On the judicial front, Wyoming’s Attorney General along with other state attorneys general filed a lawsuit in Florida which resulted in the judge ruling on the unconstitutionality of the health reform law. This was also supported by the current Governor, Matt Mead.

Legislation was passed last March 2011 which provides that a study be done whether or not Wyoming should establish an Exchange or participate in a regional Exchange.  There is the Wyoming Health Benefit Exchange Steering Committee which is doing the study. The inclination of this committee has been that the State should be running the Exchange and not the federal government.

If Wyoming does not do the needed groundwork, the likelihood of the federal government coming in to put up the Exchange seems more certain. There is worry though that the Exchange will not be feasible and the population of Wyoming may not be enough to sustain it. The Steering Committee has also been exploring idea of sharing a regional exchange, coordination with other states will be the big issue in this approach and also which states are actually willing to partner.

If the study proves that the Exchange is not feasible, some elected officials are saying that it would be better for the federal government to run it and let them take the loss.

While concerned officials are weighing their options, one thing certain is the ticking clock. There is the January 1, 2013 deadline to have an acceptable Exchange establishment plan in place to consider. Hopefully state officials will be able to have an Exchange (in whatever form), that has taken into consideration the unique needs of Wyoming.

Like other states, it was granted a $999,873.00 Exchange Planning and Establishment Grant on September 30, 2010 under the administration of the Wisconsin Department of Health Services. Among the objectives included designing an Exchange that moves beyond an aggregator of health insurance options, to a mechanism that influence how health care is delivered in the State.  Wisconsin viewed the Exchange as a “transformative force.”

Wisconsin was also one of seven states to be awarded an “Early Innovator” grant in the amount of $37.7 million on February 16, 2011. Funding under this category has more to do with the IT infrastructure involved in establishing and running an Exchange. For the grant, the state estimated that 35% of the population would benefit from the Exchange.

The election into office of Republican Governor Scott Walker (replacing former Democrat Governor Jim Dolye) has changed the tone of things. He has publicly voiced opposition to the Affordable Care Act in Wisconsin. He also supported the State Attorney General who along with other state attorneys general filed a lawsuit in Florida questioning the health reform law.

While Kansas and Oklahoma (with Republican governors) returned their “Early Innovator” grants, Walker did not immediately follow suit.  He did issue Executive Order # 10 in January 2011 that established the Office of Free Market Health Care, which emphasizes a free market approach in health care deliver. He has not totally ruled out a Wisconsin health benefit exchange, as having one is one of the objectives of this office but based on free-market principles. Another objective is to also look for ways or alternatives to not have a “federal” health benefit exchange.

With the 2013 deadline for an acceptable Exchange establishment plan to be in place drawing near, there has been no legislation filed to establish an Exchange which is a needed requirement.  On the positive side, a good deal of work has already been done in setting up an Exchange.  Let’s see what happens.

While there has been legislation against certain elements of the health reform law, none passed in the 2011 session.  A bill to prohibit elective abortion coverage except through optional supplemental policy failed to pass last February 2011.

West Virginia received on September 30, 2010 a $ 1 million Exchange Establishment Grant.  This grant will be used to assess West Virginia’s consumer and business markets using previous demographic surveys, develop an economic assessment of West Virginia health insurance market, develop education and outreach strategy for the Exchange project, and assess efficiency and effectiveness of technical capacity of current West Virginia systems.

On August 12, 2011 the state was also awarded an Exchange Establishment grant in the amount of $9,667,694. The money will be used for doing relevant consumer quality and effectiveness studies. This includes more funding for actuarial services and economic modeling. Among other uses will be to develop an operational plan that will insure financial sustainability by January 2015.

With the needed elements in place, West Virginia is working to develop an Exchange that will address the needs of local residents. Other states are grappling with elected (Republican) officials who are opposed to the health reform law. West Virginia does have elected officials who oppose element of the health reform law, but they are in the minority.

State residents will have a lot to look forward to when the Exchange will finally open.

State Governor Christine “Chris” Gregoire has a different view from the Attorney General as she fully backs the Affordable Care Act in Washington.  She also has strong ties with President Obama whom she endorsed in the Democratic presidential primaries in 2008.  In 2010, she issued an executive order to create the Health Care Cabinet which would implement health care reform in the state.  It would also look at the needed legislative changes to implement the health reform law.

