Author: Ann Marie Marciarille

Wonkblog's Sarah Kliff and others have begun to consider whether it is necessarily in a gay couple's best financial interest, under the ACA, to be married. She posts that individuals who may qualify for premium supports and subsidies through the exchanges or even expanded Medicaid eligibility may combine their incomes into a household where neither spouse is entitled to such subsidies or expanded Medicaid eligibility.  Without ever acknowledging that these same marital disincentives may also exist for heterosexual couples — the way the federal tax code systematically punishes two relatively high wage earner marital households springs to mind — she talks about assessing the "financial interest" of a gay couple.

I do think that same sex couples contemplating marriage will have some serious financial and estate planning considerations to address,  but they should extend far beyond the immediate concern of health care premium supports under the ACA and extend all the way to Medicare eligibility.  The financial implications of marriage — in theory (and for significant demographic cohorts — in reality)  a lifetime commitment  — actually merit both a short term analysis and a long term analysis.

A short term analysis might look at eligibility for family based coverage under a spouse's employer sponsored health insurance plan.  This is a good time to remember that employers are not required to offer family coverage under the ACA.  A private employer may meet its play or pay obligation, in short, by offering individual coverage under an employer sponsored commercial plan.  A spouse of any gender would then be pushed to the exchanges, Medicaid, or their own employer's insurance plan. If the spouse's employer also offers only individual coverage, then any children of the household will be pushed to Medicaid, Medicaid extension programs, or the exchanges themselves.

Mind bogglingly complex to contemplate each member of a single household enrolled in a different insurance plan? Yes. A concern peculiar to same sex couples contemplating marriage? No.

A longer term analysis might look at social security eligibility and its handmaiden, Medicare eligibility. Depending upon how a family organizes its wage income production, a spouse may qualify for a more generous benefit under the breadwinner's work record than under their own, particularly if labor force attachment has been attenuated by family or other responsibilities.  But you don't get to claim social security retirement under the employment record of a spouse of an extremely brief marriage.

Remaining unmarried to qualify for ACA premium support while planning to marry in the future for spousal social security benefits and Medicare eligibility, in short, may be inconsistent approaches. At the very least, questions of timing must be considered.

Yes, affordable health insurance coverage matters here and now beyond words. Medicare coverage during your peak health care consuming years matters too, for most Americans.

Each couple will need to do the math for themselves with so many individually relevant variables in the mix: work record, ages at marriage, anticipated retirement ages, likely income trajectories. But it won't be as simple, for many, as determining how best to attain premium supports under the ACA or to attain expanded Medicaid eligibility — as pressing as those needs are for many.

 

Yesterday, it was reported that California Insurance Commissioner Dave Jones  has issued a statement recommending that Anthem Blue Cross not be allowed to sell in Covered California's health insurance exchange for small businesses. Insurance Commissioner is an elected Constitutional office in California, so Dave Jones is certainly entitled to have his say, but his decision to single out Anthem — in light of a reported three consecutive premium hikes his office had deemed unreasonable — merits more thought for multiple reasons including what it can teach us about exchange operation, what it can teach us about state regulation of insurance, and what it means to promote consumer welfare by protecting fair competition in the exchanges.

The first thing Dave Jones' statement teaches us is that he does not, as Insurance Commissioner, control access to the opportunity to sell in the structured health insurance marketplace the ACA calls an exchange.  Covered California's own governing authority does that.  But Dave Jones knows that, so why expend the effort? The answer relates to the fact that California's exchange is not a completely open one. Not only must a company want to sell health insurance inside the exchange (and meet the statutory and regulatory requirements related to things like minimum essential benefits), a company must be permitted to do so.  And California has chosen not to make its marketplace completely open to any ready, willing, and able seller.  As I have discussed earlier, this is, in part, reflective of a decision to attempt to lower the cost of exchange sold products by limiting access to the exchange marketplace.

What has this got to do with state regulation of insurance? One way to view Dave Jones' decision to speak out from his bully pulpit against Anthem's participation in the small business exchange is to see it as an effort to promote price transparency in health insurance products and as part of an effort to breed some price sensitivity into California's taxpayers. It is Anthem, after all, that chose to announce a 10.6% rate hike in January, a 10.5% rate hike in March, and a prospective rate hike of 7.6% effective July 1st of this year.  Another way to see Commissioner Jones' decision is as an attempt to do indirectly, through public shaming, what California's state specific health insurance law and regulations will not allow him to do directly — tell Anthem that their rate hikes may not go forward. You see, California, gives its Insurance Commissioner a few valuable things: authority to review medical loss ratios, authority to investigate proposed rate hikes though not necessarily derail them, and a bully pulpit.  By current calculation, Dave Jones has attempted to use all three in his office's struggles with Anthem.

