How each state will approach health care act
7/13/2012 12:32 AM - USA Today
States are sharply divided on how — or whether — to
implement the Patient Protection and Affordable
Care Act after it was upheld by the U.S.
Supreme Court.
States are expected to establish exchanges or create
partnerships with the federal government. If states don't act, a federal
exchange is supposed to serve those residents.
In addition, the law calls for a vast expansion of
Medicaid, the federal-state health insurance program for the poor and people
with disabilities. For the first time in most states, adults earning up to 138%
of the federal poverty rate, or $31,809 for a family of four, would be
covered.
As passed and signed by President
Obama, the law threatened states with the loss of all federal Medicaid funds
if they did not expand their programs. The Supreme Court struck down that
provision, freeing states to sidestep the expansion without losing other
funds.
USA TODAY interviews with governors, top aides and health
care officials show some states forging ahead on the law and others are holding
back (number in parenthesis is the estimated percentage of people in each state
who have no health insurance):
Alabama(16%). "We do not know if the state
can afford to expand Medicaid," says Jennifer Ardis, press secretary for Gov. Robert
Bentley, a Republican and a dermatologist. "We have serious concerns about
the increased costs associated with expanding entitlement programs, but we need
to understand the larger implications of the ruling as a whole to determine how
many Alabamians might be subject to the Obamacare tax before deciding the best
course of action."
Alaska(18%). Gov. Sean Parnell, a
Republican, "has directed the state departments of Law and Health and Social
Services to review the (court) decision. It may be months before decisions are
made on Medicaid expansion and a health care exchange," says Sharon Leighow,
Parnell's press secretary.
Arizona(19%). "At this point, the governor
has made no decision" on the insurance exchange and Medicaid expansion, says Ann
Dockendorff, spokeswoman for Gov. Jan Brewer, a
Republican. "We are actively planning to see what role an exchange would play in
— and how the ruling will impact — Arizona's health care system." Brewer says,
"It is now up to the American people to save our country from the fiscal and
regulatory nightmare known as Obamacare. … If Arizonans are to have access to
the health care they need from the provider they choose, Obamacare must be fully
repealed."
Arkansas(19%). The state will rely on the
federal government for an insurance exchange. The state will expand Medicaid
services, says Gov. Mike
Beebe, a Democrat. "If (working people) have the opportunity to have health
care coverage, and if it's going to be paid for by the federal government … I
don't know how we leave our people out," he says.
California(19%). The state is "about halfway"
toward a Web-based enrollment system to meet the Jan. 1, 2014, deadline for
health exchanges, says Diana Dooley, secretary of the state's Health and Human
Services Agency. California will expand Medicaid and is expecting a 10%
enrollment increase, Dooley says. But California faces a $15.7 billion budgetary
shortfall in the 2012-13 fiscal year, according to state estimates. A more than
$8 billion tax hike is on the ballot for voters' consideration in November to
help close the gap. "If that initiative fails in November, we will have to
evaluate what impact that will have on our ability to fully implement the
(health care) reforms," Dooley says.
Colorado(14%). The state created a health
insurance exchange in 2011, says Lorez Meinhold, senior policy director for Gov.
John
Hickenlooper, a Democrat. People will be able to begin purchasing insurance
in October 2013 for coverage beginning Jan. 1, 2014. "We are creating a
Colorado-based system. But we do still need the federal dollars and will go
after the federal dollars to build the Colorado exchange," Meinhold says. The
state is not waiting for the election and has already begun using Medicaid to
cover some people without insurance.
Connecticut(11%). Under Gov. Dannel Malloy, a
Democrat, Connecticut plans to fully implement the health care act and meet all
deadlines. The state already authorized an insurance exchange and expects to
runs its own, says Benjamin Barnes, Connecticut secretary of policy and
management. The Medicaid expansion could save the state roughly $300 million a
year because the state already voluntarily covers some low-income adults without
insurance. The new law will let the state expand coverage of adults from the
current 60% of the poverty level — for which the state pays 50% of the cost — to
133% of the poverty level while the federal government pays 100% of the costs
for the first three years, Barnes says.
Delaware(12%). "We do not plan a standalone
state exchange but have been working … toward a federal partnership exchange,"
says Gov. Jack Markell, a
Democrat. "We are still reviewing our options on Medicaid expansion and
anticipate further guidance" from the federal government.
District of Columbia(12%). The District plans
to implement a health insurance exchange by Oct. 1, 2013, and has already
expanded Medicaid. "We will continue to move forward with implementation of this
landmark legislation for District residents," says Wayne Turnage, director of
the Department of Health Care Finance.
