In the session “Tracking Implementation of the ACA” four speakers offered their perspectives on the implementation of the ACA in specific states, providing varying levels of support for implementation. Session speakers included Jocelyn Johnston from the American University, Richard Nathan form The Rockefeller Institute of Government, Sara Schmitt from the Colorado Health Institute and David Warner from the University of Texas at Austin. Robert St. Peter from the Kansas Health Institute moderated the session.
Robert St. Peter kicked off the session by providing a context for state implementation of the ACA, and in particular, exchanges and Medicaid expansion. He was followed by Richard Nathan, who introduced the Rockefeller-Fels Institutes Field Network Study of the Implementation of the Affordable Care Act as one important effort to observe and study the implementation of the ACA in a cross-sectional manner. Thirty states are currently participating in this study, and other states are encouraged to join. Researchers from three of the participating states shared their state’s experiences in this session.
The three other speakers then provided a brief overview of the political context for each of the states they represented: Colorado, Maryland, and Texas. David Warner noted that Texas historically has a limited Medicaid program and is currently a single party Republican state. As a result, Texas has chosen to not expand Medicaid, develop a state-based exchange, or participate in regulating insurance plans per ACA requirements. In comparison, Jocelyn Johnson shared that Maryland is a single party Democratic state, has a long history of insurance regulations to contain costs and began its implementation efforts shortly after the ACA passed. Finally, while Colorado is currently a single party Democrat state, Sara Schmitt noted that Coloradoans view themselves as a “purple” state and have adopted a “Western pragmatic” mentality. Thus, Colorado elected to create its own state-based exchange via bipartisan agreement.
Though Maryland has experienced prolonged technical glitches with their exchange, Jocelyn Johnson announced that Maryland has 27,000 private enrollees and 42,000 new Medicaid enrollees based on their most recent report. Colorado enrolled 101,730 individuals in Medicaid, with 63,407 enrolled in private insurance plans. Sara Schmitt noted that in December, enrollment had surpassed their “worst case scenario” and their enrollment is gaining steam. Over half of those enrolled in private insurance through the Colorado exchange qualify for aid. Colorado and Maryland will continue their outreach to increase enrollment by working with navigators and insurance brokers, advocacy organizations, and faith-based groups.
Throughout the discussion, several important themes were noted. One of the themes discussed was the possibility of “churn,” i.e. individuals cycling through Medicaid and private insurance (exchange) eligibilities. It was noted that in some states, like Texas and Kansas, that have not implemented Medicaid expansion, there is a “donut hole” where an individual’s income would be too high to qualify for Medicaid, but would not meet the threshold for the premium tax credits from the ACA.
Bob St. Peter closed the discussion by asking the panelists to look forward and share their state’s anticipated next steps. Jocelyn Johnson suggested that Maryland will address churning and ensuring continuity of care. The state will focus on implementing its small business exchange (SHOP) in 2015. Another important effort planned is a hospital cap initiative to modernize hospital payments to focus on quality of care. Colorado plans to study geographic variation in health care cost in the future. In addition, the state will investigate a sustainability model for the exchange. Finally, Texas may reconsider addressing the Medicaid gap after the March 4, 2014 primaries by considering solutions such as the Arkansas model or block grants.
The Rockefeller-Fels Institutes Field Network study is currently preparing its baseline field reports for each state in the network, which will be followed by future reports. Stay tuned for their first report on the “out-front” western region out soon!