At the National Governors Association today, President Obama signalled his support for giving states flexibility–including the ability to opt out of the coverage requirements on individuals and employers, if they can otherwise meet the coverage and benefits goals of the Affordable Care Act.
In a nationwide call with advocates this morning, members of the White House policy team reiterated that this is not a retreat or a lack of commitment to the goals of the Act, as some of the early reporting seems to indicate.
First of all, this state flexibility is actually something envisioned in the law itself. The bill that the President is endorsing–sponsored by Senators Wyden of Oregon and Brown of Massachussetts–moves up this flexibility from 2017 to 2014. As the White House position paper states:
Beginning in 2017, the current law allows States the flexibility to receive a State Innovation Waiver so they may pursue their own innovative strategies to ensure their residents have access to high quality, affordable health insurance. These strategies – which must provide affordable insurance coverage to at least as many residents as the Affordable Care Act and must not increase the federal deficit – could include allowing large employers to purchase coverage through State Exchanges or increasing the number of benefit levels to provide more choices for individuals and small businesses…
The proposal offers States more flexibility while ensuring that all Americans, no matter where they live have access to affordable, accessible health insurance. Additionally, the proposal includes built-in protections to ensure that these waivers do not increase the Federal budget deficit…
Under the Affordable Care Act, State Innovation Waivers allow States to propose and test alternative ways to meet the shared goals of making health insurance affordable and accessible to all Americans, including those living with pre-existing conditions.
Specifically, State Innovation Waivers are designed to allow States to implement policies that differ from the new law so long as they:
· Provide coverage that is at least as comprehensive as the coverage offered through Exchanges – a new competitive, private health insurance marketplace.
· Make coverage at least as affordable as it would have been through the Exchanges.
· Provide coverage to at least as many residents as the Affordable Care Act would have provided.
· Do not increase the Federal deficit.
So it is important to state what this proposal is not: it does not states out of their “maintenance of effort” requirements; it does not allow states to opt-out of the individual and employer requirements without putting something else in place that would be just as effective.
And there’s the dare: for all the Republican opponents of the Affordable Care Act who say “repeal and replace,” it calls the question. The new proposal offers to Governors the ability to “repeal” if they have a workable plan to “replace” it to meet the same goals of comprehensive coverage to as many people.
Once they are engaged in the policy conversation, rather than political rhetoric, they’ll start to appreciate the policy decisions and trade-offs in the ACA. Some might rise to the challenge: Vermont’s Governor has expressed strong interest in a single-payer solution, and that is an approach that could meet the standards. One can imagine different ways to encourage on-the-job benefits, for example. Here’s other suggestions from the White House document:
The Affordable Care Act offers considerable flexibility to States without waivers. It also recognizes that new, creative effective ideas may emerge. While States have the freedom to develop their own proposals that may qualify for a State Innovation Waiver, some proposals that could qualify include:
* A streamlined system that links tax credits for small businesses with tax credits for low-income families.
* Alternatives to the individual responsibility provision – such as automatically enrolling individuals in health plans – that achieve similar outcomes.
* Alternative health plan options to increase competition and provide consumers with additional choices.
* An increase in the number of benefit levels to provide more choices for individuals and small businesses.
* Immediately allowing large businesses interested in doing so to purchase health insurance through the new private marketplace, the State-based health insurance Exchange.
What won’t meet the standards is simply more tax breaks or more deregulation of insurers. There is another proposal in Congress, backed by Republicans, that wants to give states the ability to opt-out of the Act–with no provision for coverage or benefits or protections. But then that makes the debate clear, and separates those who want to achieve the same goals through different means, and those who simply don’t agree with the goals of increased coverage and security to start with.
The dare is not just to Governors, but to Congress as well. Congress can grandstand on “repeal and replace,” but here’s a viable, bipartisan proposal that the President just endorsed. Senators argue that states need flexibility, and here the President is willing to provide it. Will they take “yes” for an answer?
But the main strategy is to engage Governors and Congressional Representatives in the actual practical conversations of reforming our health system. We’ll see if it works.