States slow to adopt health-care transition
By Amy Goldstein
and N.C. Aizenman,
As many legislatures around the country have finished their work for the
year, fewer than one-fourth of states have taken concrete steps to create health
insurance marketplaces, a central feature of the federal law to overhaul the
U.S. health-care system.
A total of 43 states, meanwhile, have made fresh cuts to Medicaid, even as
lingering unemployment and diminishing access to private coverage continue to
drive up the number of Americans turning to the public insurance program for the
poor.
Taken together, these trends highlight the ground-level challenges that
health care poses to states. A year after Congress passed the biggest revisions
to the health-care system since the 1960s, states are grappling with their own
versions of the fiscal and ideological battles that still are roiling
Washington.
States that have moved gingerly so far on health exchanges have not
necessarily rejected the idea outright. Only one, Louisiana, has told the
federal government it does not intend to build an insurance marketplace for its
residents. In states that refuse, the law allows the federal government to step
in.
An exchange must be available in each state by 2014. The idea is to help a
slice of the public for whom insurance traditionally has been especially
expensive: Americans who buy coverage on their own or as part of small
companies. The exchanges are supposed to make it easier for them to compare
health plans while creating pools of customers large enough to slow rising
prices.
States have a deadline of January 2013 to prove to federal health officials
that they are on a path to be ready.
The furthest along are seven states that have adopted laws establishing their
exchanges. California did so last year, followed this year by Colorado, Hawaii,
Maryland, Vermont, Washington and West Virginia. Two others, Virginia and North
Dakota, passed laws expressing their intent to form an exchange, without
spelling out details of how it should be run. Both states have Republican
governors who oppose the federal law but maintain it would be worse to entrust
an exchange to the federal government.
Seven other states, including some with GOP leadership, have not passed any
relevant legislation but have accepted federal grants to prepare key components
of the exchanges, including systems to determine which residents are
eligible.
Elsewhere in the country, there has been less progress. Nearly a dozen
legislatures have defeated or allowed to expire bills that would have created an
exchange, according to analyses by the National
Conference of State Legislatures and the Center
on Budget and Policy Priorities. At least 13 other states have not even
considered such proposals.
In many such cases, lawmakers oppose the federal law. But in Kentucky, where
Democrats control the governorfs office and the House of Representatives, Rep.
Tom Burch (D), who heads the Health and Welfare Committee, said his party was
simply waiting for the Obama administration to issue regulations spelling out
federal requirements in more detail. gSo much of this stuff is still
speculation,h he said.
Paul Dioguardi, the Health and Human Services Departmentfs director of
inter-governmental affairs, said he was confident states that have been slow so
far will be able to catch up, in part by borrowing the models of states that
move more quickly.
Also starting in 2014, the federal law will expand Medicaid to Americans with
incomes higher than most states have allowed until now. For now, the number of
people on Medicaid under statesf existing eligibility rules is straining the
ability to pay for them.
Medicaid is a shared financial responsibility of federal and state
governments. During the past few years, the nationfs economic crisis has
simultaneously depressed statesf revenues and increased Medicaid caseloads. In
2009, to help stimulate the economy, the federal government began giving states
extra money for Medicaid. That temporary help runs out this month.
A new
report by the National Governors Association and the National Association of
State Budget Officers makes clear that the burden of Medicaid on states remains
heavy. For the current fiscal year, 43 states have taken action to contain their
Medicaid costs. Two dozen have reduced payments to doctors, hospitals or other
providers of care; 23 have sought to lower spending on prescription drugs; and
20 have restricted certain services that the program covers.
For the coming year, 45 governors proposed further cuts, the report says,
without specifying which reductions were adopted by legislatures. Thirty-three
governors proposed to reduce provider payments, 25 to restrict benefits and 21
to require Medicaid patients to pay more for their care.
For instance, in Maryland, where Medicaid enrollment has grown by 11 percent
in about the past year to nearly 920,000, the General Assembly has just ordered
cuts to the programfs $7 billion budget totaling about 1 percent, according to
the statefs Medicaid director, Charles Milligan. The state will reduce by 2
percent its payments to managed-care organizations — the way most of Marylandfs
Medicaid patients get care. It will cut by 1 percent the programfs pay to
doctors, private-duty nurses and home care aides. And hospitals and nursing
homes will be charged a new fee of 2 percent to 3 percent to take part in the
program.
Donald Berwick, administrator of the federal Centers for Medicare and
Medicaid Services, noted that his agency has been trying to help states find
ways to cope with their Medicaid budgets. But, he said, gI think they will be
under pressure for some time.h
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