The District and Maryland are moving aggressively to implement virtual markets of insurance plans, becoming national leaders in carrying out President Obama's vision for health care reform, while their Republican neighbors in Virginia remain less than eager to implement the controversial law.
State health care policy has been in the national spotlight since the Patient Protection and Affordable Care Act became law in early 2010. Some states started working on reforms almost immediately. After the U.S. Supreme Court upheld key points of the law in June, more states have been moving forward to establish health care exchanges.
Each state's health care exchange is designed to help the uninsured, self-insured and small-business owners shop for the most cost-effective insurance coverage. The District has created a board to design and govern its exchange.
The District's push for a local exchange is ambitious, especially compared with varied strategies employed by states. So far, according to the National Conference of State Legislatures (NCSL), 12 states have passed legislation to authorize exchanges. Four states provided the authority through an executive order and four states have legislation pending.
The federal government is slated to roll out an exchange for any state that decides not to do it on its own. State governments may save time and resources by neglecting to wade into the uncertain territory of health care exchanges, but the federal version is unlikely to be tailored to states' needs, officials and experts said.
In general, each state's approach tends to skew along partisan lines. The District and Maryland are led by Democrats and striving to implement health care exchanges, while high-profile Republican Gov. Bob McDonnell presides in Virginia, which has not authorized an exchange. The issue is also likely to surface in the campaigns for president and other key elective offices across the nation this fall.
"I think it's safe to say national politics has had something to do with how states have proceeded with this," said Joy Wilson, health policy director for the NCSL. "If you're a Republican governor, it might be awkward for you to be acting counter to your national party's activity."
D.C.'s planned exchange
D.C. Mayor Vincent C. Gray, a Democrat, established the city's Health Reform Implementation Committee in early 2011 to ensure a "smooth and rapid" roll out of the law.
The board has met twice, to organize itself and to elect Dr. Mohammad Akhter as its chairman. Dr. Akhter took a year of leave from his Cabinet post at the city's Department of Health to work on the city's exchange, citing the benefits of federal reforms to D.C. residents.
Dr. Akhter said the board needs to submit a proposal on its exchange to the federal government by Wednesday to obtain an estimated $70 million to $80 million in federal funding this October to build the market's infrastructure. The board will then have a year to build the exchange and have it reviewed by October 2013, he said.
City officials said their 81-page proposal outlines the city's insurance market based on research by Mercer, a consulting firm. The proposal details program requirements, describes the likely premium cost for products offered on the exchange and estimates the long-term operating costs.
"In short, the document demonstrates to the federal government that the District has done the necessary planning work to begin the development of the exchange, while informing the work of the board as they prepare to make what will be some very critical policy decisions," said Wayne Turnage, director of the D.C. Department of Health Care Finance.
Among those decisions, Dr. Akhter said, is "what kind of insurance market are we going to have in the District?"
The city can opt for an open system that welcomes all providers, or it can be selective about which providers fit the city's needs. Ms. Wilson said exchanges should assist owners of small firms who are usually saddled by insurance plan decisions, while people covered by plans at midsized to large firms would not be affected by reforms related to the exchange.
In the District, the exchange will be mostly Internet-based, but services will still be available by phone and other means, city officials said.
Aggressive efforts to cover residents under Medicaid or the D.C. Healthcare Alliance, which enrolls many immigrants who are not eligible for the federal insurance program, means only about 5 percent of the city's population is uninsured, officials said.
Maryland vs. Virginia
In Maryland, leaders have wholeheartedly embraced the health care law since its passage. The General Assembly passed bills in 2011 and this year that set the framework for a health benefits exchange, which state officials say could provide health care access to as many as half of the state's 700,000 uninsured residents.
By diving into health care reform, the heavily Democratic state has already received $34.4 million in federal grants and is expecting to receive additional federal funds, avoiding the need for the use of state dollars, according to staff in Annapolis.
Maryland Lt. Gov. Anthony G. Brown, a Democrat and vocal proponent of Mr. Obama's law, said the state's health care exchange is "the most important component of our health care reform efforts."
But further south, the Virginia legislature this year delayed taking action to implement an exchange until the Supreme Court case was resolved. Its Republican state attorney general, Kenneth T. Cuccinelli II, sued the federal government immediately after Mr. Obama signed the overhaul into law and had hoped the entire law would be struck down by the Supreme Court.
In his role as chairman of the Republican Governors Association, Mr. McDonnell sent a letter to the Obama administration in July to outline concerns with the health care law and ask a laundry list of questions, including whether governors can "expect extensions of the deadlines for implementation (of state-based exchanges) given the uncertainty caused by the Supreme Court ruling."
In a separate letter to the state's General Assembly, Mr. McDonnell said he hopes to see Mr. Obama's health care law repealed after the November election if Mr. Obama is defeated in his re-election bid.
Amid this uncertainty, he said, "it is not prudent to spend a great deal of time and taxpayer money on building a system that we may never need to implement or that may be materially different once the rules are finally established."
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