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States and the fate of health reform, ctd.

By Suzy Khimm

I wrote last week about how the fate of health reform depends on the states, given their starring role in carrying out major parts of the
Affordable Care Act. They'll be hugely responsible for setting up the new insurance exchanges -- which have to be running by 2014 -- and enforcing the beefed-up insurance regulations. But there are changes already underway that will give us an early preview of what's to come.

One of the pieces of reform that will take effect almost immediately are the high-risk pools for adults with preexisting conditions who have trouble getting insurance elsewhere. Each state has to set up a pool by July 1, or else the federal government will have to step in. The Wall Street Journal explains:

About 35 states currently operate their own high-risk pools. ... States that already have such pools can add a new pool; those that don't can start a risk-pool. States also can build on other existing programs to cover high-risk adults or contract with a so-called carrier of last resort to provide subsidized coverage. If a state chose to do nothing, HHS would carry out its own coverage program in the state.

The states' willingness and ability to set up these high-risk pools by the July 1 deadline will be an early indicator of how cooperative states governments will be in putting the law into effect. Some observers are already worried that the 90-day implementation is too short and that the $5 billion devoted to the project won't be enough to make premiums affordable, as the Journal notes. And I imagine that some reform-resistant states may be reluctant to set up these pools -- and will not be particularly happy when the federal government has to intervene. At the same time, there will certainly be states eager to become model examples of how reform can work. Will this first step broaden the gap between states that have already made "a lot more progress toward solving the problem" and states that are already behind the ball, as Matt Yglesias asks? Or will even anti-reform state governments prove willing to enact one of the most popular parts of the new health law, however begrudgingly? Either way, it will be worth watching what does and doesn't happen by July 1 and how HHS ends up dealing with the problems that could crop up -- particularly as these high-risk pools will be building blocks for the full insurance exchanges in each state.

Meanwhile, some states are already taking another piece of the Affordable Care Act into their own hands. The WonkRoom's Igor Volsky explains how state legislators are already taking advantage of a provision in the law that allows states to place additional abortion coverage restrictions on their future insurance exchanges:

The federal health care law prohibits public dollars from being used to finance abortions and requires insurers that choose to offer abortion coverage to collect a separate check from policy holders, but the law also gives states the option of banning private insurers from providing abortion coverage to women within the exchange.

Tennessee is at least the second state to take advantage of this provision, advancing legislation that would eliminate abortion coverage from an exchange that does not even go into effect until 2014. The Tennessee House Commerce Committee passed the bill (HB 2681) on a voice vote last week. ... A Missouri Senate committee also approved a bill that would deny insurers the right to offer abortion coverage in any government exchange last month.

These are the kind of restrictions that Bart Stupak and his allies were trying to impose nationally during the reform debate. Though they didn't succeed, the law still leaves the door open for the states to act -- and I'd expect that pro-choice advocates are already working to re-engage their foes and pushing back on the state level.

UPDATE 6:30 P.M.: My Mother Jones colleague Nick Baumann points out that states' ability to restrict abortion coverage is "nothing new" -- they've been able to do so since 1945. He explains: "Health care reform may have made conservative states more likely to prohibit abortion coverage by drawing attention to the issue, but it didn't enhance their powers to do so."

Suzy Khimm is a journalist who covered health-care reform at The
New Republic and is now a political reporter at Mother Jones.

By Washington Post editor  |  April 6, 2010; 11:40 AM ET
Categories:  Health Reform  
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Comments

It will indeed be interesting.

Some states have legislatures which do not meet continuously, so some states by law cannot meet the deadline due the inability to pass legislation enabling the meeting of it.

HHS itself is facing difficulty, as it can't regulate without first receiving public comment and receiving the necessary budget from Congress: as repeatedly noted by CBO, there has as yet been no budget authorization for the necessary start-up costs (including, ironically, legal fees).

Effectively, both HHS and elements of state government are being asked to act ultra vires. If the reactions of Arizona (CHIP cuts) and Utah (new, independent litigation) are any indication, there may be considerable pushback.

