Health reform (aka Obamacare) is entering a new stage. The recent announcement by United Health Care that it will stop selling insurance to individuals and families through most health insurance exchanges marks the transition. In the next stage, federal and state policy makers must decide how to use broad regulatory powers they have under the Affordable Care Act (ACA) to stabilize, expand, and diversify risk pools, improve local market competition, encourage insurers to compete on product quality rather than premium alone, and promote effective risk management. In addition, insurance companies must master rate setting, plan design, and network management and effectively manage the health risk of their enrollees in order to stay profitable, and consumers must learn how to choose and use the best plan for their circumstances.

Six months ago, United Health Care (UHC) announced that it was thinking about pulling out of the ACA exchanges. Now, they are pulling out of all but a “handful” of marketplaces. UHC is the largest private vendor of health insurance in the nation. Nonetheless, the impact on people who buy insurance through the ACA exchanges will be modest, according to careful analyses from the Kaiser Family Foundation and the Urban Institute. The effect is modest for three reasons. One is that in some states UHC focuses on group insurance, not on insurance sold to individuals, where they are not always a major presence. Secondly, premiums of UHC products in individual markets are relatively high. Third, in most states and counties ACA purchasers will still have a choice of two or more other options. In addition, UHC’s departure may coincide with or actually cause the entry of other insurers, as seems to be happening in Iowa.

The announcement by UHC is noteworthy, however. It signals the beginning for ACA exchanges of a new stage in their development, with challenges and opportunities different from and in many ways more important than those they faced during the first three years of operation, when the challenge was just to get up and running. From the time when HealthCare.Gov and the various state exchanges opened their doors until now, administrators grappled non-stop with administrative challenges—how to enroll people, helping them make an informed choice among insurance offerings, computing the right amount of assistance each individual or family should receive, modifying plans when income or family circumstances change, and performing various ‘back office’ tasks such as transferring data to and from insurance companies. The chaotic first weeks after the exchanges opened on October 1, 2013 have been well documented, not least by critics of the ACA. Less well known are the countless behind-the-scenes crises, patches, and work-arounds that harried exchange administrators used for years afterwards to keep the exchanges open and functioning.

The ACA forced not just exchange administrators but also insurers to cope with a new system and with new enrollees. Many new exchange customers were uninsured prior to signing up for marketplace coverage. Insurers had little or no information on what their use of health care would be. That meant that insurers could not be sure where to set premiums or how aggressively to try to control costs, for example by limiting networks of physicians and hospitals enrollees could use. Some did the job well or got lucky. Some didn’t. United seems to have fallen in the second category. United could have stayed in the 30 or so state markets they are leaving and tried to figure out ways to compete more effectively, but since their marketplace premiums were often not competitive and most of their business was with large groups, management decided to focus on that highly profitable segment of the insurance market. Some insurers, are seeking sizeable premium increases for insurance year 2017, in part because of unexpectedly high usage of health care by new exchange enrollees.

United is not alone in having a rough time in the exchanges. So did most of the cooperative plans that were set up under the ACA. Of the 23 cooperative plans that were established, more than half have gone out of business and more may follow. These developments do not signal the end of the ACA or even indicate a crisis. They do mark the end of an initial period when exchanges were learning how best to cope with clerical challenges posed by a quite complicated law and when insurance companies were breaking into new markets. In the next phase of ACA implementation, federal and state policy makers will face different challenges: how to stabilize, expand, and diversify marketplace risk pools, promote local market competition, and encourage insurers to compete on product quality rather than premium alone. Insurance company executives will have to figure out how to master rate setting, plan design, and network management and manage risk for customers with different characteristics than those to which they have become accustomed.

Achieving these goals will require state and federal authorities to go beyond the core implementation decisions that have absorbed most of their attention to date and exercise powers the ACA gives them. For example, section 1332 of the ACA authorizes states to apply for waivers starting in 2017 under which they can seek to achieve the goals of the 2010 law in ways different from those specified in the original legislation. Along quite different lines, efforts are already underway in many state-based marketplaces, such as the District of Columbia, to expand and diversify the individual market risk pool by expanding marketing efforts to enroll new consumers, especially young adults. Minnesota’s Health Care Task Force recently recommended options to stabilize marketplace premiums, including reinsurance, maximum limits on the excess capital reserves or surpluses of health plans, and the merger of individual and small group markets, as Massachusetts and Vermont have done.

In normal markets, prices must cover costs, and while some companies prosper, some do not. In that respect, ACA markets are quite normal. Some regional and national insurers, along with a number of new entrants, have experienced losses in their marketplace business in 2016. One reason seems to be that insurers priced their plans aggressively in 2014 and 2015 to gain customers and then held steady in 2016. Now, many are proposing significant premium hikes for 2017.