Perhaps the most interesting aspect of all of this is the cry of "unfair competition" and "unfair to consumers" from the sellers of health insurance products and from representatives of the business community that purport to represent the inerests of small business that would like to purchase health insurance products that will have increased in cost almost 30% in a six month period. The argument is that these Anthem products are popular in the small business market and that consumers (unclear whether this is understood as employers or the ultimate health care consumers — employees) are being deprived of choice if the exchange is not open to Anthem for small business products.

Fair competition law exists to protect consumers. How can it help us here? First, your perspective on this may depend upon whether you think employers are the consumers of health insurance plans or whether you think the consumers in need of protection are the ultimate consumers of the health insurance involved — employees.  Second, it may be that the open exchange model has visceral appeal as pleas to increase the number of vendors in the health insurance marketplace almost always do. "If we only had more sellers…" and then you fill in the blank. Finally, it may be that the more competitive marketplace may involve levels of competition: first you compete to be able to sell, then you compete against those in the selling arena, then you enter perhaps a second or third round of competition in a sort of reverse auction format.

Both models can lay claim to the laurel wreath of free and open competition. So, it is not just as easy as it might seem to be to claim: let anyone sell, the market will sort it out.  Actually, health insurance markets are notoriously distorted for any number of reasons but chief among them would have to be that the buyer on one level (the employer) is not the consumer (the employees).

If we are to continue to have a health care system funded — in significant part — by employer selected and sponsored health insurance (and that is the insurance framework of the ACA), then the clarion call for free and open perfect competition in health insurance markets rings more than a little hollow.  That ship has sailed.

Instead, we can watch California and others attempt to promote their own versions of competition in highly distorted markets. And watch I will. If Dave Jones is able to use his bully pulpit to attempt to police health insurance costs in the exchange, it will be an object lesson to other states.

But noone gets to claim a monopoly on the "fair competition" mantle in this dispute.  It is not that simple but, then, it rarely is.

It  was H.L. Mencken who said: "For every problem there is an answer that is clear, simple and wrong."

[Here is a slightly edited version of my remarks at today's panel on NFIB v. Sebelius, Medicaid, and Health Care Federalism — a panel discussion at the annual meeting of the American Society of Law, Medicine, and Ethics.]

My remarks today on NFIB, Medicaid, and Federalism are
focused on the re-invention of Medicaid – by which I mean both the re-invention of Medicaid
originally contemplated by the ACA as well as the re-invention effectuated by
the Supreme Court.  And so I tip my
hand to reveal my perspective that it is not the ACA that is reinventing
Medicaid so much as it is the Supreme Court that is reinventing Medicaid. 

 

In acknowledgement of the ACA’s drafters'  bold attempt to re-invent
Medicaid by essentially federalizing it,  while so much of the country’s attention was focused on the arguably
less significant individual mandate provisions and accompanying insurance
market reforms, and the Supreme Court’s equally bold decision to reign in the
Secretary’s enforcement authority, I title these remarks: The Medicaid Gamble: Will Medicaid Survive the ACA?

 

From my perspective, the attempt to expand Medicaid
without building in a fall back provision (say, the equivalent of a federally
facilitated exchange for a non-exchange building state) was a tremendous
gamble, particularly in light of 
the now documented evidence that public support or disdain for  exchange implementation and Medicaid
expansion tracks highly ideological voting patterns making those correlates for the individual mandate seem mere partisan affairs by comparison. Not only were we, as students of the ACA,  focused on the wrong provisions of the ACA — when considering transformative power — we mismeasured the ideological force of the Medicaid expansion.  

 

I propose, in my limited time, to address three aspects of
health care federalism or health care reform implementation power struggles  that I think are particularly  pressing in light of Medicaid’s current vicissitudes:

 

1.     What’s
up with coercion? As Sara Rosenbaum phrased it so pithily yesterday, the
weaponizing of the coercion doctrine and the implications of that for Medicaid
going forward deserve some of our time. But my angle on coercion has to do
with the history of Medicaid’s origins.

 

2.     The
second is the battle being waged between the federal government and the states
over who, if anyone, should expand Medicaid.  I
want to say a few words about the battle being waged over what political unit,
within a state, should shoulder the burden of expanding Medicaid. This is a battle being waged in California.

 

3.     My
third and final topic will focus on a consideration of what will likely occur
in non-expansion states come January
1, 2014. And, I offer a few observations on what will likely occur in expansion states come January 1, 2014.

