With an opportunity to discuss nearly anything on their minds, a gathering of Anchorage realtors consistently steered an April 20 conversation with Sen. Lisa Murkowski back to health care.

Murkowski said the chief issue of concern raised at the Anchorage Board of Realtors lunch continued a trend among the many Alaskans she talks to.

“(Health care) is the issue wherever I go in Alaska and I don’t care what group I’m talking to, whether it’s fisherman, whether it’s Tribal leaders, whether it’s bankers, the conversation comes back to health care and health care costs,” Alaska’s senior senator said.

That’s because her state has the dubious distinction of having the highest-cost health care in the country, and oftentimes it’s not even close.

The State of Alaska, with a roughly $4.5 billion unrestricted general fund budget, spends upwards of $1.5 billion per year on Medicaid, employee and retiree health benefits.

Additionally, the stories a few in the crowd of independent contractors and small business owners told of monthly health insurance premiums in excess of $1,000 per month “are exactly why the (Affordable Care Act) has failed us,” Murkowski said.

She said the sweeping insurance law has undeniable positives such as allowing children to stay on a parent’s health plan longer, prohibiting denial of coverage over preexisting conditions and others.

However, individuals that do not qualify for insurance subsidies through the federal or state have had a hard time realizing those benefits as insurers try to offset thecosts incurred by frequent utilizers of care in the individual market with higher premiums on the overall pool of insurance recipients.

For those in the realtors’ situation — people whom mostly work for themselves — there is no employer to help share the premium burden.

“Absolutely unsustainable, the cost that the individual pays,” Murkowski said. “It is cheaper for you to forgo insurance to basically have a policy that says, ‘I pray that myself and my family remain healthy and that’s going to be my policy, and pay the penalty.’”

Alaska’s small individual health insurance market of about 18,000 people, for one, simply isn’t large enough to absorb the premium costs associated with frequent utilizers of the state’s also ultra-expensive care. By comparison, the Washington’s individual market has about 300,000 participants.

Individual market insurers had been forced to increase premiums by 25 percent or more per year in recent years in an attempt just to recover costs, which was not always successful. As a result, Moda left Alaska last year after losing money in the state.

Premera Blue Cross Blue Shield lost $7.7 million in the Alaska individual market over three years before the cash-strapped state last year approved a one-time $55 million individual market reinsurance program to stabilize the market and keep Premera, Alaska’s last individual health insurance provider in the state, company Alaska President Jim Grazko said in a March interview with the Journal.

The subsidy helped Premera keep its 2017 individual premium increase “down” to 7.5 percent. The insurer had requested a 42 percent premium hike before the reinsurance fund.

The federal Department of Health and Human Services is now debating whether to support the state’s reinsurance program, which would likely lessen, but not eliminate, the need for future state subsidies.

Grazko said other states intrigued by Alaska’s individual reinsurance experiment are watching closely to see if it is worth replicating elsewhere.

“It’s about stability right now,” Murkowski said of the reinsurance work going on between state and federal health officials.

Murkowski, a skeptic of the failed attempt earlier this year by House Republicans to quickly push ACA repeal legislation through Congress, said she was surprised to hear reports that the effort had been renewed and House leaders would try again to vote on health care reform before the end of April.

She was particularly caught off-guard because despite claims they had support to pass it, the actual legislation had yet to surface.

“I don’t know how you can count votes without letting people see what’s in it. They tried that before — (Former House Speaker) Nancy Pelosi, her famous quote, ‘We’ve got to pass the bill in order to find out what’s in it.’ As Republicans, we don’t want to make that same mistake,” Murkowski said.

She criticized the ACA and House Republicans’ American Health Care Act for dealing with health insurance but largely ignoring the underlying cost drivers of health care and again warned against forcing legislation through Congress just to claim a political victory.

“When the president says, ‘gosh, health care is complex,’ yes sir it is and we’ve got an obligation to get it right because it is not functioning right now for the average Alaskan,” Murkowski continued. “Let’s not rush to something that doesn’t fix the problem.”

The senator’s views as to what will cure skyrocketing individual market health insurance premiums have changed over time, she acknowledged.

Once a firm believer in the need to allow individuals to purchase health coverage across state lines — as can be done with other forms of insurance — Murkowski said she now thinks expanding consumer access could help lessen premium increases in other states with like demographics, but realizing significant benefits in her state will be harder.

That’s because Alaskans buying an insurance plan in another state will still be billed based on Alaska’s situation.

“In Alaska, it’s not just our geographic isolation, it is the fact that we are so far out of whack compared to any other state out there in terms of our cost for coverage and for our health care risk factors. We’re just a higher risk state — our access issues,” she said. “We’re not attractive to anybody.”

One place she does see opportunities for cost reductions is in drug prices. Murkowski supports allowing the importation of pharmaceuticals from Canada.

She also said she generally believes there are ways Congress can influence drug prices.

“There is much, much more that can be done through the negotiation of drug prices and I do think this is where, with this administration and this president, we might see some breakthrough there,” she said. “If you can better afford the cost of your drugs and your medical devices then perhaps, just perhaps, you can afford the coverage.”

Elwood Brehmer can be reached at [email protected].