State Implementation of Federal Reform: Resources

Following the passage of the Patient Protection and Affordable Care act, statehouses will be the critical venues where the battle for the implementation of federal reform will play out. Here are some resources on the various aspects of the implementation of federal reform in the states.

High Risk Pools | Insurance Market Reforms | Health Insurance Subsidies | Health Insurance Exchanges | Funding for States | Individual Mandates | Medicaid, Medicare, and S-CHIP | Health Care Delivery | Politics of Reform | Implementation Timelines | State Models for Implementation

See also our Messaging page for effective ways to talk about the health care law and the threat of repeal of key provisions by conservative opponents.

High Risk Pools

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• Department of Health and Human Services - Letter from HHS Secretary Sebelius to Governors (April 2, 2010)
  Sec. Sebelius asks Governors to indicate if their state will participate in the temporary high risk pool. She explains that HHS will provide individual assistance to states if they agree to participate, both in preparation of their application and during the application review process. The Secretary explains the available implementation options including requirements as they relate to eligibility, benefits, coverage, and premiums. She also outlines the flexibility that states have in the implementation and operation of the pool. The Patient Protection and Affordable Care Act (PPACA) provides for $5 billion in funding through January 1, 2014 when the program ends. The letter sets an April 30th deadline for states to submit their intent.
• Sign-On Letter to HHS (PSN signed) - Letter to HHS on High Risk Pool (April 13, 2010)
  The letter recommends four conditions in the implementation of the pool: (1) Eligibility rules should be uniform to the maximum extent possible across all states and benefits should at least include a federally-set package, (2) The use of “standard rates,” as specified in the law, needs to be quickly and clearly defined by HHS so that premium rates are not subject to manipulation, (3) Income related assistance should be available at a level that is consistent with what will ultimately be available under PPACA for individuals and families in the health exchanges, and (4) The administrative process must be simple and transparent. A final recommendation suggesting that if states cannot establish their pools within 90 days, HHS should utilize one or more of the nationwide FEHBP plans as an alternative, with risk pooled separately from FEHBP current enrollees.
• AARP - Advocacy Brief: Assuring the Promise of Federal Health Care Reform in 2010: State High Risk Pools (April 7, 2010)
  This brief explains the options available to states in operating the high risk pools as well as the design of existing pools in the 35 states that now provide the benefit (enrollment, deductibles, premiums, costs to the state, et. al.). The brief also explains the opportunities available to advocates for influencing the structure and implementation of the pools. The brief provides resources, a listing of the 35 states with existing pools, and text of the applicable sections within the PPACA.
• Kaiser Family Foundation – Issues for Structuring Interim High-Risk Pools (January 2010)
  This paper examines the role of high-risk pools as a coverage safety net and reviews key issues involved in implementing a national high-risk pool including eligibility standards, covered benefits and premiums, subsidies, consumer protections, state administration of the pools and funding limitations.
• Department of Health and Human Services - High-Risk Pool Programs Take a Step Forward (April 2010)
  This update details the 43 states that as of April 30, 2010 had told the Department of Health and Human Services how they plan to participate in high-risk pool programs: 28 indicating they would run a state-based high risk pool program, and 15 saying they would let HHS administer the high-risk program for their state's residents.
• Oregon Medical Insurance Pool (OMIP) - Summary of the Oregon Medical Insurance (High Risk) pool (May 2010)
  Through the passage of HB 3659, Oregon will administer the federal temporary high risk pool through their existing pool. The bill established a Health Authority, which is now grappling with how to administer the federal temporary high risk pool.
• Maine Director of Health Policy and Finance - Maine's Notice of Intent to apply for funding for participation in federal high risk pool (May 2010)
  This letter from Maine’s Director of Health Policy and Finance to HHS Secy Sebellius explains the state’s approach to extending this coverage through their existing Dirigo Health plan and the potential mechanisms that will provide the coverage.
• NCSL - What Legislators Need to Know about High Risk Pools (May 2010)
  This presentation (webinar and presentation slides PDF) discusses how states can address the creation of the new federal high risk pool including questions such as: What are the federal requirements that are influencing state decisions? what are the trends in state action on high-risk pools? What issues are states facing as they decide what to do? What can states learn from each other as decisions are made?

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Medicaid, Medicare, and S-CHIP

