversation back to current reality. Putting the timelines in perspective, we have 30-45 years to figure out the next major social policy. We only have two weeks to learn how to ask the president questions; let's do our jobs accordingly.

The most impactful piece of national health policy since the ACA in 2010 was regulatory in nature; most Americans have zero awareness of this; “the impetus for the ACA makeover was President Trump’s executive action on October 12, 2017, that bolstered silver plan premiums and premium subsidies, vastly improving federal assistance for millions of Americans.” The order also paved the way for individual market improvement by allowing employers to utilize individual coverage health reimbursement arrangements (ICHRAs) to provide payments for individual market premiums. Have you heard any national media discussion of a 2017 Executive Order turning ACA markets around? Outside of mathematical misrepresentation at the time, I haven't and I'm specifically listening for it. Attorney Jonathan Turley says, "What is astonishing is that the media has refused to see what should be one of the biggest stories in decades." I take exception to Mr. Turley's strong claim, but only because he is referring to the Obama administration spying on the Trump campaign rather than the media not acknowledging the revitalization of markets created by of the signature legislative landmarks in our lifetime. As evidence of the improved environments continues to build from the regulatory action (latest news is 2020 increase in effectuated exchange enrollment, only increase after initial three-year ramp-up), we will undoubtedly see COVID-19 conveniently substituted as an alternative rationale in the soon to be muddied waters of ACA market analysis.

I could list other executive orders. As I highlighted in late 2018, “stalled legislative efforts allowed the executive branch to influence market mechanics and President Trump’s first two years were unusually active”. The president has not been reticent to utilize executive action to alter ACA market dynamics. The material implications of his policies are enhanced premium subsidies for lower-income Americans and “escape options” for higher-income people to avoid ACA markets’ challenging premiums. Since 2018, I have referred to this dual-benefit with the moniker of promoting “more love, less hate”, with an income level of 400% of the Federal Poverty Level (FPL) serving as the primary class divider.

The Kaiser Family Foundation (KFF) adopted its own “more love, less hate” construct in a recent survey demonstrating increasing popularity, noting more people report being helped by the ACA and fewer report being harmed since 2016 at all measured income levels.

As impactful legislative policy has been knowingly frozen since June 2017 (perhaps known six months earlier by the good people in Whitley County, Kentucky), we should listen carefully to how the president attaches market improvements to the decisions he has made and what he says about the decisions he will make within his scope of direct authority. My grasp of the implications of his policy is solid, but the rationale for each decision and a broader theme is never established because he is only asked questions about things he is not doing. Don’t laugh; I am serious about this.

I tire of hearing him asked about and repeating “we will always protect pre-existing conditions, 100%” when queried about phantom legislation supposedly sailing through a divided Congress. We learn nothing from such pleasantries. I grow frustrated when he is continually asked about a distracting Supreme Court case that he is powerless to influence and Congress can easily erase (and certainly will post-election) with one-line legislation. On behalf of my fellow citizens, some involuntarily relegated to individuals markets, I am yearning for serious conversation about the reshaping and expansion of health insurance opportunities for those without employer-sponsored or government-provided options, which would foster genuine discussion beneficial to consumers and their eager advocates. I have heard enough antics from self-serving journalists who thinks they can add evoke a noteworthy response by asking the same old questions with a clever twist. 

In virtually every opportunity that the media and general public have to ask the president about health policy, they miss and ask the president about something outside his scope of direct authority that he has already answered countless times. Unfortunately and inexplicably, when the president begins to talk about that which he does control, the discussion is shifted back to areas of apparent comfort; away from where all the action is, away from where we might learn substantive facts and concepts, away from answers that may catalyze ACA market improvements. It is why I listen so intently (with finger on 'rewind') hoping for a sparse nugget; it is strange to say this, but the media seems to go out of their way to not allow the president to talk directly about what he is doing with regard to health policy.

The NBC Interview

Consider an interview with Chuck Todd in June 2019. The president is trying to talk about his ACA-related administrative actions as Mr. Todd is interrupting him by parroting irrelevant and dated rhetoric from the 2016 campaign. President Trump continues his on-point discussion and Mr. Todd then shifts gears to the judicial branch, and bizarrely asks the president, who is a legal defendant in a referenced case, to “drop the lawsuit”. Perhaps he takes solace in that Joe Biden, knowing the media will not correct him, has also directed the same legally-mystifying words toward the president. Mr. Todd then asks repeated questions about the legislative branch and the president is finally able to come back to what he actually controls, “I could have managed Obamacare so it would have failed or I could have managed it the way we did so it's as good as it can be”. Rather than ask exactly what that means (which would have been incredibly revealing), Mr. Todd shifts discussion completely away from health care and asks, “Are you prepared to lose?”.

