Federal

Although the House vote to repeal health care reform is symbolic only (given the Democratic Senate and White House), it is a necessary first step leading to committee by committee action over the coming months on discrete provisions of health care. One such item, medical malpractice liability reform, got a hearing last week before the House Judiciary Committee as Republicans paraded several witnesses before the committee to showcase the need for legislation from the physicians’ perspective. Since it is very unlikely that the American Medical Association’s wish list would ever become law, the best result from the committee process would be a bill that skirts the more controversial items (e.g., cap on damages) and focuses on attainable and meaningful reforms, such as health courts, stronger pre-trial evaluation and settlement pathways.  This would be a path Aetna would strongly support.

States

ARIZONA: Governor Jan Brewer has announced that she will request a waiver from the federal Centers for Medicare and Medicaid Services so that the state can set Arizona Health Care Cost Containment System (AHCCCS) eligibility below levels mandated by the PPACA. In March 2010, Governor Brewer signed a fiscal year 2011 budget that stripped funding for the state’s Children’s Health Insurance program (KidsCare) and cut 5 million from AHCCCS, effectively repealing an expansion of AHCCCS to childless adults approved by voters in 2000. However, following enactment of the PPACA, the state rescinded the scheduled cuts to comply with the law’s “maintenance of efforts” (MOE) requirement. The MOE requirement prohibits a state from having eligibility standards, methodologies, or procedures for adults that are more restrictive than those in effect on March 23, 2010, until a health insurance exchange in the state is fully operational, and for all children in Medicaid and CHIP through September 30, 2019. The MOE requirement provides an exception for non-pregnant, non-disabled adults earning more than 133 percent of the federal poverty level if a state is projected to have a budget deficit. Arizona faces a mid-year budget deficit estimated at 5 million. A .4 billion shortfall is projected for the 2012 fiscal year.

CALIFORNIA: The U.S. Supreme Court has agreed to review whether health care providers and patients have the right to sue California over budget reductions made to Medi-Cal reimbursements. The high court will review three legal challenges to California’s proposed and adopted reimbursement cuts. The Supreme Court’s ruling on the case could have major implications for efforts to address California’s budget deficit. Last week, Gov. Jerry Brown (D) released a budget proposal that would reduce Medi-Cal payments to health care providers by 10 percent to cut program spending by about 9 million in fiscal year 2011-2012. In addition, the case could have implications for other states seeking to address budget deficits by cutting Medicaid payments. With federal courts in California blocking the cuts, 22 states have joined California in appealing the issue to the Supreme Court.  The court is expected to hear oral arguments in the case next fall. A decision is expected in late 2011 or early 2012.

CONNECTICUT: Speaker Chris Donovan, members of the Public Health and Insurance Committees and a variety of advocates held a press conference last week to announce the Public Health Committee has raised the SustiNet bill based on the recent recommendations of the SustiNet Board. Few details were provided, but the original report recommends that SustiNet become a licensed insurance plan. ”We don’t need health insurance anymore, we need to move towards health assurance — health care that will be there for us, and the SustiNet plan will do that,” Donovan said. Lawmakers will face a .7 billion budget deficit by July 1. Rep. Betsy Ritter, D-Waterford, co-chairwoman of the Public Health Committee, said the plan will have to go before multiple legislative committees, with the actual bill some weeks away. A financial analysis on upfront costs is not yet available. Aetna is working with the Connecticut Association of Health Plans (CTAHP) and AHIP to secure an objective fiscal analysis of SustiNet’s, as a public option, true cost to the state, and of the strong, positive impact health insurers have on the state’s economy.

DELAWARE: In his State of the State speech, Governor Jack Markell emphasized the need for state government to spend more efficiently.  He specifically noted that the demands state employee health insurance and pensions are putting on the state budget are unsustainable. The Governor specifically stated he is open to any and all good ideas for addressing this budget issue. In other news, a joint meeting of the Senate Health Committee and the House Economic Development, Banking, Insurance, and Commerce  Committee was convened for an update on the state’s effort to implement health care reform. Rita Landgraf, Secretary of Health and Social Services, along with Bettina Riveros, Health Care Commission Chair, advised legislators the commission will spend the next six to eight weeks holding stakeholder meetings across the state seeking input on establishing a state health insurance exchange.

