July | August 2017

By Debra Miller, CSG Director of Health Policy
The first enrollment period for health care insurance under the Patient Protection and Affordable Care Act has ended. The Obama administration announced in April that more than 7 million people had enrolled on state and federal health care exchanges.
Here are some updates on what’s going on in the states with regard to health care reform.

States Try to Opt Out of Health Care Law

Kansas is the latest state to advance a bill to join a proposed interstate compact that, after Congressional approval, would exempt states from the requirements of the Affordable Care Act. Eight states have adopted the compact and Kansas is one of 12 more considering it, according to the Health Care Compact website.
The Kansas House in March approved the bill and sent it to the Senate. Sen. Mary Pilcher-Cook, chair of the Senate Public Health and Welfare Committee, told the KHI News Service it was too late to take up the bill in her committee, but she said she hoped Senate leadership would find a way to consider the bill.
The eight states adopting the compact so far are Alabama, Georgia, Indiana, Missouri, Oklahoma, South Carolina, Texas and Utah. Georgia adopted the compact first, when Gov. Nathan Deal signed legislation April 20, 2011, just weeks after passage of the Affordable Care Act. Two more states—Oklahoma and Texas—agreed to the compact that year. Arizona Gov. Jan Brewer and Montana Gov. Brian Schweitzer vetoed compact bills in 2011.
Under the proposed compact, states would receive federal funding each year based on the amount of federal funds spent for health care in 2010. The funding would be adjusted annually for population changes and inflation. The health care funding includes all nonmilitary federal funding, which includes the federal portion of Medicaid and all of Medicare, as well as other smaller programs. The compact contends federal regulations can be suspended by states. The compact website says any funds saved by a state can be used for purposes other than health care or returned to residents as tax cuts.
U.S. Rep. James Lankford of Oklahoma in February introduced a House Joint Resolution that would provide Congressional approval of the health care compact.
“The Health Care Compact is a way for states to protect their residents from the top-down, one-size-fits-all health care ‘solutions’ that have been imposed from Washington, D.C., including Obamacare,” he said in a press release.
Congress has taken no action to date.

Helping Consumers Choose the Right Insurance Policy

Consumers dread having to compare health insurance policies and research shows they aren’t very good at it. They barely have better than chance alone at identifying the lower cost plan, according to Consumer’s Checkbook, a nonprofit organization that has a 35-year history preparing plan comparisons for federal employees to use during their open enrollment period.
The Affordable Care Act charges the health insurance exchanges to “assist consumers in making easy health insurance choices.” As most employers do, the exchanges list plans in order of premium price, from low to high. While they provide consumers information to compare premiums, out-of-pocket maximums, deductibles and copayments, “consumers often choose a plan in much less time than they spend on a new car purchase,” according to Robert Krughoff, founder and president of Consumer’s Checkbook.
He said his organization has a better idea and they put up, free of charge to Illinois, a parallel website to the exchange to help consumers compare their likely health costs for the year. The organization is working on similar sites for Massachusetts and Colorado.
Estimates for each plan offered on the Illinois site include premiums and all other out-of-pocket expenses based on family size, ages of family members, self-reported health status and other characteristics, such as expected major health procedures or events. A second estimated annual expense is provided for a bad year, with higher than average health expenses, and the chances of having a bad year. The estimates can show the lowest premiums don’t necessarily mean the lowest out-of-pocket costs.
The Illinois website also provides consumers access to provider lists to see whether their preferred doctors are in the plan’s network. In addition, the website provides in-depth plan quality information and the ability to personalize the quality information to factors important to the consumer.
The Illinois website was created without support from the state or federal governments as a way to show policymakers the types of information that could be provided to consumers. The website helps consumers choose the best-priced policy for themselves and then sends them back to the official federal marketplace to enroll in the selected policy.
The website was introduced in February to more than 200 Illinois health navigators, people hired to assist consumers to sign up for subsidized health insurance plans through the exchange. Local media also have promoted the site.
Joel Ario, former director of the federal Cabinet for Health and Human Services’ Office of Health Insurance Exchanges and a former insurance commissioner in two states, predicted tools will be developed that go even further. “I’d bet on Amazon and Google to create the tools rather than a state exchange,” he told The Associated Press.

