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What’s Next for State Health Policy After King v. Burwell?

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Leaders Discuss Key Themes and Next Steps for State Policymakers
The National Academy for State Health Policy hosted an off-the-record, state-only summit to discuss the road ahead for state health reforms after the Supreme Court’s decision on King v. Burwell. The event, supported by The Commonwealth Fund, featured a panel of leading thinkers on state health policy, including:

  • Amy Dowd, Chief Executive Officer, New Mexico Health Insurance Exchange
  • Joy Johnson-Wilson, Health Policy Director, National Conference of State Legislatures
  • Peter Lee, Executive Director, California Health Benefit Exchange
  • Bettina Riveros, Health Care Policy Advisor, Governor Jack Markell of Delaware
  • Sara Rosenbaum, Harold and Jane Hirsh Professor of Health Law and Policy, School of Public Health and Health Services, George Washington University
  • Matt Salo, Executive Director, National Association of Medicaid Directors
  • Brian Webb, Manager of Health Policy and Legislation, National Association. Insurance Commissioners
  • Facilitated by: Trish Riley, Executive Director, National Academy for State Health Policy

Officials from 43 states and the District of Columbia participated in the July 9 summit. Participants represented Medicaid, CHIP and insurance agencies, public health departments, budget offices, state legislatures, and state-based exchanges.

Promising Practices in Reaching, Enrolling, and Retaining Children in Coverage During Early ACA Implementation

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This brief shares strategies for finding, enrolling, and retaining children in health coverage, which other states can implement relatively quickly and inexpensively.
Many of these promising practices are the direct result of the strong working relationships between state officials and advocates and coalesce around several themes:

  • Targeting outreach efforts to specific populations.
  • Engaging and educating new partners.
  • Keeping children enrolled in coverage.

For more information about improving children’s coverage, including links to many of the resources and promising practices listed in this paper, please visit the Advancing Children’s Coverage Toolkit.

The State-based Marketplaces: A Focus on Innovation, Flexibility, and Coverage

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One of the central elements of the Affordable Care Act (ACA) is to establish “one-stop shopping” through health insurance marketplaces allowing consumers to find and access affordable, high-quality health coverage either through private health insurance, and the subsidies available for those who qualify, or through Medicaid. The ACA and related regulations define a spectrum of marketplace models that can be operationalized: the State-based Marketplace (SBM), where states assume all responsibility for operation and maintenance of a marketplace; the State Partnership Marketplace (SPM), where states assume responsibility for plan management and/or consumer assistance and the Federally-Facilitated Marketplace (FFM) performs remaining functions; and the FFM, in which all marketplace functions are performed by the federal government.
In the wake of the U.S. Supreme Court’s recent decision in King v. Burwell, affirming the availability of federal subsidies to states opting to use the FFM model, there is growing interest in state and federal marketplace options and performance. While states implementing both the FFM and SBM model had to overcome hurdles in building and managing multifaceted IT platforms, both are making significant progress in meeting the ACA’s coverage and access goals. However, the advancements and opportunities of SBMs are not as well known as the challenges state and federal marketplaces have faced. This paper seeks to explore and highlight early developments in states that have implemented the SBM model.
Full Brief 


State Enrollment Experience: Implementing Health Coverage Eligibility and Enrollment Systems Under the ACA

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The Patient Protection and Affordable Care Act (ACA) included new eligibility and enrollment requirements, which have presented states with significant implementation opportunities and challenges. Although states had choices about whether to host a health insurance exchange or expand Medicaid, the ACA required all states to make major changes to Medicaid eligibility policy, including adding mandatory coverage of new groups, implementing streamlined eligibility and renewal , incorporating new eligibility and verification requirements, and coordinating enrollment systems with exchanges.
As a result, states had to create or significantly update existing systems, collaborate and coordinate with other state and federal agencies, and develop new processes to support enrollment. States implemented these changes within a constrained timeframe, with much activity occurring between the Supreme Court ruling in NFIB v. Sebelius in summer 2012 and the first open enrollment period in fall 2013. In addressing the challenges of ACA implementation, many states and federal agencies were highly innovative, developing approaches that set a new standard for promoting effective enrollment in public programs.
Drawing on key informant interviews and ongoing engagement with states between 2013 and 2015, this brief examines states’ early experiences implementing ACA’s eligibility and enrollment requirements; highlights promising practices and lessons learned; provides some context on the state experience; and concludes with possible areas of focus for future enrollment and implementation efforts. With the recent Supreme Court decision in King v. Burwell, there is new momentum for state and federal agencies to learn from early experiences with ACA implementation to further improve enrollment systems in future years. This brief offers reflections to support continued growth and movement.

