The Status of Health Insurance Exchanges

This post is written by new Wright on Health blogging partner Nicole Fisher. Nicole is the Senior Policy Director at Health Systems Innovation Network where she does health economic and policy analyses generally focusing on Medicare, Medicaid and health reform. She also is a current PhD student at the University of North Carolina in the Health Policy and Management Department and writes on a variety of health care topics for several think tanks and websites. Nicole also has a masters degree in Public Policy from the University of Chicago and an undergraduate degree from the University of Missouri.
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With less than two years before state-based health insurance exchanges are to be operational, most state legislators and health policy experts still cannot come to an agreement on how to set up, operate, monitor or fund state exchanges. However, despite persistent confusion and concerns surrounding health insurance exchanges, the White House recently released a report on the progress of state-level health insurance exchanges. This publication took a favorable and possibly misleading view of the headway being made by states that are creating their online insurance marketplaces.

The Administration claimed that there are currently 28 states making great progress in establishing an exchange. Even if that were true, this indicates that 22 states  -or about 40 percent- are refusing to comply with the Patient Protection and Affordable Care Act (PPACA).

Although the report does not lie, it also doesn’t exactly accurately portray where most states stand either… The Administration chose to furtively count states that fall into a grey area as making progress toward setting up an exchange. Many states have, in actuality, refrained from any legislative activity or the state legislature has merely set up a committee to “study options”. What this really indicates is that many states are purposefully not complying with the PPACA mandate to create an exchange, but also managing not to violate it so that they are allowed to keep federal funding, at least until the January 2014 deadline.

Figure 1 below illustrates exchange status more accurately by categorizing, into six categories, where states stand in terms of state-based exchange implementation. These classifications range from states that have already established an exchange to states who have taken legislative action not to create an exchange.

As the White House rightly exhibited, there are a few states that have made significant progress in setting up an exchange and benefited greatly from the extra federal dollars. Rhode Island recently received an additional $60 million from the federal government for their collaboration with Massachusetts and Vermont to improve system integration associated with health insurance exchanges. California, Colorado and Washington have also seen legislation signed into law following the passage of PPACA to implement a state health insurance exchange.

In contrast, based on a February 2012 analysis of all states, Figure 1 shows that five states have no legislative activity whatsoever related to a health care exchange; and several states such as Wisconsin, Louisiana and Florida not only rejected setting up an exchange, but returned the grant money bestowed to them from the federal government to establish an exchange. More common scenarios, and where Figure 1 differs from the White House, are that many states are merely “investigating options” or allowing an exchange bill to bounce around legislative committees but never go to a vote. These alternatives allow states to keep their federal funding, but take no action to set up an exchange.

For example, the state of North Carolina had a Republican majority who drafted an exchange bill. That bill, however, was moved from one committee to another over than span of months for “reading.” For the past year, that same bill hasn’t seen the light of day and the Republican majority has no intention of ever letting it. This way, the state is allowed to spend federal exchange dollars, but not actually carry out the Administration’s plans. New Hampshire also had an exchange bill written, but after passing the Senate, that bill failed to pass the House of Representatives. In doing so, New Hampshire was allowed to keep exchange funding, but use the stalemate as a way of not having to revisit the idea of exchange implementation until a future session. South Carolina on the other hand used the original Exchange Planning Grant from the federal government to create an exploratory committee on exchanges, but decided after its creation that no legislation should be written.

As the economic crisis continues, unemployment remains high and the Supreme Court prepares to hear oral arguments for various provisions of PPACA in March, the number of states moving forward with enacting an exchange should become stagnant. This could further undermine the “progress” being made by states that fall into the grey area. Regardless, whether states are stalling efforts to create state-level exchanges, “studying” alternative options and costs, or flat out rejecting the idea, it’s safe to say that the optimism demonstrated in the White House report is a bit rosier than the real state of state-level health insurance exchanges.

 

ObamaCare Keeps Working

When the Census Bureau released the latest numbers on insurance coverage, I wrote a post to highlight that nearly 500,000 young adults went from being uninsured to having insurance. An excerpt from that post actually got picked up by Jonathan Cohn at TNR. Now there’s more evidence that ObamaCare is working for both young and old Americans. The Department of Health and Human Services recently announced that, in fact, more than 2.5 million Americans between the ages of 19 and 25 were covered by their parents’ health insurance in the first half of 2011. That’s not surprising given that the Affordable Care Act included a provision that allows those under age 26 to remain on their parents’ coverage.

And the good news isn’t just for twenty-somethings. Early data show that America’s seniors are also benefiting from the Affordable Care Act. How you ask? Well, one of the first provisions enacted targeted the Medicare Part D “donut hole.” Part D is the program that provides prescription drug coverage for Medicare beneficiaries, and it was designed with a giant gap in coverage right where people needed it most. (As an aside, that was done for purely political reasons, to keep the price tag a little lower on the legislation when it was being debated on Capitol Hill.) Well, ObamaCare didn’t completely eliminate the donut hole, but it did shrink it, by reducing the proportion of costs the beneficiary is responsible for. The result? Nearly 2.7 million older Americans saved an average of $569 each on their prescription drugs through October 2011. Moreover, some 24 million Medicare beneficiaries received free preventive care. This is good news served with a side of good news.

It’s true that health reform is still very much in the process of being implemented. My glasses are not so rose-colored as to expect that every element of the law will be a success. Some things won’t work, and will need to be retooled or abandoned. But some things, as these developments underscore, will be successful, and when that happens, it should be roundly acknowledged.

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Will We Get to Watch the Supremes on TV?

The Supreme Court is a fancy place. They do things with a strong sense of tradition and that most definitely applies to how they hand down their opinions and what information is made available to the public. It is relatively recently that they began releasing time-delayed audio recordings of oral arguments. Television cameras remain a no-no. I suppose the idea is that they want to be able to hear cases and deliberate without feeling scrutinized. Introducing the real-time effect of television could produce some sort of Hawthorne Effect. If the Justices know that America’s watching, perhaps they’re worried that they’ll rule differently than they otherwise would.

I have mixed feelings about this. On the one hand, I believe in preserving traditional institutions, and I don’t think that anything and everything needs to be televised. On the other hand, the outcome of this case has the potential to affect many Americans who are unlikely to ever read a majority opinion from the Court, but would certainly catch snippets on the tube.

Perhaps that’s why so many groups are asking the Court to allow television cameras in the courtroom for the first time. There’s the Association of Health Care Journalists, C-SPAN, the Radio Television Digital News Association, the New York Times, and most interestingly, Iowa Republican Sen. Chuck Grassley. My hunch is that their requests will be denied, but I hope I’m wrong, because I’d watch this case around the clock like it was the Casey Anthony trial.

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