Posts Tagged ‘PPACA’

States Find Medicaid “Silver Lining” in Court Decision

June 28, 2012

By Robert Holden, Vice President

Prior to the Supreme Court’s decision, most Court watchers’ attention was focused on the challenge to the individual mandate.   Striking down the individual mandate could have brought down the entire Affordable Care Act (ACA), or at least eliminated the private health insurance provisions of the law.  But instead of striking down the private insurance provisions, the Court instead supported the plaintiff states’ contention that the law unfairly allowed federal agencies to withhold Medicaid funding to compel state compliance with the ACA’s Medicaid expansion.  As Chief Justice Roberts stated in the Court’s ruling (which can be found here in full):

“The threatened loss of over 10 percent of a state’s overall budget is economic dragooning that leaves the states with no real option but to acquiesce in the Medicaid expansion.”

The Medicaid holding, what disappointed Colorado Attorney General John Suthers referred to as the “Silver Lining,” offers states a real opportunity to opt out of the Medicaid expansion under the ACA and continue to receive funding for their existing Medicaid programs.

The Supreme Court’s decision will have enormous fiscal impacts on the states and political implications on ACA implementation.  While implementation of a state-level health insurance exchange has always been optional under the law, Medicaid eligibility expansion to 138% of the federal poverty level was practically a given.  Federal funding would have picked up the entire direct cost of additional Medicaid claims, at least for a few years.  But the states would be required to support the administrative cost of adding, in some instances, 50% more enrollees to Medicaid programs already strained by the recession.  These additional costs were tolerable for states only given the alternative catastrophe of losing all of their existing federal Medicaid funding if they did not agree to the Medicaid eligibility expansion.  This proposition will be revisited now that they can avoid those administrative costs and receive Medicaid matching funds.

Thirty states have now either joined lawsuits to strike down the ACA, or have made formal requests for flexibility in Medicaid reform implementation.  If a large number of these states opt out of the ACA’s Medicaid expansion, and assuming implementation of the private insurance exchanges, many people formerly eligible for Medicaid will now seek federal subsidies in the health insurance exchanges.  This gives states inclined to disrupt ACA implementation leverage by increasing federal costs in two ways.  A larger number of state residents will be seeking federal subsidies – adding to the program’s bottom line.  Additionally, states could continue to opt out of creating state exchanges and rely on a federally established insurance exchange.  What the states do next will frame much of the debate as we head into the ultimate challenge for ACA implementation in November.

***

Robert Holden is Vice President at Stateside Associates managing the health care practice, addressing issues concerning public and private payers, as well as service and product providers. Mr. Holden also uses his issue and policy group experience to guide the legislative and regulatory monitoring teams focusing on healthcare policy issues.

#StatesideChat w/ @MarkShurtleff

February 17, 2012

By @StatesideAssoc

Stateside Chat is a new and exciting forum that was rolled-out earlier this week. The foundation of this new feature is a high-level conversation between Stateside’s Issue Managers and elected officials, state and local government affairs practitioners or other leaders in our industry. This content will be incorporated into our posts as a regular feature that will present a new and unique perspective with each conversation.

The first-ever Stateside Chat (used here as the Twitter hashtag for the forum, #StatesideChat) happened Monday afternoon between Utah Attorney General Mark Shurtleff (@MarkShurtleff) and Stateside President Constance Campanella. This initial #StatesideChat was setup as a means of introducing the medium and was met with an amazing response. Not only was the Attorney General gracious with his time, he was direct and thorough in answering the questions posed through the @StatesideAssoc Twitter account.  And, he was immediate and direct at responding to questions from journalists, citizens, constituents and others who had joined the conversation.

Twitter makes a great forum for discussing policy and politics with State elected leaders because of the benefits it offers. Not only can any of the participants jump into the conversation from wherever they are using a computer, tablet or smart phone, but anyone is welcome to watch and/or participate. Not only that, but the forum provides a lasting written record of what was discussed and can be accessed at any time.

