Health Care Deadline Looms: How States Are Setting Up the Exchanges

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"We never intended for our exchange to administer Medicaid, enforce the individual mandate [to have health insurance], or distribute federal tax credits," Herbert wrote in the letter.

Thurston says they want the federal government "just to say that what we have done is good enough, but I really anticipate there will be things they want to see a little more of."

Thurston anticipates the federal government will come back and say it needs "a little more information about this, a little more work here."

And that's not all Utah wants.

In the letter, Herbert asked the U.S. Department of Health and Human Services to certify Utah's exchange as compliant, as well as the minimum federal standard.

"I respectfully request that you instruct HHS to declare the Utah exchange model as the minimum federal standard," Herbert wrote. "I am confident that if you make this change, several other states will join Utah and request certification for 'state-based exchanges' based on our model."

19 State-Based Exchanges – Calif., Colo., Conn., Washington, D.C., Hawaii, Idaho, Iowa, Ky., Md., Mass., Minn., Miss., Nev., N.M., N.Y., Ore., R.I., Vt. and Wash.

6 Partnerships -- Ark, Del., Ill., Mich., N.C. and W.Va.

2 Undecided -- Va. and Fla.

That makes 23 states that will have federal exchanges, 19 states will have state-based exchanges (including the District of Columbia), six are planning on partnership exchanges between the federal government and the state, Utah is waiting on an answer from the federal government, and two states have not officially announced their decision: Virginia and Florida.

Virginia Gov. Bob McDonnell has repeatedly said he will likely reject the state-based exchange, paving the way for the federal government to come in, but an official response is likely to come Friday afternoon according to an aide.

Florida Gov. Rick Scott indicated last month that he was considering implementing a state-based exchange. He has made no official announcement either way and the Republican governor's office told ABC News on Thursday that they had no update on a decision, despite being a day away from the deadline.

Renee Landers, a professor of law at Suffolk University Law School in Boston who has written extensively on the new law, says if the remaining states don't make an official announcement by Friday, it's likely they will default to the federal exchange.

"If they don't decide to do it themselves, the default is the federal government will set it up," Landers said.

Landers boils down the decision by the nation's governors as this:

"If you want to wash your hands of [the ACA] as much as you can, entirely a federal exchange is your choice. But if you want as much control as possible, then the state exchange is the way to go; and the partnership, well every partnership is complicated," Landers said. "Sometimes it's nice to have the help, but on the other hand, you don't always get your way."

The Five Who Broke Party Lines

Not all of the country's Republican governors rejected the state-based exchanges: Iowa Gov. Terry Branstad, Mississippi Gov. Phil Bryant, Idaho Governor Butch Otter, New Mexico Gov. Susana Martinez and Nevada Gov. Brian Sandoval all decided to assert more control over the plan and, despite some grumbling, will set up the state-based exchanges.

"If the state really believes in federalism and state control, then operating its own exchange is the best way," Landers said."Its appeal is that it relies on competition in the market for health care coverage instead of a public system."

Landers says the new law also tells states they can form inter-state compacts and run exchanges by region, though none of the states decided to so. But "the federal government, in areas where they have contiguous states with a lot of shared markets, you can see the federal government saying, 'We won't have two infrastructures for those states, we will have one,'" the professor said.

One example could be New Jersey and Pennsylvania, two states that will have federal exchanges and are next to each other.

"I think it's funny that governors who purportedly want to be in charge of their own fate don't want to be involved [in setting up the exchanges]," Landers said.

"But then they have no responsibility for things that go wrong and there will be things that go wrong, mistakes will be made and they will have deniability."

This story has been updated since it was first posted.

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