At Health Services Research**, I have a commentary out this morning that looks at the wide amount of discretion that states have in promoting a wide variety of goals for their specific individual health insurance market. The ACA has always been a story of 51 states (including DC) and 3,000 counties but since October 2017 with the termination of CSR payments, the possibility space has widened dramatically.
Here the big decisions state regulators and elites can make:
- Expanding Medicaid to 138% FPL instead of not expanding or expanding only to 100% FPL — Yes lowers non-subsidized premiums and slightly increases subsidized net premiums
- Silver loading and/or Silver Switching vs Broad Loading — 3 states broad load which raises costs for everyone and lowers enrollment
- Managing Monopoly and spread games
- Messaging support and advertising
- Outreach and advertising to gap fill for what used to be done by Healthcare.gov
- Elite messaging support or opposition
- Our JHPPL paper touches on this
- Reinsurance and subsidization to support net prices paid by people earning over 400% FPL
- Managing the allowable parallel markets such as Short Term Plans and Farm Bureau Plans
State regulators and insurers have tremendous discretion to shape their states’ markets however they wish. Some states will make choices that I normatively like and others will make choices that make me gag. The ACA requires states to make decisions and states will choose who to prioritize and how to do so from a very wide toolbox.