Q&A with Pennsylvania’s Insurance Chief: Jessica Altman Explores the Evolving Role of Insurance Coverage

Pennsylvania Insurance Commissioner Jessica Altman

In late March, Jessica Altman became Pennsylvania’s insurance commissioner, responsible for protecting consumers in the fifth-largest insurance market in the United States and the 14th-largest in the world.

Altman, who is vice chair of the National Academy for State Health Policy’s (NASHP) Health Care Access and Finance Steering Committee, helped implement the Affordable Care Act (ACA) when she worked at the Department of Health and Human Services’ Center for Consumer Information and Insurance Oversight. She joined Pennsylvania’s Insurance Department in 2015 as its chief of staff and served as acting commissioner since August of 2017.

Altman talked to NASHP recently about the evolving role of health insurance coverage in state and national politics, and how her own career trajectory has followed the evolution of health insurance as the country’s critical health care issue.

Q: How did you come to insurance regulation?
Health insurance is a critical part of the ACA, which fundamentally changed the way the health delivery system works in our country. Working on the ACA demonstrated to me the impact that government can have and the unique and critical role that insurance plays in each of our lives. No one likes to think about insurance – it is strange to invest time and money in something you hope you will never need – but it’s so important for the critical times in people’s lives, whether you need your health insurance for an illness, your car insurance after an accident, or your homeowners insurance following a fire. I have always wanted to be in public service, and when I moved from the federal government to the state level, what especially appealed to me was the consumer protection aspect of this job and the ability to work more directly with consumers and address the issues most important to them.

Q: How has the ACA worked in Pennsylvania?
In many ways, the ACA has been a huge success in Pennsylvania. Our uninsured rate is at an all-time low, and I believe there is a sense of financial security and access to coverage that did not exist before the ACA. When engaging in various communities, I have seen people cry tears of joy because they were able to find better health insurance coverage under the ACA today for thousands of dollars less than ever before. Pennsylvania’s exchange is also among the nation’s healthiest, with five major health insurers insuring about 400,000 residents.

Implementation of such transformative reform has not come without its challenges though, and state regulators are constantly responding to changes directed by the federal government, while implementing policies that we believe will mitigate any potential harm and be in the best interest of the people we serve. One example of our responsiveness is how states around the country recently dealt with President Trump’s decision to stop making payments to fund the cost-sharing reduction program. States found a way (the so-called “silver loading” strategy) to account for these costs by building them into health insurance rates, while actually helping consumers better afford more generous coverage because of the way the premium tax credit structure works.

Q: Does it surprise you that the ACA has had such a profound effect on the country’s health policy dialogue?
Yes and no. I am surprised by the magnitude of the ACA’s impact considering that much of the act focuses on reforming the individual and small group market, while leaving many areas of the system, and in fact the areas where the majority of Americans receive coverage, employer-sponsored coverage and Medicare, relatively unchanged. I think many people have a perception that the ACA reforms are broader than reality. I see this every year when we go through the rate review process, and I hear from many consumers their concerns about requested increases, only to find that most of them will not be impacted because they do not rely on the individual market for coverage. The individual market serves only about 5 percent of Pennsylvanians, and while it is an important and challenging market that we will continue to work to improve, most people are served by other areas of our system that are not experiencing the same volatility that the individual market is today.

Simultaneously, I am not surprised by the profound impact of the ACA because the act represents a fundamental shift in how our government approaches health care. It was a huge step in ensuring health care coverage is a right and not a privilege in this country. There is no doubt that the shift has come with some growing pains, but I believe it has also demonstrated that health insurance is a fundamental right and need, and government should play a role in it.

Q: Did you know how controversial the ACA would be years after its inception?
I was among the first hires to implement the ACA and we had only a few months to make decisions and implement the early regulations while scrambling to set up an organizational structure. When you’re in that environment, you don’t have time to think about how important the work is, but I did have moments when I thought about how friends and family members with pre-existing conditions would finally, for the first time in their lives, get affordable and high-quality insurance. Because of that, I always believed that the ACA would gain acceptance over time. There are many reasons why the ACA remains controversial today, from pieces of the law itself, to changes made to it over time, to just plain politics, but I remain hopeful that we can work together to embrace what is so good about the ACA while looking for solutions to what may not be working.

Q: Is having the country’s persistent debate about ACA important, despite its contentiousness?
Having a national dialogue about our health care system, who that system is working for and who it is failing, is unquestionably valuable. What is important is under the ACA, at the end of the day, is that no one must worry if they can get health insurance if they have a devastating need; it is now there for everyone who needs it. As changes have been discussed and made, I think the dialogue has instilled in people an appreciation for the necessity of coverage from a financial stability perspective, which is why the ACA has made such a difference. My hope is that this dialogue will help move us forward. We need to fix what needs to be fixed, and focus on the many other problems our health care system has, namely cost. The ACA gave us the assurance of coverage, but we have a long way to go to get to the assurance of truly affordable care. Let’s talk about that.