Posted by: rmgregory | April 6, 2010 12:17 PM | Report abuse

It will indeed be interesting.

Some states have legislatures which do not meet continuously, so some states by law cannot meet the deadline due the inability to pass legislation enabling the meeting of it.

HHS itself is facing difficulty, as it can't regulate without first receiving public comment and receiving the necessary budget from Congress: as repeatedly noted by CBO, there has as yet been no budget authorization for the necessary start-up costs (including, ironically, legal fees).

Effectively, both HHS and elements of state government are being asked to act ultra vires. If the reactions of Arizona (CHIP cuts) and Utah (new, independent litigation) are any indication, there may be considerable pushback.

Posted by: rmgregory | April 6, 2010 12:24 PM | Report abuse

It will indeed be interesting.

Some states have legislatures which do not meet continuously, so some states by law cannot meet the deadline due the inability to pass legislation enabling the meeting of it.

HHS itself is facing difficulty, as it can't regulate without first receiving public comment and receiving the necessary budget from Congress: as repeatedly noted by CBO, there has as yet been no budget authorization for the necessary start-up costs (including, ironically, legal fees).

Effectively, both HHS and elements of state government are being asked to act ultra vires. If the reactions of Arizona (CHIP cuts) and Utah (new, independent litigation) are any indication, there may be considerable pushback.

Posted by: rmgregory | April 6, 2010 12:24 PM | Report abuse

"The WonkRoom's Igor Volsky explains how state legislators are already taking advantage of a provision in the law that allows states to place additional abortion coverage restrictions on their future insurance exchanges"

This is not accurate, as states already have the power to ban insurance coverage for abortions. Several states already have such bans in effect.

Posted by: zathraszathras | April 6, 2010 12:27 PM | Report abuse

rmgregory,

you're right. We can look back as recent as ARRA and the COBRA subsidies to see how botched that got by the government. Each state then had to determine who paid the monies (insurer or employer) and waited for the money on their 941's. My state of NJ changed their mind about 3 times in the span of a week on the regs as their website got updated daily and changed.

Just further proof that the government will do this about as well as if they were swinging a hatchet to kill a fly.


And the fact that most believe the $5 billion (that's not one year that's the total amount) will be used up and need more money will just start the process of understanding how the numbers were wrong. The question will be HOW wrong and how far off.

Posted by: visionbrkr | April 6, 2010 12:58 PM | Report abuse

Exactly how is an abortion of convenience a healthcare issue? If the mother's life is in jeapordy, it's understandable, but that's not what we are talking about, is it?

The SCOTUS has just reaffirmed an individual's civil right to have a handgun in the D.C. case. So, if someone cannot afford a handgun that is otherwise qualified and wants one, do we also supply handguns to low income people that cannot afford one?

How's this any different? Just goes to show how stupid all of this is.

Posted by: WrongfulDeath | April 6, 2010 12:59 PM | Report abuse

Thank you for covering this topic. For implementation of the temporary national high-risk pool, I've heard that the law allows HHS to go around non-cooperating states by allowing qualified residents of those states to apply directly to a national program (probably contracted to some private or non-profit entity that will administer the program). Is this true? Thanks again!

Posted by: hillgirl8024 | April 6, 2010 5:34 PM | Report abuse

States banning private coverage of abortion is very different than banning coverage of abortion ON AN EXCHANGE. People think of the exchange as being a public entity even if the plans are private. I expect the number of states to ban abortion coverage on the exchange to increase dramatically.

The other issue is that women seeking abortions are more likely to be young invincibles who will be forced to buy insurance under the new regime. So they have to buy insurance they don't use, and they also have to pay $350-$750 that Planned Parenthood charges. This is way worse than current law.

Posted by: bmull | April 6, 2010 10:09 PM | Report abuse

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Posted by: sophiyabush07 | April 7, 2010 7:12 AM | Report abuse

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