Others, like United, are withdrawing from some states. ACA exchange administrators and state insurance officials must now take steps to encourage continued or new insurer participation, including by new entrants such as Medicaid managed care organizations (MCOs). For example, in New Mexico, where in 2016 Blue Cross Blue Shield withdrew from the state exchange, state officials now need to work with that insurer to ensure a smooth transition as it re-enters the New Mexico marketplace and to encourage other insurers to join it. In addition, state insurance regulators can use their rate review authority to benefit enrollees by promoting fair and competitive pricing among marketplace insurers. During the rate review process, which sometimes evolves into a bargaining process, insurance regulators often have the ability to put downward pressure on rates, although they must be careful to avoid the risk of underpricing of marketplace plans which could compromise the financial viability of insurers and cause them to withdraw from the market. Exchanges have an important role in the affordability of marketplace plans too. For example ACA marketplace officials in the District of Columbia and Connecticut work closely with state regulators during the rate review process in an effort to keep rates affordable and adequate to assure insurers a fair rate of return.

Several studies now indicate that in selecting among health insurance plans people tend to give disproportionate weight to premium price, and insufficient attention to other cost provisions—deductibles and cost sharing—and to quality of service and care. A core objective of the ACA is to encourage insurance customers to evaluate plans comprehensively. This objective will be hard to achieve, as health insurance is perhaps the most complicated product most people buy. But it will be next to impossible unless customers have tools that help them take account of the cost implications of all plan features and report accurately and understandably on plan quality and service. HealthCare.gov and state-based marketplaces, to varying degrees, are already offering consumers access to a number of decision support tools, such as total cost calculators, integrated provider directories, and formulary look-ups, along with tools that indicate provider network size. These should be refined over time. In addition, efforts are now underway at the federal and state level to provide more data to consumers so that they can make quality-driven plan choices. In 2018, the marketplaces will be required to display federally developed quality ratings and enrollee satisfaction information. The District of Columbia is examining the possibility of adding additional measures. California has proposed that starting in 2018 plans may only contract with providers and hospitals that have met state-specified metrics of quality care and promote safety of enrollees at a reasonable price. Such efforts will proliferate, even if not all succeed.

Beyond regulatory efforts noted above, insurance companies themselves have a critical role to play in contributing to the continued success of the ACA. As insurers come to understand the risk profiles of marketplace enrollees, they will be better able to set rates, design plans, and manage networks and thereby stay profitable. In addition, insurers are best positioned to maintain the stability of their individual market risk pools by developing and financing marketing plans to increase the volume and diversity of their exchange enrollments. It is important, in addition, that insurers, such as UHC, stop creaming off good risks from the ACA marketplaces by marketing limited coverage insurance products, such as dread disease policies and short term plans. If they do not do so voluntarily, state insurance regulators and the exchanges should join in stopping them from doing so.

Most of the attention paid to the ACA to date has focused on efforts to extend health coverage to the previously uninsured and to the administrative stumbles associated with that effort. While insurance coverage will broaden further, the period of rapid growth in coverage is at an end. And while administrative challenges remain, the basics are now in place. Now, the exchanges face the hard work of promoting vigorous and sustainable competition among insurers and of providing their customers with information so that insurers compete on what matters: cost, service, and quality of health care.

Editor's note: This piece originally appeared in Real Clear Markets. Kevin Lucia and Justin Giovannelli contributed to this article with generous support from The Commonwealth Fund.

       

In an increasingly international and interconnected economy, Seattle was global before global was cool.

The region’s competitive global assets include internationally competitive firms, strategically important ports and one of the nation’s largest foreign-born populations.

Still, today’s unique economic moment demands an extra measure of purposeful global engagement.

As cities and metropolitan areas begin to emerge from the Great Recession, leaders are realizing the need to restructure the economy — to move from one based on debt and consumption to one powered by production and innovation.

At the same time, most economic growth over the next decade will occur outside of America’s borders. As of 2009, the combined economies of Brazil, India and China eclipsed that of the United States and now account for more than one-fifth of the global economy. By 2018, their share is expected to surpass one-quarter.

The developing world, with a rapidly rising middle class, represents a huge market opportunity for American firms. China and India alone are expected to increase their urban populations by more than 500 million over the next 20 years, which naturally leads to a rise in their consumer classes. By 2050, Chinese and Indian consumers will account for more than half of all middle-class consumption worldwide, up from just 2 percent in 2000.

These growing metropolises will also require massive investments in infrastructure and face huge challenges as they expand, challenges that U.S. firms have the expertise to solve — in transportation and mobility, in sustainability and clean energy, in information technology and software.