The president’s implication that ACA markets were in much better shape due to his executive actions was correct, but I have never heard his clear explanation of why that is the case; "I had a choice; I could have let it implode and killed it or I could have managed it" is an extremely fascinating claim but wholly insufficient in detail. Most of us have no idea what the president is referring to when he speaks fondly of his "management of Obamcare", which he has done several times, because he has never been asked. Mr. Todd’s interview should have been focused specifically on his relevant actions; instead, Mr. Todd directed the president away from discussing his policy actions to hypothesize what other branches of government might be up to; and it only led to the same conversation we had heard many times before.

It gets worse. A recurring problem with such interviews is media misinterpretation and overreaction followed by public outcry. For example, the Supreme Court litigation regarding ACA constitutionality is due to a district court ruling that the individual mandate is not only unconstitutional but inseverable from the remainder of the law. Congress (legislative branch) can address severability by declaring its intention or unfathomably allowing the Supreme Court (judicial branch) to discern such intent. The president is technically a defendant but an unwelcome one as “intervenor defendants” (led by California) wish to argue that the inconsequential (in their view) mandate ($0 penalty) is constitutional.

He is an outside voice, but he is repeatedly asked about the case as if the outcome and pursuit of the legal claim itself are his decisions. The delay in legislative action is deliberate, a Congressional charade, and an unfortunate pre-election game, and one where the media and the president willingly oblige. It is unproductive and distracts focus away from what is occurring in ACA markets, not only from the general public but those professionally engaged in facilitating ACA market functionality.

It is underappreciated how much stagnation has occurred in ACA market development due to misguided public discussion. In the third year of the ACA makeover, only a minority of small states have provided their low-income residents real advantages through pricing equilibrium. Ask yourself how much you hear about appropriate market pricing benefitting low-income citizens versus short-term plans, funding for advertising, and open enrollment timelines; then ask your friends who receives ACA market subsidies which they care more about.

Don't draw comfort in only hearing political spin because you surely believe the people who really need to know the policy details are learning from objective sources. They're not. Read what they said a few years ago about administrative action implications and how they are "surprised" by the improved environment today, which they now attribute to markets being "resilient to policy headwinds", rather than empirically understanding policy and dispassionately explaining its new benefits to consumers. It takes a lot of mental gymnastics to retrospectively label policy as "headwinds" after witnessing troubled markets improve (worst year to best year) with policy implementation that led to reduced costs for low-income consumers, subsidized enrollment increasing in 2018 and 2019 (coinciding with repeal of individual mandate penalty) after a sharp decline in 2017, insurers returning to markets, flattening premiums after years of steep increases, and record consumer popularity with more people helped and fewer hurt, all occurring amidst rampant public misinformation and partial stakeholder response. Perhaps some would argue that policy implications are "resilient to media headwinds", but nationwide market results would be much better with a culture of objective reporting focused on relevant matters and the discipline to ask the president the right questions.

I expressed a direct cause/effect rationale of increasing popularity in February last year, "Insurers and consumers haven’t favorably changed their opinions of ACA markets because the alternative environment has changed. They have favorably changed their opinions of ACA markets because ACA markets have changed. For those who have spent the last few years reflexively reporting on ACA regulatory updates with characterizations of 'gutting', 'sabotaging', and 'undermining' without seeking to appreciate the complicated dynamics, the rest of us can appreciate why an improved market environment is so hard to reconcile." But it needs to be reconciled now; ACA consumers are the casualty of not acknowledging the evolving market dynamics.

The ridiculous amount of focus on the ongoing political battle regarding the optimal duration of short-term health plans is an example that provides more clarity of the prioritization of politics over consumer advocacy. This is a small (but growing due to ACA) market that provides lean benefits to people with short-term needs or perhaps longer-term for people without reasonable solutions in ACA markets. Suggestions that these state-approved insurance plans are “sabotaging health care” and characterizations of them as “abusive junk” are beyond the pale of rational discussion, but that is the current reality with a minor insurance product being overly-politicized. California is a noteworthy example. “Before 2017, California quietly regulated short term health plans, reflecting California’s values. In 2017, President Obama issued an executive order which overrode the California rule. President Trump later relaxed Obama’s decision, effectively restoring California law. After California’s Commissioner called Trump’s action 'another attack on the integrity of the nation’s health insurance markets', California prohibited the sale or renewal of short-term health plans."