Download the Brief

 

Adult Dental Benefits in Medicaid: Recent Experiences from Seven States

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Oral health is an important part of overall health, however, access to dental coverage for low-income adults remains a challenge, particularly since these benefits are optional for state Medicaid programs. This brief summarizes policy lessons from seven states (California, Colorado, Illinois, Iowa, Massachusetts, Virginia, and Washington) that have recently added, reinstated, or enhanced their Medicaid adult dental benefits. These states took a variety of approaches—including incrementally extending benefits to populations like pregnant women—and all attempted to do so in a fiscally sustainable way that provides meaningful access for program enrollees. Important factors in their decisions included funding opportunities through the Affordable Care Act, personal engagement by high-level state policymakers, building on lessons from improvements to children’s access to dental care, and strong partnerships with dental associations and oral health coalitions.
Accompanying case studies provide an in-depth look at each state’s choices on adult dental benefits.
A companion webinar features a conversation with state officials from Colorado, Iowa, and Washington about their experience with Medicaid adult dental benefits.
This project was supported by the DentaQuest Foundation.

 

New Mexico’s State-Based Marketplace: An Emerging Model

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The Supreme Court’s ruling in King v. Burwell could have a significant impact on states. If the Supreme Court finds for the petitioners in King v. Burwell, states with Federally-Facilitated Marketplaces (FFMs), and possibly State Partnership Marketplaces (SPMs), may have to adopt a new model that qualifies as a State-Based Marketplace (SBM) to maintain access to the advanced premium tax credit (APTC) for their citizens.
Under the assumption that such a ruling would allow APTC to be available in SBM states that use the healthcare.gov technology platform, there are existing federal-state hybrid exchange models that current FFM or SPM states could adopt to protect these subsidies. One proposed model is New Mexico’s exchange, which is a SBM that is proposing to run core exchange functions while using the healthcare.gov technology platform from the Centers for Medicare and Medicaid Services (CMS) for individual enrollments. This proposed model would allow states that declare their intent to establish a SBM to operate most core exchange functions while using the federal platform for individual enrollment and, importantly, qualify as a SBM.

Download the Issue Brief

 

State Experiences Designing and Implementing Medicaid Delivery System Reform Incentive Payment (DSRIP) Pools

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Several states are operating DSRIP programs through their Medicaid programs under the authority of Section 1115 demonstrations. These programs incentivize system transformation and quality improvements in hospitals and other providers serving high volumes of low-income patients.
This report, prepared by NASHP staff, for the Medicaid and CHIP Payment and Access Commission (MACPAC), provides an in-depth analysis of eight current DSRIP (and DSRIP-like) programs in addition to federal, state, and provider perspectives on program implementation. It also offers insight into the role of DSRIPs in the Medicaid delivery system by examining key policy issues including program design, financing, measurement, and monitoring.  Findings from this report are also featured in MACPAC’s June 2015 Report to Congress.
View the report on MACPAC’s website

Oral Health and the Triple Aim — Evidence and Strategies to Improve Care and Reduce Costs

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Oral health is linked to overall health, and mounting evidence suggests that addressing oral health can help states improve patient care, improve population health, and reduce costs. This brief, supported by the Washington Dental Service Foundation, explores how oral health intersects with diabetes, maternal and child health, and avoidable emergency department use. State policies to leverage this evidence include Medicaid benefit design, professional education and licensing, and incorporating oral health into reform efforts. A companion toolkit dives deeper into evidence on potential cost-savings and case studies of strategies to connect oral health care and medical care service delivery.

Download the Brief

Making Multipayer Reform Work: What Can Be Learned From Medical Home Initiatives

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april2015-health-affairs-coverMedical home initiatives across the United States are demonstrating that multipayer reform, although complex and difficult to implement, is feasible when committed stakeholders negotiate strategies that are responsive to the local context. Seventeen multipayer medical home initiatives launched between 2008 and 2014 all navigated four critical decision-making points germane to any multipayer payment model: convening stakeholders; establishing provider participation criteria; determining payment; and measuring performance. The NASHP medical home team explores in the April issue of Health Affairs the lessons learned from these experiences. Heeding these lessons will help inform those leading multipayer efforts “to better anticipate and navigate known obstacles and improve their chances for successful implementation.”

The full article is available on the Health Affairs web site.

Support for this paper was provided by The Commonwealth Fund.

Achieving a Culture of Health: Governors Weigh In

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Governors hold a unique capacity to help promote a culture of health using the tools of their state governments in purchasing, regulating, and policymaking. Governors in 48 states made State of the State or inaugural addresses in 2015, laying out their priorities for the year ahead.
In these addresses, 40 governors referenced health issues such as Medicaid, behavioral health, insurance exchanges, health care costs, infant mortality, rural health, and improving services for seniors and persons with disabilities. A number spoke to the importance of early child development, and many governors are developing policy agendas to make their states healthier. The National Academy for State Health Policy (NASHP) developed a summary of health policy issues addressed in the 2015 State of the States.
Governors, along with other state leaders, recognizing the need for policies to focus on more than just medical care and access to it are helping to create a nation in which one’s ethnicity, income or ZIP code does not hamper their ability to eat fresh food, live on safe streets, sustain emotional and mental well-being, or find and afford health care.
The State of the State and inaugural addresses provide a snapshot of the activities underway across the nation to promote a culture of health.
Download the Brief

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