Opinion Columns & Blogs

Kathleen Sebelius: Act empowers states

As governor of Kansas, I saw up close the urgent need for health care reform. I heard it when factory owners told me their biggest concern was not manufacturing costs but rising insurance premiums, and when families said they felt like hostages to insurance companies that could deny or cancel coverage with little accountability. I saw it in our state budget, where rising health care costs prevented investments in our future.

The Affordable Care Act puts states in the driver's seat, because they often understand their health needs better than anyone else — and that is why it is so frustrating to hear opponents of reform falsely attack the law as "nationalized health care."

The truth is that states aren't just participating in implementation of the law; they're leading it.

Consider the state-based health insurance marketplaces that will be created under the law in 2014. These marketplaces, called exchanges, will allow individuals and small-business owners to pool their purchasing power to negotiate lower rates. They'll also serve as a one-stop shop where insurers must compete to deliver the best deal. Starting in 2014, members of Congress will have to purchase health coverage through these marketplaces as well.

Although the law gives states the option to design and run their own exchanges, some critics have claimed this could burden states if they're not given adequate resources and flexibility. I agree. But what these critics miss is that the law already gives states most of the resources and flexibility they're asking for.

States have discretion, for example, to offer a wide variety of plans through their exchanges, including those that feature health savings accounts. Utah and Massachusetts already operate exchanges but take very different approaches: Utah allows all insurers to participate; Massachusetts has stricter standards. Under the law, both approaches could work.

States also have the flexibility to decide what benefits plans must offer. They can choose to require basic protections, based on the typical benefits people get through their jobs, or set higher standards.

And states' costs of designing their exchanges will be fully funded by the federal government through 2015, with additional funds available to help determine which residents are eligible.

Some critics have said there has not been enough analysis of how exchanges would affect employer-based insurance. But the nonpartisan Congressional Budget Office has closely studied this and estimated that only 24 million Americans will be insured through these marketplaces in 2019, compared with 162 million covered through the workplace.

The law gives states new flexibility in Medicaid, too. Beginning in 2014, states will be able to offer more affordable Medicaid benefits that resemble typical employer plans. Because costs of long-term care are driving the growth in Medicaid budgets, there are new options and federal support to help states bring down these expenses, such as through cost-effective care models like health homes.

The law does make Medicaid available to more working families. But the federal government will cover 96 percent of this expansion, and nonpartisan experts suggest that states will save money overall through reductions in the "hidden cost" they pay for uncompensated care provided to the uninsured.

The Affordable Care Act gives states incredible freedom to tailor reforms to their needs. The one thing the law does not permit is going back to the broken health insurance system we had a year ago.