State officials who oppose the Patient Protection and Affordable Care Act of 2010 (PPACA) are simply complaining about regulation delays and other implementation problems because they want to kill the law, not because they have much interest in fixing the problems.
Some Democrats on the House Energy & Commerce health subcommittee made that case today at a subcommittee hearing.
The subcommittee gave the hearing the title “State of Uncertainty: Implementation of PPACA’s Exchanges and Medicaid Expansion.”
In a background memo prepared before the hearing, the committee staff said that the U.S. Department of Health and Human Services (HHS), and the Center for Consumer Information and Insurance Oversight (CCIIO), the HHS agency in charge of HHS PPACA implementation efforts, have failed to answer many questions about how PPACA will work.
States are still not sure how a federal PPACA health insurance exchange, or Web-based insurance supermarket, will really work, or how much a state will really have to spend to run an exchange, committee staffers said.
Some of the other open questions relate to how flexible the exchange program and other PPACA deadlines will be, and exactly how programs for determining whether consumers are eligible for new and expanded health programs will work, staffers said.
The Democrats on the committee scoffed at the idea that the state officials are making the complaints with a sincere desire to improve PPACA implementation.
Rep. Frank Pallone Jr., D-N.J., said Republicans first tried to repeal PPACA, then went to the U.S. Supreme Court to kill the law, and then hoped the November elections would kill the law.
“Their next move is to delay implementation under the guise of a lack of information,” Pallone said.
Rep. Tammy Baldwin, D-Wis., who is moving to the Senate in January, said Republican state officials should change their approach.
“The Affordable Care Act is the law of the land,” Baldwin said.
Rep. Henry Waxman, D-Calif., one of the leaders of efforts to draft PPACA, said House Republicans are like members of a Groundhog Day Congress who repeat the phrase “we can’t do it” over and over again.
“Make it work,” Waxman said.
Dr. Joshua Sharfstein, the Maryland health secretary, said PPACA critics have suggested that PPACA would reduce competition in the health insurance market.
So far, the PPACA exchange system seems to be on track to increase competition in the state,Sharfstein said.
“We’ve got more insurers interested than actually serve the Maryland market now,” Sharfstein said.
Nuts and bolts
PPACA implementation officials from states with governors who generally oppose PPACA said they have serious complaints about problems with PPACA implementation.
Bruce Greenstein, the Louisiana health secretary, said Louisiana still has questions about how HHS would really go about paying for Louisiana’s efforts either to create an exchange or hook up to a federal exchange.
For Louisiana, another concern is that even states that decide not to set up an exchange will be responsible for enforcing the PPACA minimum essential health benefits (EHB) rules in their states, Greenstein said.
Starting in 2014, PPACA will require all non-grandfathered individual and small-group plans to cover a state’s EHB package. An individual or small-group plan must cover the EHB package whether it is sold through an exchange or outside the exchange system.
Dennis Smith, the Wisconsin health services secretary, said he still has no idea how the new PPACA health insurance premium tax credit subsidy will really work or how exchanges are supposed to calculate the cost-sharing subsidies for low-income consumers.
Giving program managers and consumers a clear idea of who is eligible for what is important, because each complete eligibility determination process costs Wisconsin about $150 each, whether the applicant turns out to be eligible or not, Smith said.
Smith said he believes that, even after new PPACA subsidies are applied, 59 percent of Wisconsin residents who have individual coverage will face an increase in their premium bills. The average increase could be about 39 percent, Smith said.
The current PPACA “modified adjusted gross income” (MAGI) rules and program eligibility rules are extremely complicated and mean that individuals in the same family could end up with completely different results, Smith said.
“There are going to be a lot of unhappy people,” Smith said.
Gary Alexander, the Pennsylvania public welfare secretary, said PPACA and other federal laws and programs also could require Pennsylvania to change its main health program data system in a way that could cost about $250 million and make the system more primitive rather than more advanced, Alexander said.
PPACA also will take asset tests out of eligibility determinations, and that could mean Medicaid will have to cover people with substantial amounts of assets, Alexander said.
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