America’s metropolitan areas are uniquely positioned to take advantage of this dual challenge through increased trade and investment. The top 100 metro areas not only produce three-quarters of our gross domestic product, they also concentrate our most innovative firms, our research institutions and universities, and the majority of our skilled workers.

So how does the central Puget Sound region stack up? Recently, I came to Seattle as part of the Global Cities Initiative, a joint project of the Brookings Institution and JPMorgan Chase. This initiative aims to catalyze a shift in economic development priorities and practices that would result in more globally connected metropolitan areas and more sustainable economic growth.

The metro area has a strong platform for trade: firms such as Boeing, Microsoft, and Amazon; world-class research assets including the University of Washington and the Fred Hutchinson Cancer Research Center; and a strong legacy of globally oriented leadership, with a wide coalition, including public, private and civic leaders, actively promoting a regional strategy for global engagement.

The data bear this out: While Seattle is the 15th largest metro area in the United States, it has the sixth highest export total, sending more than $47 billion in goods and services abroad in 2012. These exports are overwhelmingly driven by globally competitive clusters in aerospace and information technology.

Partly due to this industry specialty, Seattle’s economy is also highly innovative and uniquely oriented toward science, technology, engineering and math: More than one-quarter of jobs in the metro are in STEM occupations, the fourth highest share of any metropolitan area in the country.

Still, in such a competitive and dynamic global economy, no metro area can afford complacency. In order to maintain its position in the global economy, Seattle needs to get serious about global engagement.

First, focus on global trade and investment. Continue the collaborative efforts of your public, private and civic leaders to focus economic development strategies on growth abroad. In Seattle earlier this month, regional leaders committed to expanding these efforts, joining the Global Cities Initiative’s Exchange, through which the metro area will develop a strategy to increase foreign direct investment in key industries.

Second, invest in what matters. To compete globally, metro areas must be strong at home. In Seattle, this means shoring up your workforce-development pipeline so that local residents have a path to good jobs in advanced industries. It also calls for a regional approach to financing and delivering transportation solutions that not only reduce congestion at home, but also improve your connections abroad.

Finally, metropolitan leaders must look beyond their own borders, identify their trading partners, and build relationships to increase both trade and investment. For example, as part of the Global Cities Initiative, Chicago and Mexico City entered into a first-of-its-kind economic partnership that builds on the extensive economic, social, cultural linkages between the two metros to make both more prosperous.

There are promising efforts under way in the region, as the King County Aerospace Alliance has started collaborating with Aéro Montréal so that the two aerospace clusters can be more competitive.

Simply put, in today’s economic landscape, every city is a global city. The success of regional economies hinges on their engagement throughout the global economy. Seattle has an enviable hand to play; but success is not inevitable.

This opinion piece originally appeared in the Seattle Times.

       

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The world’s top economies had much to discuss at the G-20 summit in Brisbane, Australia last month, including reinvigorating global growth, the reduction of trade barriers, financial regulation reforms, and global infrastructure. The G-20 meeting took place at a key time for U.S. international economic policy, as it came on the heels of President Obama’s prior stops at the APEC summit and the ASEAN summit. As the U.S. joins its G-20 colleagues in aiming to boost G-20 GDP by an additional 2 percent by 2018, there remain many questions about how G-20 countries will follow through with the goals set in Brisbane.

On December 3, the Global Economy and Development program and the Economic Studies program at Brookings welcomed U.S. Treasury Undersecretary for International Affairs Nathan Sheets in his first public address since being confirmed in September. Following the recent G-20 meeting, Sheets discussed his perspectives on priorities for international economic policy in the years ahead across key areas including trade, the international financial architecture, and the United States’ evolving economic relationships.

Join the conversation on Twitter using #GlobalEconomy

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• U.S. Economic Engagement on the International Stage: A Conversation with U.S. Treasury Undersecretary Nathan Sheets

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• U.S. Economic Engagement on the International Stage: A Conversation with U.S. Treasury Undersecretary Nathan Sheets

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• 20141203_sheets_international_economic_engagement_transcript

      

We will likely look back on 2015 as a consequential year in China’s evolving global strategy. The September crash of the stock market in Shanghai marks the first contemporary occasion when China’s internal difficulties have had global consequences. In November, China will take over the leadership of the G-20 and have an opportunity to put its stamp on the evolving tools of global governance. And on September 28, President Xi Jinping will address the world during the 70th anniversary of the only global body in which China already has full powers—the United Nations.

A rising power, cut from different cloth

But with greater consequence comes greater responsibility. President Xi’s job at the U.N. in 2015 will be harder than in recent years. For the past several years the international community has been transfixed by the narrative of the rising powers, and of American, or at least Western, decline. Now, America’s economic recovery, its energy revolution, its leadership on Ebola, and its re-engagement around the Islamic State (or ISIS)—however partial—has gutted the “American decline” narrative. 

