2018 MIDTERM ELECTION

Time: D H M S

NY Times confirms what I said in April: Killing King = Killing (some) state exchanges...and that's PERFECTLY FINE.

Yup, there's no denying that all of this sounds like a whole big bag of hurt. Installation, configuration, maintenance and improvement of technical infrastructure costs money, time and know-how.

The funny thing is, if the King v. Burwell plaintiffs are shot down and if Healthcare.Gov ends up in the free and clear to continue operations including providing the federal tax credits, I, for one, would have no problem with some or all of the state-based exchanges making the move to HC.gov.

It's certainly more fiscally efficient (HC.gov has cost somewhere around $250-$300 per enrollee to date, as opposed to the several thousand dollars per enrollee that most of the state exchanges are costing....or, to use an extreme case, the $57,000 per person that Marco Rubio's Republican "Anti-Obamacare" Brainchild, "Florida Health Choices" has cost to date).

The main advantage of running their own exchange, aside from the King v. Burwell Sword of Damocles hanging over their heads, is that SBMs have more flexibility to do things like offer additional financial assistance to enrollees (as Vermont and Massachusetts do) or even stronger healthcare coverage mandates (Hawaii currently has a state law requiring employers to provide coverage to employees working 20 hours or more, vs. the 30 hour threshold that the ACA requires).

Overall, however, it seems to me that in addition to the economic economy of scale/efficiency advantages of running the exchange via HC.gov, it also simplifies the marketing of the exchange: Instead of promoting a bunch of different websites which no doubt confuses the heck out of some people, every state can just promote Healthcare.Gov, period.

Now that the Supreme Court hasruled that health insuranceconsumers can receive federal subsidies regardless of their state’s role in running their insurance market, fewer states may stay in the game.

...As my colleague Abby Goodnough reported this month, state struggles continue. The Hawaii exchange is collapsing, while Vermont’s looks shaky. Even some exchanges that have performed relatively well — including Washington and Minnesota — are experiencing substantial information technology problems. And the expense of managing an exchange is also climbing in many places as federal start-up funding diminishes. The Washington Post reported in May that nearly half of the states are suffering from financial difficulties.

“There is no new money now to build new infrastructure, and there are no grants available to fix these systems if they’re struggling,” said Heather Howard, the director of the State Health Reform Assistance Network at Princeton University, which was set up to advise states on exchange building. “So the only path forward may be to use HealthCare.gov.”

My guess is that Vermont and Minnesota are most likely to move to HC.gov, for both technical and financing reasons. Rhode Island doesn't have serious technical probems to my knowledge, and just passed a new budget which I think resolved that issue, so they're probably OK.

Other states like Colorado and Washington State are still having some issues, but I think they're likely to stick around.