GEORGIA: The Exchange Workgroup formed by former Governor Sonny Perdue had its final meeting last week and will submit a list of issues for Governor Deal’s administration to review before deciding how to proceed on the issue of instituting an exchange in Georgia. As the head of this workgroup for Governor Perdue is continuing under Governor Deal’s administration, it is likely that there will be some enabling legislation during the 2011 session, though it is unclear what that will be. The legislative session began January 11, 2011 and continues for 40 legislative days.

IOWA: The General Assembly convened in Des Moines on January 10 and is expected to adjourn on April 29, 2011  In the November elections, Republicans took control of the House and gained a few seats in the Senate, narrowing the Democrats’ majority there. Republican Terry Branstad was sworn in as governor for the second time. Having served in the post from 1983 to 1999, Branstad is the longest-serving governor in Iowa’s history. The state’s budget deficit is projected to be more than 5 million for fiscal year 2012 and will dominate legislative discussions. House Speaker Kraig Paulsen has vowed to remedy the deficit through spending cuts rather than tax increases. The Governor’s proposal to revise the state’s annual budget to a two-year cycle will also be debated. Bills of interest so far include several challenging PPACA’s individual mandate, a prohibition on abortion coverage, creation of mandate-lite policies, a mandate for coverage of smoking cessation programs, a rate review bill that would require a public hearing for any increase over 10 percent in the individual market, and a bill establishing 0 as the minimum required payment for state employees.

INDIANA: Governor Mitch Daniels has issued an executive order  establishing the Indiana Health Benefit Exchange. In his order he directs the Indiana Family and Social Services Administration (IFSSA) to cooperate with appropriate state agencies, including the Department of Insurance (IDOI), to establish and operate the exchange. The IFSSA Secretary or the secretary’s designee will serve as the incorporator of the Exchange. If, after careful analysis, the state deems it appropriate to proceed with creation of the exchange, a board of directors will be selected. The board will include representatives of state agencies and the Indiana General Assembly. Standing Committees will be appointed that have stakeholder representation. In addition, Governor Daniels submitted a letter to HHS Secretary Kathleen Sebelius requesting approval of a state plan amendment to extend the Healthy Indiana Program (HIP) beyond its expiration date. HIP, the state’s consumer-directed program for covering the uninsured population, is scheduled to expire in 2012. Daniels notes he has received communication from HHS staff indicating the state plan amendment will be rejected due to HIP’s required level of contribution from participants.  The Governor said the state intends to utilize the program for the newly eligible Medicaid population pursuant to PPACA. Daniels cautioned that Indiana does not have the time and financial resources necessary to complete new rigorous requirements for applying for a waiver extension if the amendment is rejected. The current 45,000 enrollees in the program would have to be transitioned into traditional Medicaid.

MISSOURI: The 96th General Assembly convened on January 5 and is expected to adjourn on May 30, 2011. With 106 members to the Democrats’ 57, the GOP has the largest number of seats it has ever held in the House and is just three members short of being veto-proof.  Given the large Republican majorities in the General Assembly and 70 percent voter support for Proposition C – an effort to turn back health care reform, the legislature will be under pressure to do nothing to move Missouri closer to enactment of federal health reform.

Significant health care bills filed this session include a resolution calling on the Attorney General to file a lawsuit challenging the constitutionality of the PPACA, a bill requiring statutory authorization by the General Assembly to implement PPACA, a bill expanding the autism mandate, an MLR bill for large carriers requiring a 90 percent MLR for Missouri-associated revenues and 85 percent for smaller carriers, a bill requiring the state employee health plan to offer a minimum of three high-deductible options with differing annual deductibles and annual out-of-pocket expenses, a bill prohibiting “Most Favored Nation” clauses, legislation creating transparency and publication of carriers’ fee schedules and requiring carriers to contract with providers willing to meet certain provider participation terms and conditions, and creation of a uniform group application for insurance.