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• Centers for Medicare and Medicaid Services (CMS) – New Option for Coverage of Individuals under Medicaid (April 9, 2010)
  This is a letter from CMS directed to State Health and Medicaid Directors that provides initial guidance on Section 2001 of the PPACA: Medicaid Coverage for the Lowest Income Populations, which establishes a new eligibility group and the option for States to begin providing medical assistance to individuals eligible under this new group as of April 1, 2010. Under the law, for the first time since the Medicaid program was established, States will receive Federal Medicaid payments to provide coverage for the lowest income adults in their States, without regard to disability, parental status or most other categorical limitations, under their State Medicaid plans.
• Center on Budget and Policy Priorities - Federal Government Will Pick Up Nearly All Costs of Health Reform’s Medicaid Expansion (April 20, 2010)
  This issue brief raises sound and in-depth arguments to counter the claim of health reform critics that states will be left with the burden of paying for the expansion of Medicaid under the PPACA. One of the counter arguments made in this report is in the its first five years, the Medicaid expansion will add just 1.25 percent to what states were projected to spend on Medicaid over that
  period in the absence of health reform, while providing health coverage to 16 million more low-income adults and children. Another finding is that the federal government will assume 96 percent of the costs of the Medicaid expansion over the next ten years, according to an analysis of CBO estimates.
• Center on Budget and Policy Priorities - No Need to Wait Until 2014: States Can Cover Low-Income Adults in Medicaid Now (April 20, 2010)
  This issue brief explains that provisions within the PPACA include a new coverage option included in PPACA allows states to cover low-income adults now. Adopting this option could provide needed federal funds to states that currently fund their own coverage programs for low-income adults who are not eligible for Medicaid. It also provides a new pathway for states that want to expand coverage to adults without children before 2014. The new provisions also allow the state to bypass the far more complex waiver process. The brief answers key questions such as the benefits states can offer, limitations on enrollment, the flexibility for states to set a threshold below 133% of the federal poverty line and the federal matching rate.
• Kaiser Family Foundation – Medicaid and Children’s Health Insurance Program Provisions in the New Health Reform Law (April 2010)
  This brief summarizes all the new Medicaid and CHIP provisions and includes a chart listing all of the relevant provisions and how they compare pre- and post-reform. The explanations focus on coverage and financing, benefits and access, dual eligibles and long-term care, and cost estimates.
• Families USA - Early Medicaid Expansions under Health Reform (April 2010)
  This report discusses how states can expand their Medicaid programs earlier than federal reform requires them to do so (2014), and why they should. Starting in April 2010, states will be able to phase in Medicaid expansion through a state amendment process.
• Kaiser Family Foundation - Financing New Medicaid Coverage Under Health Reform: The Role of the Federal Government and States (May 2010)
  Under the health reform law, the Medicaid program will undergo a significant expansion by 2014. Millions of low-income adults who currently cannot qualify for coverage in most states will be made eligible for Medicaid. The federal government will finance the vast majority of the new costs of coverage. This issue brief examines how the federal government and the states are expected to split responsibility for financing the expanded Medicaid coverage.
• Alliance for Health Reform - Webcast: the New Health Reform Law and Medicare (May 7, 2010)
  This archived webcast, cosponsored by Kaiser and the Alliance for Health Reform, examined how the health reform law affects Medicare, including a detailed look at the key provisions that made it into the final law and what it means for Medicare beneficiaries, the federal budget and the health care industry. An interim final rule was released by HHS on May 5th and comments will be accepted until June 4, 2010.
• Kaiser Family Foundation – Medicaid Coverage and Spending in Health Reform: National and State-By-State Results for Adults at or Below 133% FPL (May 26, 2010)
  Performed by the Urban Institute for the Kaiser Commission on Medicaid and the Uninsured, this analysis and video presentation shows that the expansion of Medicaid under the health reform law will significantly increase the number of people covered by the program and reduce the uninsured in states across the country, with the federal government picking up the vast majority of the cost. Nationally and across states this analysis shows that increases in state spending are small compared to increases in coverage and federal revenues and relative to what states would have spent if reform had not been enacted.
• Center on Budget and Policy Priorities - Medicaid Expansion in Health Reform Not Likely to "Crowd Out" Private Insurance (June 22, 2010)
  Contrary to claims by some critics, this report finds that the Medicaid expansion in the new health reform law will overwhelmingly provide coverage to people who otherwise would be uninsured, rather than shift people who already have private coverage to Medicaid. Historically, states that have expanded Medicaid coverage for low-income adults have not experienced significantly lower rates of private coverage.
• Inside Health Reform - CMS Proposes Medical Home Demo With Private Insurers, States (June 3, 2010)
  Inside Health Reform reports that CMS is proposing to launch a first-ever partnership involving Medicaid, Medicare, private insurers and states to test the idea of offering primary physicians payments for coordinating care under a “medical home” demonstration. This initiative will likely lay the foundation for future experiments by a new CMS innovation center created by the health reform law. The plan is based on a model promoted by primary care groups. Details are available on the CMS website.
• The Commonwealth Fund - Closing Of Medicare Part D Doughnut Hole Begins (June 1, 2010)
  The Department of Health and Human Services announced that $250 checks will be automatically distributed beginning June 1 to seniors who have fallen into the "doughnut hole" of their Medicare Part D prescription drug plans. HHS Secretray Sebelius said that about 80,000 seniors initially will receive their checks. Some 4 million seniors should qualify by year’s end.
• Reid Bill Would 'Recapture' $20 Billion In Medicaid Rebates From States
  According to Inside Health Reform, states aren't likely to see a dime from the Senate health care bill's increased Medicaid rebates for prescription drugs, and many are worried about losing money that they're already collecting due to a little-noticed revision Democrats made before bringing the bill to the floor. The legislation would direct its new rebate revenue mostly to the federal government, which is seen as a trade-off for federal funding of the merged bill's Medicaid eligibility expansion but might have the unintended effect of penalizing states that have secured deep discounts on their own.
• States Upset With Guidance On Medicaid Dug Rebates, Still Have Questions
  Inside Health Reform reports that CMS' guidance on the increase in Medicaid rebates verifies what many state officials feared: The federal government will keep the full 8 percentage point increase called for in the new health reform law, regardless of whether states had negotiated higher rebates on their own. The provision is expected to cost states millions of dollars and could potentially result in a lawsuit against the agency, sources said.

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