(Seattle)–The big buzz today at a meeting of the National Association of Insurance Regulators was that President Obama would speak to the thousand-plus people gathered here–and then that he wouldn’t. Maybe he didn’t want to get involved in a down-to-the wire battle over whether insurance companies will have to grow more efficient and spend more of our premium dollars on health care–or just keep doing business as usual, with double-digit premium increases.

It ought to be obvious that when all Americans are required to show proof of health insurance, the largely for-profit companies that sell it shouldn’t be free to do as they please–cutting their proportion of health spending and increasing profits to keep Wall Street happy. But it’s far from settled.

From the meetings that are going on–often technical discussions in airless meeting rooms–you’d barely know what’s at stake. The hundreds of lobbyists and insurance executives are keeping quiet in public. Yet my own public request for more debate and consideration of last-minute and insurer-friendly changes to important proposals defining what insurers can call "health care" were brushed off with an equally polite "No. it’s too late for that.

I credit the rank and file state insurance regulators who have spent
thousands of hours trying to write regulations that make sense. But
they don’t have the final say. At the same meeting, one of the state insurance regulators who will vote on the regulatory proposals that the NAIC will send to the White House was taking openly pro-insurer positions.

Most alarmingly, I learned later that the commissioner apparently even agrees with
insurers that broker fees–the commissions paid to insurance
salesmen–should be counted as "health care." Every extra dollar
that insurers can count as fake health care means more freedom to raise premiums and keep paying astronomical executive salaries.

Now that regulatory proposals meant to require that insurers 80% to 85% of your premium dollars on health care are close to final votes, the state commissioners–a majority of them political appointees–will have the final say. Not all political appointees are in thrall to the insurance industry, of course–but too many of them are still appointed by governors who consult with their insurance industry campaign contributors first. And too many of them see an insurance company executive job as their next employment.

The chairs of six key Congressional committees sent the NAIC and the Department of Health and Human Services a slightly desperate letter this week, saying they never intended to let health insurance companies use a deduction of all federal taxes to artificially boost the amount they appear to be spending on health care. NAIC staff just brushed off the letter, saying the (vague) language of the law is more important than what the people who wrote it intended.

Here’s the full response, as quoted by Sarah Kliff at Politico Pulse:

NAIC health policy manager Brian Webb signaled how the group feels
about the issue: “Unfortunately you can’t establish congressional
intent after the fact. We see this as a comment from the Hill.”
Democratic aides have said NAIC was waiting for the Hill to provide
clarification on the issue, but Webb thinks otherwise. "We’re
interested in their read of the legislation, very interested. But we’re
not necessarily waiting for their interpretation."

On the lobbying side, insurance companies are peppering the NAIC with letters–including some not-so-veiled lawsuit threats--demanding even bigger tax deductions, and the redefining of more administration as "health care."

There’s also little media coverage aside from Kliff, a specialist on the insider details of health care policy. If you say "regulation"to most reporters, they run off whimpering. Yeah, it’s a very hard story to sell to editors, and only a few have been successful.

That doesn’t change the fact that billions of dollars are at stake, and insurers are spending hundreds of millions to make sure it goes their way. It’s not over yet, though. And we underfunded consumer advocates–at least there are several here at the meetin–aren’t giving up.