State support of three Affordable Care Act pillars--health insurance market reforms, insurance exchanges and Medicaid expansion--varies widely and raises questions about how consumers can benefit from healthcare reform no matter where they live, according to an analysis by The Commonwealth Fund released Friday.
The report examined new reform action taken by all states and the District of Columbia between January 2012 and November 2013. It found 32 states plus the District of Columbia implemented at least one ACA market reform, such as banning pre-existing condition exclusions or covering essential health benefits. Seventeen states passed legislation allowing regulators to enforce or develop rules about ACA market reforms.
Twenty-six states are expanding Medicaid, and 16 set up their own exchanges; the District of Columbia did both. Ten states--California, Colorado, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, New York, Oregon and Vermont--championed the ACA by creating their own exchanges, expanding Medicaid and enacting either all or most of the law's market reforms. Maine, South Dakota and Virginia emerged as leaders in implementing market reforms even though each has a federally-run marketplace and declined Medicaid expansion.
Five states--Alabama, Missouri, Oklahoma, Texas and Wyoming--withheld ACA support, the study found. They're not enforcing market reforms, the federal government runs their exchanges and they rejected Medicaid expansion. Though federal regulators have intervened in these states, they can't alter Medicaid expansion decisions, the study noted. And since moving to another state with expanded insurance eligibility isn't a choice many low-income Americans have made, millions of low-income residents may go without coverage as a result of state decisions, according to the report. This thwarts the ACA's underlying purpose.
"The Affordable Care Act was designed to ensure that all Americans have access to affordable, comprehensive health insurance that provides people with meaningful financial protection and security," Commonwealth Fund President David Blumenthal, M.D., said in the study's announcement. "State actions will play an important role in determining whether the law achieves its goals."