Several states that announced opposition to the Affordable Care Act (ACA) ahead of the election, are now wrestling with how to implement state requirements after a favorable election and Supreme Court ruling on the law. Deadlines are fast approaching for the implementation of state run health insurance exchanges, those that miss the deadline may find themselves with federally administered exchanges and less control over other health care programs.
States must decide by Friday whether they will implement a customized, state-run health insurance exchange. Failure to implement their own exchange will result in having a generic one created for them at the federal level through the Department of Heath and Human Services. Many states with Republican governors opposed to the law filed a claim that the law and requirements like this one were unconstitutional but, the Supreme Court voted to uphold the law. The decision by Republican governors to stand in opposition to the law even after the ruling and the Presidential election which showed support for the policy within the American public, has manifested in states refusing to implement their own customized solutions.
This choice is somewhat counterintuitive given the ideological history of a states rights based view in the Republican party. Followed to its logical end,it would seem that these governors might prefer to run their own exchange despite being opposed to the thrust of the law in an effort to maintain state control at some level. However, states like Arizona are providing an object lesson in how this tortured opposition is playing out in practice. Governor Brewer has yet to make a decision one way or another, but, in the interim, state health officials have spent millions working through the planning required to build a state run exchange on the off chance she goes that way.
The same is true in Wisconsin, were democratic officials there are asking the Governor to move ahead on implementation and have started a bit of the leg work even while the Governor leans toward the federal exchange option. Rep. Ron Kind, Senator Herb Kohl, Rep. Gwen Moore, Senator-elect Tammy Baldwin, and 2nd District Representative-elect Mark Pocan, together crafted a letter asking the Governor to implement a customized exchange for Wisconsin.
Ohio is also working on a middle way, wherein the exchange will be administered at the federal level but the state will retain control over the certification of health care plans on the exchange and determining eligibility for Medicaid. This middle way is notable given a massive state supported initiative to make Ohio a health information technology hub running over an ultra high speed broadband network that leverages its university and health care provider network to attract jobs and become a national model for health IT. In Pennsylvania, state health officials there recently announced that they have far exceeded federal goals for getting health care providers signed up on their health information exchange, while on the health insurance front that state may run multiple exchanges including one managed by insurance providers themselves leading to a somewhat confusing labyrinth of online portals for both providers and patients to navigate.
In New Jersey, Governor Chris Christie originally vetoed a plan proposed by the statehouse to set up a state run exchange, saying he would await the outcome of the election, now that the outcome is clear, he has yet to announce publically what he will do. In Tennessee, it appears that Governor Haslam is likely to push on with a state run exchange over ceding any control to Washington, despite in-state opposition.
Even in states where there is support for the exchange in the administration, local lawmakers are often putting up their own challenges to implementation. In Minnesota, Governor Mark Dayton has been working at the executive level to maintain momentum on building out his state’s exchange despite moves in the statehouse to block those efforts.
The ACA came with some of the shortest, and strictest implementation deadlines for a bill of its scope in some time. Many states who have supported the bill from day one are racing against the clock to meet those requirements, for the states in this list, that window is even shorter, and federal officials have indicated a certain unwillingness to allow much by way of extension, indicating that federally administered options may go into effect for states dragging their heels even if they are in the process of building out systems. Watch this space.