Q: Has it been hard to see the ACA dismantled by the Administration?
It has been incredibly disappointing. What was proposed in the ACA stabilization package (reinstatement of cost-sharing reduction subsidies for moderate- and middle-income residents and creation of reinsurance to help high-risk consumers) would have been a measurable benefit to state insurance markets around the country. I worry about the subset of the population [about 1 to 2 percent of Pennsylvanians] who depend on the individual markets and are not eligible for financial assistance. They’re not protected from decisions that have been made in Washington or from future decisions that may weaken the ACA and increase premium prices. But, I always have hope that those of us who have the privilege of serving the public will do whatever we can to protect insurance coverage and have a positive impact.

Q: What will be the impact of the “thin,” short-term policies that the Administration is proposing on state ACA marketplaces?
There are a number of different plans being talked about that don’t guarantee the comprehensive coverage that ACA provides, for example, coverage of essential health benefits, no discrimination against those with preexisting conditions, no caps on insurance limits, and the right to appeal if coverage is denied. I am working to be a source of accurate information in my state for the public, no matter what insurance choices they ultimately have. We will use the state laws we have to educate and protect consumers.

All insurance regulators around the country are concerned about the overall impact that these short-term policies will have on states’ individual markets if they are able to draw healthier people out of those major markets and drive up costs. Here in Pennsylvania, we don’t have laws or regulations that expressly address these short-term plans, but that will not prevent us from monitoring their impact on the market and looking for ways to mitigate negative impacts on those we serve. In particular, we have already revoked a number of licenses of insurance professionals who misrepresented these plans to consumers and will continue to ensure no consumer is misled about the coverage these plans provide – or do not provide.

Q: Do you have tools and responsibilities you didn’t expect to have as a commissioner given the dramatic changes in the national health insurance landscape?
I came into the job when the ACA already existed, but I know other regulators around the country have seen a huge transition. Insurance has historically, and by law, been a purely state-regulated industry. The ACA introduced a dual role, where the federal government has become a secondary regulator in addition to state regulators, and that has definitely been a challenge. Grappling with that will continue to be a challenge, and not limited to just health insurance – it’s true of other areas of insurance where the federal government plays a significant role, like flood insurance. State regulators are problem solvers and our job is to solve the problems facing our consumers. Because of this dual regulatory framework, we need the federal government to be a partner in solving those problems. Unfortunately, that is not what is happening today.

Q: How hard is it to be an insurance commissioner in this era when you need to quickly respond to sudden federal changes to the ACA coverage?
Insurance regulators have always had to mobilize quickly and respond to emergencies such as floods, fires, or earthquakes by getting on the ground and helping the consumers we are here to protect. However, we would much rather focus on those natural disasters than disasters coming due to eleventh-hour and late-breaking decisions from the federal government.

Historically, before the ACA, we only had state-regulated insurance markets, but with these decisions coming from the federal level where sometimes the only role we are able to play is to mitigate a decision that we were not part of making, it’s very frustrating. But, it is rewarding is to be on the ground and indeed try to mitigate those situations.

Q: Do you see your job changing in the months and years ahead?
We have a lot of work to do to monitor numerous things that are coming our way to shape our markets, for example, the potential proliferation of association or short-term health insurance plans. In addition to consumer protection, my department’s role is to serve as a trustworthy source of information, and we’ve been doing much more to be proactive and inform consumers about these issues. When the federal government curtailed insurance market sign-ups and enrollment time, we launched our own coalition of elected officials, insurers, citizen groups, and health care providers to make clear to consumers what was happening, and what the time limit for marketplace sign-up was. I see that effort continuing.

Q: How does being part of NASHP help you in your job?
I’m a big believer in states learning from each other, from what they have done and brainstorming what we can do. It is invaluable to have credible data and state leaders from around the country get together to talk about different approaches and experiences and do it in a nonpartisan and slightly wonky way. That’s incredibly valuable for us who take the time to take advantage of it.

We insurance regulators have the National Association of Insurance Commissioners that plays an irreplaceable role in convening state regulators and facilitating thought and action on national issues facing the insurance industry and the regulatory community, but to have the additional opportunity to meet and talk with state leaders from departments of human services, Medicaid, and other health care systems who have different perspectives allows us to better engage in a comprehensive discussion of state health care policy.

Q: Your governor is proposing integrating the Department of Human Services with the Department of Health to improve efficiency and innovation. Where does your department fit into improving overall improvement of health care delivery?
I am privileged to serve alongside a group of cabinet members who lead Pennsylvania’s health and human services agencies, including my predecessor Teresa Miller, who value collaboration and are committed to taking a unified and coordinated approach to Pennsylvania’s most pressing health care issues. As we look to combat the opioid crisis, to find value in our health care system, to improve health in our rural communities, and deal with the many other issues all state health officials are facing, having the level of communication and partnership that we do is a major asset. We all have different levers and priorities and strategies for our own agencies or constituencies, but doing that in a way that we are all moving in the same direction and with the same ultimate goals in mind is going to mean we get there faster and, at the end of the day, hopefully achieve better outcomes.