POLITICO, by Kyle Cheney and Jason Millman –
December 3, 2012:
Sure, the Obama administration is dumping piles of Affordable Care Act rules in everyone’s laps now. The danger, though, is that the rules have been held up so long that the states’ insurance commissioners — even the ones that want to implement the law — may have trouble making up for lost time.
That’s the word from the National Association of Insurance Commissioners meeting near Washington, D.C., last week, where commissioners from around the country told POLITICO that the Department of Health and Human Services has left large holes in its guidance for states building insurance exchanges — online marketplaces for individuals to access subsidized insurance plans.
But that was before Friday’s regulation dump, which gave health care stakeholders hundreds of pages of guidance on everything from the health exchanges to the multistate plans that are the heath care law’s replacement for the “public option” so many liberals wanted.
Friday’s new rules included a 373-page HHS regulation that covers risk adjustment in the exchanges, cost-sharing limits and user fees for the federal exchanges; a 122-page Office of Personnel Management rule that spells out the guidelines for the Multi-State Plan Program; and the Internal Revenue Service put out a 42-page rule on the Medicare payroll tax that will be charged to high-income earners to help pay for the law.
But the sudden deluge of regulations doesn’t change the fact that insurance commissioners have been kept waiting for months, and they say the delays have made their jobs significantly harder.
Until now, most of the loudest complaints about the lack of guidance on the Affordable Care Act came from Republican governors. But at the insurance commissioners’ conference this week, the officials in the trenches implementing the law — even in states that have been its strongest supporters — quietly expressed the same concerns.
Commissioners from Democrat-led states that have rushed to implement exchanges say they’ve been in a holding pattern awaiting word from the Obama administration. And the things they want out of the regulations — especially the technical details they want about federal exchanges — aren’t likely to be totally resolved by the new rules released Friday.
“We’re still very much depending on getting further guidance from HHS. There are still some major gaps,” said Washington State Insurance Commissioner Mike Kreidler, whose state has long pursued its own exchange. “The timetable that we have is going to be a real challenge. … We’re still plowing ahead but without some of this critical guidance from the federal government, it’s going to be very difficult.”
Likewise, Nevada Insurance Commissioner Scott Kipper bemoaned “slow and not completely comprehensive” regulations from the Obama administration despite the state’s long-held plans to operate its own exchange.
“We’re going to make it, I think. We’ve gotten an awful lot of cooperation from our industry,” he said. “It’ll be tight.”
The trepidation from states like Washington and Nevada gives credence to complaints — often chalked up as political — by Republican governors who have pleaded for clarity on the law. Some, like Oklahoma Gov. Mary Fallin, have said participating in an exchange would be irresponsible without more information.
But even among the states that have refused to build their own exchanges — instead either partnering with Washington or allowing the federal government to build one for them — there’s no less frustration among commissioners about what they say is a dearth of guidance.
“I think there’s frustration on everybody’s part because [HHS officials] don’t know exactly where they’re going sometimes even though they’re supposed to guide us,” said South Dakota Insurance Director Merle Scheiber. “Lines of communication are open, but it doesn’t seem like anything gets solved.”
Another GOP commissioner grew visibly frustrated when asked whether he had been talking with HHS about the contours of a federal exchange.
“We’re not having the conversation because we don’t know what the answers are,” the GOP commissioner said.
HHS did not respond to a request for comment.
Other commissioners were more deferential to the administration, describing ample communication and little worry about meeting deadlines.
Nebraska Insurance Director Bruce Ramge, who had been preparing to run a state-based exchange until Gov. Dave Heineman shot it down earlier last month, described regular conversations with HHS and its Center for Consumer Information and Insurance Oversight. Now, he said he’s focused on smooth implementation of a federal exchange.
Iowa Insurance Commissioner Susan Voss, similarly said a trickle of regulations from the administration was beginning to answer states’ outstanding questions. And Hawaii’s insurance commissioner, Gordon Ito, reported no concerns about his state’s ability to operate an exchange on time.