These #StatesideChat dialogues will evolve over time as we find the best ways to highlight the unique insights, talents and experiences our guests will bring to the table. As a means of facilitating conversations amongst stakeholders in our industry, we want #StatesideChat to be as fruitful and relevant as possible for clients, other friends of Stateside Associates and interested members of the public.

Let us know who you’d like to see featured as a guest in an upcoming #StatesideChat by sending us a Tweet @StatesideAssoc or an email to gg@stateside.com.

What follows is the majority of the conversation, reordered and lightly edited to maintain the flow of the conversation for the reader. You can see this conversation in its entirety by searching Twitter for the hashtag #StatesideChat. Our next #StatesideChat will be held with the Minority Leader of the Arizona House of Representatives Chad Campbell (@RepCampbell) on March 12.

We thank Attorney General Mark Shurtleff (@MarkShurtleff) for being so generous with his time, and for his commitment to transparency in government.

Stateside Associates @StatesideAssoc

Welcome, General @MarkShurtleff and thanks for participating in our Inaugural #StatesideChat

Stateside Associates @StatesideAssoc

@MarkShurtleff I have some prepared questions for you and I’m sure I’ll have plenty of follow up questions as we go. #StatesideChat

Stateside Associates @StatesideAssoc

I know you’re a man of action, are you ready to get started? #StatesideChat

Mark Shurtleff @MarkShurtleff

@StatesideAssoc Fire away #StatesideChat

Stateside Associates @StatesideAssoc

You came in to office shortly after #RAGA was formed (the Republican Attorneys General Association, a part of RSLC). #StatesideChat

Stateside Associates @StatesideAssoc

What’s your advice to AG’s about balancing the partisan side of the job with policy and enforcement obligations? #StatesideChat

Mark Shurtleff @MarkShurtleff

@StatesideAssoc Rs & Ds will differ on role of Gov’t. I believe in less Gov’t & best consumer protection is free market. #StatesideChat

Stateside Associates @StatesideAssoc

@MarkShurtleff Right. But you still have to keep an eye on your partisan side and that causes controversy right? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat Once in office collaborate effectively across party lines to enforce laws and protect the public & state & individual rights.

Mark Shurtleff @MarkShurtleff

#StatesideChat on key issues of role of govt, political values & standards do enter in. i.e. Rs felt Obamacare is unconstitutional & sued.

Stateside Associates @StatesideAssoc

@MarkShurtleff Mark, you ran for Senate and withdrew for personal reasons. Any office look good for the future? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat I love public service. It has been a great honor to serve these 12 years. I’m going to step away for a time but WILL BE BACK!

Stateside Associates @StatesideAssoc

@MarkShurtleff GREAT! Good news. Now to something current. Immigration. Did your research re: Dred Scott influence you? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat I spent 6 years researching US history on recognizing rights of all people under the law. Despite rough start US is special.

Mark Shurtleff @MarkShurtleff

#StatesideChat America has tried to be a place where we welcome all peoples who yearn for freedom & opportunity but must balance rule of law

Stateside Associates @StatesideAssoc

@MarkShurtleff Special how? What does American Exceptionalism mean to you? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat American exceptionalism means we deal with current immigration in a just, pragmatic, fair, truthful, compassionate way.

Mark Shurtleff @MarkShurtleff

#StatesideChat And we tell the TRUTH about immigration & recognize the absolute economic need for migrant workers & positive contributions.

Mark Shurtleff @MarkShurtleff

#StatesideChat In America we are special in that we look at the worth of individuals & our Constitution protects rights of all who live here

Mark Shurtleff @MarkShurtleff

@StatesideAssoc #StatesideChat That’s not to say we don’t better secure border & FIX legal migration & naturalization. Feds have FAILED us!

