But not every state is Massachusetts when it comes to health care reform. “The question is, in Mississippi, do they run those ads, and does somebody from the tea party get on afterwards and say, ‘Stick it to the government. Pay a penalty instead.’ ” said Jonathan Gruber, an MIT economist, who worked on the Massachusetts and federal plans.
A few states have begun their own advertising and public-education campaigns. California, Maryland, and Washington, among others, have already started planning their pushes. Yet many of the states that are resisting the health care law—refusing to build their own exchanges or to expand their Medicaid programs—are those with the largest uninsured populations. Those states already tend to have lower-than-average rates of participation in Medicaid by populations that are currently eligible, suggesting either cultural resistance to public assistance or systems that have discouraged enrollment. Those factors suggest greater challenges in bringing uninsured people into the health care system. “There may be unevenness from state to state,” Pollack said.
Another challenge is creating and supporting the online marketplaces where individuals will find the insurance plans. Nine states have refused to expand their Medicaid systems to cover new populations—leaving a gaping hole in those states’ coverage expansions. About 20 have decided not to help build the state insurance exchanges where individuals will be able to shop for plans. The federal government is planning to intervene in those states and install its own exchanges, but it’s clear that uncooperative states will be able to throw a few wrenches into implementation.
When individuals come to seek insurance, they will be interacting with brand-new systems. Aside from Massachusetts, no state has built the kind of regulated online insurance marketplace outlined in the health care law. The idea is for each state to have a website similar to what Kayak is for travel: People will go online, answer a series of standardized questions, and immediately find out what insurance plans they can purchase and what financial assistance they qualify for.
The back-end labor involved in building the necessary IT infrastructure has proven to be tremendous and full of unexpected complexity, say officials in the states that have been working most diligently to create their own exchanges. The exchanges must be able to communicate with a yet-to-be-built federal eligibility database; state-based, often antique, Medicaid computer systems; and the many insurance plans that wish to sell in the market. The vendors building the systems are starting from scratch, and regulations spelling out the precise specifications for data connections are still pending.
Connecticut’s exchange plan was conditionally approved by HHS this week, putting it near the head of the pack. Still, Kevin Counihan, CEO of the Connecticut Health Insurance Exchange, said that getting to the finish line in time will be a scramble. “Do I think it’s going to be ugly getting there? You bet,” he said. “If everything works perfectly, we’re fine. But things don’t work perfectly in life, and they certainly don’t work perfectly in IT development.”
In the states that don’t want to help, additional challenges are coming. Some parts of the federal apparatus can be identical in every state where it’s operating. But the federal exchange will need to be tailored to meet the regulatory and eligibility standards in each state, an effort that could be complicated by recalcitrant state officials. Medicaid systems that cooperate only minimally could undermine the “no wrong door” approach behind the exchange design. Instead of a few clicks separating consumers and health insurance, Medicaid-eligible populations in some states may instead be forwarded to a separate eligibility and enrollment system managed by state officials.
Gary Cohen, the head of insurance oversight at HHS, said this week that the federal government will be ready to do its part in time. It’s hard to know, however, because the final regulations and technical specifications for the federal exchange are still outstanding.
The skeptics are worried. Michael Cannon, the director of health policy studies at the libertarian Cato Institute, who has been advising state officials to fight the law through noncompliance, says he thinks HHS is behind schedule. “They have very little time to do this, and they really need the manpower,” he said. “An indication of how difficult this is for the federal government is that they aren’t telling anyone what kind of progress they’ve made.”
Oklahoma has sued the federal government, arguing that the health care law’s statutory language means that federal tax credits can’t be offered in a federally run exchange. Maine has argued that the Supreme Court ruling about the law’s Medicaid expansion throws other Medicaid provisions into question. Both suits are considered long shots, but they are evidence of the strong opposition that some states continue to express, even as the exchanges’ effective date draws near.