The short-term plan saga is emblematic of responses to President Trump's regulatory changes. Reactions are politically reflexive without regard to apolitical consideration or general interest in underlying policy implications. President Trump's short-term plan action has helped ACA popularity through the "less hate" measure and provided longer-term coverage to people without ACA market solutions than afforded by President Obama's restrictions. It is undoubtedly important to provide reasonable coverage options for those harmed by the ACA and we should understand this, but the short-term plan drama has unfortunately played out more as a political distraction than a helpful discussion item to consider in educating stakeholders about ACA dynamics.

If we are going to effectively advance health policy, we need a dramatic public discussion shift from the politically familiar to the technically relevant. That means bringing the discussion back to the value of benefits that consumers receive relative to the price they have to pay for health insurance. There are untapped opportunities to significantly improve this equation under current law. We do not need new legislation. We do not need a Supreme Court ruling. We simply need to cancel the outside noise and understand the current law and its associated new regulations, and that starts by asking the man who is in charge of implementing the law what he is doing. He gave us two weeks notice; let's be ready.

The Town Hall

When the president talks about legislation, it is often nothing more than an opportunity to make campaign-related comments, and residual fodder for the news media and his political opponents to do the same with their noxious “taking away health care” narratives. When the president talks about administrative action, it is substantive and worthy of attention.

President Trump hosted a Fox News town hall in March. Expecting that audience questions would be unoriginal, of the variety learned from media professionals, and outside of pertinence to executive authority, I submitted a question asking about the administration’s actions and posture. It was unsurprisingly excluded from the dialogue, but the audience would have learned more from my question about the ACA than they did from both the questions asked and President Trump’s responses. You may disagree with my complementary tone (I would extend the same respect to any president) or question my commentarial flavoring on factual assessments, but you will agree we would have learned much more from the president had he been asked about his policy actions for a change.

“President Trump: On health care, a survey from the Kaiser Family Foundation released eleven days ago indicates Obamacare private markets are more popular than ever. Specifically, since you have assumed office, more people report ‘being helped’ by Obamacare & fewer report 'being hurt’.

This all makes sense. When you assumed office, Obamacare was very unpopular, hanging by a thread, and expected to be repealed. Instead of repealing it, you had the courage to do what your predecessor had not done. You made Obamacare more tolerable.

In your first month, your executive order catalyzed relief for Americans from a one-size-fits-all mandate. You listened to the courts. In October 2017, you stopped payment of cost-sharing reduction reimbursements. Two months later, you signed legislation which struck the individual mandate penalty from the law.

The numbers don’t lie. Americans now have more choices & better access to lower cost insurance. In fact, a government report indicates the percentage of enrollees on federal exchanges who have access to premiums of ‘$75 or less’ is up from around 70% in 2016 and 2017 to around 80% in 2018 and 2019. In 2019 and 2020, premiums are remarkably lower than the previous years and both years have seen more insurers participating after declines in the previous three years.

While your actions have reflexively been criticized as ‘sabotage’ by Democrats, they have directly made Obamacare work better for most enrollees and have created alternative options for those who it was not designed to work for. Your new HRA rule has the potential to double market size and add more stability to the program.

Rather than talk about ‘canceling Obamacare’, why not champion your strong three-year record of reviving private markets? A large-scale repeal of the program did not occur in 2017 when the circumstances were ripe. Even with a large Republican victory in November, it is very unlikely that repeal appetite is there for a program that is now more popular and functioning better. Actuarial analysis tells us that market underperformance is due to states not fully embracing your action.

Section 1332 allows states to be innovative and address inherent Obamcare flaws and challenges. Insurers and states have not fully complied with federal rules, usually resulting in plans people buy being more expensive than they should be. Many states have taken a ‘wait and see’ approach, not investing in efforts in what they believe to be a temporary environment. Why do you speak of wanting a full-scale remodeling of private markets when you have had remarkable success improving the current one?”

Are you thinking that Fox News rejected my question about unfamiliar executive branch territory and decided to go with familiar questions about the legislative branch and judicial branch instead? You are correct. You can probably guess the two questions…they are always the same two questions.

