Regulation and Compliance > State Regulation

PPACA, State-by-State: A Q&A with Iowa Insurance Commissioner Susan Voss

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Iowa Insurance Commissioner Susan VossQ: What challenges do you anticipate your particular state running into with upcoming health care reform provisions?

Susan Voss: I don’t know if it’s unique to Iowa – I’ve certainly talked to other commissioners who feel it’s important – but I would think the medical loss ratio implementation in 2014 for some of our smaller carriers will be challenging. I wrote a letter to the secretary of Health and Human Services asking for some kind of a waiver or phase-in for some of our smaller carriers so they can meet the 80 percent medical loss ratio by 2014. That’s the No. 1 issue we’re dealing with.

No. 2 is, we’re just beginning to have discussions with state agencies about the health insurance exchanges that will go into effect in 2014. We received a $1 million planning grant, and we will have our first meeting with various state agencies this week to see how we go about that and what kind of staff we need to hire. Iowa is unique because it passed an informational exchange last year that has to be up and running sometime next year – there’s not really a deadline – so we’re supposed to have that type of exchange created in the near future, then morphed into a purchase exchange. Then, we’ll have an additional challenge with the exchanges.

Q: What exactly is an informational exchange?

SV: It’s if consumers want to find out something like the different programs that are available or what types of group insurance is available in Iowa, or the average rates for a person of a certain age or group size. There’s no purchasing involved; they’d have to go out on their own to do that. Then we’re doing links to the various public products that are available, whether it’s children’s health insurance or medical care, or Medicaid, or if you qualify for one of Iowa’s special programs, it will all be linked on the informational website.

Q: For producers licensed to sell health insurance in your state, what developments might they look out for in the short-term?

SV: I think our insurance community is interested in the exchanges – are they going to be a part of that equation of continuing to help consumers purchase or find the right plan? I’ve had a lot of discussions with them, and we’re working with them pretty closely, and we will continue discussions as we move forward. We also will have a series of six public meetings across the state over the next year on what exchanges will entail.

Q: What should producers concentrate on the most over the next 10 or so years with regard to health care reform’s affects in Iowa?

SV: The NAIC has done a resolution where we know that agents and brokers continue to be an important part of the equation and service to consumers. If there are more restrictions on what an agent can do, how can we maintain their viability? I think that will be a challenge. It all depends on how health care reform rolls out.

Q: Have you had any carrier activity as a result of the reform law?

SV: We’ve had six carriers exit the market, but they were carriers that would have had a very, very small number of policyholders in Iowa, so when the new law comes out and says medical loss ratios are based on the state-only book of business, if you can’t make those ratios, it might be pretty difficult. That’s a challenge we have – if part of the law still allows for an open market and consumers to maintain their health care, we want to make sure those companies are still around in a few years.

There are 30 total companies licensed to sell life and health products in Iowa, but only three or four major players. A lot of carriers are looking at their business right now.

Q: Is your state doing anything differently or preparing in any special way for health care reform?

SV: We did apply for a consumer assistance grant with the federal government, and we’re hoping to receive that money so we can do more education and outreach. We have a fairly high insured population in Iowa; we don’t have some of the challenges of other states, so our issue is, who are those people, and how do we reach them?

Q: What did you get out of President Obama’s recent meeting with several state regulators?

SV: We talked about some of the concerns we have, and I think we highlighted medical loss ratios. Another think we really talked about was that we still have to crack the underlying health care costs. Those are the drivers of health insurance premiums, and until we look at utilization and the cost of treatment and unhealthy lifestyles, health care costs will continue to rise, and so will premiums. So how can we all work together on that component of health care reform? The states are trying really hard to talk to one another and work together. We have monthly meetings with consumer advocacy groups in the state to update them on everything we’re doing on health care reform and how we can work together.

Prior to her appointment in 2005, Susan Voss had been with the Iowa Insurance Division for 11 years. She was appointed 1st Deputy Commissioner for the Iowa Insurance Division of the Department of Commerce in 1999 and represented the division before the Iowa General Assembly. In addition, she has worked with other state regulatory bodies in addressing health care-related issues.

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Iowa Facts At-A-Glance


United States


Total population



Median annual income



Health costs and budget

Health spending per capita


$5,283 (by state of residence)

Average employee contribution for family premium (% of total premium)



Health coverage

Uninsured population (% of total population)



Uninsured children (% of children)



Medicaid enrollment (% of total population)



Medicare enrollment (% of total population)



Monthly CHIP enrollment, June 2009



Health status

Infant mortality rate (per 1,000 live births)



Teen death rate (per 100,000 population)



AIDS diagnosis rate (per 100,000 population)



Overweight or obese children (% of children)



Adults who visited the dentist/clinic (% of adults)



Adults with disabilities (% of adults)



Source: Kaiser Family Foundation State Health Facts