And Xi’s putative allies in the forging of a post-American order—Russia, Brazil, and India—won’t be nearly the help to China they have often been presumed to be. President Vladimir Putin will speak against the backdrop of Russia’s aggressive strategy in Ukraine and now Syria; Brazil’s President Dilma Roussef against the backdrop of a deep recession and a huge corruption scandal; and while President Narendra Modi is still riding relatively high internationally, he’s hardly riding in a pro-China direction. 

China is more consequential than any of these other three, of course. But it faces its own challenge to its narrative as it doubles down on its assertive posture in the South China Sea and as its handling of the stock market collapse shows serious cracks in the narrative of the “Beijing model.” As Chinese growth has slowed, especially in the manufacturing sector, so has its consumption of global commodities—and the knock-on effect has been slower growth in dozens of developing countries that had ridden China’s boom. China isn’t quite the alternative “pole” to the West it has been hyped to be. 

Still, China is now clearly the number two economy in the world; the number two defense spender; the dominant force in politics and economic integration in East Asia; and an increasingly important voice on global issues. So hype and narrative aside, the world will be listening closely to what President Xi has to say at the U.N.—as they will when he takes the reigns of the G-20. 

In what direction is Chinese leadership heading?

At a 700-person-strong gala dinner in Seattle on Tuesday, President Xi rehearsed the arguments. China is committed to a peaceful rise. China has learned the lesson of the Second World War, and recognizes that military hegemony is not an option. China is committed to the multilateral order, and the U.N. Charter. He even teased the international relations scholarly community: “There is no Thucydides trap,” he said, referring to the idea that the growth of Chinese power will cause fear in the United States and lead to war. He stressed his theme about forging a “new kind of great power relations” that eschewed military competition for more creative approaches to cooperation on win/win issues. 

All these would be welcome messages at the U.N., and if he means it, they are profoundly important messages. But if Xi wants these messages to be believed, if he wants to gain credibility at the global level, he’s going to have to do more than just talk a good game. 

First, China is going to have to start acknowledging that leadership is less about abusing the privileges of power and more about absorbing costs. The world may be hungry for leadership, but it’s not hungry for leadership of the abusive kind. It’s hungry for actors capable and willing to set a direction and bear the lion’s share of the costs of action—because that’s the only thing that’s ever overcome the collective action challenges that otherwise bedevil cooperation at the international level. 

China is going to have to start acknowledging that leadership is less about abusing the privileges of power and more about absorbing costs.

Second, he has to put his strategy where his principles are. He could start with the U.N. Charter. It’s an essential document of the international order, but only if the great powers abide by its essential principles (not by every detail.) The most essential of these are the prohibition against the acquisition of territory by force and the assertion of non-interference in sovereign affairs (except with the backing of the Security Council). The United States has violated these principles, notably in Iraq—its violation was of a temporary nature, of course, but had huge consequences. Russia has violated these principles—its violation in Crimea is modest in scale but notionally permanent and a fundamental violation of the foundational principles of the U.N.

China’s actions in the South China Sea have been more subtle than these, but no less invidious or injurious to the notion of a stable international order. If China wants others to believe that it still intends for its rise to be peaceful, it needs urgently to shift strategy in the South China Sea—and it would be in a strong position, then, to call on the other great powers to recommit themselves to the principle of the non-use of force and respect for sovereignty. 

[Xi] has to put his strategy where his principles are. He could start with the U.N. Charter.

I’m reasonably optimistic about the first idea. China was among the most neuralgic of countries when it came to the global response to SARS a decade ago; it’s learned its lesson and was far more forward leaning on Ebola. It chipped in, albeit not to scale, on the eurocrisis. It’s made financial contributions to the counter-ISIS campaign. And it’s made commitments that, if kept, will make a vital difference on the climate. These efforts represent a serious start, and if President Xi expands China’s role in this kind of leadership it could position him well on global issues—especially during his G-20 presidency. 

I’m not so optimistic about the second. China shows every sign of being locked in an assertive-tilting-to-aggressive strategy in the South China Sea, consequences be damned. And with Russia also seemingly locked into a “wrong-foot the West” strategy, the United States and its allies will increasingly be pulled into an escalatory response—creating exactly the kind of Thucydidean trap President Xi ostensibly wants to avoid. (The United States bears responsibility here too, and it can also take steps to lower tensions in Asia.) 

The problem is, the further out we go along the pathway of security tensions in Asia, the more we undermine the prospects for win-win cooperation on global challenges like terrorism and climate. For now, these twin strands of strategy are in roughly equal balance—both rivalry and restraint are leitmotifs of Xi’s worldview, and of America’s. But 2015 is going to be an important testing time for the viability of this dual-strand approach. If Xi wants to start tilting the balance to win/win approaches, his speech at the U.N. is a good place to start. But even that would only be a beginning.