Florida(21%). "Florida will opt out of
spending approximately $1.9 billion more taxpayer dollars required to implement
a massive entitlement expansion of the Medicaid program," says Gov. Rick Scott, a
Republican. The state also won't build insurance exchanges. "Florida already has
health care safety net programs for those with the greatest need, including
Florida KidCare to ensure no child goes without health care in Florida. … But
even though the federal government has promised to initially pay 100% of the
increase in Medicaid payments for the first three years of Obamacare, the burden
increasingly shifts to Florida taxpayers in future years. Medicaid, which has
been growing for years 3½ times as fast as Florida's general revenue, will soon
grow even faster under Obamacare, and education funding will be adversely
impaired if we do not control the growth in Medicaid spending."
Georgia(20%). "It's far too early to say how
we're going to approach the Medicaid expansion," says Gov. Nathan Deal, a
Republican. "The court changed the rules of the game on expansion and we'll need
to see what the executive branch issues in regulations. … We will wait until the
election, which will determine our next steps. However, Obamacare is far too
costly for the state with the estimated $4.5 billion in new costs over the next
10 years. … We have to look at the most cost effective ways to increase
insurance coverage for Georgians. From the state perspective, it's
unaffordable."
Hawaii(8%). "We are planning to fully
implement our state-based exchange and the Medicaid expansion," says Gov. Neil
Abercrombie, a Democrat.
Idaho(17%). "Obamacare has been bad for
America from the beginning," says Gov. C.L. "Butch" Otter, a Republican. "Change
is now in the hands of the American people and we must elect a new president and
congressional candidates who will repeal Obamacare."
Illinois(15%). The state will work with the
federal government to set up an insurance exchange. The state supports expanding
Medicaid. "We'll move forward to deliver the benefits of the Affordable Care Act
to millions of people in Illinois," says Deputy Gov. Cristal Thomas, a
Democrat.
Indiana(14%). "Absolutely no decision has
been made to establish a state-based exchange," says Gov. Mitch
Daniels, a Republican. "Before a decision can be made, the state needs more
information about how a federally based exchange will operate and be funded. … A
Medicaid expansion would put 1 in 4 Hoosiers (approximately 500,000 new
enrollees) in Medicaid at a cost of approximately $2 billion over 10 years."
Daniels says a decision on whether to expand Medicaid will be made by the next
governor and Legislature.
Iowa(12%). Gov. Terry
Branstad, a Republican, joined the lawsuit against the law "because he
calculated that it would cost $800 million for 150,000 new Iowans to join the
Medicaid rolls, which is something neither Iowa nor the federal government can
afford," says Tim Albrecht, a spokesman. "His goal is to make Iowa the
healthiest state in the nation through other methods."
Kansas(13%). Gov. Sam
Brownback, a Republican, says no decision on expanding Medicaid or creating
an insurance exchange will be made until after the November election. "It's a
political question now," he says.
Kentucky(15%). The state will operate its own
insurance exchange but has not decided whether to expand Medicaid, says Kerri
Richardson, communications director for Gov. Steve
Beshear, a Democrat.
Louisiana(17%). "Come this November, we are
going to elect a new president and a new Congress who will repeal and replace
Obamacare," Gov. Bobby
Jindal, a Republican, says. "That's why we have refused to implement the
Obamacare health exchange or the Medicaid expansion."
Maine(10%). Gov. Paul LePage, a
Republican, says the court ruling "has verified what President Obama has refused
to admit all along, which is to say this law is an enormous tax on the American
people. The federal government can force you to do or buy anything, as long as
they call it a 'tax.' This massive tax hike will only destroy the American
economy as it forces us over the financial cliff. … It is now up to the American
people to demand full repeal of Obamacare. The Washington, D.C., elites cannot and
should not run our lives."
Maryland(13%). Under Gov. Martin
O'Malley, a Democrat, the state has "passed legislation to create a health
care exchange, setting up standards and regulations to run the program and
creating the framework for a marketplace where individuals and small businesses
can purchase coverage," says Raquel Guillory, a spokeswoman for O'Malley.
Maryland also supports expanding Medicaid.
Massachusetts(5%). Gov. Deval
Patrick, a Democrat, expects Massachusetts to fully adopt the federal law
and will have to make only small changes in its existing system of universal
health coverage, which the federal law is modeled after. The health insurance
exchange must reconcile some differences between the state and federal law by
2014, such as the amount of the penalty for not buying insurance and the income
levels that trigger the penalties.
