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President's Perspective: The Sky Did Not Fall

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Fortunately for all of us the sky did not fall in 2014. A year ago at this time the nation in general and healthcare providers in particular were all in a tither about whether the rollout of the Affordable Care Act (ACA) was going to be a boon or a boondoggle. The answer, of course, was yes. After a chaotic start to new insurance sign ups through, and the-world-is-ending-as-we-know-it prognostications from virtually all sides of the political spectrum, we survived.

Here in Iowa you could even claim we thrived. The political compromises that resulted in the Iowa Health and Wellness legislation resulted in tens of thousands of Iowans gaining coverage that they didn't have before, provided hospitals and physicians with reimbursements for services they couldn't get before, and brought nearly a billion dollars of federal funds into Iowa that we wouldn't have gotten before.

That said the year was not without its bumps. While thousands of Iowans were able to work their way through the new system, it wasn't without considerable frustration for many of them trying to figure out confusing and complex choices. Insurance coverage information for providers was incomplete at best and changing month to month as individuals determined on their own if they were going to keep up with their payments to plans that were not a hundred percent subsidized. The state as a whole was still trying to determine which insurers were going to participate in the new marketplace, which elements of the ACA were actually going to be enforced on employers and insurers, and how accurately had these same insurers predicted their prices and costs for said coverages.

This latter issue was boldly demonstrated with the December takeover of CoOpportunity Health by the Iowa Insurance Commissioner. In a way CoOpportunity appears to be a victim of its own success. The two-state co-op enrolled roughly 100,000 Iowans and Nebraskans against an initial projection of less than half that. Depending on one's perspective the problem came either from CoOpportunity underpricing itself, drawing more members with higher risks than anticipated, or from the federal government's decision to allow people to keep existing insurance plans that didn't meet federal ACA requirements, thereby depriving CoOpportunity the chance to enroll previously insured and presumably healthier members to offset the higher risk populations. Whatever the cause, the result was a clear example that implementing the ACA is not without peril.

To its credit, Iowa overall appears to be handling the transition well. Community groups of all stripes worked together across the state to help educate citizens about their new insurance choices and well over 100,000 did so. Charity care and bad debt for both hospitals and physicians across the state appear to be markedly reduced. There are still people without coverage, and they are still getting cared for in times of duress, but access is always either challenging, or directed to more expensive Emergency Room resources for people without adequate insurance, so the additional coverage for folks is helping them access care earlier and at, hopefully, at a lower cost. At the same time Iowa achieved a model that retains a modicum of individual responsibility for people of all income groups relative to their own health and payment for services. All in all, it's typical Iowa: a practical, pragmatic set of solutions to what could have been either an explosive political stalemate or, even worse, an attempt to ignore that the problem existed at all.

For 2015 there will be new challenges. CoOpportunity's early stumble leaves only one insurance carrier in the new government-mandated market space. To be a viable market we will need viable competition. We will need to decide, particularly if the Supreme Court rules against insurance subsidies in federally based insurance exchanges, whether Iowa moves ahead with establishment of an Iowa-based marketplace that reflects the specific needs of Iowans versus the hybrid we have today.

And while insurers and providers continue to reshape themselves for the much heralded era of population health, there are a host of other issues coming down the pike. Iowa is one of only four states without a law covering telehealth services, one of the fastest growing and most innovative ways to deliver more cost effective healthcare in the future. We still haven't finished the transformation of delivering and paying for behavioral health services in a new and better way based on regional approaches versus ninety-nine different counties.

Iowa will need to respond to the possible adoption of an Interstate Physician Licensure Compact that will allow physicians licensed in Iowa to offer services, particularly telehealth-based services, in other states and vice versa for physicians licensed in other states that have already adopted the compact offering their services to Iowans. That last step alone could have a major impact on the availability of services, particularly to rural areas, in ways we can't even imagine today.

Which of course leaves plenty of room for unintended consequences, unforeseen situations and conflicting ideas, the resolving of which appears to be a uniquely admirable quality of this state.

Take a bow, Iowa.