America's Health Insurance Plans, a national trade group, is asking these questions of business owners, consumers and its own members across the country as part of a national "listening tour" that stopped in Rhode Island on Sept. 26.

The goal of the tour, as AHIP president and CEO Karen Ignagni explained it to a small audience at the Rhode Island Quality Institute in Providence, is both to promote AHIP's own vision for reform and to help shape it by getting input from key constituencies.

Insurers have long been involved in reform discussions, Ignagni noted, but mostly responding to - and, (though she did not say it), sometimes fiercely opposing - others' plans. This time, she said, AHIP wants to spearhead its own reform effort and make 2009 a national "health care year."

The keystones of the AHIP plan, as described in promotional materials, are affordability, quality, value, the ability to choose among plans and coverage portability. And the fundamental premise is that reform is needed now.

Rhode Islanders did have some things to say about the plan and the tour stop, though a lot wasn't quite what AHIP was seeking.

Attendance at the actual forum was sparse, less than a dozen people, not counting invited speakers. Yet outside, despite heavy rains, a small crowd gathered to decry insurers' profits and their restrictions on care.

The protest was led by local members of Health Care for America Now, which is also pushing for reform but blames the insurance industry for many of today's problems. Ignagni, a Rhode Island native who has previously worked for the AFL-CIO and former U.S. Sen. Claiborne Pell, did not engage the protesters, but she responded to similar concerns at the forum.

Among the panelists was Karen Malcolm, executive director of Ocean State Action, which has signed on to the Health Care for America Now campaign, and she got right to the point.

"There is an elephant in the room, and it's how much we are paying for the administration and the profits of the big insurance companies," Malcolm said. She noted that while Medicaid administrative costs are in the single digits, for private insurers they're much higher.

Ignagni said this issue "is raised around the country," and she's glad to be asked because "it's quite reasonable for the public to ask us to demonstrate our value."

Federal figures, she said, show that "for more than two decades, administrative costs have been consistent" as a share of health care dollars. And private plans spend more on administration, she said, because "government programs don't do disease management; they don't do care coordination; they're not providing personal health records; they're not doing decision support [for physicians] ... yet every policy adviser who talks about doing health care reform talks about doing that."

Malcolm also confronted Ignagni with the notion that for-profit insurers' fiduciary obligations to their shareholders will forever put them in a conflict of interest: They can't do their best for consumers and still make big profits. But Ignagni disagreed, saying the best approach is to set performance standards for all health plans, and let for-profit and nonprofit plans compete.

"If we're going to continue with ideological discussions," she added, "we're not going to be able to give legislators a cookbook for how to do reform."

Other topics discussed at the forum included the value of stripped-down "basic" plans that could be offered nationwide - an idea that Mark Deion, a local representative of the National Small Business Association and other advocacy groups, endorsed - and of managed-care-type programs that limit access to costly services such as MRIs and CT scans.

In the 1990s, Ignagni noted, tight controls "drove inflation below zero," but there was a major backlash. And Mary Riley, an executive board member of Council 94 of the American Federation of State, County and Municipal Employees, said even the more limited programs being implemented now sometimes deny necessary services to patients.

Also discussed were positive and negative incentives to promote preventive care and wellness; different approaches to ensure universal coverage - including guaranteed access, as Rhode Island has, or high-risk pools for the uninsurable; and the need to limit consumers' out-of-pocket spending, which Ignagni said is one of the biggest points raised on the tour so far. •

To learn more about AHIP's plan, go to www.americanhealthsolution.org.

To learn more about Health Care for America Now, go to www.healthcareforamericanow.org.