Legislation to create a Washington health benefit exchange was enacted on May 11, 2011. The bill WA S 5445 2011 (Enacted as Chapter No. 317) established the health benefit exchange development board that will oversee the establishment of the Exchange.  There was also legislation filed against elements of the federal health reform act in the 2011 legislative session but did not pass.

Washington received an Exchange Planning and Establishment Grant on September 30, 2010 in the amount of $996,285. The fund is used to develop an implementation plan, focus on cost containment and quality, conduct IT infrastructure review and assessment, and focus on legislation relevant to Exchange establishment. The administrator is the Washington State Health Care Authority.

On May 23, 2011 the state was awarded an Exchange Establishment grant (Level One funding) in the amount of $22,942,671. The Administrator is likewise the Health Care Authority. The grant will be used to develop options and recommendations on policy decisions relating to the Exchange.  It will also be used to develop a health IT system for the planned Exchange.

With available funds, executive branch support, and needed legislation, Washington State looks on track to establish a State-based Exchange.

All these factors look bleak for the establishment of a Virginia health insurance exchange.  Yet there is actually a group that is working towards the establishment of an exchange although viewed as part and parcel of the state’s own desire to have a better health care system. This is known as the Virginia Health Reform Initiative. This is under the office of the Secretary of Health and Human Resources.

A report to the Virginia Health Reform Initiative Advisory Council and Task Force Members dated August 12, 2011 tackled the topic on Health Benefit Exchange Issues. Public meetings have also taken place regarding the issue. Like other states Virginia wants a direct hand in the establishment of an Exchange and is taking the right step by going through the process necessary to establish an Exchange. States that are too far behind in laying the groundwork for having an Exchange may ultimately wind up with what they do not want in the first place; the federal government running an Exchange for them.

While not everything is clear yet, things are moving in the right direct. Legislation has been enacted (2011 HB 2434, Chapter No. 823) for the intention of setting up a state based health insurance exchange.  It calls for the Governor through the Secretary of Health and Human Resources, to provide recommendation, by the 2012 legislative session, regarding a health benefit exchange.  It is not yet the bill that will establish an Exchange; at the very least the process is continuing.

While there are many issues surrounding the health reform law and the establishment of an Exchange, what is imperative is that there is participation from local state officials in its creation. This is something that the State of Virginia has been working on.

Aside from improving health coverage his other concern is trying to control the spiraling cost of health care and views reforming health care with a single payer system as an integral part of the solution.  The establishment of a Vermont health benefit exchange is going as planned.  Through 2011 HB 202, Act No. 48, which was signed by the Governor on May 26, 2011, legislative authority was granted to establish the Exchange. The Exchange will be a division inside the Department of Vermont Health Access. There is also a navigator program as part of the Exchange. This is outlined in the health reform law and is tasked to help employers and individuals select a qualified health insurance plan.

Vermont actually has a health reform plan of its own which will align in various aspects with the federal health reform law. This is known as Green Mountain Care which will be anchored by the health exchange to be created.

Like other states, Vermont received a $1 million Exchange Planning and Establishment Grant.  This is under the administration of the Vermont Department of Human Services. The fund is used to analyze the current insurance market, assess various Exchange organizational models, model potential funding mechanisms, and develop proposed legislation for the 2011 and 2012 sessions.  Work has been ongoing in line with the objectives set.

Vermont is also part of the group of states along with the University of Massachusetts Medical School that was awarded an “Early Innovator” cooperative agreement in the amount of $35 million last February 16, 2011.  Residents can look forward to a state-based Exchange that has the needed local inputs.

There have been differences with the federal government in various respects most notably in mandating everyone to purchase a health insurance.  Utah was one of the 26 states that filed a lawsuit in Florida where it was ruled that the health reform law is unconstitutional.  With similar cases in other courts ruling in favor of the health reform law, the U.S. Supreme court will have the final say on the matter. Utah also enacted a statute signed on March 21, 2010 which does not allow any state agency from executing health reform without legislature passing a provision or state agencies recommending action.

Notwithstanding some differences, the fact is Utah has an up and running Exchange that is functional. This includes a working web portal where qualified individuals can actually choose and enroll in a plan as what has been envisioned by the federal government.  The State has taken a gradual approach in accepting customers with only a small group allowed to enroll to fully test the system used. It has gradually been allowing more qualified individuals following a set plan.

