When Helen Darling joined the National Business Group on Health as its president over a decade ago, she recalls the move as the “perfect culmination” of her career, which, until that point, had involved everything from research to policy writing to benefits consulting and health care purchasing.

“Her knowledge of health policy, corporate health plans and the health delivery system is encyclopedic,” says Mike Davis, executive vice president, human resources, at General Mills, who was chairman of the NBGH board of directors when Darling was hired in 2001.

Pam Kimmet, senior vice president, human resources, at Coca-Cola Enterprises, Inc. has known and worked with Darling for more than 10 years. “She is so skilled at dissecting complex issues and identifying tangible actions that make a difference. Her contributions have been extensive,” Kimmet says. “From helping employers think about how to do a better job of educating their employees to be more efficient health care consumers, to educating regulators and legislators about how to remove impractical or ineffective aspects of laws or regulations facing employers. … [Or even] to working with the health care community on evidence-based medicine, Helen has made an enduring impact and has been a balanced and reasoned voice on the dialogue of health care.”

As Darling gets set to retire in April, she sat down with EBN to reflect on her legacy, health care reform and the future of employer-sponsored health care.

What are some of the biggest changes you’ve seen to employer-sponsored health care over the course of your career?

In a funny way, my career has waxed and waned in the same way that employer-sponsored has. When I first started, it was the old days of comprehensive insurance, [when] you had a small deductible and co-insurance, and everybody was covered [by] pretty rich benefits through their employers and they paid next-to-nothing for them.

Then as costs rose pretty rapidly, and there was a growing alarm over what the costs were relative to the growth in the economy, we then had managed care come in as the answer to a set of problems. Then of course, we all saw a rebellion against managed care. … Then we had, again, pretty much of an explosion in costs with the preferred provider organizations. If people had the choice, and they could now do pretty much what they wanted to do and there would still be very good reimbursement for that, then we saw a big increase in use. … Now everybody says, "Well, wait a minute, we can't afford this."

Now we have a very different version [of health care with] consumer-directed or high-deductible health plans, as a way to try to control costs. … employers began putting in plans that said [to employees], "Okay, if you want freedom, you're welcome to it, but you're going to have to pay a lot more than you used to."

Obamacare is poised to fundamentally change the way Americans access health insurance. Overall, do you see this landmark legislation as a good thing for Americans in general, and American businesses more specifically?

First of all, if we start with the fact that there were, and really still are, close to 60 million people in the United States who have not had access to affordable health insurance, I would say that we needed desperately as a nation to solve that problem.

There are many things about the Affordable Care Act, in its original design, that were quite promising. I think that on balance, you would say it's better to pass laws, no matter how flawed they are. … I know enough about policy and politics in this country in health care, at least, to know that probably that was the best we were going to get.

But there were other things where they didn't do a good job at all, either in the law or later. The biggest one is cost control. They had almost nothing in the legislation that would have controlled cost. They had a lot of things in there that would drive them up. I would say the biggest negative of the law.

When the Supreme Court ruled, much to everybody's amazement, that the states could decide whether they wanted to expand Medicaid up to the point that the law allowed — even though it was a 100% paid for by the federal government — it basically assured that a significant number of states, some of the worst states from an insurance point of view, would actually do nothing about Medicaid. A key pillar of the Affordable Care Act was literally knocked on its knees, particularly in places like Texas where you have so many millions of uninsured.

[Then] there were features in the law that were really bad ideas, like making full-time employment 30 hours. … Almost no one goes below 35 [hours] and calls that full-time. As I understand, there's no other federal law that does that.

The people who wrote the law and the people who are writing the regulations try to use the law to advance their own public policy agenda [and] that really [goes] beyond some of the policy justifications.

For example, they put in a requirement that preventive services and drugs had to be paid for [at] 100% and there could be no cost-sharing. That’s a good example of where the theory is really quite sound. They also made certain that the services that they were going to make free to the consumer, to the patient, were evidence-based. It wasn't just getting your hair done or massage therapy, it was for [services where] there's evidence that it's really valuable as an investment.

The trouble is that the people that they've turned it over to, the U.S. Preventive Services Task Force – who know nothing about coverage decisions – have gone beyond the evidence. … [Like] recommendations for coverage that go beyond the evidence but, because of the way the law was written, they have to be obeyed, unless somebody's going to go in there and change them.

That sounds small, but it isn't small, it's a lot of money. It's going to be a lot more money and it's going to drive up everybody's costs and it's also going to drive up a lot of over-use of services that, in fact, can have harmful consequences down stream.

If you make it much easier to give people tests and do screenings, especially if it's done for asymptomatic people, you have a very high probability of finding a lot of false positives, which then have to be followed up on. It's not just that it's a waste of money in many instances; it actually can cause harm.

What are your thoughts about the overall roll-out of the law?

The federal government has never had any experience with insurance. The federal government is actually horribly under-resourced in terms of the kind of skills they need for executing a complex law like this. They did frankly a terrible job of rolling it out. They were told by dozens, including us, that they needed to have experts in execution and implementation — not policy people making decisions about execution, but people who are operations people. Turn it over to them. Give it to them and let them do it and pay attention to what they say and that didn't happen. … Now we have a problem of implementation that could be quite crippling and that's discouraging.

What advice would you have for employers at this particular juncture, as many Obamacare provisions are set to come into effect in 2014?

I think the most important thing to say is that they should, if they're not already taking every possible step they can to control their costs and manage the benefits appropriately, they should take them now. … The second thing I would say, is putting an emphasis on encouraging people, providing either rewards or penalties, depending on where you are, to help your employees and their dependents to choose healthier lifestyles.             

Overall, would you say this system we have of employer-sponsored health care coverage is a success or a failure? Why?

I don't think anybody, if we were starting from scratch, would design the system we've got. … Right now, the Affordable Care Act, whatever its other strengths and weaknesses, tried to preserve employer-sponsored coverage. At least, that's what they say. Now they're not doing as good a job as we would like to see, but if you look at even our own [NBGH survey] data of employees who work for large employers, many employees say that they prefer to have their employers help them get coverage. They don't want to be getting it on their own.

Over time, if some of those alternative systems [health insurance exchanges] are working well, then large employers might say, "Well, if it's working well, maybe that's a better approach." But again, it's the private exchanges and the public exchanges. Right now, we don't have any evidence that those alternatives work well, and I think most employers and employees would be worrying about making a change now until they’re comfortable that what they would move to would be at least as good as, and probably better, than what they have right now.

What do you see as the biggest threat to employer-sponsored health care coverage in this country?

The cost. We have a very expensive health system and the main reason we have a very expensive health system is because of prices. … if we don't all institute good cost control, then it's going to be impossible for employers of any size to afford to provide health benefits. They may provide something, but they're not going to come anywhere near close to covering the cost.

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