       

       

Editor's Note: The National Perspectives on Global Leadership (NPGL) project reports on public perceptions of national leaders’ performance at important international events. The sixth series of commentary focuses on the Cannes G-20 Summit and discusses the ongoing euro crisis, the rising G20 profile, and the growing social mobilization around concerns with the global crisis. Read the other commentary »

OVERVIEW: COMPARATIVE PERSPECTIVE ON THE CANNES G20 SUMMIT

Despite the euro zone crisis, the profile of the G20 was raised in many member-state capitals, and G20 leaders and media did focus on other agenda items and domestic issues.

Reporting from 13 G20 countries reveals that, through the eyes of the national media, the euro crisis “overwhelmed,” “dominated,” “totally sidetracked” or “hijacked” the Cannes G20 Summit on Thursday night through Friday afternoon, November 4-5, 2011. Only Argentina seems to have been captivated by the bilateral meeting between US President Barack Obama and their leader, President Cristina Kirschner, to such a degree that it overshadowed the global preoccupation with the Greek debt crisis and its implications for the euro zone and the global economy. As she did at other G20 summits, Cristina Kirschner found a way to project her own priorities and portray them to the Argentine public through deliberate preparation with her cabinet beforehand and in regional consultations, and this also held true at her appearance at the B20 (G20 business summit) held just before the G20.

Other Issues

G20 leaders and the national media in G20 capitals were, nonetheless, able to focus on several other G20 issues of vital interest to their publics.

Kirschner and other leaders were indeed able to project to the national media in their capitals other issues and priorities, despite the euro crisis capturing public attention around the world. The two most frequently profiled international issues in the G20 capitals surveyed here, were the financial transactions tax proposal and the G20’s work on tax havens that began in London in 2009. Among the other issues discussed was the strong focus on development by Chinese President Hu Jintao and on least-developed countries by South African President Jacob Zuma. The Financial Stability Board (FSB) action on “too big to fail” banks was highlighted by The Washington Post on Saturday morning, as well as by the Canadian media, in part because Canada’s central bank governor, Mark Carney, was named head of the FSB, replacing Mario Draghi. Japanese Prime Minister Yoshihiko Noda was able to keep his country’s media focused on his priorities.

What was also of interest to NPGL country observers was the extent to which some G20 leaders were able to profile their domestic concerns, linking the Cannes G20 deliberations on either Europe or the on-going G20 agenda to jobs and growth at home. Canadian Prime Minister Stephen Harper highlighted the fact that the G20 Action Plan on Growth and Jobs, which was endorsed in Cannes, corresponded exactly to the title of his government’s 2011 budget. Brazilian President Dilma Rouseff highlighted the International Labour Organization’s social initiative on the G20 agenda, likening it to her government’s domestic program of social inclusion.

South Africa’s Jacob Zuma emphasized jobs as crucial to South Africa’s future, which coincided strongly with the Congress of South African Trade Unions labour leader’s meeting with Nicolas Sarkozy in Cannes. U.S. President Barack Obama’s major thrust in Cannes was to support the Europeans’ efforts to resolve the euro crisis themselves as being critical to jobs and growth in the United States against a background of a U.S. job report the same day. In her appearance at the B20 meeting, Cristina Kirschner declared herself against the “anarchic financial capitalism” that had dramatically impacted people in the real economy, not just bankers and banks.
 
Despite the overwhelming force of events in Greece, Italy and global financial markets on the same days that the Cannes summit took place, events which riveted the world’s attention, G20 leaders and the national media in their capitals were, nonetheless, able to focus on several other G20 issues of vital interest to their publics.

Communications

The global crisis managed to create a higher profile for the G20 in many G20 capitals.

The combination of the euro crisis drama and the growing social mobilization around peoples’ concerns with the global crisis, managed to create a higher profile for the G20 in many of its capitals.
 
Our NPGL colleagues from China begin their commentary by saying: “the first thing that should be reported from Beijing is that China’s media have begun to pay more attention to the G20 than in the past.”

From Germany, we learn that “the Cannes event generated a higher volume of media coverage than previous G20 summits.”
 
“This summit had a great deal of relevance for the Argentine public,” we are told by our NPGL colleague in Buenos Aires. “After London, the summit in Cannes has received the greatest attention by the media,” she adds. “The Cannes summit was seen to have a large impact on the Argentine public.”
 
And in South Africa, “surprisingly, media coverage was not cynical, such as ridiculing G20’s role, which we have witnessed in the recent past. Again this probably was due to the magnitude of the issues at stake, and in that sense, probably more closely resembles the political dynamics around the London summit.”