Michigan(13%). No state GOP
leaders, including Gov. Rick Snyder,
have committed to adding roughly 500,000 uninsured residents to the Medicaid
rolls beginning Jan. 1, 2014 — despite a federal pledge to pay the full tab the
first two years and ultimately 90% of all costs after that. Even if the federal
government ultimately pays 90% of the expanded Medicaid costs, Michigan's share
could run $200 million annually, according to the Senate Fiscal Agency. Sara
Wurfel, Snyder's spokeswoman, says the administration wants to study the cost of
expanding Medicaid coverage — in concert with lawmakers — to determine the "best
course of action" for the state. State Senate Minority Leader Gretchen Whitmer,
D-East Lansing, says she worries that the issue will become mired in a partisan
slugfest, perhaps leading the state to miss out on critical federal dollars to
help its neediest citizens.
Minnesota(9%). The state will keep planning
to develop a health-coverage exchange and to expand Medicaid, says Lucinda
Jesson, commissioner of the Minnesota Department of Human Services. Bills have
been introduced to create a state exchange, but the GOP-controlled Legislature
elected not to pass one. Gov. Mark Dayton, a
Democrat, last year extended Medicaid to 84,000 adults earning less than $8,400
a year.
Mississippi(19%). The state is moving to
establish a free-market health insurance exchange but will not expand Medicaid,
says Gov. Phil Bryant, a
Republican. "Even when the expansion is fully funded by the federal government,
the state would still have to come up with an additional $110 million in
administrative costs to support the 400,000 potential new participants," Bryant
says. "I plan to work with conservatives across the county to elect Mitt
Romney, so we can repeal and replace Obamacare."
Missouri(14%). "We're just now beginning to
review this ruling so that we can understand exactly what it means for
Missouri," says Gov. Jay Nixon, a
Democrat. "This ruling has significant complexities and implications for
families, health care providers and insurers."
Montana(17%). Gov. Brian
Schweitzer, a Democrat, says: "We are reviewing the decision. Unlike the
federal government, Montana can't just print money. We have a budget surplus and
we're going to keep it that way. The federal law means Montana's Medicaid
population will double. … Preliminary estimates … indicate an additional 84,000
people will be eligible for Medicaid here by 2019 — at an estimated cost of more
than $1.2 billion by the same year. With Montana's share of the bill estimated
at $71 million, a new approach to controlling health care costs is needed. There
are still a lot of unanswered questions."
Nebraska(12%). Gov. Dave
Heineman, a Republican, says: "My biggest concern is that an unfunded
expansion of Medicaid means state aid to education for the Omaha, Lincoln, North Platte
and Lexington Public Schools and many other Nebraska school districts will be
cut. … Cutting funding for the education of Nebraska's children and increasing
taxes on Nebraska's families are not my priorities. … Reviewing this decision in
a detailed, thoughtful and responsible manner will take weeks and months before
a complete determination can be made on what this ruling means for
Nebraska."
Nevada(21%). The state is setting up a health
insurance exchange and using funds provided in the law to do so, says Jon Hager,
executive director of the Silver State Health Insurance Exchange. Gov. Brian
Sandoval, a Republican, "does not intend to automatically accept the
Medicaid expansion. We will continue to examine (the ruling) to fully understand
its implications," says Mary-Sarah Kinner, Sandoval's press secretary.
New Hampshire(10%). Gov. John
Lynch, a Democrat, last month signed a law preventing the state from
establishing an insurance exchange. That means the state's exchange will be run
by the federal government. Lynch says the law "will help provide access to
affordable health care to many more of our citizens and help our small
businesses with the high costs of health care. The court's decision allows those
important provisions to go forward."
New
Jersey(15%). Gov. Chris
Christie, a Republican, says, "I still believe this is the wrong approach
for the people of New Jersey, who should be able to make their own judgments
about health care." Christie is weighing whether letting the federal government
set up the state health insurance exchange would be a less expensive option, he
said on Fox News Channel's Fox and Friends show. He also said he's not
sure the state needs to expand Medicaid under the law because the state's
program for the poor and disabled already is inclusive. He praised one part of
the Supreme Court ruling that pulls back the federal government's ability to
force states to expand Medicaid to include people with incomes up to 133% of the
poverty level.
New Mexico(21%). The state is developing its
own insurance exchange, says Matt Kennicott, communications director for the New
Mexico Human Services Department. "There are still a lot of questions that need
to be answered and a lot of moving pieces on Medicaid expansion," Kennicott
says.