Connecticut to Market Exchange Expertise

By all reports, Connecticut’s health exchange—Access Health CT—has been a success. Now the state has designs on setting up a consulting business to help other states.
“We have something that is working and we want to share it,”
Lt. Gov. Nancy Wyman told The New York Times. Wyman serves as the chair of the board of directors for the exchange.
Plans are underway to license the Connecticut technology, selling an “exchange in a box,” according to Kevin Counihan, executive director of the exchange. The Hartford Courant reports Maryland is considering shutting down its exchange and using Connecticut’s for the next open enrollment period. The Courant also reported Connecticut is looking for $11 million from the federal government to perfect its model and spread it to other states.
Federal enrollment data released in March showed only four states with larger numbers of sign-ups for marketplace health insurance plans than Connecticut, but those states—California, Colorado, New York and Washington—are all considerably larger. Even before the last month of open enrollment, 57,465 individuals in Connecticut had selected a marketplace health insurance plan, compared to a goal of 33,000.
Only 15 states are running their own health insurance exchanges and, like Maryland, some of them have encountered significant problems. States can reconsider their earlier decision to forego a state exchange and apply for federal funds and designation in 2014.

Enrollment Extended for Those ‘In Line’

Just one week before the March 31 deadline for enrollment in health insurance plans available through the health insurance exchanges, the Obama administration issued guidance allowing those “in line” to have more time to complete their applications and make their first premium payment for coverage to start May 1. The guidance issued by the Department of Health and Human Services will apply to the federal health exchanges as well as those run in partnership between a state and the federal government. Consumers with special cases also received a delayed sign-up provision.
After a slow start when the exchanges opened in October 2013, enrollment picked up and reached 7.5 million, exceeding by half a million people the original projections by the Congressional Budget Office. About half of those people enrolled in March. Those people “in line” will add to the final tally.
Several states, including Maryland, Minnesota and Nevada, had taken similar steps of offering extensions as the end of March deadline loomed.

Closing the Coverage Gap: States to Watch


Nearly 5 Million Missing Out on Health Coverage

As debates over expanding Medicaid eligibility continue in a number of legislatures across the country, large numbers of people remain in a kind of no-man’s land.
The Kaiser Family Foundation, in a December 2013 report, estimated 5 million adults are not poor enough for Medicaid coverage under the old rules in their home states that have not acted on expansion. These 5 million adults, about half men and half women, are also ineligible for federal subsidies to purchase health insurance through the exchanges under the Affordable Care Act. Subsidy eligibility is set in the law for incomes between 100 and 400 percent of the federal poverty line—between $23,850 and $95,400 per year in 2014 for a family of four.
Congress did not intend to leave these individuals out of health care coverage. The coverage gap is a direct result of the decision by the U.S. Supreme Court that put the decision to expand Medicaid eligibility to 138 percent of poverty in the hands of each state.
In the vast majority of states, Medicaid eligibility for certain groups—adults and mostly those who do not have children—had remained fixed at the eligibility levels for the old welfare program that was replaced by President Clinton’s welfare reform in 1997. The old eligibility levels were established as dollar amounts, which became progressively lower percentages of poverty each year after 1997.
For instance, in Missouri, a parent can make no more than 19 percent of the poverty level— about $4,500 a year for a family of four—to qualify for Medicaid. Eligibility for children is much higher under Medicaid and CHIP. Childless adults don’t qualify at all.
Todd Foltz, a Missourian who has lost his job and his employer-provided insurance because of his multiple sclerosis, has been to Jefferson City to tell his story. “For me, it’s becoming not just a gap, but a crevasse, and it’s becoming not just frightening but terrifying,” he said at a House committee hearing, according to the Kansas City Star.
Twenty-six states—the latest is New Hampshire—and the District of Columbia are moving forward with Medicaid expansion; 19 states are not. The remaining five states are still debating the issue and could submit a state plan amendment to the federal government in 2014.