If President Barack Obama ever needs a little background music the next time he belts out an Al Green tune, he probably could count on Jay Angoff, an accomplished keyboarder, who also happens to head the Health and Human Services's office in Kansas City. The president knows Angoff, having tapped him for the difficult job two years ago of implementing the Affordable Care Act.

At that time, The Washington Post described  Angoff as  a "class-action litigator who specialized in making big insurers pay out" and who would be expected to implement "big reforms smoothly and keep insurance companies honest." Angoff's experience included serving as Missouri's director of insurance from 1993 to 1998 under Gov. Mel Carnahan. After leaving ACA's Office of Consumer Information and Insurance Oversight this year, Angoff has remained a senior adviser to Health and Human Services Secretary Kathleen Sebelius. He was in St. Louis last Friday to attend the Missouri Health Data Summit, sponsored by the Missouri Foundation for Health, the Health Care Foundation of Greater Kansas City and the Midwest Health Initiative.

While Angoff might enjoy keyboarding for the president,  he seemed less fond of Washington itself. In response to a "welcome home" comment, he cited the cost of little things in Washington as a metaphor for what he disliked about the life in the nation's capital: "If you put a quarter in a parking meter there, you get 7 1/2 minutes. It's great to be back in Missouri."

How did politics make it difficult for you to implement ACA?

Angoff: The hard part had nothing to do with politics. The toughest thing was meeting the statutory deadlines. Within 90 days after the law was passed on March 23, 2010, we had to establish high risk (insurance) pools in each of the 50 states. It usually takes a state one year to establish a high risk pool. We had to establish 50 of them within 90 days. We also had to establish the early retirement reinsurance program for companies that provide health insurance for people before they are eligible for Medicare. Otherwise, these individuals would have had to pay really high prices for insurance based on health status. We also had to establish a web site within 90 days to enable people to get comparative price and product information. These were aggressive deadlines; I'm pleased to say we met them.

But there have been other far-reaching changes.

Angoff: Within 180 days after the act, we had to implement the Patient Bill of Rights. Those are things like prohibiting insurance companies from having annual limits (on coverage), prohibiting insurance companies from rescinding coverage based on a technicality, and allowing parents to keep their kids on their policies until the kids are 26. That already has helped more than 2 million people, including me. I have a 22 year old daughter who's a senior in college. When she graduates in a couple of months, she'll be able to stay on my policy. A lot of people are in that position.

And yet many ordinary people, including people in Missouri, seem to dislike the law. How do you explain this disconnect?

Angoff: I'm no expert on this, but polls show that when people are asked specific questions about provisions of the Affordable Care Act, they like them. When they are asked whether they support or oppose allowing kids to stay on their parents policies until age 26 or preventing insurance companies from canceling policies based on a technicality, or allowing people to get insurance when private insurance companies refuse to insure people — people are in favor of these individual provisions.

Do you think the law can succeed without the controversial individual mandate requiring people to buy health insurance?

Angoff: I know Congress and academics have studied ways to encourage people to buy insurance and penalize people who don't buy it, which would have the same effect as the individual mandate. Those are things that are out of our hands. But the department believes in the likelihood that the mandate will be upheld.

Keep in mind that the mandate is strongly supported by the insurance industry. When people understand it, I think they are more sympathetic to the concept of everyone having insurance, everybody being in the pool and being insured. There is a cost that we all pay now for people who don't have insurance. I think when people understand that, then they realize that it's a benefit to have everyone in the pool. That allows risks to be spread as broadly as possible and for rates to be kept at reasonable levels.

Another contentious issue is the medical loss ratio requiring insurers to spend at least 80 percent of premium dollars on health care and quality improvement.

Angoff: That's a very important regulation because it maximizes the amount that people pay for health insurance (that) actually goes to health care. That was difficult to get done, but we got it done by the end of last year.

How effective is the new law to allow HHS to conduct direct review of what it considers excessive rate hikes, including in states where the insurance departments have no authority to review rates?

Angoff: I think this reg has some teeth in it, particularly in Missouri. When I was at the Missouri Insurance Department, and even today, the department has no authority to review rates. It's one of the few states where the insurance commissioner or director does not have that authority.  The law doesn't give us authority to roll back rates, but it does make a finding of what's reasonable. This has had the effect of making insurance companies look more carefully at how much they raise their rates because they know the information will be publicized.

In  2014, those who don't have insurance will buy it through (insurance) exchanges. Until that time, the high risk pools (now serving about 50,000 people, including more than 1,000 in Missouri) have been set up for them. We call this the Pre-existing Condition Insurance Plan or PCIP.  This program will exist until 2014 for people who have been refused insurance based on health status. They are now getting insurance under the PCIP at the same rate they'd pay if they were in good health. That's a terrific program.

How confident are you that states like Missouri will have insurance exchanges in place by the deadlines?

Angoff: The rhetoric sometimes exceeds the reality. In a lot of these states, even those that are suing us, we're still working closely with their insurance departments, medical directors and directors of health departments. I mean these people are professionals. They realize the likelihood is that the law will be upheld, and that it's in everybody's interest to implement it. The deadline for HHS to make the decision about whether a state can operate its own exchange is 2013. The exchanges have to be operating by January 1, 2014. 

The court decision is going to be resolved pretty soon -- in a couple of months. Most people are realists. They realize that the Affordable Care Act is law and that the law is likely to be upheld. So there is a lot of good cooperation between the states and the federal government regarding implementing the law.

If churches and church-related hospitals are exempted from providing contraceptive coverage for their workers, who is going to cover the cost of this service?

Angoff: Covering contraception saves money. So the administration's position is that we balance defending or preserving religious liberty with expanding preventive services. There have been lots of studies showing that providing contraceptive coverage is a net benefit to the insurer. It doesn't cost the insurance companies to provide this service. It reduces cost; it doesn't raise cost. So we have to anticipate that the insurance industry won't object to that.