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This Week in US Health Reform

Posted by John McDonough  November 18, 2012 07:20 PM

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Less than two weeks into the new post-election phase of Affordable Care Act implementation and a clearer picture is emerging. Republican-controlled states are beginning to decide whether to launch their own health insurance exchanges and whether to embrace the ACA's expansion of Medicaid. These two charts -- courtesy of Sarah Kliff at the Washington Post and the Wall Street Journal -- give a useful snapshot of how things looked midway thru this past week:

NA-BT681_EXCHAN_G_20121115200014.jpg















DB_medicaid_map_lg.jpg


There is much uncertainty and flux in both categories. The most compelling divide is partisan, though not completely. At least three states with Republican governors now aim to set up their own Exchanges, including New Mexico whose Governor, Susana Martinez, is a new GOP celeb as the party tries to figure out how to attract more Latinos (who happen to like the ACA a lot). Only one Democrat Governor is in the "no" category, and that is Missouri's Jay Nixon whose voters prevented him from acting by executive order in a November 6th state ballot initiative.

We are now looking at the need for a sizable federal fallback exchange to serve consumers in the states that say "no."  There is irony in this. During the ACA's crafting, most Democrats wanted a single, muscular federal exchange, and lost that fight because moderate Senate Dem Ben Nelson from Nebraska demanded that states have right of first refusal in exchange for his vote.

Now it appears we will have that muscular federal exchange -- assuming the Obama Administration can secure adequate funding -- thanks to conservatives such as Rick Perry and Bobby Jindal.  I believe this is good; consumers in these states will be far better served by a federal exchange than one those governors would create: of, by, and for the insurance industry.

While only 12 states are undecided on exchanges (and some, such as Wisconsin's Scott Walker, decided in the negative on Friday), there is far more uncertainty about state choices on expanding Medicaid where as many as 20 states are undecided. This is not surprising because, unlike the exchanges, there is no deadline for state decisions. States that say no will forfeit 100% federal financing in 2014, '15 and '16, with federal support dropping to 90% by 2018. (On average, states get 56% federal reimbursement from traditional Medicaid.)  This process is far from done and I will predict that by 2018, all 50 states will participate in the Medicaid expansion.

Just look at Florida where Republican Governor Rick Scott has been the leading ObamaCare critic among all 50 governors. This past week, Scott announced he wants to find a way "to get to yes" to implement the ACA in Florida:

"The election is over and President Obama won," Scott said. "I'm responsible for the families of Florida ... If I can get to yes, I want to get to yes."

Perhaps a looming gubernatorial election in 2014 might be a factor as well as FL voters' November 6th rejection of a ballot initiative to prevent ACA implementation in the Sunshine State.  This process is taking shape and it is only beginning.

On other noteworthy fronts, the New York Times reported:

"Mitt Romney blamed his loss on Obama's "gifts" to specific interest groups - "especially the African community, the Hispanic community and young people" - and said the health care law's young adult coverage and the contraceptive coverage helped Obama win with young voters. 'Free contraceptives were very big with young college-aged women. And then, finally, Obamacare also made a difference for them, because as you know, anybody now 26 years of age and younger was now going to be part of their parents' plan, and that was a big gift to young people,' Romney said in a conference call with his finance committee..."

Meanwhile, Louisiana Governor Bobby Jindal said it's time for Republicans to stop acting like the "Stupid Party."  Wow.  Methinks he was talking about rape and abortion, though he declined to be specific. How about creationism and climate change for two?  Meanwhile, in Jindal's state of Louisiana, 29 percent of non-elderly adults have no health insurance. 29 percent. Maybe that's something worth being a little less "stupid" about, too? Bobby?

Wonders never cease when it comes to the ACA.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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