The legislative branch question was asked first: “Republicans have failed to come up with an alternative plan to Obamacare. How do you plan to rally the Republicans around a plan? And what would be included in that?”

The president begins (media folks, pay attention, you have to hear this)…the president begins his response lamenting that his biggest disappointment is the lack of opportunity to talk about what he has done on health care. Wow! It is not just me that notices this. Please take the hint…ask him…he wants to talk about it. More importantly, Americans need to hear about it. Two weeks. Two weeks to get this right.

“I think it’s probably the thing that I’m most disappointed that I haven’t been able to say what a good job we’ve done. I haven’t been able to sell what a great job we’ve done.”

He then provides lip service to the legislative question with the individual mandate repeal accomplishment and of course, “Preexisting conditions: 100 percent”, highlighting one of several requirements of legislation he would be willing to sign, and mentions the other, the obviously more opaque “great health care”; then he starts talking about what he has really done…health care plans 60-65% less expensive for unsubsidized enrollees challenged by ACA premiums.

Sounding like his HHS Secretary, “What we’ve done is we’ve really managed Obamacare — the remaining portion — we get rid of the bad part, but the remaining portion — really well. And you know, before I got involved, you know what was happening with the rates and Obamacare: They were going up at levels that nobody has ever seen before. We are managing it.

And I had a decision to make. This was very important. I said to my people — and we have great people: Seema, Azar — I mean, great people that are so good at it. I said, ‘You know, I have a little problem: Do we manage it great until we get something much better or do we manage it poorly and say Obamacare is horrible?’ And I said, ‘We’ve got to do the right thing. We’ve got to manage it really, really good.’

So it’s not great healthcare, but we’re managing it fantastically. And you don’t see all those stories about the rates going through the roof anymore because we know what we’re doing.”

OK. There is a lot of stuff there to think about…lots of follow up questions…What are the 'good parts'? What makes them good? What specifically are you doing to ‘manage it well’? Which policy actions had the beneficial rate impact? What did you mean by "little problem"? What were the crucial decision points when you committed to managing it well rather than poorly? How do you connect your policies with stable financial results, insurers returning to markets, improving popularity across income segments? How can states, employers and consumers better understand the implications of your actions and appropriately respond? Is your work complete? Without legislation on the horizon, what executive action might we expect in the future? What regulations are you saving for a second term?

Those are my words to paraphrase the follow up questions…it turns out the president's comments were so substantive that moderator Martha MacCallum interjected to follow up rather than let the audience member do so...things just got serious and we need someone with professional training to pointedly ask the president what me meant by "manage it great until we get something much better"…ready….”So, Mr. President, I just want to follow up quickly (I'm crossing my fingers now, 'please, please, please be about something he just said') on that because the issue of preexisting conditions ('#$@&%*!'), you say you’re going to protect them —but your administration is also fighting Obamacare in the courts. So how do you — how do you promise people that you’re going to protect them — based on that?”

Do you better understand why we collectively have absolutely no idea what the president is doing with the ACA? Do you understand how President Trump continues to improve ACA markets or “manage them well” as he would say, yet effectively maintain an anti-ACA persona? Ask the president about what he is doing; stop asking him about phantom legislation and a lawsuit where he has no influence. There is much more that we could talk about that is actually occurring, it is really fascinating (trust me) stuff, and a broader understanding would enhance our mutual ability to optimize ACA markets; it would be more fun, more productive, and ultimately benefit ACA consumers. The Town Hall was another missed opportunity.

How did the president actually answer the judicial branch question? For what it's worth, calm and subdued. “Look, we’re running it really well…But, what we’re doing is managing it really well” and then he correctly and gently tells the professional newswoman that he is, contrary to frequent media portrayal, not the plaintiff. "It’s called Texas vs. — you understand — it’s Texas who is suing", he says, looking for acknowledgment, willing to respond with words to the question but first wanting to assure there is mutual understanding that the question is not real.

Outside of learning that the president shares my lamentations for the wrong questions always being asked, I gleaned nothing from this exchange. and I doubt anyone else did either.

The Fox News Interview

Like the interview with Chuck Todd, there was predictably discussion between Chris Wallace and the president about all three branches of government. After asking questions about the “sense” of a law being legally ruled unconstitutional based on judicial merit, excuse me, I meant to say 'based on policy implications, current circumstances related to a pandemic, and political calculations', Mr. Wallace asks the president about a legislative plan; same old question, same old answer. Here it comes again..."We're going to always protect people...". Surprise. Not this time. This time the president's answer was different.