From Tokyo, “Japanese public and media attention to the G20 meeting in Cannes was higher this time.”

But, interestingly, in contrast to massive attention to the G20 summit held in Seoul a year ago, “very little attention” was paid to the Cannes G20 Summit by the Korean media and public.

Other Leaders, Leading

In this intense context, two sets of leaders stood out visibly in most G20 capitals as the euro crisis–G20 drama unfolded: Nicolas Sarkozy and Angela Merkel battling for the core of Europe against George Papandreou and Silvio Berlosconi on the periphery. Barack Obama was given lots of space in the media in France, the United States, Mexico, Australia and South Africa, but he was seen as “marginal” in Germany, “detached” in the United Kingdom, and “not given special attention” in Canada, for example. Christine Lagarde, the new head of the International Monetary Fund (IMF), seemed to be given more play in the G20 emerging market economies media, than in the G20 industrial economies of the West. Leaders were varied in the intensity of their participation in the summit and their interactions with the global and national media.

Concluding Remarks

In the end, the euro crisis took centre stage at the Cannes summit in the eyes of most of the world, but as observed through the media in G20 capitals, other issues managed to surface for public attention, and national leaders from G20 countries were able, in several cases, to project their own priorities amid the welter of events in Athens and Rome, as well as Cannes, during those two turbulent days in early November 2011. The profile of the G20 was strikingly more visible in many capitals, but serious questions were raised in Mexico and Korea, especially about the future of G20 summits.

Our NPGL colleague in Mexico noted that “the fact that no specific goals, financial commitments or timelines were set for the principal agenda items included in the communiqué was highlighted in commentaries [in Mexico] that focused on why the leaders’ level G20 is not really the ‘premier’ forum its founders proclaimed it to be and why its very existence as a global steering committee is at stake.” From Korea, we heard that “the image of the G20 leaders that prevailed in Korea was one of a confused and ineffective bunch.” The sense in Australia, however, was that the G20 is “the best option on offer.”

As Mexico prepares to take up the presidency next year, and as we look ahead to Russia and Australia’s presidency in the years ahead, it is clear that many challenges remain.

UNITED STATES

As surely was the case in other countries, the Greek debt drama, with the proposed referendum, withdrawn referendum and the vote of confidence, overshadowed and seemed to stymie action by G20 leaders in Cannes. But the competing headlines in Washington focused on the jobs report for October, which showed mixed results with public sector jobs falling significantly while private sector employment grew steadily again, and the debate in Congress between Republican and Democratic versions of a jobs bill. CNN’s John King was called upon to comment on the G20 summit from his perch in Iowa, reminding viewers that there was a seamless connection between the president’s efforts to push Europeans to deal with their debt and financial fragility, and his reelection prospects.

There is no doubt that in Washington, Athens was more visible than Cannes, and that the G20 summit took a back seat to the euro crisis. The Financial Times opined that the “forum’s high ambitions delivered meager results” as a headline. This certainly is borne out by the communiqué, which indeed did not push forward the specifics of the G20 agenda.

President Obama made his position extremely clear in his actions and words at Cannes, that he regarded the euro crisis as a European problem and the solutions were within Europe’s grasp and did not require outside support for the moment — a geopolitical strategy, which revealed his conviction that Europe is pivotal for the United States economically and strategically, keeping China and Asia more in the background. The fact that the Cannes summit put out an Action Plan on Growth and Jobs and the interdependence of the United States and Europe is the centerpiece for global growth, linked well to his domestic agenda of recovery and employment.

Other Issues

Importantly, the G20 summit approved an FSB report, making public for the first time a list of 29 “too big to fail” banks that would be subject to more vigorous FSB oversight and higher capital requirements, in order to protect taxpayers from bailing out failed banks. This is a highly significant G20 accomplishment, following directly from the seminal London G20 Summit in April 2009, at which the expanded FSB was established, incorporating all G20 countries into what was a highly euro-centric predecessor, and carrying forward the London G20 priority on strengthening national andglobal mechanisms for financial oversight, supervision and regulation. Interestingly, only The Washington Post carried this story as part of its G20 coverage — no articles on this G20 action appeared in The New York Times or the Financial Times.

Communications

President Obama’s press conference at the conclusion of the Cannes G20 Summit was carried live on CNN late on the morning of November 4, with wide CNN commentary afterward, linking Obama’s thrust in Europe with his domestic economic and political agenda. The Washington Post on November 5 grasped the strategic point of the president in an editorial: “Cannes heat: President Obama delivers the right message to Europe.” The Post argued, based on Obama’s remarks in Cannes, that “even if we [the United States] had the money to rescue the euro, it’s not clear that we should make such an investment, unless and until Europe itself had exhausted its resources, which it has not yet done… if the Europeans mean it when they say that the fate of their union itself depends on saving the euro, they will find a way.”