There are still various issues that need to be aligned with federal rules for an Exchange.  Utah is working this out.  It has a $1 million Exchange Planning and Establishment grant awarded last September 30, 2011.  The intent of the grant is to allow Utah to continue moving forward on current Exchange efforts, expand the Exchange-research, develop web-based tool for eligibility purposes, and fund additional and current staff positions.

Other states have taken a look at the Utah model for setting up an Exchange. While many states are still grappling with how to best approach and build an Exchange, Utah is far ahead. This is one Exchange that is truly state-based and is actually a state initiative, built without federal government prodding.

The State Senate and House passed SB 7 which was signed by the governor on July 19, 2011. This is a state market reform act which includes an interstate health care compact, it also allows Texas with other states to seek control of Medicaid, Medicare, and commercial coverage from the federal government. Efforts to pass legislation that would create a Texas health insurance exchange proved fruitless; all measures filed failed to pass.

In 1993, Texas had its own form of health reform through the establishment of the Texas Insurance Purchasing Alliance which was a form of “exchange” for health insurance.  This was also created by state legislation and designed to help small businesses provide health coverage for their employees. As it turned out “cherry picking” occurred. Insurance companies picked and covered healthy clients outside of the “exchange” and let the less healthy individuals in the “exchange”. This caused premiums to go up inside the “exchange” as it became a high risk pool. With prices higher inside the exchange than outside the program eventually failed.

Texas has the highest percentage of uninsured in the U.S. at 26% and is also the highest in absolute number with over 6 million uninsured.  This situation needs to be addressed.

While there has been vocal opposition to put up an exchange, ground work to establish one has actually continued with the $ 1 million Exchange Planning and Establishment Grant awarded to Texas last September 10, 2011. This is being administered by the Texas Department of Insurance.  Consultations have been ongoing and work continues on the objectives set for the grant.

With the 2013 deadline for having an acceptable Exchange establishment plan drawing near, the federal government may have to step in if the required legislations are not passed.  It’s good to know that needed local inputs will be available with the work that is quietly going on.

A law was passed (S 79) and signed by Governor Bill Haslam on March 18, 2011. In essence the law provides that a person can choose whether or not to have a health insurance policy and will not be penalized if  he/she chooses not to have one. It further states that any local or state employee cannot act to impose or collect any penalty in this regard.  From a business point not having mandatory purchase of a health plan would mean a smaller market for a Tennessee health insurance exchange.  It does not however total remove the market.

With regards to legislation filed to establish an Exchange, none occurred during the 2011 legislative session.  There is work ongoing though through the Insurance Exchange Planning Initiative to see whether Tennessee should establish a state-level exchange, and how it should be structured.  There have been consultations with various stakeholders on this matter. More than 20 meetings and consultations have been held.  Amount these are meetings with providers and advocates, the Tennessee Association of Mental Health Organizations, the NFIB and Kingsport Chamber of Commerce, the Association of Government Accountants, and other stakeholders.

Tennessee has been trying to get as much input as possible on this matter. Even if no law has been passed to establish an exchange, at least the needed data and inputs are being gathered. This will be of great help in establishing an Exchange that will address the needs of local residents.

Governor Dennis Duargaard as far back as April 2011 issued a press release pertaining to his approval of two bills. These bills, SB 38 and SB 43, he said prevents the federal government from directly interfering in the handling of the local health insurance system. In his view The Affordable Care Act in South Dakota will allow the federal government to encroach on the local authority of the State.

On the legislative front, no bill was filed in the 2011 session for the establishment of a South Dakota health insurance exchange. Legislation is needed for establishing the Exchange.  Other states that openly oppose the health reform law have been working quietly in the background to set up an Exchange. There are issues on its final form but at least work has begun.

Legislators in other states have at least filed bills to establish an Exchange even with the executive branch openly against the health reform law. Whether it passed or not is another issue.  As for South Dakota there is no issue on this matter with the non-filing of any bill for Exchange establishment.

This really puts the state in a bind since the best exchange would be with the participation of local officials. An Exchange that reflects the needs of South Dakota residents can still be established. It would be made faster though with some sort of local state initiative even if done quietly.

The jury is still out for South Dakota, only time will tell if the local elected officials have made the right decisions with regards to establishing an Exchange.