If you don’t know what is coming, brace yourself. It's big. The president responds that the Supreme Court has just provided “powers that nobody thought the president had” and that he would be signing “a full and complete health care plan” within two weeks. What??? The president who has not been reticent to utilize executive action to makeover ACA markets and expand consumer options just learned he has “new powers”? He said this on national television Sunday? Stating it mildly, this should attract attention. Maybe we should now get serious now and pivot from legislative/judicial regurgitation and begin asking the president about his intentions on regulatory matters, where he not only has been incredibly active and reshaped individual markets the last two years, but…, he thinks he now has new freaking powers? It seems to be the opportune time to subtly shift to relevant questions. Offline, “Producer, can we cut some of the silly stuff from the rest of the interview? I need to know more about this.”

“What are the details of this plan that will be implemented with your newfound presidential authority?” That is certainly a semblance of the next question I would expect from any interviewer who understood what Mr. Wallace just heard, after allowing adjustment time for emotional composure. Instead, he incredulously appears unreactive and asks nothing about the new "full and complete health care plan” and fills his later time with questions about the president’s opportunistic niece trying to sell a salacious book. This is before he reprises his self-amusing 2016 banter about Mr. Trump’s imagined unwillingness to accept an election defeat; fun to revisit old times I guess.

There was nothing more for Americans to learn about a potential monumental health care change? Yes, my head is still there and 'mute' has been hit for the Mary Trump book dissection. Like every health care professional actively engaged in attention to policy detail, I am perturbed that there was not much more probing from Mr. Wallace of the president’s intentions on a matter within his purview, and overall disappointed with the interview’s shortcomings.

Health policy social media would surely be active with discussion about Mr. Wallace’s inexplicable lapse and ripe with creative brainstorming to consider what the president may be thinking. I wish. KFF President and CEO Drew Altman remarked “Hopefully, Chris Wallace’s interview will set a new standard for interviewing President Trump.” Say what? I am at a loss to explain this perspective; from Mr. Wallace’s interview, we “learned” the following from the health policy discussion: there is currently a pandemic, unemployment is up, fewer people have group coverage now, there is an ongoing court battle, and the president is planning to issue another Executive Order with a “full and complete health care plan” in the next two weeks based on newfound presidential authority. We have no clue what the Executive Order is about, we already knew everything else, and Mr. Wallace did not ask any questions about the startling Executive Order.

If I am ever blessed with an opportunity to interview the President of the United States, I can assure you I will not adopt Mr. Wallace’s “standard” of avoiding the most important matter under the authority of the interviewee. I will ask the president directly about the relevant decisions he makes, and I will not recycle old questions about Congress or the Supreme Court with a creative spin.

At the outset of this article, I was clear that my intention of collectively learning to ask the president the right questions two weeks from the interview was ambitious. It just got harder. When I developed that goal, it was before I was aware I would meet vocal resistance from the President and CEO of the “most trusted source of information on health care issues”…but I will persevere. For you Hamilton fans out there, I’m not giving up my shot. I will continue to persuade each of us to lose interest in the distracting familiar arenas where there is repetitive talk but no activity. We need focused transparency on the room where it happens, and when we are asking the man who makes it happen, we need to be certain our questions are about the right room. I can't tell you precisely which room that is; I can only provide the address: it's 1600 Pennsylvania Avenue.

The President’s Detractors Response

The president’s vocal detractors generally have two notably distinct responses to his health care proclamations, and their applications are customarily selective. One is alarmism, peppered with gross overreaction, and usually accompanied by misrepresented dire implications. The second is scoffing at what they believe to be a lack of seriousness, which unsurprisingly correlates with his frequently being questioned outside his purview. The reaction to the Fox News interview was almost exclusively met with scoffing rather than alarmism.

A week after the interviewed aired, there are surprisingly no serious news stories on the president’s comments, while there was a short piece regarding the president’s similar perceived newfound powers on DACA. Health policy journalists antagonistic toward the president, however, freely and flippantly weighed in on Twitter. Julie Rovner, Chief Washington Correspondent for Kaiser Health News, tweeted “@realDonaldTrump promises a comprehensive health plan ‘in the next 2 weeks.’ What’s the over/under on that?” Nicholas Bagley, whom I regard as “the most recognized expert on ACA-related legal matters” but generally prone to alarmism, was uncharacteristically unmoved by the president’s bullish interpretation of his new authority and added the DACA decision “conferred on the executive branch no new powers”. Some commentators had previously suggested that the president has an uncanny propensity to arbitrarily provide two-week timelines. Aaron Rupar, a journalist at Vox who apparently agrees, quipped “Trump routinely cites a two week timeframe for new policy initiatives when he's just making stuff up”.

