While Kansas received an initial $1 million grant for planning an exchange, legislation was introduced to make it difficult for the insurance commissioner to spend the remainder of the money.

Kansas sought and was denied a waiver to the 80/20 requirement on the medical loss ratio. In January, the state administration submitted a comprehensive waiver to totally change the Medicaid program and incorporate all its populations into managed care, St. Peter said. The largest insurer in the state was not bidding on that Medicaid contract, although five bidders have since come forward on the KanCare contract.

“All of that, and then we lost our top three Medicaid administrators in the state,” St. Peter said.

Upon taking office, the new Republican governor immediately signed on to the health reform lawsuit but still wanted to be able to receive some of the grant money, said Susan Voss, Iowa insurance commissioner for the past eight years (pictured at left). Gov. Terry Branstad is committed to going forward, and Iowa has received a total of $8.7 million to consider options for an exchange.

[Commentary: Fire, aim, ready – will states make the right investments in HIX IT?]

But the legislature has not passed related legislation. “We can’t seem to get to square one,” Voss said. “I think given the politics we have, a lot of conservative folks in the legislature say they don’t want the federal government in their business, so they’re not going to pass the exchange. But if the legislature doesn’t pass the exchange, the federal government is in their business. The governor says let’s have a plan so that we can get moving.”

Last year when Iowa was dealing with the rate review issues in the Affordable Care Act, however, the legislature passed into law a section in the state insurance code that said the insurance commissioner may implement any portion of the ACA by rule.

“So we’re trying to figure out what we’re going to do. Under sunshine laws, if we have a meeting it has to be open,” Voss said. Meanwhile, Iowa is gathering ideas about the exchange and hired consultants to do studies.
“We don’t even know what kind of system we would have, who would be in it, and what the essential benchmark package would be,” she said, adding, “they’re all waiting until the Supreme Court decision comes out.”

That ruling, expected at June’s end, will occur after the legislature leaves, potentially exacerbating the time crunch states are already up against.

“I worry we’re going to get to this summer, and then there’s going to be a scramble at the same time that the election is going on, and that really does take away from getting people to come to the table,” Voss said. People’s expectations will be high that the exchange is going to be beneficial and helpful. “But we’ve got to get it right, or close to the end zone,” she added.

No wrong door
California policymakers have understood that it makes sense to advance a state insurance exchange. The exchange will serve as a gateway to coverage to millions of uninsured and a means to help organize the insurance marketplace in a way that plans will compete more squarely on price, quality and service, according to Belshe.

The exchange offers the opportunity to deliver more value through better quality and affordable products by actively purchasing on behalf of individuals and small businesses.

[Q&A: How the S.C. Tea Parties took on the GOP over HIX – and won.]

Updating the eligibility and enrollment systems has been a major focus for the past several months.

”The success of reform, in many ways, is dependent on how well we do in identifying, enrolling and retaining people in coverage,” Belshe said (pictured at right). “It’s instrumental in terms of the financial viability and affordability of the products that we offer and our leverage in the marketplace.”

The vision of “no wrong door” for enrollment means millions of people will have their eligibility determined in real time and with a top-notch customer experience through any health and human service program. That is significantly different from how public programs operate today, she said.

Currently, California has multiple county and state information technology systems, and nearly 30,000 county eligibility workers to determine eligibility and to enroll people in Medicaid and other human services programs and a separate system for the Children’s Health Insurance Program (CHIP). Applicants will also have an online self-service option, which can free up some of the county workers to focus on the most difficult cases.