Sabrina Corlette: 'We're Still Seeing a Fair Amount of Price Volatility'

Sabrina Corlette is a senior research professor at the Georgetown University Center on Health Insurance Reforms. She previously worked as the director of health policy programs for the National Partnership for Women & Families. With the Affordable Care Act's insurance marketplaces beginning their third open enrollment this week, RealClearHealth talked to Corlette about what's working, what's not working, what the marketplaces' risk pools look like, and what should be on the agenda of a new administration in 2017.

A transcript follows.

Earlier: Douglas Holtz-Eakin on 3rd ACA Open Enrollment

RealClearHealth: Looking back at the rollout of the ACA, what has worked better than expected?

Sabrina Corlette: We have 16.4 million new people insured, thanks to the law. The marketplaces, after a little bit of a rocky start, are up and running and running pretty successfully, getting people into coverage.

Thankfully, people with preexisting conditions are able to get access to health insurance coverage in a way that they weren't able to before the law was enacted. And, knock on wood, prices are staying pretty moderate. The health care cost growth that we were seeing rise at such incredible rates before the law was passed, those annual rates of increase have moderated a little bit.

RealClearHealth: What has been the biggest failure of the Affordable Care Act?

Sabrina Corlette: The number one issue right now is the failure of a pretty significant number of states to implement the Medicaid expansion, and that's leaving thousands and thousands of low income people without any health care coverage at all. So we're in this perverse situation, where people who have moderate means are able to get access to federal financial help to get health coverage, but if you're poor, you can't get anything in these states. There is literally nothing for you; they call it the Medicaid coverage gap. And that is, thus far, one of the biggest disappointments in the law.

RealClearHealth: Do insurers now have a good idea of how to price insurance on the marketplaces?

Sabrina Corlette: The first year, we had a lot of people coming into the marketplaces that had pretty serious health conditions -- a lot of pent up demand -- and there was a lot of uncertainty from among the insurance companies about how to really price for that accurately.

That kind of uncertainly is definitely diminished. Interestingly, though, we're still seeing a fair amount of price volatility. Some insurance companies are increasing their prices. Some are decreasing their prices. And some are staying about the same.

Because the first couple of years of pricing were such a shot in the dark for the insurance companies, some of them priced really high, some of them priced really low, and now there's sort of a gravitation to the mean, I think. So some are coming down. Some are coming up. I think we're still probably in for another couple more years of volatility before the market truly stabilizes. But, hopefully, by the time the ACA's risk mitigation programs expire, we'll see a little more certainty for the insurance carriers about what they can expect in terms of risk.

RealClearHealth: Looking ahead to 2017, what would you put at the top of the agenda?

Sabrina Corlette: I still think that there are significant problems with affordability for people who are trying to buy coverage through the marketplace. Congress has said that if something is more than 8 percent of your income, it's not affordable.

But, I'll tell you, for a lot of consumers, 8 percent of income to spend on health insurance is still way too much. And we're just talking about premiums. The deductibles in many of these plans are very, very high, so we hear from a lot of people who are in good faith paying their premiums and are shocked to learn when they go to the doctor or get some kind of care that there's a pretty high deductible that goes along with it. I think those are big barriers for a lot of folks, particularly low- and moderate-income folks, to get coverage. So I would love to see Congress take another look at how affordable these products really are.

RealClearHealth: There aren't many people buying unsubsidized insurance on the marketplaces. What can be done to address that?

Sabrina Corlette: There are some things that you can do that might not be so terribly expensive. Obviously, if you're talking about enhancing the subsidies, making the subsidies more generous, that is a big cost for the federal government. But there are things you could do, for example, to look at how the deductibles work. If you could maybe cover a little bit more primary care or some prescription drugs that people need to treat chronic diseases before they have to pay that deductible, I think that would be a huge help to a lot of people.

The deductible serves as a very blunt instrument. So not only are people delaying or forgoing unnecessary care, but often, unfortunately, they are forgoing necessary care. So if we can figure out a way to insure that people have affordable primary care as well as the care that is needed to treat chronic conditions and keep people healthy, I think that would be a big step forward.