So, whereas the G20 profile receded in the face of the euro avalanche, US global interests were projected clearly and forcefully by the American president to European leaders and to the US public, from his participation in the Cannes G20 Summit. The link between US domestic political imperatives and a global strategic thrust was forged and made visible by Obama’s presence in Cannes.

Other Leaders, Leading

The image of the G20 leaders that prevailed in the US media from the Cannes G20 Summit was predominantly Obama with European leaders, not with Asian leaders or leaders from other parts of the world represented in the G20 grouping. Even The Washington Post editorial contained a photo nested into the editorial itself of Obama, Merkel, Sarkozy and Cameron talking in an animated fashion with the G20 France imprimatur in the background. This was clearly consistent with the dominance of the euro crisis in the meeting itself, and with Obama’s strategic focus and message. In other G20 summits, Obama with Hu Jintao in London, or Berlusconi thrusting himself between Obama and Medvedev in Pittsburgh, were memorable images. In Washington, the West was shown at Cannes as being front and centre stage, with The New York Times carrying an amusing and insightful portrait of the relationship between Barack Obama and Nicolas Sarkozy.

      

Health reform (aka Obamacare) is entering a new stage. The recent announcement by United Health Care that it will stop selling insurance to individuals and families through most health insurance exchanges marks the transition. In the next stage, federal and state policy makers must decide how to use broad regulatory powers they have under the Affordable Care Act (ACA) to stabilize, expand, and diversify risk pools, improve local market competition, encourage insurers to compete on product quality rather than premium alone, and promote effective risk management. In addition, insurance companies must master rate setting, plan design, and network management and effectively manage the health risk of their enrollees in order to stay profitable, and consumers must learn how to choose and use the best plan for their circumstances.

Six months ago, United Health Care (UHC) announced that it was thinking about pulling out of the ACA exchanges. Now, they are pulling out of all but a “handful” of marketplaces. UHC is the largest private vendor of health insurance in the nation. Nonetheless, the impact on people who buy insurance through the ACA exchanges will be modest, according to careful analyses from the Kaiser Family Foundation and the Urban Institute. The effect is modest for three reasons. One is that in some states UHC focuses on group insurance, not on insurance sold to individuals, where they are not always a major presence. Secondly, premiums of UHC products in individual markets are relatively high. Third, in most states and counties ACA purchasers will still have a choice of two or more other options. In addition, UHC’s departure may coincide with or actually cause the entry of other insurers, as seems to be happening in Iowa.

The announcement by UHC is noteworthy, however. It signals the beginning for ACA exchanges of a new stage in their development, with challenges and opportunities different from and in many ways more important than those they faced during the first three years of operation, when the challenge was just to get up and running. From the time when HealthCare.Gov and the various state exchanges opened their doors until now, administrators grappled non-stop with administrative challenges—how to enroll people, helping them make an informed choice among insurance offerings, computing the right amount of assistance each individual or family should receive, modifying plans when income or family circumstances change, and performing various ‘back office’ tasks such as transferring data to and from insurance companies. The chaotic first weeks after the exchanges opened on October 1, 2013 have been well documented, not least by critics of the ACA. Less well known are the countless behind-the-scenes crises, patches, and work-arounds that harried exchange administrators used for years afterwards to keep the exchanges open and functioning.

The ACA forced not just exchange administrators but also insurers to cope with a new system and with new enrollees. Many new exchange customers were uninsured prior to signing up for marketplace coverage. Insurers had little or no information on what their use of health care would be. That meant that insurers could not be sure where to set premiums or how aggressively to try to control costs, for example by limiting networks of physicians and hospitals enrollees could use. Some did the job well or got lucky. Some didn’t. United seems to have fallen in the second category. United could have stayed in the 30 or so state markets they are leaving and tried to figure out ways to compete more effectively, but since their marketplace premiums were often not competitive and most of their business was with large groups, management decided to focus on that highly profitable segment of the insurance market. Some insurers, are seeking sizeable premium increases for insurance year 2017, in part because of unexpectedly high usage of health care by new exchange enrollees.

United is not alone in having a rough time in the exchanges. So did most of the cooperative plans that were set up under the ACA. Of the 23 cooperative plans that were established, more than half have gone out of business and more may follow. These developments do not signal the end of the ACA or even indicate a crisis. They do mark the end of an initial period when exchanges were learning how best to cope with clerical challenges posed by a quite complicated law and when insurance companies were breaking into new markets. In the next phase of ACA implementation, federal and state policy makers will face different challenges: how to stabilize, expand, and diversify marketplace risk pools, promote local market competition, and encourage insurers to compete on product quality rather than premium alone. Insurance company executives will have to figure out how to master rate setting, plan design, and network management and manage risk for customers with different characteristics than those to which they have become accustomed.