Mr. Bagley wonders if the president’s plan will align with Idaho’s consideration of escape options in 2018. There is some rationality here. The president has little opportunity to offer “more love” and he cannot appropriate funds; his 2017 Executive Order did so by complying with a court order. It’s more likely that President Trump is planning something of the “less hate” variety but we really don’t know. Brian Blase, an economist and a key architect of President Trump’s health agenda, believes the Executive Order will align with the administration’s stated policy.

While I have been recognized for rationality and a “tempered response” when others have been alarmed on ACA developments, I was apparently alone in my alarm last Sunday. As mentioned, the president speaks freely about issues outside his purview where he does not control timelines or outcomes. I yawn while others react. It’s different when he is talking about what he can control. I think there is something important here that deserves our attention, and the right questions from Mr. Wallace might have brought a better understanding of what the president is doing and more serious attention to a substantive matter. Even if it is a false alarm, learning to ask the president the right questions will have long-term dividends in understanding and improving individual health insurance markets.

ACA Market Misunderstanding

ACA market dynamics are more misunderstood than anything I have professionally seen in my twenty-six year career in the health industry. In 2016, I wrote “The implications of this law are complicated and require a comprehensive appreciation of incentives for health plans, employers, employees and individuals. The majority of comments that have reached a general audience are not from objective sources and have obfuscated public understanding; in fact, it was the repeated misperceptions of the legislative impact that initially piqued my interest in writing about the program details.” It's still true and I'm still writing.

The ACA mathematical dynamics are elusive and convoluted. I have argued that we each need to make a difficult personal decision and swallow the red pill (no political context) and we need to agree to come back to earth to have policy discussions. In most policy debates, there are two political narratives competing over truth. With the ACA, "we have two political narratives that are in agreement with each other but disassociated from the truth.” I think there are three general misunderstandings that carry us away from reality.

The first is the arena misunderstanding discussed in this article. Almost all the public discussion over the last three years has been focused on imagined legislation and court decisions. The real activity has been President Trump’s administrative activity and states’ response to it. The market improvement since 2016 has been remarkable. We should learn from it; chalking it up to 'resilience to policy headwinds' to align with focus through a politically-biased lens (supported by interpreted comments in arenas where the president's authority is less consequential) is untenable. We need our focus on the room where it happens, and we will better understand what has happened.

The second is related to the first; it is the propensity to have a political rather than a mathematical understanding. The ACA is about convoluted math. If you approach ACA understanding from a political basis, you are deliberately handicapping your comprehension ability. Understanding the ACA requires "casting aside the rigid requirement that policy implications must align with ascribed political motivations." Our view of President Trump's policy should be based on the actual policy rather a politically-based assessment of a policy that we won't allow him to talk about. Of course, asking him about it would makes things a lot easier as most of you would prefer to hear someone talk about it and not to personally assess the policy yourself, otherwise you would have already done so and be properly informed rather than parroting what you hear from the politically-inclined crowd.

The third area is the least talked about and needs to be understood. Much of the policy action assessment, especially from the president's opponents, has been based on a classical actuarial understanding of traditional markets. The classical understanding is that community-rated (where premiums do not vary by health status) and risk-rated markets cannot effectively coexist. As a risk-rated market has premiums which vary by health status, healthier people are inclined to enroll in a market with cheaper premiums. A community-rated market is left with only with sick people who do not qualify for lower premiums in the risk-rated market. This theory is true, but it is not representative of ACA market reality. The ACA does not predominately divide the population by health status; it divides the population by income. Before comparing the ACA risk pool to an off-market one, it's important to understand that the ACA market itself is comprised of two risk pools. This is almost universally missed in discussions to provide solutions for higher-income eligible enrollees who do not qualify for premium subsidies.

