Only 18 states and D.C. will run insurance exchanges

Washington As a mid-December deadline arrived for states to declare their intentions to pursue state-based health insurance exchanges, only four states led by Republican governors had decided to join the pack. In these states and the 14 states — plus the District of Columbia — with Democratic or Independent governors that decided to forge ahead on a state-based coverage marketplace model, the move had support from physicians who continue to strive for a voice in the exchange development process.

The Dept. of Health and Human Services recently gave more time for states with an interest in either the state-based or partnership exchange option to declare their intentions and submit blueprints. Dec. 14 was the deadline for states to declare and submit blueprints on state-based exchanges. Feb. 15, 2013, is the deadline for submitting letters of intention and blueprints on exchanges that will be operated under a federal-state partnership.

According to a list from the Dept. of Health and Human Services at this article's deadline, state-based exchanges will operate in 18 states and D.C. Eleven of them already had received conditional approval from HHS for the exchange blueprints that they submitted.

Consultant Avalere Health LLC estimated that the states with their own insurance marketplaces would enroll only 2.8 million people out of the 8.2 million nationwide who are expected to obtain coverage through exchanges in 2014.

“I do think that there will be a number of states that … wish that they had been prepared and ready to do state-based exchanges. I wouldn't be surprised if there were still some ways for that to happen, even after the deadline,” said Ben Danielson, MD, a pediatrician in Seattle. Washington is one of the 11 states that had received conditional approval by HHS to operate a state-based exchange.

Utah, a pioneer in the exchange arena, also wants conditional status but must revise its blueprint first. Utah already operates an exchange that offers 140 health insurance plans to more than 7,600 individuals in small businesses throughout the state. To comply with the provisions of the Affordable Care Act, Utah's exchange would have to expand to include larger businesses and individuals, something the state plans to do in the near future, Republican Gov. Gary Herbert wrote in a recent letter to President Obama.

Additionally, the Utah exchange would need to include a mechanism to separate the individuals who qualify for Medicaid from the ones who would qualify for federal subsidies for private coverage on the exchange, said David Lind, president of employee benefits research firm David P. Lind Benchmark in Clive, Iowa.

In a Dec. 13 letter to the Utah governor, HHS Secretary Kathleen Sebelius said her department would work with the state in certifying the exchange, and that she supported the state's goals of expanding the current exchange's offerings beyond small businesses.

Lind said his home state of Iowa is pursuing a partnership exchange with the federal government, an option under which at least some control is deferred to federal officials. Cost concerns may prevent the state from doing a full state-based exchange right now, but once it works out some issues, “I wouldn't be surprised if Iowa reverts from a partnership to a state-based exchange” in a few years, Lind said.

Some surprises on the list

Most GOP governors have appeared resistant to their states forming their own exchanges in part due to their general opposition to the health system reform law. But in Idaho, Republican Gov. C.L. “Butch” Otter decided that it would be more prudent to operate a state-based exchange than have the federal government administer the marketplace, the outcome for any state that rejects the exchange concept.

“Our options have come to this: Do nothing and be at the federal government's mercy in how that exchange is designed and run, or take a seat at the table and play the cards we've been dealt. I cannot willingly surrender a role for Idaho in determining the impact on our own citizens and businesses,” Otter said. His decision to pursue a state-based exchange is subject to legislative approval.

The Idaho Medical Assn. is part of a broad-based coalition that will urge state lawmakers to pass legislation to authorize a state-based exchange, said Susie Pouliot, the association's chief executive officer. Pouliot said the association also would push for the inclusion of at least one physician on the exchange's governing board.

Despite all of the fears and political wrangling associated with the ACA, the exchanges are “a pretty amazing opportunity to see health care reform come to life,” said Dr. Danielson. He is a member of Washington state's exchange board but was speaking as an individual. Through the exchange, “there can be ways for people to make relatively better-informed decisions about their insurance. To be able to potentially improve access to some of the lower-income tiers is really important and ends up systematically improving all of our lives.”

In Mississippi, a red state that has been developing its own exchange, the state's insurance department has been proactive in seeking physician input, said Steven Demetropoulos, MD, president of the Mississippi State Medical Assn.

“We appreciate the department placing physicians on various planning committees during the development phase,” Dr. Demetropoulos said. Regardless of what happens with the state's exchange, “Mississippi physicians will continue to offer the best care to patients that we can provide, no matter the patients' insurance status.”