Implementing the Affordable Care Act:
State Action on the 2014 Market Reforms
The Commonwealth Fund
March 12, 2013
Kevin Lucia, JD, MHP
Katie Keith, JD, MPH
CHIR’s Monitoring and Analysis
of Health Reform
• Document state action on the Affordable Care Act in all 50
states and DC, including:
• Health insurance market reforms
• Health insurance exchanges; and
• Other regulatory changes to ensure a level playing field.
• Comprehensive data collection and real-time analysis of
legislation, regulations, and other state materials.
• Project generously supported by the Commonwealth Fund.
Regulating Health Insurance:
Cooperative Federalism
• States are and continue to be the primary regulators of health insurance
for consumers in the individual and small group markets.
• Congress adopted a cooperative approach for regulating health insurance
when it passed HIPAA in 1996 for shared regulation between the federal
government and the states.
• When does the federal government enforce?
• State reports that it is not enforcing.
• HHS determination that state has failed to “substantially enforce.”
• Most stakeholders want the states to implement and enforce the
Affordable Care Act.
The Affordable Care Act
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•
Signed March 23, 2010 by President Obama
Implemented in phases:
2012 and 2013 – Preparing for 2014
2010 – Early Market Reforms
2014 – Heavy Lifting
•Eliminates lifetime and annual caps on benefits essential health
benefits
•Bans preexisting condition exclusions for children under 19
•Expands dependent coverage to age 26 without limitations
•Requires minimum standard of appeals procedures after an
insurer denies a claim
•Implements new medical loss ratio standards
•Requires review of certain rate increases
•Establishes temporary federal high risk pools
•Guaranteed issue/renewal
•Ban on preexisting condition exclusions
•Coverage of essential health benefits
package
•Modified community rating based on
age, tobacco use, geography, family
membership (individual or family
coverage)
•Nondiscrimination
•Health insurance exchanges
State Action on 2014 Market Reforms
• Issue brief released in February 2013 and available – with interactive
map – on Commonwealth Fund website.
• Reviewed state legislation, regulations, sub-regulatory guidance on
seven of the Affordable Care Act’s most significant consumer
protections:
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•
•
•
Guaranteed issue
Waiting periods
Rating requirements
Preexisting condition exclusions
• Essential health benefits
• Out-of-pocket costs
• Actuarial value
• Surveyed state regulators to assess whether the state has full authority
to enforce the 2014 market reforms without new legislation.
State Action on 2014 Market Reforms
• State progress in implementing the 2014 market reforms:
• 11 states and DC passed new legislation on at least one of the seven
protections.
• Only Connecticut addressed all seven protections.
• 39 states have yet to take action on the seven protections.
• State ability to enforce the 2014 market reforms:
• 11 states passed new legislation to enforce the Affordable Care Act.
• Of the remaining states, at least 22 reported limits on their ability to
enforce without new legislation.
State Progress in Implementation
Future Expectations for State
Implementation of Market Reforms
• Most states still have a long way to go but many plan to introduce
legislation in 2013.
• States will continue to vary in their approach – including the type of
state action they use.
• State regulators may be creative in implementing the law using
existing authority to implement or enforce these reforms.
• There is a continued need for ongoing monitoring and analysis of
state implementation of the Affordable Care Act.
Thank you!
Kevin Lucia, JD, MHP
Research Professor and Project Director
kwl@georgetown.edu
202-687-4928
Katie Keith, JD, MPH
Assistant Research Professor
kmk82@georgetown.edu
202-687-4954