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State Republicans’ health reform playbook: not ‘repeal and replace,’ but ‘oppose and implement’

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Up on the Hill, health reform repeal is having a small renaissance. Congressional Republicans held a repeal press conference earlier this week; on Thursday, Rep. Denny Rehberg urged the Supercommittee to strip away key parts of the law’s funding. "Every day I get up, I do at least something to fight Obamacare," Rep. Steve King boldly declared at a Wednesday press event.

But at an insurance industry conference, just nine blocks down the street, opponents of the health reform law were having a completely different discussion: how to move forward on implementation.

J. Scott Applewhite


“We definitely didn’t support the Affordable Care Act,” says Laura Minzer, director of health care council at the Illinois Chamber of Commerce. She’s among the hundreds of attendees at the State Issues Conference this week, hosted by America’s Health Insurance Plans, which lobbies for the insurance industry. “That being said, it is the law, and Illinois feels its in the best interest for us to set up this law, rather than have the federal government come in.”

Minzer, and others, get the politics: with a Democratic Senate and President, any repeal efforts here in D.C. are doomed. And that leaves states with a choice, either implement the law, or have the federal government come in and take over the job.

“Our state knows what’s best for us,” she says.

Krista Drobac directs the National Governor’s Association’s Center for Best Practices health division, where she works with all 50 states on health reform. She told me that only two states, Florida and Louisiana, have ruled out setting up their own health exchanges, the new insurance marketplaces that will come online in 2014. Other states have blasted the law politically and seen implementation slow down in the face of local opposition. But they’re all taking federal funding or bureaucratic steps to do at least something on implementation.

Most of the battle centers on health reform’s exchanges, the new marketplaces that launch in 2014 and will, ideally, work like an Expedia for health insurance. If states haven’t made sufficient progress on their exchanges by the start of 2013, the federal government will come in and do the job for them.

“The red states are mostly thinking, what are our options?” Drobac told an audience of insurance executives. “They’re being very diligent, preparing their states for an exchange, looking at different scenarios. States overwhelmingly want to do this themselves.”

And even in the reddest of red states, ones where there is strong political opposition, insurance plans are plotting a way to move forward. As Politico’s Kate Nocera reported earlier this week, Blue Cross Blue Shield Association huddled with its state insurance executives to strategize on countering “hard core conservatives” who want to block health reform.

At a closed-door meeting, insurance executives went over agenda points including “What motivates conservatives to oppose creating exchanges? Myths vs. facts” and “tactics and strategies.” Health insurance executives also heard from Aaron Sisk, a staff attorney with the Mississippi Department of Insurance, on possible ways to move forward even if their legislatures opposed implementation.

“They had a lot of states up there talking about how they were having the Obamacare problem in their state,” says Sisk.”So they’re trying to figure out how to move forward. Especially in states that are having trouble moving legislation, I think you’ll start seeing a lot more executive orders.”

The most surprising example of health-reform opponents moving forward can be found in Wisconsin, a state where Republicans control both the governor’s office and legislature. Politicians there definitely aren’t fans of the law.  “We think there are going to be more losers than winners,” says Dan Schwartzer, the state’s deputy insurance commissioner.

But, given that it is the law, the state has gone all-in on implementation. Wisconsin is one of five states that has an “Early Innovator” grant, a multi-million award given to states meant to serve as leaders on setting up exchanges. The state continues to work with Jonathan Gruber, an MIT economist who helped implement both Massachusetts’ health law and federal health reform, in estimating the new law’s impact on its market.

Come 2014, Schwartzer would like to see all health insurance sold through the state’s exchange. “Quite frankly, we want to take the entire portfolio and dump it into the free market web portal,” says Schwartzer.

In Washington, Republicans are raising many questions about the future of the health reform law. The pending court cases, too, create a good amount of uncertainty. But for people with boots on the ground, like Schwartzer, there’s not a lot of question about what his state will do moving forward: “Our governor decided pretty early on, we’re going to do this. We’re not turning back.”

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