Monday, July 16, 2012

Cameron Smith: Obamacare options for Alabama

  As Alabama and the nation continue to process the Supreme Court's June 28th opinion on the Patient Protection and Affordable Care Act (PPACA), most of the talk has revolved around the preservation of the individual mandate, albeit in the Court's reformulation as a tax.

  But the Court's holding leaves Alabamians with two important decisions to make: Should the state expand Medicaid under the PPACA and should the state set up its own PPACA-compliant health insurance exchange?

  In the PPACA opinion, seven Justices placed a significant restriction on the coercive power of federal spending by striking down the ability of the federal government to condition all Medicaid funding on a state's willingness to expand Medicaid coverage under the PPACA. As a result, Alabamians are asked to balance expanding Medicaid to include an additional 351,000 to 456,000 citizens against the reality of scarcely being able to fund existing Medicaid obligations.

  At first glance, the Medicaid expansion is enticing for every state. Those favoring the Medicaid expansion may argue that Alabamians paying federal taxes should not miss an opportunity to leverage even more federal funds. The federal government will cover 100 percent of the PPACA Medicaid expansion until 2016. After that, the federal government will pay 95 percent in 2017, gradually reducing its contribution to 90 percent by 2020.

  But arguing for states to leverage more federal spending is the equivalent of telling an alcoholic that the first sip of his drink is on the house. Even with the federal government covering the majority of the initial cost, the PPACA Medicaid expansion is far from free. Depending on the extent to which Medicaid markets the new coverage, the ultimate cost to Alabama could fall between $470 million to $693 million from 2014 to 2019. Beyond that, what percentage Alabama will be required to fund is anyone's guess.

  The next question Alabama must deal with is whether it will set up its own health insurance exchange under the PPACA or fall under the yet-to-be-created federal health insurance exchange.

  Alabama Governor Robert Bentley created the Alabama Health Insurance Exchange Study Commission (AHIESC) in December 2011 to investigate the logistics of setting up a state health insurance exchange. However, many Alabamians may not have heard much about the commission's report and for good reason. Politicians are not exactly thrilled to reveal the exchange's estimated $34-$50 million annual administrative price tag.

  To further curb the enthusiasm for an exchange, the AHIESC also recommended that it be funded by assessing fees on "all products sold in the small group and individual [health insurance] markets, including those sold inside and outside the Exchange." In other words, the AHIESC recommends taxing the health insurance of Alabamians to pay for the PPACA exchange itself.

  Supporters of an Alabama PPACA exchange may suggest that failing to set up an Alabama exchange will invite legions of federal regulators to descend on Alabama and take away healthcare options. But in reality, individuals in Alabama participating in the federal exchange may never notice the difference; federal insurance subsidies will attach to enrollment in both state and federal exchanges, and the same minimum plan standards will apply.

  But there is one important difference. If Alabama sets up its own exchange, it is left with the tab after federal funds dry up. That could easily be another $50 million price tag per year and potential tax increases for a state that is not exactly flush with cash.

  Even as conservative and liberal ends of the political spectrum push for radically different outcomes, the two PPACA choices before Alabama ultimately converge into one: join the growing number of states rejecting the PPACA exchange and Medicaid expansion or be willing to pay for them.

  About the author: Cameron Smith is General Counsel and Policy Director for the Alabama Policy Institute, a non-partisan, non-profit research and education organization dedicated to the preservation of free markets, limited government and strong families, which are indispensable to a prosperous society.

  This article was published by the Alabama Policy Institute.

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