 

 

 

FIRST:

 

The immediate challenge before the states will be to
determine whether Medicaid expansion under the ACA is gift or Trojan Horse. And that determination may take a while.  Those of you familiar with the rollout of original Medicaid,
know that this takes time. 
Although 11 states were all in on original Medicaid  by 1967, New York was kicking around
legislation that  same year calling
for Medicaid’s repeal. Still, 8 more states were onboard by 1970, almost all
participating within four years, though Arizona (the final hold out) was not
onboard until 1982. I will note that Texas considered exiting the Medicaid
program as recently as 2011. But they did not. I  am still uncertain which way that cuts on the coercion
analysis.

 

Given Arizona Governor Brewer’s relative haste to be all in
on Medicaid expansion this time out of the gate, I have been wondering if there
are lessons that may be learned from Arizona’s  journey to participation in original Medicaid.  I 
discern three possible lessons:

 

Lesson # 1 
The cost of uncompensated care – however you slice and dice it – is  a budget buster. Arizona’s interest in
original Medicaid participation seems to have roughly correlated with the
exponential growth in indigent care costs born by the state (rising from $50 M
in 1974 to $125 M in 1980).  Although these numbers seem almost unbearably quaint by our standards, this represented significant money to Arizona in the 1970's and 1980's.  Mind you that Arizona, in the
mid-1960’s was insulated from the indigent care costs of some its poorest
citizens because those same individuals were  then eligible for free or reduced price care through the
federally funded Indian Health Service. So, let that be part B of the first
lesson: cost shift to the federal government where ever you can and for as long
as you can while you sort  this
out.

 

Lesson #2 When all was said and done, financial
exigency coupled with the argument that Arizonans were still taxed for the
program in which they chose not to participate, seems to have ruled the day.

 

 

Lesson #3  Arizona, to this day, operates what it describes as its
state Medicaid program under a section 1115 waiver originally bargained in the
1980’s.  I can find no mention of federal funding on the front page of Arizona's Medicaid web portal. 

 

Maybe these lessons are old
hat.  Maybe better historical grist
is to be found in the 1997 rollout of the CHIP program, you say?  Then you could look at the work of Ian
Hill at the Urban Institute. Perhaps. But we may want to reach back beyond
CHIP’s rollout and analogize to a rollout that – unlike CHIP—does not allow states
to impose waiting lists or impose enrollment limits to curb costs.  This is what makes the ACA Medicaid
expansion a gamble, in part, — neither of these options are available.

 

Ultimately, chastened by the cost of
uncompensated indigent care, Arizona came onboard with original Medicaid.  And, Arizona’s governor at least, does
not seem eager to be a poster child for “health care reform done right, outside
the ACA.”

 

At one point there were other
fleeting candidates for that role but the interest, now, has coalesced around
“health care reform done right, inside the

ACA.” Arkansas is the current
leading contender, though HHS’s provisional approval of a premium support
program or privatized Medicaid expansion won’t really mean much until we see
what the actual terms of the plan are. 
What we do know – as Sidney Watson so ably outlined yesterday —  “cost effectiveness” (the sina qua non
of Medicaid premium support programs) may be in the eye of the beholder,
especially in light  of the recent
invitation to the states to apply for 1115 waivers that broaden that phrase to
include incorporating imputed savings from reduced churning in the non-privatized Medicaid eligible
population and in the invitation to factor into the analysis reductions  in commercial insurance rates offered in the exchanges as products of increased
competition. 

 

I don’t know what “cost
effectiveness” will mean anymore, though I do think it will be interesting to
try to calculate whether the value of increased insured lives in some state
exchanges will enhance insurance rate competition and, arguably, benefit all
exchange purchasers, not just Medicaid premium funded purchasers.  The antitrust scholar in me would like
to see that. Because if the CBO is even close to accurate that it will cost the
federal government $6,000 a year to cover another individual American under
Medicaid expansion but $9,000 a year to cover the same individual (with the wrap
around coverage and premium subsidies necessary to make the commercial
insurance “Medicaid-like”), there are going to have to be some mighty
interesting offset calculations ahead. 

 

 

SECOND

 

While much of our attention is
directed at the federalism arena sparring between the states and the federal
government, I think not enough attention has been paid to the sparring between
and among political units within the states over the Medicaid expansion. 

