Missouri voters have apparently approved a ballot measure prohibiting the governor from using an executive order to authorize the creation of a Missouri health insurance exchange under the Affordable Care Act. Mindful that the vast majority of the eighteen states that have begun health insurance exchange formation have done so under legislative authorization but that three states are proceeding under executive order, the ballot measure is apparently designed to foreclose the latter option in Missouri.
I cannot help but be intrigued by the question of whether a ballot measure can tie the executive powers of a Constitutionally elected official in this way (Art. III, Section 51 of the Missouri Constitution does specify that a ballot measure may not be used to advance an unconsitutional purpose) but today's post is more along the lines of, "Say, how's that going to work?"
This makes it likely Missouri will be part of the federal health insurance exchange. What do we know about what that will mean? We know (from press reports on the content of the draft statement of work used in the federal government exchange building bidding process) that federal exchange development proceeds and that at least one major contract has been awared to build a federal data services hub to help run the federal exchange. We know that the contractor will handle technical and systems requirements to develop and deliver plan management services, including certifying and decertifying of health plans offered on the federal exchange. We know (from an HHS bulletin in May) that the federal exchange will allow all qualified plans to offer coverage in the exchange, contemplating a wide open health insurance market.
What does Missouri gain or lose from passing on the opportunity to structure and operate its own health insurance exchange? It looks like Missouri loses or lessens the power to influence the choice of the state benchmark plan for the exchange, a choice that could be more or less sensitive to the health insurance needs and preferences of Missouri citizens and Missouri health insurance markets. It also looks like Missouri loses any authority over certifying or de-certifying participants in the health insurance exchange that will serve its citizens. Without a look at forthcoming federal exchange operations regulations, it is difficult to say more.
Health insurance regulation is an area traditionally reserved to the states. This is why we have state health insurance commissioners. How the traditional state authority to regulate health insurance on the state level — which will continue undisturbed for health insurance products sold outside the health insurance exchange that will serve Missouri– will dovetail with the federalization of health insurance exchange operation in Missouri promises to be interesting to watch.
All of these developments at least raise the spectre of a multi-layered regulatory structure of health insurance in Missouri. And those who purchase in the federal exchange that will serve Missouri may benefit from richer benefits and a more consumer-protective health insurance regulatory framework. Time will tell.
Missouri State of Mind 