States Moving 'Assertively' with ACA Provisions

Even as the U.S. Supreme Court prepares to debate the constitutionality of the individual mandate, and Republican presidential hopefuls vow to scrap "ObamaCare" if they win in November, nearly every state is quietly implementing the provisions of the Affordable Care Act, a review shows.

The study by The Commonwealth Fund found that as the second anniversary of the Affordable Care Act nears, 49 states and the District of Columbia have already acted to support implementation.

"I do see states moving assertively forward on implementing the provisions that went into effect in 2010," Sara Collins, vice president for Affordable Health Insurance at The Commonwealth Fund, tells HealthLeaders Media.

The report reviews state action on 10 early reforms, including the Patients' Bill of Rights that went into effect in September 2010. Between Jan. 1, 2010, and Jan. 1, 2012, 23 states and the District of Columbia had taken new legislative or regulatory action on at least one of these reforms, and an additional 26 states had taken other action to promote compliance with the reforms, such as issuing bulletins to insurers, The Conference Board said.

The reforms include:

• expanding dependent coverage for young adults up to age 26,
• prohibiting lifetime limits on health benefits,
• phasing out annual dollar limits on health benefits,
• prohibiting preexisting condition exclusions for children under age 19,
• prohibiting rescissions (cancelling insurance, except in cases of fraud or intentional misrepresentation),
• covering preventive services without cost-sharing,
• expanding coverage of emergency services,
• allowing choice of primary care provider,
• allowing choice of pediatrician, and
• allowing access to obstetricians and gynecologists without a referral

"Most states have either passed laws, issued regulations, or have taken other measures such as sub-regulatory guidance or exercising policy review to make sure the residents in their states are protected by these new provisions in the law," Collins says. "The fact that 49 states have moved forward to fulfill their role in the implementation of these reforms is pretty significant."

The lone exception is Arizona. "They officially told the researchers in the study that they are not moving forward to enforce the regulations," Collins says. "There is a nuance about some of the stuff the Arizona insurance department itself is taking care of, but the state itself is not moving forward."

"But let's be clear: People are protected by the provisions of the law whether or not their state moves forward with the provisions of the law. If Arizona says it can't pass legislation to implement the rule then obviously the federal government will need to enforce it."

Otherwise, Collins says, there does not appear to be much of a Red State/Blue State divide when it comes to implementing the ACA. "If you look at states that passed laws to give themselves the legislative authority to implement all 10 of these provisions, it's a mix: Connecticut, North Carolina, Maryland, Hawaii, Iowa, New York, Virginia, Vermont, Maine, Nebraska, North Dakota, and South Dakota," Collins says. 

The Affordable Care Act was signed into law on March 23, 2010 by President Obama, with early market reforms taking effect six months later. The report found that the speed at which many states adopted the new provisions of the ACA probably was more dependent upon the schedules of state legislatures. The report also suggested that some states remain cautious about further ACA implementations until the U.S. Supreme Court rules on the constitutionality of the individual mandate. That ruling is expected in June.

The report warns that even though states have until 2014 to fully implement the ACA, some reforms could prove to be more difficult because they are new and don't exist in state law.

"When you look down the road to the 2014 reforms—the bans on underwriting, the guaranteed issue provisions, the new federal subsidies that will be flowing into states along with the Medicaid expansion—these are important changes that states are going to be experiencing in their markets, and also just in terms of their overall fiscal health," Collins says. "These are long-term chronic issues that we have experienced for many years and these provisions really do address some of the serious issue that states have faced."