 

Take California, for example.  For several decades, California has
worked hard at unwinding its statewide safety net. The full story would talk
about county by county variable standards for public assistance or the
incredible inconsistency with which MediCal applications were processed in
California but today I just want to focus on the state’s forcing (dare I say
coercing?) of the counties to assume responsibility for medical indigents.  Seen from one perspective, California
has perfected devolving the apparatus of the welfare state to the political
unit closest to community life. 
Seen from another perspective, unevenly burdened counties (particularly
those with high populations of uninsured Californians or undocumented
Californians such as the 198,000 undocumented individuals living in San Diego
County alone, roughly 6.5% of the total population) stagger under county
indigent expenses that only serve to emphasize the truism that California is
simultaneously our richest state and our poorest state. 

 

This means that, for Medicaid
expansion to be funded in California, the counties will have to transfer money
to the state. Fearful of bankrolling Medicaid expansion for the working poor
while still being left to serve the merely poor and definitively undocumented,
the counties are hanging tough. 
And that is what all the newspaper coverage about the Gov. Brown’s
negotiations with the counties to fund Medicaid expansion have been about.
Nicole Huberfeld has spoken, with dismay, of the state “ownership” of
Medicaid.  County "ownership" of
Medicaid anyone?

 

THIRD:

 

What will happen on January 1,
2014?

 

In some places, the bridge to
January 1, 2014 is already being built – not just the obvious example of
Massachusetts, but  groups like the 500,000 early Medicaid enrolled (wait for it — wait for it — on a county by county basis) in
California for example.

 

In October of 2013, the exchanges
will open– whatever forms they take – the navigators, non-navigator assistance
personnel, and just about every other insurance counselor you know — including yourselves — needs to be
braced for the biggest outpouring of those in need of insurance counseling we
may ever see in our lifetimes.  I do not see this as
a failure of the ACA in particular except insofar as it is health care reform grafted on our byzantine health insurance system. 
We are all of us woefully unprepared to understand our  health insurance system and the
complexity of selecting the appropriate insurance products for ourselves. Think
the rollout of Medicare Part D, only cubed.

 

But the real confusion will mount
when Medicaid expands in some places and not in others. The American public is
not aware that a mere state line may separate them from government funded
health insurance.  When this does
begin to percolate into public consciousness we will have a natural experiment
in border effects.  Conventional
wisdom is that, but for certain very specific disease groups, Americans do not
migrate to attain health insurance. If there ever were a fact pattern to test
that truism, I believe we’ve found it.

 

The confusion may likely peak when so many newly insured — as they did in Massachusetts — decide they are ready for their closeups.  By this, I mean the real gamble of the ACA may have been that we have sufficient provider supply to serve all of the newly insured. Our self-manufactured primary care provider shortage as well as our shortage of Medicaid accepting specialty physicians may show us up as the biggest gamblers of all on January 1, 2014.

 

Closing

 

All of this makes me want to know what  the cicadas will think about
health care reform and  Medicaid expansion the next time they arise?  ]Well, if we’re talking those  synchretized 17 year cycle East Coast
cicadas – I haven’t a clue. But if we’re talking the Missouri Brood Cicadas –
on a three year cycle (but split into three evenly sized non-synchretized
broods, so that one brood is always singing in the trees), I am confident
Medicaid expansion will be back before the Missouri legislature again next
session and possibly the session after that. 
Like Missouri Brood Cicadas, we just can’t stop ourselves.

 

 

 

 

 

 

 

 

 

I keep getting asked what I think about the anticipated health exchange prices published by Covered California in this past week. After noting that Oregon, Washington, and other states also have some version of their anticipated exchange purchase premiums up for different markets, I tell people I am not surprised.

You see, California's numbers are coming from a state where health insurance is relatively robustly regulated on the state level.  Significantly, California's small employer market (the market whose expected premium data was released this week) already requires insurers to issue policies to all comers. The risk pool for California's small employer market already mirrors — to a certain extent — the characteristics of the post-ACA small employer market. 

Does this fact mean the failure of sticker shock to materialize is any less real? No. 

Does this fact mean that sticker shock (if that term includes premium increases prompted, in part, by a mandated increased richness of insurance products offered to a wider scope of insurance seekers) is not quite possibly still ahead elsewhere? No again.

Yes, I am looking at you Missouri.

I also note that the California's "active purchaser model" of exchange development may well have played a significant role here.  Insurers must compete to sell through the California exchange, unlike some states where all may sell in exchanges that are, essentially, clearinghouses.( Note that the federally facilitated exchanges will be open exchanges)

This means I also had the contrarian reaction to last week's announcement that United Health Care, Aetna, and Cigna are all sitting out the first round of Covered California sales in certain product markets. That is what it means to have an active purchaser model exchange in a state with a robustly state regulated insurance market — some insurers (in this case relatively small players in California's individual market) will choose to watch and learn from the sidelines before calculating whether they can play in the pool.  This is good news. If we can learn anything from California's past– the too rapid expansion of certain ill-conceived insurance products in the the 1990's followed by hasty market retreat at the price of considerable insurance market dislocation shortly thereafter — it is this:  that the announcement that the pool is open may not mean that everyone should jump in at once.