New
York(15%). Gov. Andrew
Cuomo, a Democrat, has ordered the establishment of a state-based health
exchange aimed at the roughly 2.7 million New Yorkers
lacking health insurance. The goal is to be ready to accept applications on Oct.
1, 2013. The state also will expand Medicaid. Regardless of the fall
presidential election, Cuomo's office says, "New York's planning efforts are
focused on implemented the federal law as it stands."
North Carolina(18%). The Legislature did not
set up a health care exchange before adjourning this year and Gov. Bev Perdue, a
Democrat, is reviewing options, says Chris Mackey, Perdue's deputy
communications director. Perdue, who is not running for re-election this year,
says it's up to the Legislature to decide whether to expand Medicaid.
North Dakota(12%). The state is not moving to
implement the law. "The health care plan is wrong for North Dakota," says Gov.
Jack Dalrymple, a Republican. "Our citizens want the freedom to make their own
decisions about their health-care coverage. Instead of embracing government-run
health care supported by a tax on the American people, we should be pursuing
market-based reforms that make heath care more affordable, that encourage
greater participation and provide Americans with more choices."
Ohio(14%). Ohio probably will let the federal
government create a health exchange for the state, says Lt. Gov. Mary Taylor, a
Republican. She estimates the move would save Ohio $43 million. She called a
federal exchange rather than a state-run exchange "the lesser of two evils."
Ohio is reluctant to expand Medicaid but hasn't ruled it out. John McCarty,
state Medicaid director, says Ohio estimates that the health care law will add
$369 million to the state's costs in 2014 even without expanding Medicaid,
making the state reluctant to take on any other obligations, even if the federal
government promises to pay most of the cost.
Oklahoma(18%). Gov. Mary Fallin, a
Republican, plans to wait until after the November election to decide how to
proceed, according to local news accounts. The Legislature has declined to
establish health care exchanges. Fallin hasn't decided whether to expand
Medicaid coverage to more uninsured adults, mostly at federal expense.
Oregon(17%). The state is on pace to
establish its health insurance exchange in 2013, says Tim Raphael,
communications director for Gov. John
Kitzhaber, a Democrat. The state isn't waiting for the presidential election
to take action. "The governor supports covering the uninsured and changing the
way health care is delivered to improve health, provide better care and reduce
cost," Raphael says.
Pennsylvania(11%). Gov. Tom Corbett, a
Republican, likely will push the state to set up its own exchange because it can
do it better than the federal government, spokeswoman Kelli Roberts says.
Corbett has not yet decided whether to expand Medicaid. Corbett said after the
ruling that the law will "raise health care costs for our families, our
employers and our state" but that he would comply and "do all we can to ensure
the negative impact of this law affects the lives of Pennsylvanians as little as
possible." Corbett "hopes that in November we will have a change in leadership
and repeal this law, but what we are focused on is making sure we are doing what
is right" in complying with the law, Roberts says.
Rhode
Island(12%). The state "has already done tremendous work to
establish a (state-based) exchange and plan for Medicaid expansion, says the
office of Gov. Lincoln
Chafee, an independent. "Rhode Island is committed to implementing Medicaid
expansion in order to close the coverage gap and reach nearly universal coverage
for all Rhode Islanders."
South
Carolina(19%). Gov. Nikki Haley, a
Republican, opposes health care exchanges and expanding Medicaid. "We're not
going to shove more South
Carolinians into a broken system that further ties our hands when we know
the best way to find South Carolina solutions for South Carolina health problems
is through the flexibility that block grants provide," says Rob Godfrey, the
governor's spokesman. The state plans to delay action until after the November
election.
South Dakota(13%). "We will not attempt to
set up an exchange before the November election," says Gov. Dennis Daugaard, a
Republican. "I'm not very enthusiastic about expanding Medicaid. In South
Dakota, people still believe in self-reliance, and I think able-bodied adults
should be self-reliant. … My hope is that, after the election, the next
president and congress will repeal this law."
Tennessee(15%). Gov. Bill Haslam, a
Republican, "firmly believes Obamacare should be repealed because it increases
the number of people covered by a broken health care system rather than
addressing cost issues," says Dave Smith, a
spokesman. "The state has been doing preliminary planning for health care
exchanges. The governor, in addition to advocating for repeal, believes it is
the state's responsibility to be prepared for multiple scenarios" and prefers a
state-run exchange.
