Although health care reform was front and center on the national stage last year, the states are now the primary venue for the health system changes that lie ahead. Last year, the Supreme Court and the presidential election were flash points for the health care debate; this year, the dynamics will play out in 50 statehouses, 50 governors' mansions, and hundreds of state agencies.
"This is federalism turned into reality," Rhode Island Insurance Commissioner Christopher Koller said at a recent
Janet Weiner, MPH, is Associate Director for Health Policy at the Leonard Davis Institute of Health Economics within the University of Pennsylvania.
AcademyHealth National Policy Conference in Washington, D.C., where nearly 700 researchers and policymakers gathered to discuss health care reform in the aftermath of the Affordable Care Act. "The feds have narrowed the bands [in the insurance market] and raised the bar. But delivery system change happens at the local level."
'Artifical partisan cast' Although media attention has focused on states' decisions whether or not to run their own health benefit exchanges or to expand Medicaid, panelists cautioned against using an "artificial partisan cast" to characterize the challenges states face in implementing the law.
According to Joshua Sharfstein, MD, Maryland's Secretary of Health and Mental Hygiene, the "Big P" politics of red and blue states have been replaced by the "little p" politics of getting stakeholders together to compromise and reach consensus. "The ACA is what we have. Increasingly, this is about getting this to work," he said.
Even in Maryland, where the Democratic majority and governor have committed to expanding Medicaid and running its own exchange, "little p" politics are still present. Dr. Sharfstein described reaching out to insurance broker organizations and holding more than 100 public meetings as Maryland decided on a benefits package and customizes its exchange.
'Strip away the politics' Bruce Greenstein, Secretary of the Louisiana Department of Health and Hospitals, agreed that the political battles should now be directed at how the states will implement the ACA. "Let's strip away the politics that have been driving the debate," he said, and replace them
Photo: Hoag Levins
Louisiana Secretary of Health and Hospitals Bruce Greenstein said 'it's hard to make the business case' for a state-run insurance exchange.
with a more nuanced approach. For example, he notes that most states (including his own) have chosen not to develop their own exchanges. "It's hard to make the business case for a state taking over all the operations of an exchange," he noted, given the tight deadlines, limited capability of state governments, and the complexity of synchronizing the law with state insurance regulations.
'States are doing the math' Greenstein also explained why some states are choosing not to expand Medicaid, even in the face of large federal subsidies (100% of the cost through 2017). "You shouldn't do it, just because something's on sale," he said, prompting laughter from the audience. On a more serious note, he added, "States are doing the math now... it's complicated." Louisiana's refusal hinged on concerns about the cannibalization of private health insurance (estimating that 40% of the expansion population already had insurance), disruption of the hospital safety net for the uninsured, and the administrative costs of the expansion.
But Joan Aiker, co-Executive Director at the Georgetown Center for Children and Families, thinks that all the states will eventually expand their Medicaid programs. "There's a huge [federal] resource on the table, and states will find it hard to turn that down." If the history of the Medicaid program is any indication, states will adopt the program over time. Eight states did not participate in Medicaid (enacted in 1966) until 1970, and the last state to do so was Arizona in 1982.
'Huge federal resource on the table' Whether or not a state chooses to expand its Medicaid program, the ACA will
Photo: Hoag Levins
Co-Executive Director of the Georgetown Center for Children and Families predicted federal funds will ultimately motivate all states to expand their Medicaid programs.
have a significant impact on existing operations, according to Julie Weinberg, who directs New Mexico's Medicaid program. Eligibility and enrollment systems will need to be updated and interactive with the new exchanges. "How do we interact with our buddies in the [division of] insurance? How do we manage the 'no wrong door'? How do we achieve it?" she questioned.
Koller, Rhode Island's Health Commissioner, put it another way. In this new state "sandbox" of health care reform, three entities must "play nice": Medicaid, health insurance exchanges, and insurance regulators. "We who work at the state level are working with the consumers and working with the providers trying to get consistent signals to the providers to get [health system] transformation."
Greenstein of Louisiana urged state policymakers to get beyond the political battles over the state-run exchanges and Medicaid expansion. "If I had one wish, I would grant everyone amnesia... let's start today and go forward."
