As of last spring, Missouri was considered on track – ahead, even - in developing a state health insurance exchange. It’s intended to be a centralized online marketplace where individuals and small businesses can compare and purchase health plans. Under the federal health law, exchanges are supposed to be up and running in each state by 2014. But politics appear to have put the brakes on efforts to set up one up in Missouri.
The so-called "Show-me Health Insurance Exchange" would be for health insurance what Travelocity is for airline tickets: a place where people can view multiple plans at once and assess policies and prices. That’s according to State Representative Chris Molendorp from Raymore, Missouri. The Republican spent last session crafting legislation to establish the framework for a state-run exchange.
Molendorp opposes the mainstay of the federal health law, an insurance mandate, but he took the lead in setting up an exchange because if Missouri doesn’t, under the federal health law the federal government will run one instead.
Lawmakers didn’t like that idea.
In April, Molendorp’s proposal for a “Show-me health insurance exchange” passed the house unanimously.
"Every wing of the Republican Party, whatever 'ism' that you are - if you're a moderate, or a country club, or a tea party - whatever part of the Republican party you think you are, all of them agreed that exercising our sovereignty and planning our own exchange was the right thing to do.”
Molendorp’s legislation made it unanimously through the Senate’s insurance committee. But with session nearing an end and with possible blocks from some opponents, the bill never hit the floor. Instead, the Senate created an interim committee to look into the issue while session was out.
Then last month, the U.S. Supreme Court agreed to take up legal challenges to part of the federal health law. The court is expected to reach a decision by early summer.
Republican State Senator Scott Rupp of St. Charles County, who heads the Senate's interim exchange committee, says as a result, his work is on hold. The committee won’t be issuing any recommendations to the Missouri legislature on an exchange this coming session.
“At this time, it’s a hyper political environment," says Rupp. "There’s a lot of questions with the Supreme Court. This is not a time where we’re going to be trying to make major policy decisions with so much uncertainty. This is one that we need to continue to work on, but this is not the way to ram something through and get it done."
Rupp says federal extensions on some state exchange deadlines and increased flexibility in how states and the federal government would run exchanges have also lessened the urgency to take action right now. Molendorp says he doesn’t plan to re-introduce his exchange proposal.
But Missouri is not the only state that's likely to wait.
“The decision by the Supreme court to do a ruling this year did increase the number of 'let’s wait' states,” says Anne Gauthier, with the National Academy for State Health Policy.
Gauthier says up to 15 states are holding off until they hear what the court has to say. But she says the longer states wait to prepare, the fewer options they’ll have when exchanges are live in 2014. She says that’s why in some states, even where exchanges are politically unpopular, groups are still continuing to prepare for one.
In Kansas, for example, where officials there returned about $30 million in federal funds for an exchange, health leaders are still meeting to research various exchange options and details.
That now appears to not be the case in Missouri, even though the money is there.
Missouri asked for and won federal funding this summer, mainly to build the IT infrastructure for a new exchange and update the state's old Medicaid computer system. It got at least $21 million. But most of it seems to be tied up, partly because of a flap over who controls the process.
Missouri Governor Jay Nixon is a Democrat. His administration, the insurance director who Nixon appoints, channeled grant funds to a quasi-government body, the board of the Missouri Health Insurance Pool (MHIP). It’s not subject to legislative oversight.
“What concerns me about this administration is they keep having a pattern that keeps popping up of running around the legislature and bypassing us," says Republican State Senator Jane Cunningham of St. Louis County.
Cunningham also serves on the Senate interim committee on health exchanges, which held public hearings on the issue across the state this summer and fall. Tension between some committee members and the MHIP board flared up in September, when Cunningham and some colleagues got word the MHIP board was about to accept the exchange grant funds and start the process of setting one up. They learned of this in the middle of one of their hearings in Jefferson City.
“Three of us immediately left the hearing, drove across town as quickly as we could to get to the other board meeting that we were not apprised of and requested an immediate meeting," says Cunningham.
The board postponed accepting the funds. A House budget committee later held a hearing scrutinizing the board.
Neither the Nixon administration, the insurance department, nor the board of MHIP has responded to KCUR’s requests for comments on this, but it now appears the whole process may be stuck. The board is looking at moving the grant and health exchange planning to a public agency that's subject to legislative oversight.
The situation in Missouri has been frustrating for some health policy experts, like Thomas McAuliffe with the Missouri Foundation for Health (which also helped fund the state's exchange planning efforts).
“To me, even though the funds are sitting some place waiting for someone to set up a bank account and to accept it, that’s no different than Kansas returning it,” says McAuliffe.
And with the legislative session beginning next week, it’s even more uncertain whether anything – grant funds, planning activities, or exchange legislation - will move forward in the months ahead.