Achieving these goals will require state and federal authorities to go beyond the core implementation decisions that have absorbed most of their attention to date and exercise powers the ACA gives them. For example, section 1332 of the ACA authorizes states to apply for waivers starting in 2017 under which they can seek to achieve the goals of the 2010 law in ways different from those specified in the original legislation. Along quite different lines, efforts are already underway in many state-based marketplaces, such as the District of Columbia, to expand and diversify the individual market risk pool by expanding marketing efforts to enroll new consumers, especially young adults. Minnesota’s Health Care Task Force recently recommended options to stabilize marketplace premiums, including reinsurance, maximum limits on the excess capital reserves or surpluses of health plans, and the merger of individual and small group markets, as Massachusetts and Vermont have done.

In normal markets, prices must cover costs, and while some companies prosper, some do not. In that respect, ACA markets are quite normal. Some regional and national insurers, along with a number of new entrants, have experienced losses in their marketplace business in 2016. One reason seems to be that insurers priced their plans aggressively in 2014 and 2015 to gain customers and then held steady in 2016. Now, many are proposing significant premium hikes for 2017.

Others, like United, are withdrawing from some states. ACA exchange administrators and state insurance officials must now take steps to encourage continued or new insurer participation, including by new entrants such as Medicaid managed care organizations (MCOs). For example, in New Mexico, where in 2016 Blue Cross Blue Shield withdrew from the state exchange, state officials now need to work with that insurer to ensure a smooth transition as it re-enters the New Mexico marketplace and to encourage other insurers to join it. In addition, state insurance regulators can use their rate review authority to benefit enrollees by promoting fair and competitive pricing among marketplace insurers. During the rate review process, which sometimes evolves into a bargaining process, insurance regulators often have the ability to put downward pressure on rates, although they must be careful to avoid the risk of underpricing of marketplace plans which could compromise the financial viability of insurers and cause them to withdraw from the market. Exchanges have an important role in the affordability of marketplace plans too. For example ACA marketplace officials in the District of Columbia and Connecticut work closely with state regulators during the rate review process in an effort to keep rates affordable and adequate to assure insurers a fair rate of return.

Several studies now indicate that in selecting among health insurance plans people tend to give disproportionate weight to premium price, and insufficient attention to other cost provisions—deductibles and cost sharing—and to quality of service and care. A core objective of the ACA is to encourage insurance customers to evaluate plans comprehensively. This objective will be hard to achieve, as health insurance is perhaps the most complicated product most people buy. But it will be next to impossible unless customers have tools that help them take account of the cost implications of all plan features and report accurately and understandably on plan quality and service. HealthCare.gov and state-based marketplaces, to varying degrees, are already offering consumers access to a number of decision support tools, such as total cost calculators, integrated provider directories, and formulary look-ups, along with tools that indicate provider network size. These should be refined over time. In addition, efforts are now underway at the federal and state level to provide more data to consumers so that they can make quality-driven plan choices. In 2018, the marketplaces will be required to display federally developed quality ratings and enrollee satisfaction information. The District of Columbia is examining the possibility of adding additional measures. California has proposed that starting in 2018 plans may only contract with providers and hospitals that have met state-specified metrics of quality care and promote safety of enrollees at a reasonable price. Such efforts will proliferate, even if not all succeed.

Beyond regulatory efforts noted above, insurance companies themselves have a critical role to play in contributing to the continued success of the ACA. As insurers come to understand the risk profiles of marketplace enrollees, they will be better able to set rates, design plans, and manage networks and thereby stay profitable. In addition, insurers are best positioned to maintain the stability of their individual market risk pools by developing and financing marketing plans to increase the volume and diversity of their exchange enrollments. It is important, in addition, that insurers, such as UHC, stop creaming off good risks from the ACA marketplaces by marketing limited coverage insurance products, such as dread disease policies and short term plans. If they do not do so voluntarily, state insurance regulators and the exchanges should join in stopping them from doing so.

Most of the attention paid to the ACA to date has focused on efforts to extend health coverage to the previously uninsured and to the administrative stumbles associated with that effort. While insurance coverage will broaden further, the period of rapid growth in coverage is at an end. And while administrative challenges remain, the basics are now in place. Now, the exchanges face the hard work of promoting vigorous and sustainable competition among insurers and of providing their customers with information so that insurers compete on what matters: cost, service, and quality of health care.

Editor's note: This piece originally appeared in Real Clear Markets. Kevin Lucia and Justin Giovannelli contributed to this article with generous support from The Commonwealth Fund.

       

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