Rolling out provisions of the Affordable Care Act will be a challenge for all states, regardless of size. Witness Maine and Vermont not exactly sprawling metropolises, but both are enduring their fair share of bumps along the road to implementation.
Maine has just emerged from a bitter, drawn-out fight over the future of Medicaid expansion, while some health systems in the state are railing against Anthem's planned narrow-network on the health insurance exchange. Vermont has seen battles in-state over the future of a healthcare CO-OP, and congressional GOP members are challenging the legality of a portion of its exchange.
The plight of these two states is really no different from others who have had their own issues to wrestle with, but there have been some surprises in Maine and Vermont. Take Maine, for example. In terms of Medicaid expansion, it is not surprising Republican governor and Tea Party favorite Paul LePage vetoed two different attempts to expand the state's Medicaid program, a voluntary option under the ACA. What was surprising was that members of the Democratic-controlled Legislature couldn't pressure a handful of moderate Republicans to vote to override the veto, considering the overwhelming support from advocates and state hospitals for expansion.
When it comes to the state's health insurance exchange, controversy began when word leaked out that the state's No. 1 carrier, Anthem Blue Cross and Blue Shield, was planning to team with MaineHealth to offer a lower-cost, narrow-network option in the exchange, pending regulatory approval. MaineHealth is the largest integrated healthcare network in the state and includes eight hospitals in Maine, several physician organizations, a laboratory network, a behavioral healthcare facility, and a rehabilitation center that is a joint venture with HealthSouth. Narrow networks are not a new phenomenon; nationwide, many insurers are working closely with health systems to control costs through these products. Individuals buying through the exchange are likely to be more cost-conscious, and self-insured employers also want to trim healthcare expenses.
However, the concept of narrow networks is new to rural Maine, where providers can be spread across a wide terrain. Though the Anthem-MaineHealth plan would include 32 of the state's 38 hospitals, the excluded systems including Lewiston's Central Maine Healthcare claim some patients would be forced into changing providers and possibly enduring lengthy travel to see a PCP or specialist. Anthem counters that the product will be lower cost and will offer a broad network, though that didn't keep Central Maine officials from labeling the product a backroom deal. Maine is in the midst of holding somewhat contentious hearings on the issue, though is hard to fathom the state's Bureau of Insurance disallowing a product from the state's most influential insurer.
Vermont, meanwhile, has had both internal conflicts and a dispute with Republicans in the House of Representatives over its state-run health insurance exchange. The internal issues began when Vermont became the only state (out of 24) to reject a healthcare consumer-oriented and -operated plan, which had hoped to offer products in the state's health insurance exchange. The Vermont Health CO-OP received a $33.8 million federal startup loan and was putting pieces into place to compete in the exchange with market leader Blue Cross and Blue Shield of Vermont and MVP Health Care. After having its bid to offer insurance in the state rejected, a war of words erupted between CO-OP officials and state regulators. Cooler heads eventually prevailed, and the CO-OP is in the midst of restructuring itself in hopes of state regulators taking another look. Good luck with that.
Meanwhile, a Republican-led committee in the House of Representatives has charged Vermont's health insurance exchange with standing in violation of federal law. At issue is a state law requiring businesses with 50 and fewer employees to buy their health benefits through the exchange (Vermont Health Connect). This means as many as 100,000 individuals employed at small businesses could join the exchange in 2014.
However, the House Oversight and Government Reform Committee charged the state with going against what was spelled out in the ACA regarding voluntary participation in the exchange. Vermont state officials disagree, naturally, citing state's rights and charging Congressional Republicans with continuing their politics-infused attack on the ACA.
True, none of these issues individually are going to derail healthcare reform efforts in either Maine or Vermont. But they have made the transition a bit more bumpy than originally envisioned.
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