Texas(25%). Gov. Rick
Perry, a Republican, opposes the insurance exchanges and Medicaid expansion,
calling them "brazen intrusions into the sovereignty of our state. I stand
proudly with the growing chorus of governors who reject the power grab." Texas
has an estimated 6.2 million uninsured residents and the highest rate of
uninsured among the states. "Neither a 'state' exchange nor the expansion of
Medicaid under the Orwellian-named Patient Protection and Affordable Care Act
would result in better 'patient protection' or in more 'affordable care,' "
Perry says. "What they would do is make Texas a mere appendage of the federal
government when it comes to health care." Expanding Medicaid as the law
envisions "would only exacerbate the failure of the current system and would
threaten even Texas with financial ruin," Perry says, adding that the law's
"unsound encroachments will find no foothold here."
Utah(14%). Gov. Gary Herbert, a Republican,
says the state may not expand Medicaid. He wants states more involved in setting
health care policy. "We have 50 incubators of innovation and policy, who have
experience with their own unique circumstances and challenges," he says. "The
federal one-size-fits-all mentality is short-sighted and simply bad policy." He
says the state will run a "consumer-oriented, market-driven exchange."
Vermont(9%). Gov. Peter Shumlin,
a Democrat, supports meeting the requirements of the law for Medicaid and the
health benefit exchange. The state is setting up the exchange on its own, with
the help of federal funds. Shumlin supports a government-financed health care
system covering every Vermont resident.
Virginia(13%). The state challenged the law
in court. But Gov. Bob
McDonnell, a Republican, also has said the state would comply with the law
and has made plans to set up its own health exchange. "If we have to choose
between accepting another new federal bureaucratic monstrosity of a federal
health-care exchange vs. a state exchange where we can determine what goes in
there — if that's the Hobson's choice we are faced with — my inclination is we
ought to have a state-based exchange," McDonnell says. "But I think even a
state-based exchange is a bad idea. It's more bureaucracy." McDonnell says he
worries about the impact of Medicaid expansion on the state's budget and will
push to have the law repealed.
Washington(13%). "Our state has already moved
to develop a health care exchange. Our governor also supports the Medicaid
expansion," says Karina Shagren, a spokeswoman for Gov. Chris
Gregoire, a Democrat.
West Virginia(14%). "We're going to review
the Supreme Court's ruling, and work with our federal delegation on how we move
forward," says Gov. Earl Ray Tomblin, a Democrat.
Wisconsin(9%). Gov. Scott
Walker, a Republican who joined the lawsuit opposing the law, says
"Wisconsin will not take any action to implement Obamacare. I am hopeful that
political changes in Washington, D.C., later this year ultimately end the
implementation of this law."
Wyoming(16%). "There are numerous questions
that the federal government will have to answer before we can fully understand
the implications of the ruling and the state's new options for the Medicaid
expansion," says Renny MacKay, a spokesman for Gov. Matthew Mead, a
Republican.
Contributing: John McAuliff, Jessica Tully, Dennis Cauchon, Judy Keen,
Larry Copeland, Chuck Raasch, USA TODAY; Marty Roney, Montgomery (Ala.)
Advertiser; Dennis Wagner, The Arizona Republic, Phoenix; Kevin Pieper, The
(Mountain Home, Ark.) Baxter Bulletin; Keith Matheny, The (Palm Springs, Calif.)
Desert Sun; Trevor Hughes, Fort Collins (Colo.) Coloradoan; Mike Chalmers, The
(Wilmington, Del.) News Journal; Rick Neale, Florida Today, Melbourne, Fla.; Tim
Evans, The Indianapolis Star; Jessie Halladay, The (Louisville) Courier-Journal;
Alison Bath, The (Shreveport, La.) Times; Brian Shane, The (Salisbury, Md.)
Daily Times; Kirsti Marohn, St. Cloud (Minn.) Times; Brian Eason, The (Jackson,
Miss.) Clarion-Ledger; John Adams, Great Falls (Mont.) Tribune; Bill O'Driscoll,
Reno Gazette-Journal; Alesha Williams Boyd, Asbury Park (N.J.) Press; Matthew
Daneman, Rochester (N.Y.) Democrat and Chronicle; Jon Ostendorff, Asheville
(N.C.) Citizen-Times; Tracy Loew, Statesman Journal, Salem, Ore.; Ron Barnett,
The Greenville (S.C.) News; Jonathan Ellis, Argus Leader, Sioux Falls, S.D.; Bob
Smietana, The (Nashville) Tennessean; Brian Passey, The (St. George, Utah)
Spectrum; Adam Silverman and Nancy Remsen, The Burlington (Vt.) Free Press; Ben
Jones, The (Appleton, Wis.) Post-Crescent.