There are indeed real threats to ACA markets, but they are disassociated from the purported concerns we hear about in the public sphere. You probably haven't heard about them because there is no boogeyman associated with them. We should strive to encourage recognition of ACA challenges outside of political attachments. I am talking about real problems here, not whether we have optimized risk pools with a precise open enrollment timeline. The biggest threats to ACA markets today are Metalball and Lionfish, not short-term plans and lack of an individual mandate. You are unfamiliar with these concerns? They are threatening ACA markets across the country. People who care about ACA consumers talk about its real threats; people who care about political hackery talk about things like short-terms plans and “disruptive” open enrollment maintenance on Sunday mornings.  The states who have responded appropriately have reduced consumer net premium and quietly attracted more young, healthy individuals to ACA markets; others are plagued by Metalball and Lionfish, and many don't even know it.

The ACA makeover is a multi-year process as states progress at different speeds. Wyoming got there first and Virginia was one of the first to prescriptively eliminate Metalball, requiring "the Bureau will only allow the use of the induced demand factors established by CMS and used in the Federal Risk Adjustment program." The Lionfish concern is a larger challenge for states, but Rhode Island left one off its exchange in 2017, noting "it would have reduced the subsidies available to all exchange enrollees, making coverage less affordable if people chose plans other than the new low-cost options.”. Earlier this month, Colorado passed anti-Metalball legislation that said:

"(a) THE COMMISSIONER MAY ADOPT RULES DESIGNED TO:

(I) MAXIMIZE THE PURCHASING POWER OF EXCHANGE CONSUMERS WHOSE HOUSEHOLD INCOME IS UP TO FOUR HUNDRED PERCENT OF THE FEDERAL POVERTY LINE; AND

(II) ASSURE PREMIUM PRICING THAT COMPLIES WITH THE REQUIREMENTS IN THE FEDERAL ACT FOR MODIFIED COMMUNITY RATING." 

The Colorado legislation reinforces the insurance department's regulatory authority and stresses the consumer benefits of compliance. Other states will surely follow, but reaction to federal policy is slow and scattered; imagine the alternative results if these substantive issues were at the forefront of discussion rather than all of the repeal and Supreme Court blabber. I was with the media on the repeal discussion in the summer of 2017, but when we learned there would be no legislative repeal and the market would be reshaped by executive action, I moved on. The consequences of media misfocus could be severe. The concern today is not that Americans do not like the ACA makeover; it's that they have no idea it is occurring; imagine if Chris Wallace had shown President Trump the chart below and asked for his reaction to changing market dynamics. We would have spent last week talking about substantive ACA issues.

When Secretary Azar two years ago said “the president who is supposedly trying to sabotage the ACA has proven better at managing it than the president who wrote the law”, he was right in substance. I'm glad he said that; it was long overdue. It was, however, tremendously lacking in clarity. What has he done to manage it better? “When you have a president who’s willing to take decisive action, who understands business, who’s willing to work with the private sector, you can find a way to help American patients, even within a failed system like the ACA” doesn't help at all. It offers little in the way of substantive understanding. In fairness, no one, outside of me, has demanded or expected more. We should change that; rather than be politically dismissive of his comments, we should ask him what all this means. I want to hear him say “we stratified the market by income and helped those for whom the ACA was designed to work, and we provided other solutions for those whom it would never work. We have messaged these actions to the states. We worked within the law's constraints to provide the best possible options for consumers.” That would be substantive, as opposed to the safe conservative posture of "being willing to work with the private sector".

Does all this make sense now? Executive branch questions for the executive branch; nothing about court cases or new legislative plans. Ask the president about his scope of responsibility. Don't venture into other areas just because it is more familiar. Got it? Good. I think we may be ready. Should we give this thing a shot? To make it easier, why don't we give another network a chance and interview the HHS Secretary rather than the president? That way, it will be much harder for the interviewer to confuse executive branch authority with other branches. The president has to sign Congressional legislation, but the HHS Secretary doesn't play any role in creating the law. He runs a federal agency and implements the law. The discussion will be limited to activities within the HHS agency and stay away from discussion about the Supreme Court and legislative plans. Action:

Secretary Azar: “When you have a president who’s willing to take decisive action, who understands business, who’s willing to work with the private sector, you can find a way to help American patients, even within a failed system like the ACA.”

Interviewer: Secretary, some questions about the details of those specific points (video).

OK, so we still have a few things to learn. It’s good that the president gave us two weeks. If journalists are legitimately concerned about the Supreme Court overturning an unconstitutional law, maybe they should ask Members of Congress about it. It is, after all, it is a Congressional law that has been ruled unconstitutional. Congress can fix it. Ironically, an unwillingness to strike the penalty-free mandate suggests Congress believes it is an essential part of the law, which is precisely the plaintiff's argument. It is clearly the role of Congress to address this, and clearly the role of media to ask Congress about it.

