Wardell Sanders, President, New Jersey Association of Health Plans

Can you provide some key data about New Jersey’s individual health insurance market, such as its role and size?

If you don’t have public health insurance, such as Medicare or Medicaid, or employer sponsored health coverage, the individual market is critical. The individual market is for people who are self-employed or between jobs. Or their employer does not provide health insurance. The numbers fluctuate, but the latest data for the third quarter of 2025, published by the New Jersey Department of Banking and Insurance (DOBI), found there were about 565,000 people in the market, or about five to seven percent of New Jersey’s population.

What do you see as the major challenges facing the health care exchange and the individual market?

As background, the exchange is where people seeking insurance through the individual market can shop and compare plans. New Jersey has done a good job organizing the exchange, which simplifies, standardizes, and organizes the marketplace. The key challenge is the challenge facing every health insurance market: affordability. We’ve been fighting this battle for decades, if not longer — and the confounding problem only seems to be getting worse. The biggest factor impacting access to care is affordability.

Before the Affordable Care Act, you were on your own paying for coverage.  Now we have subsidies, a good thing, though they do mask the underlying problem. And the increased, enhanced subsidies, created during COVID, expired at the end of 2025.  With the expiration of the enhanced subsidies, some folks will buy less comprehensive coverage while others are going to say, “I can’t afford this.” The larger problem to tackle, especially in markets where there are no subsidies, like the small employer market, is to make coverage affordable.

Let’s say you can make one or two changes to the rules. What would they be?

Well, I want my first wish to be that I get three wishes. Let’s start with the out-of-network billing. If someone went to an emergency room or even an in-network hospital and unknowingly saw an out-of-network provider, they could face large, unexpected bills. New Jersey made real progress by passing a law — later followed by a similar federal law — that took consumers out of the middle of those payment disputes. That was a major win.

But the challenge now is how New Jersey resolves those disputes behind the scenes. The state relies on an arbitration system that looks at a charge-based fee profile, essentially what providers list as their charges, not what care actually costs. Because charges are often inflated, this approach drives arbitration awards higher and doesn’t encourage meaningful negotiation or affordability.

There are two other fixes worth noting. First, New Jersey’s insurance “minimum standards” rules predate the Affordable Care Act and now conflict with ACA affordability standards. Most observers agree these rules are outdated and are leading to inefficient and confusing plan designs. Aligning more closely with federal standards would improve affordability and clarity.

Finally, restoring enhanced federal subsidies for the individual market would make a significant difference. Those subsidies help consumers maintain coverage and reduce uncompensated care, which ultimately benefits hospitals and the broader health care system.

On affordability, multiple recommendations exist. What do you see as the first steps needed to make a real difference?

The first step to improving anything is measuring it. Under the Murphy administration, New Jersey created the cost growth benchmark program to better understand where health care dollars are going. By collecting data from insurers — and some providers and facilities — the state can identify where we are spending the most money and what the major cost drivers are over time.

The program also sets clear goals, including keeping health care cost growth below certain rates of inflation. Early reports show that the real problem is prices, not utilization. People are not necessarily getting more care — the care they receive is simply more expensive. It remains to be seen whether encouraging providers and facilities to contain costs will be enough to drive meaningful change. But measurement is the essential first step. You have to understand where the problems are before you can target solutions.

Finally, we want to ask a question beyond your professional life. If you had to choose, who would be your real-life hero?

I admire people who work for the benefit of others, often at personal risk. In health care, there are many heroes, especially those working in emergency care. Anyone who has spent time in an emergency room with a loved one — as I have — knows how extraordinary those professionals are. They are heroes.

If I had to name one individual, it would be Kim Dae-jung. Early in my career, I worked in Washington, D.C., with South Korean exiles who were supporting him while he was imprisoned and later living in exile. I was part of efforts to help organize his return to South Korea, where he went on to play a central role in ending the military dictatorship, became president, and later received the Nobel Peace Prize. He was a deeply influential figure in my life and a true hero.