Jeremy LaMont @Jeremy_LaMont

@StatesideAssoc Question for @MarkShurtleff What are practical challenges in enforcing current copyright law on the internet?#StatesideChat

Stateside Associates @StatesideAssoc

.@Jeremy_LaMont @MarkShurtleff Great question. Thanks for participating. AG Shurtleff? #statesidechat

Mark Shurtleff @MarkShurtleff

@Jeremy_LaMont #StatesideChat Difficulty lies in “worldwide” nature of Internet & ability of long arm of law to reach crooks offshore.

Mark Shurtleff @MarkShurtleff

@jeremy_lamont #StatesideChat But the law can & must stop those who allow & facilitate fraud & crime to be committed through their service.

ethanmillard @ethanmillard

@MarkShurtleff What parts of the new health care reform do you like? #statesidechat

Mark Shurtleff @MarkShurtleff

@ethanmillard #StatesideChat I like the protections ACA re Pre-existing conditions.

Mark Shurtleff @MarkShurtleff

@ethanmillard The Fed Dist Ct & 2nd Circuit agree w/GOP AGs that individual mandate of “Obamacare” is unconstitutional. #StatesideChat

ethanmillard @ethanmillard

@MarkShurtleff Do you think the mortgage fraud settlement was large enough? #statesidechat

Mark Shurtleff @MarkShurtleff

@ethanmillard #StatesideChat Yes the $25 Billion mortgage settlement w/ 5 largest banks is sufficient as a start & will stop bad conduct

Jeremy LaMont @Jeremy_LaMont

@StatesideAssoc Following the AG’s bank foreclosure settlement, will we pursue other mortgage holders like Fannie/Freddie? #statesidechat

Mark Shurtleff @MarkShurtleff

@Jeremy_LaMont #StatesideChat We are beginning settlement discussions with another 9 lenders which will cover 80% of mortgage market.

Stateside Associates @StatesideAssoc

@MarkShurtleff Remember Reagan’s 11th Commandment? What price will GOP pay for most negative nominating process ever? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat I firmly believe in Reagan’s 11th. GOP presidential candidates’ brutal negative attacks are doing the party harm & helping Ds

hct3 @hctthree

@MarkShurtleff #StatesideChat Have you endorsed a candidate for the GOP nomination this year?

Mark Shurtleff @MarkShurtleff

@hctthree #StatesideChat Yes. I joined Romney’s team >1 year ago. He is best qualified to save our economy & only one who can beat Pres Obama

Stateside Associates @StatesideAssoc

@MarkShurtleff Last question from me. How do you get business leaders to not be paralyzed with fear re working with an AG? #statesidechat

Mark Shurtleff @MarkShurtleff

#StatesideChat AGs must connect w/ business & show we believe in free market & only use power to keep level playing field & punish bad acts

Mark Shurtleff @MarkShurtleff

@StatesideAssoc #StatesideChat America is great today because of two equal pillars: Rule of Law & Free Market. State AGs stand between.

Mark Shurtleff @MarkShurtleff

@StatesideAssoc #StatesideChat JUSTICE guaranteed by Constitution requires AGs equally balance rights, laws, duties, penalties & liberties.

Stateside Associates @StatesideAssoc

@MarkShurtleff And business needs to inform and innovate and be good actors. Thank you, General Shurtleff! #statesidechat

Steve Arthur @stateGRguy

@MarkShurtleff Any thoughts on a federal balanced budget amendment passing? #Statesidechat

Mark Shurtleff @MarkShurtleff

@ethanmillard #StatesideChat Yes @ if that bat has the law & Constitution @ its core, I’ll swing up & away with all my might! TY 4 engaging

Mark Shurtleff @MarkShurtleff

@stateGRguy #StatesideChat Future success of our nation requires BB Amendment but w/Dems controlling Senate, it won’t happen.

Jeremy LaMont @Jeremy_LaMont

@MarkShurtleff Thanks for the opportunity to engage. More people would get involved with their gov if it was this accessible. #StatesideChat

Mark Shurtleff @MarkShurtleff

#StatesideChat Looks like we’re done. I love Twitter & other new media! Gives me chance to connect directly with people. Let’s do it again.