President Trump is not a plaintiff in the lawsuit. He can't stop it. “Why are you trying to repeal the ACA in the courts?” and “Where is the legislative plan?“ are not relevant discussion items for executive branch actions. The one appropriate question that President Trump could be asked about legislation is "Would you sign the Congressional legislation to repeal the individual mandate"? We know the answer, but it wouldn't hurt to ask, but only once. We don't need every network to repeat the same question and try to create a story.

Jake Tapper is also dead wrong on the administration's legal proceedings. The president defended the ACA in district court. He lost, but he won on a decision to stay the ruling. He later agreed with the district court decision with a few caveats (only some states, some items are severable). Meanwhile, CA and 19 other states intervened to defend law on behalf of residents. The president's position to stay the court ruling has never changed. Mr. Tapper either is uniformed about the administration's consistent legal position or is suggesting without basis that the administration has decided to not argue to stay the ruling due to the pandemic. If Mr. Tapper wants to discuss the case (he shouldn't) with the executive branch, he should at least have his facts straight. His fear-mongering "unconscionable during a pandemic to take health insurance away" is not close to any legal briefing that the Trump administration has filed.

Even the health policy "experts" in the media appear unequipped to ask the right questions. We may never know what we need to know about White House action in ACA markets until we have someone “at the center of a Venn diagram that overlaps two tiny population groups, those that really understand this ACA math stuff and those that have access to the President of the United States.”  We shouldn't have to wait for that; we should start with asking the executive branch about the executive branch, even if we don't understand the technical details first.                               

Unique Discomfort

I am comfortable writing. This article is out of my comfort zone in several respects. I am not a professional journalist; I am a technical expert and work as an actuarial consultant. I am accustomed to studying policy, assessing its implications and reacting to journalists’ understanding of it, and sharing my technical clarifications. In this case, there is no policy, there is no story, and there is nothing to react to. I am literally writing about something I expect will happen, but I don't know what it is.

I am a nice guy. I have said some things in article that are not so nice, frankly about people whom I personally like. I don't like doing that. I am sympathetic to the people in the individual health market. It has historically been a disadvantaged marketplace and I applaud federal initiatives to work toward equity with group markets. I have been blessed with employer-sponsored insurance my entire adult life and I recognize my inability to share the personal perspective of those in different circumstances. To my knowledge, none of the ACA architects participate in the individual market. That may explain some of the policy blind spots. The ACA has helped millions of people; it has also hurt millions of people; I have many friends who will reject one side of that argument. I'm unafraid to tell them they are unable to understand the legislative implications of the law because they do not have an objective lens. Regardless of policy views, if we're not going to repeal the ACA (and Republicans aren't), we should work together to make it work for those relegated to a historically disadvantaged marketplace. That starts my having rational discussions about policy implications in the public sphere, and the media has the responsibility to lead the charge.

While I am a numbers guy and not a political guy, I do pay attention to health policy that impacts numbers. President Trump’s executive actions have certainly done that. Other than legislation that repealed the individual mandate penalty, there has been little in the legislative and judicial branch that has had any impact. A presidential Executive Order could have huge implications; I'd like to begin analyzing, but there is no hint of what to analyze.

Aided by the media focus away from his authority, President Trump has managed to improve health insurance options for Americans without access to government programs and employer-sponsored plans while maintaining an anti-ACA political persona. I am inclined to believe his upcoming Executive Order may fit that mold, offering flexible choices for consumers, fostering sustainable markets, while being branded and accepted by detractors as an anti-ACA initiative. This has worked like a charm in the past. Smart people have been fooled into traditional risk pool thinking and believing the ACA individual market is a high-risk community-rated market that cannot compete against risk-rated markets.

In summary, we may have a major health care Executive Order on the horizon that is much more impactful than the previous ones. I usually read news from the professionals and interpret it from my unique insights. There is no news here; instead of writing about the news, I am reporting that a major change in health policy may catch many of us flat-footed in August. Shame on us if it does. Collectively, we have a lot to learn in a short amount of time if we are going to properly understand the Executive Order implications sans the political baggage that usually inhibits our understanding. We need to learn not only to ask the president right questions, but to interpret the ACA as a income-stratified market with a mathematical rather than a political appreciation. Let's have our questions ready; we can pick this conversation up again when we have an Executive Order to discuss. We should know how to ask the president questions this time. We were given two weeks’ notice.