Red and Blue States Move Further Apart on Health Care Policy, Stephanie Armour,, Wall Street Journal (Feb. 28, 2018)

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HEALTH POLICY

Red and Blue States Move Further Apart on Health Policy

Cost and the scope of coverage will look very different depending on which party is on control

Health-care options in any given state are likely to depend on which party controls the statehouse. Here, a hospital room in Cumming, Ga., early this year. PHOTO: ROBERT RAY/ ASSOCIATED PRESS

By Stephanie Armour

Updated Feb. 28, 2018 5:15 pm ET

Democratic and Republican states are moving in opposite directions on health policy, leaving Americans with starkly divergent options for care depending on where they live.

The Trump administration and congressional Republicans, by easing many of the Affordable Care Act's nationwide requirements after failing last year to repeal the entire law, are effectively turning major components of health policy over to the states. The roughly half of states controlled by Republicans are therefore moving aggressively to roll back the law widely known as Obamacare, while the smaller number of Democratic states are working to bolster it.

As a result, the health-care options in any given state are likely to depend on which party controls the statehouse. That dictates access, cost and coverage, particularly for the roughly 17 million people nationwide who buy their own insurance and the 29 million people who lack it entirely.

Increasingly, state health-care policy reflects the ruling party's goals. In Democrat-controlled California, a patient with a costly medical condition may likely get relatively affordable premiums, while a young, healthy and self-employed professional could pay more. In

Republican Texas, the sicker patient will likely do less well or go without coverage, while the younger, healthier one will have less-comprehensive options that may cost far less.

"You're seeing red and blue states moving further from each other," said Sam Richardson, a health economist at Boston College. "You're going to have blue states hang on to what they can. For red states, the more they can dismantle Obamacare, the more they'll look like before Obamacare. They'll have higher rates of uninsured, but other innovations."

                                                                                                       This divergence reflects a seismic

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rollback of the Obama administration effort to promote a more standardized, nationwide health system. The ACA sought to have the healthy help cover the costs of the sick and the wealthy help cover the poor, and it has led to about 20 million people gaining health coverage. But Republicans

have long balked at the ACA's idea of taxing higher earners to pay for health care and have opposed the law's mandate that individuals who don't get care through their job or through a government program get coverage or pay a penalty.

The divergence has existed for years. Eighteen largely GOP states never accepted the federal money to expand Medicaid under the ACA. But now it is widening, with GOP states seeking work requirements in the program, and that gap is also accelerating in the individual insurance market.

After congressional Republicans tried repeatedly last year, unsuccessfully, to repeal the health law, they did repeal the individual mandate, beginning in 2019.

In the meantime, the Trump administration has worked to take apart the law piecemeal. One proposal would allow the type ofless-comprehensive health plans limited under the ACA. Another would let businesses and some individual band together in associations to get non­ ACA-compliant plans. Those actions, along with a willingness to impose new requirements on Medicaid, have emboldened Republican-led states to further undercut the law they have long opposed and raised alarm in Democratic states, where lawmakers are preemptively looking to buttress the law from any GOP policy changes.

On Tuesday, 20 Republican state attorneys general sued to overturn the law, arguing that it is unconstitutional now that the individual mandate has been repealed.

Under the administration's proposals, states are expected to get more flexibility in waiving some ACA requirements and oversight of plans that don't comply with the ACA.

Democrats say non-ACA-compliant plans would siphon younger and healthier people away from the law's exchanges, which they say would cause premiums for older and less-healthy

Health and Human Services Secretar y Ale x Azar at a conference last week in Washington. PHOTO: JOSE LUIS M AGANA / ASSOCIATED PRESS

people to jump. Republicans say being able to offer cheaper and less-comprehensive plans amounts to more consumer choice.

Health and Human Services Secretary Alex Azar told reporters he is exploring options to let states "create affordable, individualized insurance" for their systems.

"There is no single one right answer," he said.

States like Indiana and Kentucky are being allowed to impose certain changes on Medicaid for the first time, like requiring recipients to work or undertake similar activities before they get benefits. In Idaho, Republican Gov. Butch Otter is largely flouting the ACA by letting insurers sell plans that don't comply with the law.

By contrast, Democrat-led states such as California and Maryland are looking to block or limit the expansion of cheaper and less-robust health plans that don't adhere to ACA rules. Nearly a dozen states are considering measures requiring residents to have health coverage, essentially re-imposing an individual mandate with new modifications .

Washington state Insurance  Commissioner  Mike Kreidler  said he is drafting a rule that would ban so-called short-term plans, which aren't ACA-compliant, from being carried longer than 90 days.

"How are we going to protect this from the feds?" Mr. Kreidler said. "You're going to see states take these types of action."

New Mexico, at the behest of the state legislature, is studying plans to allow more people to buy into Medicaid, a state-federal program for the low-income and disabled.

As the states fight it out, the Republicans' proposed and actual changes could erode some of the ACA's basic goals like ensuring that health insurance bought by individuals meets certain standards, and that it is priced equally regardless of a person's medical history.

States with a large share of Democratic legislators, especially those with a Democratic supermajority, are more likely to have generous public health insurance programs and more regulated private insurance than red states, according to a 2015 report by University of Houston researchers.

"If I was chronically ill and didn't get insurance through an employer and if I was in a red state, I'd be really worried right now," said Nicholas Bagley, a University of Michigan law professor.

Republicans counter that greater autonomy works best. GOP-designed arrangements tend to allow for lower taxes, they say, while letting individuals find insurance policies that work for them, rather than forcing people into rigidly defined plans.

                                                                               "Give us flexibility at the state level," Republican

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Ohio Gov. John Kasich told reporters recently. "Let me design a Medicaid program I want. Let's change the Obamacare essential benefit to what I want."

Insurers that offer ACA plans want to see those markets strengthened, so that rates wouldn't surge and enrollment, particularly among healthier consumers, would remain steady.