States that want to create their own health insurance exchanges, rather than accept a federal model, have until September 30 to inform the U.S. Department of Health and Human Services of the minimum requirements for all plans sold in the exchange.
The choice between a locally-crafted exchange and one dictated from Washington lately has Republican lawmakers in several states feeling as if they're stuck between a rock and a hard place. Some Republican-appointed state regulators are recommending creating an exchange.
In Kansas, the Insurance Commissioner recently has urged state officials to send the feds a list of essential benefits. Republican Governor Sam Brownback, like other opponents of the Affordable Care Act, wants to wait for the outcome of the November elections, lest all that planning for exchanges end up being for naught if Mitt Romney wins and repeals the Affordable Care Act.
At a recent hearing, Insurance Commissioner Sandy Praeger heard recommendations for minimum benefits from business, consumer and medical groups, and is going to give them to Brownback.
"We want good coverage, but we want these products to be affordable," Praeger said, as the Topeka Capital Journal reported. "So it's balancing the coverage versus the cost."
[See also: HIX regs and the health reform challenge]
Meanwhile, in Wyoming and Idaho, both with GOP-controlled legislatures and Republican governors in office, lawmakers are still picking apart the exchanges and wondering if they should create them.
When the Idaho Health Care Task Force met recently, the Spokesman-Review reported, one Republican state senator asked the state's insurance department director, Bill Deal, how much more flexibility state officials would have with a state-based exchange compared to the federal fallback exchange.
Deal, a former Republican lawmaker and former owner of a family insurance company, W.W. Deal Insurance Agency, replied: "I would say we have some latitude in areas that I think are important to Idaho," citing state approval of insurance plan rates and benefits. "If we go to a federally facilitated exchange, we pretty much lose the authority to regulate the health insurance industry in Idaho," he added.
Deal has tepidly supported the creation of an exchange, along with some Republican lawmakers who unsuccessfully pushed legislation that would have created one.
Late last month, the state's health care task force heard arguments against the creation of the exchange from Michael Cannon, a policy analyst at the libertarian Cato Institute, and a representative from the American Legislative Exchange Council, a business lobbying group. As NPR's StateImpact Idaho reported, Cannon told lawmakers there's no benefit to an Idaho exchange and that not creating one would actually shield Idaho businesses from costs and regulatory headaches associated with exchange-based insurance.
"The inaction of not creating an exchange protects employers from the employer mandate, and it protects nearly half of the uninsured in Idaho from the individual mandate," Cannon said. "We're talking about all employers and more than 100,000 Idahoans you can protect from Obamacare's employer and individual mandate just by refusing to create an exchange." (For more on Cannon's argument, see this paper published in Health Matrix: Journal of Law-Medicine. For a rebuttal, see this article in Health Affairs by Timothy Jost, from the Washington and Lee University Law School.)
In Wyoming, where some 14 percent of residents are currently uninsured, it seems that legislators are not likely to create an exchange, the nonprofit news site WyoFile reported. Some are considering alternatives, like private exchanges (or barring state officials from implementing the ACA), while some, even Republicans, think a federally facilitated exchange could bring some benefits.
Those opposed to the exchange think it won't work in rural, sparsely-populated Wyoming, "where many consumers and small businesses choose low-benefit policies, often with high deductibles," WyoFile wrote.
"The whole idea behind insurance is to protect your assets," Republican state representative Elaine Harvey argued at a committee meeting. "And so [under the ACA] you can't buy a high-deductible catastrophic plan that will keep you in your home and keep you from losing your car while you make widgets. Everybody has to buy everything. The plans all have to be certified and to be certified they have to contain the 10 benefits the federal government prescribes."