There's some disingenuity in Bertolini's message as it's evolved over the past two weeks, however. Yesterday he told WonkBlog's Sarah Kliff that the Supreme Court decision doesn't matter, that Aetna and the industry will continue with innovation regardless of the decision, and that a deficit reduction deal is more important than the ACA. That's backwards. If the ACA's new rules for health insurers and array of cost-cutting incentives for healthcare providers and insurers are left in place, they will likely have a bigger long-term impact on government spending than any tax-and-spending deal the Congress strikes. Bertolini's own boasts about Aetna's recent accomplishments and strategy indicate as much, though he's now working to unmoor their origin and continued impetus from the ACA. Check out the denial in his exchange with Kliff:
“The Supreme Court ruling does not matter for our business strategy,” Bertolini says. “It’s a political event. Whether or not the Supreme Court impacts the Affordable Care Act in some way, we still have to keep moving forward to impact the cost of care in America.”Sarah Kliff does great work, but methinks her boss Ezra Klein would have stopped Bertolini right there to ask: where did the impetus for those pilot programs and ACOs come from? The ACA provides incentives to healthcare providers to form ACOs and has funded a host of pilot programs itself. Yes, Aetna has been experimenting with ACOs since 2007 (per the Aetna press release Kliff links to), and yes, the ACA incentives for ACOs are provided through Medicare. But the ACA has spurred healthcare providers nationwide to seek out ACO partnerships. And, as Bertolini has acknowledged elsewhere, the cumulative pressure to cut costs on multiple fronts provided by the ACA is spurring innovation of the kind he boasts about.
Bertolini and I had a chance Thursday to talk about how he sees the health insurance industry changing. He (like everyone else) sees costs going up — and thinks that’s bad for business. That goes back to 2005, when the company did a “deep dive” looking at where their various products were headed.
“We saw an individual market in inexorable decline and, on the small group side, fewer were offering benefits and costs were rising. We knew we had to change something,” Bertolini said.
It was around then that Aetna began testing out ways to deliver better health care, for a lower price. There have been 57 pilot programs in total, big and small, scattered across the country. It is now participating in 10 accountable care organizations, where it bands together with doctors and reimburses them on the quality of their work, rather than quantity. Seventeen more of those are in the pipeline.
Bertolini was more honest in assessing the role of the ACA back on June 12, when he spoke to the Wall Street Journal's Anna Wilde Mathews. My emphasis:
WSJ: How are you preparing for the Supreme Court ruling?Here too, I think there's a good measure of denial. If the ACA's new rules of the road for insurers and/or incentives to providers are struck down...trust us, and trust market competition, to keep that model airplane aloft. Bertolini credits the incentives and strictures for driving change to date but wants to convince us, in effect, that they have already done their work -- as if the ACA could do its work by serving as a gigantic two-year bluff.
Mr. Bertolini: There are a lot of things that we would have needed to do in order to be competitive in the marketplace anyway. If the Affordable Care Act were to go away tomorrow, we still would be better off as an organization, because who can argue with getting a lower health-care delivery cost, more streamlined administrative structure, making yourself simpler and less complex to do business with? If that all happened and then health-care reform went away, we would be better off and so would our customers. Our view is this is just an action-forcing event, through which we can drive some change, not only inside our company, but across the industry. That otherwise wouldn't have happened.
WSJ: If the law were struck down, are there things you would have to unravel?
Mr. Bertolini: People assume that what's in the bill is what we are implementing. But what happens is the bill is sort of like an airplane model kit. You've got these directions that come with all these parts. You start putting it together and you go, 'You know what? I'm not going to do it that way. I'm going to do it this way.' [Laughs.] In regulation you actually get a chance to fix it. I think this is what we are seeing. So, I would argue, on the Supreme Court case specifically, that the individual-coverage requirement, the guaranteed issue and community rating [provisions that require insurers to sell plans to consumers regardless of pre-existing health conditions and not peg premiums to health status], are all things that needed to be fixed in regulation anyway.
As they were structured, they were unworkable or weren't going to work the way they were intended.
The Supreme Court case, from my perspective, is important in its constitutional role, but has far less impact on the Affordable Care Act than I think the American public and the political blogosphere is giving it.
I am not convinced.