“If there’s to be a train wreck, we gov­er­nors would rather be spec­ta­tors than con­duc­tors.”

Modern Healthcare - - The Week In Healthcare -

Govs. Ha­ley Bar­bour of Mis­sis­sippi, Bobby Jin­dal of Louisiana, Mary Fallin of Ok­la­homa, Robert Bent­ley of Alabama and Rick Perry of Texas, among oth­ers, signed the letter.

Se­be­lius took to the opin­ion pages of the Wash­ing­ton Post on Feb. 9 to re­spond, ar­gu­ing that the law al­ready al­lows for am­ple lo­cal over­sight. “What these crit­ics miss is that the law al­ready gives states most of the re­sources and flex­i­bil­ity they’re ask­ing for,” she wrote.

Legal ex­perts say the gov­er­nors are tak­ing a two-pronged ap­proach in their fight against the re­form law. “While pur­su­ing hav­ing this rolled back in the courts, they are pur­su­ing a roll­back in the po­lit­i­cal arena,” said James Napoli, se­nior coun­sel at the law firm Proskauer Rose in Wash­ing­ton. “I think what we are see­ing with these let­ters is the states ex­ert­ing their po­lit­i­cal will and stak­ing out their po­lit­i­cal po­si­tions.”

Some Repub­li­can gov­er­nors also have sought to change their Med­i­caid pro­grams. Last week, Utah Gov. Gary Her­bert met with CMS of­fi­cials to re­quest a waiver to charge some ben­e­fi­cia­ries’ higher co-pays and link provider re­im­burse­ments with care qual­ity. Florida and Ari­zona also are seek­ing Med­i­caid waivers.

Utah is one of only two states al­ready op­er­at­ing an in­surance ex­change. The Utah pro­gram, where about 1,000 work­ers have ac­cessed in­surance, “demon­strates that states can use mar­ket prin­ci­ples to solve dif­fi­cult is­sues in health­care,” Her­bert said in a speech last week at the Her­itage Foun­da­tion.

Mitch Daniels, the Repub­li­can gov­er­nor of In­di­ana, has been one of the most vo­cal crit­ics of the law. “If there’s to be a train wreck, we gov­er­nors would rather be spec­ta­tors than con­duc­tors,” Daniels wrote last week in the Wall Street Jour­nal. Daniels and Her­bert were among the 21 gov­er­nors who signed the letter to HHS on the ex­changes.

The gov­er­nors also asked Se­be­lius for a new in­de­pen­dent anal­y­sis on how many res­i­dents in each state are ex­pected to seek cov­er­age through the ex­changes, how many will join Med­i­caid rolls and what the cost will be to the states. In 2014, Med­i­caid el­i­gi­bil­ity will ex­pand to house­holds with in­comes up to 133% of the fed­eral poverty level, com­pared with 100% of the fed­eral poverty level cur­rently re­quired.

The states are con­cerned about the ad­min­is­tra­tive bur­den of “churn” be­tween the two pro­grams. Within a year of the ex­changes be­ing op­er­a­tional, half of adults with fam­ily in­comes be­low 200% of fed­eral poverty will shift be­tween the ex­changes and Med­i­caid, or 28 mil­lion peo­ple, ac­cord­ing to a study pub­lished in Health Af­fairs last week.

On an­other key point, the 21 gov­er­nors want full au­thor­ity to de­cide what types of health ben­e­fits will be of­fered to con­sumers in the ex­changes. HHS is ex­pected to is­sue rules this spring on these min­i­mum ben­e­fit re­quire­ments for health plans op­er­at­ing in the ex­changes.

Napoli said the min­i­mum ben­e­fit pack­age rules are an area where the Obama ad­min­is­tra­tion and the gov­er­nors might have room to ne­go­ti­ate. “That’s one is­sue where there could be some com­pro­mise,” he said.

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