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Health Reform Differs Across States: Report

5 states play no role in federal marketplace, Medicaid expansion or insurance reform

WebMD News from HealthDay

By Karen Pallarito

HealthDay Reporter

FRIDAY, Jan. 31, 2014 (HealthDay News) -- Californians' experience with health reform is probably very different from that of, say, the citizens of Texas.

California is one of 10 states that have done the most to roll out provisions of the Affordable Care Act, according to a new Commonwealth Fund report. These states, including Colorado, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, New York, Oregon and Vermont, have committed to implementing "the most significant aspects of health reform," the report states.

Most states, in fact, have played an active role in preparing for the health reform law, the report finds.

Texas, by contrast, is one of five states, including Alabama, Missouri, Oklahoma and Wyoming, with a hands-off approach to the health reform law, sometimes called Obamacare. These states aren't enforcing health insurance market reforms established under law, they rely entirely on the federal HealthCare.gov marketplace to enroll eligible consumers in health plans and they have declined to expand Medicaid, explained the report released Friday.

Other states fall somewhere in between.

"We tend to think about states as being fully opposed or fully supportive of health reform but the report shows that, in reality, there are many shades of gray that are worth recognizing," said study author Katie Keith, a former research professor at Georgetown University's Center on Health Insurance Reforms, now with the consulting firm Trimpa Group, L.L.C.

Take Virginia. It didn't expand Medicaid, nor did it establish its own marketplace, Keith pointed out. "But it is taking on a significant regulatory role in the marketplace by conducting plan management and [it] enacted legislation on all of the market reforms that we studied," she said.

Expanding access to affordable health care had been one of President Barack Obama's major campaign promises during the 2008 election cycle. After months of debate, negotiation and political wrangling, he signed the Patient Protection and Affordable Care Act in March 2010.

In June 2012, the U.S. Supreme Court upheld the law's individual mandate requiring that most Americans have health insurance or pay a penalty. But the court also allowed states to opt out of the law's Medicaid expansion without losing the federal funding they already received to administer Medicaid in the states.

The new report raises an important question: Will consumers experience health reform differently based on the decisions their states made?

Twenty-four states, by the Commonwealth Fund's count, have declined to expand Medicaid or remain undecided. Texas is one of them.

"We have 1 million people who are uninsured today who are too poor to get help through the marketplace and will have no access to affordable insurance," said Stacey Pogue, a senior policy analyst at the Center for Public Policy Priorities, an Austin-based advocacy group for moderate- and low-income Texans.

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