NEBRASKA: The 102nd unicameral legislature has convened in Lincoln where it is expected to spend much of the session grappling with a budget deficit approaching 5 million for the 2011-2013 biennium. Implementation of the PPACA is expected to receive serious attention as well, with six bills relating to implementation or rejection of PPACA introduced to date. Bills of interest include legislation creating an Exchange Task Force, an interim committee for PPACA study, and several bills challenging the individual mandate, prohibition of abortion coverage, and a cochlear implant mandate. In addition, a bill banning discretionary clauses in health and disability income insurance contracts has been introduced.  The legislature began its work on January 6 and is tentatively scheduled to adjourn on May 26, 2011.

NEW HAMPSHIRE: The legislature convened on January 5, 2011, and is scheduled to adjourn on June 30, 2011. Governor John Lynch will continue as the state Executive; however, Republicans have gained control of both chambers in the legislature. In addition to the state’s budget deficit, implementation of federal health care reform will continue to be a priority for the governor and the legislature. Given the Republican majority and anticipated revenue shortfalls, there will be limited, if any, activity on health insurance issues. The legislature will, however, be paying close attention to federal health reform implementation issues and activities. In addition, there have been discussions about eliminating certain state mandates if they are not included in the essential benefits required under the PPACA. In 2010, the state enacted legislation granting certain powers to the commissioner with respect to implementation of PPACA.  This legislation also created a legislative oversight committee, to which the Department of Insurance (DOI) must report monthly. This month the DOI submitted a request for a waiver of the 80 percent minimum loss ratio (MLR) requirement for individual health insurance market policies until 2014.

NEW YORK: In a new report, the United Hospital Fund (UHF) looks at how New York might set up health insurance exchanges. One option is to let HHS run the state’s exchange, While that could save money, it would also mean ceding key operational and regulatory issues to the feds. It might also jeopardize existing consumer protections in Medicaid that are unique to New York. If the state sets up its own exchange, it must decide whether to join a multi-state exchange, a statewide entity, or small local ones. UHF noted that New York might consider following the leads of Massachusetts and California by creating an independent public authority to run an exchange. Former Governor David Paterson created a 35-member Exchange Committee that met only twice and did not make any recommendations. Governor Andrew Cuomo has not indicated his plans for establishing an insurance exchange in New York.

PENNSYLVANIA: Governor Tom Corbett has announced his intention to nominate Michael Consedine as the next Insurance Commissioner. Consedine is a partner at the law firm of Saul Ewing, where he serves as Vice Chair of its Insurance Practice Group.  Prior to joining Saul Ewing 12 years ago, Consedine served as state Insurance Department Counsel.

The Corbett transition team has announced that adultBasic, Pennsylvania’s health insurance program for low-income adults, is expected to expire on February 28 due to lack of funding.  The announcement, unusual in that it comes from an incoming  administration, was necessitated by the need to provide advance notice to enrollees and to inform them of alternative coverage options. Originally started by former Governor Tom Ridge and funded through the state’s allocation of Tobacco Settlement dollars, the program was later funded through the 2005 Community Health Reinvestment Agreement (CHRA).  While that agreement between the Rendell Administration and the state’s four Blue Cross plans expired on Dec. 31, 2010, additional funding was later provided by the plans pursuant to the CHRA’s formula.  It now appears those additional funds will be exhausted by the end of next month.

TENNESSEE:  A new Commissioner of Insurance appointed by Governor Bill Haslam took office last week. Julie McPeak is an attorney at the Nashville firm of Burr and Forman and the former Commissioner of Insurance in Kentucky.  Aetna is scheduling a meeting with the new Commissioner within the next several weeks.