Steve Arthur @stateGRguy

@MarkShurtleff #StatesideChat Thank you for taking the time for this chat. It is much appreciated.

Mark Shurtleff @MarkShurtleff

@StatesideAssoc Thanks for setting up this great #StatesideChat & giving me chance to engage directly with the people.

In a Presidential Election Year, States Left to Pick Up the Pieces of Health Reform

January 26, 2012

By Robert Holden, Vice President

On January 25, the Department of Health and Human Services (HHS), through its Center for Consumer Information and Insurance Oversight (CCIIO), released information identifying the three largest health plans in each state, as well as the three largest national Federal Employee Health Benefit Program (FEHBP) plans to aid states as they consider how to implement health reform.

From the perspective of the states, the implementation of the Affordable Care Act (ACA) has long been a waiting game.  After its enactment in 2010, it became clear quickly that states would be doing much of the heavy lifting when it came to implementing the insurance reforms required under the act, primarily because until then health insurance regulation was almost exclusive to the states.  Nevertheless, states were dependent on federal guidance and rulemaking before they could make progress towards many of the private insurance reforms and the 2014 implementation date for health benefit exchanges.

Throughout 2011, states had anticipated that federal HHS rules would then define the specific benefits that would be covered in each of these categories so that they could address this issue in the 2012 legislative sessions.  However, after recommendations from the Institute of Medicine, HHS did not propose rules addressing specific benefits.  Instead, the agency released a December 16, 2011, bulletin advising the states to develop a “bench mark” based on employer plans in their states, which could be the basis for benefits in their respective exchanges, and which HHS would review in 2016.  This removed a potentially charged issue from discussion at the federal level until well after the 2012 election.

Now, even with information identifying their largest health plans, states must contend with a lack of federal guidance addressing one of health care reform’s most politically charged issues: what benefits will be covered under the new system?

Essential Health Benefits, the benefits that must be covered by health insurance plans offered through state health benefit exchanges, are defined broadly in the ACA to include the following categories: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.

While many of these categories are already covered by health plans, states have long had their own individual concepts of what constitutes an “essential” benefit.  Each session, states introduce scores of bills mandating health insurers provide coverage for specific health benefits.  These have been generally opposed by the insurance industry as increasing costs, but frequently address popular concerns, such as continued coverage of routine mammograms or coverage for the treatment of autism spectrum disorders.  The ACA acknowledged the potential for increased costs created by coverage mandates.  Because federal subsidies would keep premiums affordable for individuals utilizing the state exchanges, the act requires states to pay costs attributable for benefits required beyond the essential health benefits provided for under the ACA.

Unsurprisingly, the details of the essential health benefits had been greatly anticipated by state legislators who now, in light of the HHS bulletin, may have substantial leeway in preserving their current mandates.  At a minimum, states will be able to use health plans (subject to their state’s mandates) to create a benchmark for the new state health benefit exchange.  While there is still uncertainty as to how the state benchmarks will be judged by HHS in 2016, states have already started to determine processes to review their state mandates and how they fit into the ACA’s essential benefits.

Prior to the release of the HHS bulletin, Massachusetts and Minnesota introduced a number of bills placing a moratorium on new mandates, as well as legislation to require a comprehensive regulatory review of mandated benefits in their states.  While Massachusetts legislation proposes to authorize the Division of Health Care Finance to review the mandated benefits, and Minnesota legislation authorizing their Commissioner of Commerce to do the same, South Carolina, Rhode Island and West Virginia would look to their respective insurance commissioners.

Regardless of the review process, states will be revisiting their mandated insurance benefits this legislative session, and the issue will undoubtedly receive attention at the state insurance commissioners’ (NAIC) meeting in March.  Stakeholders, including disease treatment advocates, pharmaceutical and equipment manufacturers, as well as health care provider groups will be pressing the case that their services and products are essential to health care consumers.


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