Thursday’s U.S. Supreme Court ruling upholding the federal health law has provided more clarity to the region and country.
But as key parts of the law now move to states to implement, uncertainty – largely due to politics – surrounds how states will enact those measures.
Shortly after the ruling, Kansas Insurance Commissioner Sandy Praeger summed up the nearly 200 page Supreme Court ruling like this:
“Public Policy in this country now is that all people will have access to health care services and a means to pay for it.”
But when it comes to making that a reality, things get more complicated. A lot lies at the state level in preparing for the next big wave of the law’s provisions, which take effect in 2014.
One of the biggest issues is how states set up a health exchange. That’s the online market places where individuals and small businesses will go to compare and shop for health policies. The state could run it, or the federal government, or there could be some sort of partnership. Praeger says the state’s done a lot of background work, but that still might not be enough.
“I think it’s too late for us to be a state-based exchange because we needed legislation this session that gave us the go ahead and created the governance structure,” says Praeger.
States have until mid-November to indicate whether they’d want to participate in a joint federal state exchange. So far, political opposition and uncertainty over the law have kept Kansas, Missouri and other states from moving forward in developing an exchange.
In Missouri, a ballot initiative will appear on the November ballot in Missouri that aims to prohibit the creation and operation of a health exchange in Missouri unless the legislature or voters gives it the ok. It also prohibits the governor from creating one through executive order.
Governor Nixon has not commented on this, but following the Supreme Court ruling, he issued the following statement:
“We’re just now beginning to review this ruling so that we can understand exactly what it means for Missouri. This ruling has significant complexities and implications for families, health care providers and insurers in our state. Here in Missouri, I'm committed to working collaboratively with citizens, businesses, medical providers and the legislature to move forward in a way that works best for families in our state.”
Missouri State Senator Scott Rupp, a Republican who headed an interim committee last year looking into the exchanges, says he doesn’t anticipate Missouri having anything to do with one.
“So by not creating the exchange, you’re just simply putting that back on the federal government, saying we want the free market system in our state.” says Rupp. “Go ahead and do it in our state, but we’re not going to do it with Missouri tax dollars.”
Across the state line, Kansas Governor Sam Brownback returned a federal grant last year that would have helped the state develop the infrastructure for an exchange and become a model for other states. Following the Supreme Court ruling, Brownback’s office said they wouldn’t be taking any action to implement the law.
“Stopping ObamaCare is now in the hands of the American people. It begins with electing a new president this fall,” Brownback said in a statement.
David Gentile, President of Blue Cross Blue Shield of Kansas City, says the Supreme Court’s ruling affirmed the work the insurance company has already been doing with regards to the law. But he’s also looking forward to getting more specifics on insurance rules and more guidance in how to prepare for the exchanges.
“The difficulty with the federal exchange process is we really don’t know what the rules are yet. The regulations haven’t been published yet, and there’s a lot of uncertainty in how it impacts the individuals, employers, insurance carriers, or how it impacts the states in their ability to interact with the state process,” says Gentile. “It’s just a big void, a big unknown for us.”
Aside from what the exchanges look like and who runs them, there are other unknowns relating to health coverage in Kansas and Missouri.
“In general the ruling gives us quite a bit of clarity on almost all aspects of Affordable Care Act,” says Ryan Barker, with the Missouri Foundation for Health. “The little question which I guess is a big question is around this Medicaid expansion.”
The health law expands Medicaid eligibility, but the Supreme Court’s ruling makes that expansion voluntary for states. If states do participate in it, the federal government would fully pay for the expansion for the first three years, after which states would then pay about ten percent of the costs.
Barker says in Missouri, where Medicaid eligibility is very low, the decision would affect between 250,000 and 300,000 Missourians who don’t have insurance. U.S. Senator Roy Blunt of Missouri says expanding the program would still be too big of a burden:
“States are already struggling to pay current Medicaid costs,” says Blunt. “Education funding is going down in many states every year, including ours in the last three years.”
There’s also uncertainty in Kansas.
The Kansas Health Institute estimates about 130,000 residents would be affected by a Medicaid expansion. Barb Langer is with the University of Kansas Medical Center and used to oversee the state’s Medicaid program.
“Kansas was one of the states that filed in the lawsuit [challenging the health law], and one of the things they were concerned about was the cost of the Medicaid program with the expansion,” says Langer. “So I think there will be continued resistance or concern about adding another third to the current Medicaid program. And the Supreme Court ruling gives states the right to choose not to.”
The situation creates another level of uncertainty for people who make little or no money and don’t qualify for Medicaid under the current guidelines. For now, they fall into a hole, where they don’t make enough under the law to qualify for subsidies to buy insurance. Kansas Insurance Commissioner Sandy Praeger says between that and figuring out how the exchanges will run, a lot of work lies ahead as the law unfolds.
“Well, it’s gonna be a heavy lift, and we’re just going to keep our head down and keep focused,” says Praeger.
And with many unknowns still out there with the law, she and others will be looking to see how this plays out in Topeka and Jefferson city over the next few years.
This story is part of a reporting partnership that includes KCUR, NPR and Kaiser Health News.
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