Politics & Policy

Bluegrass Bummer

Does Kentucky's experience with health-insurance overregulation hold lessons for repealing Obamacare?

In the mid-1990s, Kentucky was one of eight state governments that boldly went where the rest of the country refused to go: The commonwealth imposed Clintoncare’s restrictions on its insurance companies, even though Clintoncare had been vanquished from the national stage. In Kentucky and the other seven states, insurance premiums skyrocketed, healthy people stopped buying insurance, and insurance companies exited the market in droves. Only three of the eight were able to untangle themselves from the harmful provisions; only one, Kentucky, was able to pull off a full repeal.

Trey Grayson was elected Kentucky secretary of state in 2003, the year before Gov. Ernie Fletcher was able to finalize the repeal — you’ll note it took ten years to accomplish. Grayson, who is currently running for the Republican nomination to replace Jim Bunning in the U.S. Senate, says that those pushing to repeal Obamacare can take a few lessons from the Kentucky experience. “On the one hand it gives you some hope, because in Kentucky we were able to gradually repeal the elements that were driving up the number of uninsured, that were increasing premiums at a rate higher than the national average, that were driving insurance companies out of the state,” Grayson says. “But unfortunately it took ten years, caused rates to be higher, hurt our economy and hurt our state government from a revenue standpoint. So a lot of damage was done.”

In 1994, Democratic governor Brereton Jones strong-armed a version of Clintoncare through the Democratic-controlled state legislature over the reservations of Republicans and some conservative Democrats. Much like Obamacare, Kentucky’s House Bill 250 forbade insurance companies to deny coverage or charge higher rates based on pre-existing conditions, thus negating the point of insurance — which, properly understood, involves paying premiums to hedge against risk. Under Kentucky’s laws, as under Obamacare, you could wait until you got sick to buy coverage and still obtain it at the same rates as everyone else. (Obamacare includes a requirement that healthy people have insurance, which its proponents say will prevent the premium hikes and insurance-company flight that Kentucky experienced. But the penalty for evading this requirement is relatively small; its constitutionality is suspect; and it might not even be enforceable.)

The problem with such regulations is that healthy people make the rational decision to drop their coverage and wait until they get sick to renew it. As healthy people stop paying into the risk pool, premiums for those who remain skyrocket. If insurance companies are forbidden from increasing premiums to keep up with costs, they leave town or close down. Unsurprisingly, average premiums in Kentucky increased between 36 and 165 percent in the wake of the reforms. Within four years, over 40 insurance companies had stopped offering individual insurance coverage. The two remaining providers, Anthem Blue Cross/Blue Shield and a state-run plan called Kentucky Kare, teetered on the brink of insolvency (Kentucky Kare went under in 1999).

By the late 1990s, Grayson says, “If you said House Bill 250, it was a four-letter word.”

In 1998, the Kentucky legislature, still controlled by Democrats, started repairing the damage by passing a reform package that modified the insurance requirements but didn’t repeal them. In 1999, party switches gave Republicans control of the state senate, and the legislature repealed most of the harmful provisions. Finally, in 2003, Kentucky elected a Republican governor for the first time since 1967, and one of his first acts was to sign a moratorium on new insurance mandates. These reforms slowed the rise of premiums and started bringing insurance companies back to the state.

“What was interesting,” Grayson notes, “is that the repeals were done in a bipartisan manner. Democrats, many of whom voted for House Bill 250, saw the negative impact.” Rising premiums and fleeing insurance companies gave opponents of the bill a compelling story to tell. “When we had evidence, we used it,” Grayson says. “That was what convinced Kentucky voters.” The bill’s opponents armed themselves with facts, and the case against House Bill 250 grew too overwhelming to resist.

This is the first lesson proponents of repeal should take from Kentucky: Construct a narrative around all of the bill’s negative consequences. “So, for example, we’ve already had John Deere and Verizon and some other companies take charges for the next quarter,” Grayson says. “As we learn about businesses choosing to drop insurance or delay expansion plans or whatever they have to do to avoid this, I think we have to take those real-life consequences and tell the public.”

The second lesson, he says, “is that you don’t have to do a full repeal right off the bat. If you can start getting rid of some of the bad elements, try that.” Repealing the most unpopular parts of the bill — new taxes on investment, on income, on medical devices — can pave the way for repealing the spending provisions: “If those taxes have to be repealed or phased out,” Grayson says, “then you start to have a financial concern: How you are going to pay for all this stuff as the subsidies are phased in?”

Liberals are much more influential in Washington than in Kentucky’s statehouse in Frankfort: When the big problems with Obamacare start surfacing, they will push, not for repealing the bill, but for nationalizing even more of the health-care industry. They will call for a stronger penalty for not purchasing insurance or, if the Supreme Court invalidates that provision, they might push for a “public option” to offer a taxpayer-subsidized alternative to the private insurance companies they have broken. When the public option doesn’t work (and we know it won’t, thanks to another failed state experiment in Maine), liberals will argue that the only way to fix the broken system is to make the government the “single payer” for all medical costs.

Opponents of Obamacare must be prepared to make the opposite case, starting with this election cycle. The strongest lesson from Kentucky is that the longer Obamacare stays on the books, the more damage it will inflict on the economy. Conservative candidates such as Grayson can and should run on this issue. Health-care reform “is clearly on the minds of voters,” he says — it’s the second thing people want to talk to him about, after the University of Kentucky’s performance in the NCAA tournament — “and most folks I talk to are not real pleased. I think voters want us to do something about it — hopefully before the damage gets done.”

– Stephen Spruiell is an NRO staff reporter.

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