Shades of gray color most states on implementing the ACA, report finds

The split among states on the Patient Protection and Affordable Care Act is more complicated than for and against.

Seven states—Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Oregon and Vermont—that have expanded Medicaid, are operating their own exchanges and are taking steps to enforce an array of new insurance regulations. At the other extreme are five states—Alabama, Missouri, Oklahoma, Texas and Wyoming—that have done nothing to implement the law.

But most fall somewhere in between, taking steps to implement or enforce some requirements of the law while ignoring others.

This divergent landscape is detailed in a new report issued by the Commonwealth Fund.

“It's harder to say this state has fully opposed the Affordable Care Act or fully supported the Affordable Care Act,” said Katie Keith, director of research at the Trimpa Group and a co-author of the report. “I think there's a lot more shades of gray that we just wanted to bring to the forefront.”

Most attention has been focused on whether states have established exchanges and expanded Medicaid. Sixteen states and the District of Columbia are running their own insurance marketplaces, while 34 states have defaulted to allowing HHS to run their exchange, with HealthCare.gov as the primary enrollment portal. Roughly half the states have opted to expand Medicaid eligibility to individuals who make up to 138% of the federal poverty threshold ($15,856 for a single adult, or $32,499 for a family of four).

But states are also faced with the option of enforcing market rules—either through laws or regulations—that were part of the federal healthcare reform law. There were 10 rules that took effect in 2010 (e.g., children must be allowed to remain on their parents' plans until age 26) and seven more that took effect this year (e.g., individuals can't be denied coverage for pre-existing conditions).

As of Nov. 1, 32 states and the District of Columbia had taken legislative or regulatory actions to enforce at least some of these provisions, according to the Commonwealth Fund report. Roughly a third of those states have taken steps to enforce all 17 rules. That group includes four states—Maine, North Carolina, South Dakota and Virginia—that haven't expanded Medicaid or established their own exchanges.

Kevin Lucia, a research professor at Georgetown University and co-author of the study, suggests that more states may be enforcing the market rules because it's a role they're comfortable filling. “This is something that traditionally the states have always done,” Lucia said. “They have always played this enforcement role.”

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