Look at the technology. It’s incredibly complex and it may not work come “go-live” on Oct. 1. Health exchanges have to communicate with the federal data hub. That system has been spotty. It’s supposed to give income data and confirm citizenship. Exchange systems also must communicate with Medicaid systems, which are different in every state. In Colorado, the Medicaid computer system is an old one that has never worked well. The concept of getting real-time insurance quotes and instant estimates of tax subsidies may be fiction.
Contingency plans: If your state is building an exchange, ask about their contingency plans. If states have to deploy these, they could be interesting and expensive.
How much is the exchange costing? States that are doing their own exchanges have gotten big federal grants worth hundreds of millions of dollars. It’s always worth taking a look at how much your state is spending to enable private health insurance companies to sell to more people.
Who will be left out? In Colorado, we have a big population of uninsured people and a large number of Latino immigrants. Those who are undocumented won’t be eligible to shop on the exchange. What will happen to them? What about others who find coverage too expensive or choose to opt out?
Young people. Insurance companies and exchanges will be marketing to young, healthy people. Look for insurance drives on college campuses, etc. These young people are cheap to cover and having them in the risk pool helps cover the really sick people. Between coverage on exchanges and coverage through their parents’ health plans, young people are hot.
Are exchanges succeeding? The whole purpose of exchanges is to give more people access to affordable health insurance. Every exchange (state or federal) will be tracking numbers on a daily basis. Compare how many people your state (or the feds) promised to cover and how many are actually signing up. Also take note of what they are buying. Are the cheapest plans the hot sellers? Are most people opting for catastrophic coverage or the most expensive “platinum” plans?
What are exchanges anyway? Most people don’t have a clue what they are. In our state, the exchange is called Connect for Health Colorado. People don’t seem to make any connection between this entity and health reform. The same may be true where you live.
Feel free to check out coverage on the Solutions website. You’ll hear that Colorado is leading the pack on exchanges, but our exchange managers and Medicaid folks have been sparring behind the scenes. We learned that they needed a mediator and the Robert Wood Johnson Foundation provided one. (Mediator to triage health exchange problems)
The latest news this week is that we’re seven weeks out and the Medicaid portal isn’t working properly and is spitting out errors. Tech errors prompt red light warning for exchange)
Two sources who have really helped me over the past several months are consultants who are tracking exchanges:
Ready or not, here they come – maybe.
The Government Accountability Office has released two lengthy reports (and handy one-page summaries) on preparedness of both the individual and SHOP, or small business, exchanges.
In both cases the assessment was mixed – much has been done, but there’s still a big hill to climb between now and Oct. 1, when enrollment begins. The GAO had more concern about the preparedness of the small business exchanges. As we’ve noted before, one key feature has already been postponed a year, the ability of small business employees to choose their own plan, rather than have their employer choose it.
The reports are a good guide to where things stand – and can help you assess progress in your states:
We heard a fair amount last week about what states plan to do with their exchanges – and we’ll know more when the new state decision-making deadline rolls around on Dec 14.
In the coming days or weeks, we’ll get many many pages of new HHS regulations, some of which pertain to state exchanges and benefit packages. (Jordan Rau runs down some of the outstanding regs in this KHN piece ).
But it’s probably a good time for some of you to review exactly what an exchange is, and how to build one. We’ll look at two stories that should help clarify that, one from NPR’s Julie Rovner and one from The Washington Post’s Sarah Kliff.
First, I want to clear up a misperception I think some of you may have about the federal fall-back exchange. We’re written before about the state run exchanges (Decision deadline Dec. 14 – the law requires HHS to certify exchange plans by Jan. 1, 2013) and the state-federal partnerships ( Decision deadline: Feb 15) But I’ve heard some folks get confused about the third option, the federally run exchange. These exchanges will still be state-based. In other words, the people in those states – Alaska, for instance, and South Carolina – won’t all go into one gigantic national exchange that serves all the all the states that don’t run their own. Instead, the federal government will establish an exchange in each of those states, working to some degree (it will vary) with state health and insurance officials.It’s not one big federal catch-all.
Also, states that don’t do their own for 2014 can still decide to take them on in subsequent years.
So let’s go back to the exchange basics: Continue reading
ProPublica’s Tracy Weber and Charles Ornstein, also AHCJ’s president, lay out in maps how various health reform mandates will play out and which states will participate. They find that “The maps here show the lack of consensus on two key parts of the act: Creating insurance exchanges and expanding Medicaid.” By Nov. 16, states have to submit plans to create an insurance exchange or decide to have the federal government run the exchange.
Jason Millman of Politico writes about the looming deadline to set up exchanges and decide whether to accept an expansion of Medicaid.” So far, just 13 states and the District of Columbia have told HHS they plan to control their own exchange.” Millman reports that many questions about implementation remain to be answered: “Leading up to the election, the Obama administration has sat on key rules governing exchanges, the benefits that health plans must cover, employer requirements and the Medicaid expansion.“
The Associated Press’ Ricardo Alonso-Zaldivar details which states are on track to set up their own exchanges, which have decided not to do so and which states are planning to expand Medicaid programs. He reports that Republicans are asking for cuts to the health care law or money-saving delays in its implementation but Senate Majority Leader Tom Daschle, D-S.D., says that isn’t likely: “I think Democrats are increasingly emboldened about the health care act,” Daschle said. “The president won re-election partly by defending it. There is a new dynamic around the health care effort.”
For more about what to watch for in state’s decisions on exchanges, as well as decisions on essential benefits packages and Medicaid expansion, see the AHCJ webcast “The state countdown: Fate of exchanges after the election.“ Moderated by AHCJ health reform topic leader, it featured three experts who are doing hands-on work in the states.
Update: Kaiser Health News’ Daily Report features a number of articles forecasting the next steps in health reform implementation and activities in various states.
Just days after the November elections, states will have to make final (or reasonably final) decisions about whether they are going to run their own health insurance exchange and what that will look like – or whether the federal government will take responsibility for all or part of the exchange.
States also are grappling with decisions about the essential benefits packages, and although there’s no deadline, expect the pace of their Medicaid expansion decision making to pick up after elections.
If President Obama is re-elected, states will probably pick up the pace of implementation. If Mitt Romney wins, they will probably anticipate repeal – but what happens to all the preparatory work they’ve been doing for the past two years, and will it contribute to new state-based solutions that Romney says he wants?
In a special webcast on Thursday, we’ll talk to three experts who are doing hands-on work with both “red” and “blue” states. AHCJ members will listen in on the call and be able to submit their own questions. You also can send questions in advance to email@example.com. A recording of the webcast will be available to AHCJ members shortly after it is over.
Joanne Kenen, AHCJ topic leader/health reform and deputy health care editor at Politico Pro, will moderate a discussion with:
- Joel Ario, managing director, Manatt Health Solutions
- Cheryl Smith, director, Leavitt Partners
- Heather Howard, lecturer in public affairs, Princeton University; director, State Health Reform Assistance Network