By now, many of you will have read Angelina Jolie's powerful op-ed in the New York Times outlining her decision in February of this year to begin a series of surgeries (double mastectomy, eventual removal of her ovaries,etc.) as part of her effort to live with the BRCA gene mutation. If you haven't, you may read it here:http://www.nytimes.com/2013/05/14/opinion/my-medical-choice.html. And you might even follow up on the incredible outpouring of comments from readers at the same site.

I am not certain second-guessing Angelina Jolie on this is a worthwhile enterprise, but should you care to do so, she has been remarkably forthcoming on her treatment decisions at: http://www.pinklotusbreastcenter.com/. 

Not every American woman is as wealthy or well-informed about the BRCA gene mutation and about what their health insurance might think about this genetic mutation — particularly at the time, like Angelina Jolie, when a woman is asymptomatic. 

The path to the identification of the breast cancer type one susceptibility protein began in 1990 with the recognition that such a protein might exist and the 1994 actual identification and cloning of the protein.  Angelina Jolie, seem from this perspective, is a fortunate woman to live in a time when she can look the BRCA gene mutation in the eye. Although her mother, Marcheline Bertrand, knew what was killing her by the time she died in 2007, she probably never faced the choices before her daughter now.

The capacity to search for genetic evidence of likely future disease has been difficult for our health insurance system to digest.  In a system traditionally based on insurance underwriting designed to reward the insurers best skilled at sorting the sick from the well and the currently-well from the likely-to-become-sick, the advance of this kind of gene testing has been revolutionary. 

Various statutory and regulatory attempts have been made to protect the genetically forecast-to-be-sick, such as the Genetic Information Nondisclosure Act of 2008 ("GINA") but, even then,  most of the focus was on protecting gene information confidentiality and not on addressing the fears of women concerned about the insurance implications of being tested for BRCA1 and, later, BRCA2. Such fears have driven a  number of women appropriate for the testing to forego it. You can read about one study that tried to quantify this here: http://cebp.aacrjournals.org/content/11/1/79.full.

I think of these women, and not Angelina Jolie, when I note that testing for the BRCA gene mutation, after appropriate screening, is included as a covered preventive service under the ACA. You can find the the Center for Consumer Insurance Information and Oversight ("CCIO") discussing counseling, screening, and testing for BRCA here: http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs12.html This combined with constraints of pre-exisiting condition exclusions found in the ACA, should increase the number of women identified, counseled, and tested for BRCA gene mutations– whatever they decide to do now or later with the information.

So, here's to Angelina Jolie for telling her story in a straightforward, honest, and even graceful manner.  Grace is playing the cards you are dealt in life, after all.  As for the rest of us who are not independently wealthy movie stars, here's to the ACA's attempt — through a science-based determination to identify high value preventive services that should be available to as many as possible — to give those among us with the BRCA gene mutations an opportunity to live with grace as well.

 

It has been a few years since AHRQ has begun to use stimulus money to promote targeted academic detailing projects in the United States. Pfizer's CEO is just recently on record that this kind of conflict-of-interest behavior — where trained clinician consultants visit physicians, pharmacists, nurses, other clinicians, and health care system decisionmakers nationwide to share unbiased, noncommercial information about medications and other therapeutic options with the goal of improving paitent care — must be stopped.  Academic detailing, he insists, is directly analogous to commercial  pharmaceutical company funded detailing and if the latter is increasingly subject to sunshine and disclosure requirements, so should the former be.

Now, why would Pfizer want to track the path of academic detailing done by the government or at the government's direction? Would shadowing the government-sponsored academic detailiers to counter-detail with commercially prepared or selected materials be the next logical step?  And then would the government counter counter academic detail? And Pfizer renew its commercial detailing efforts in the wake of every government sponsored academic detailing visit?

Would any health care provider or decision maker have any time in the day to do anything other than meet and greet prescription drug educators/detailers?  Is that the best and highest use of the scarce clinical time of primary care providers, for instance?

Of course the fight for the hearts and minds of those clinicians and decisionmakers who control our nation's total drug spend is no joke.

About a week ago, I blogged about state governments struggling to comply with or evade the ACA's employer pay or play requirements for health insurance. A few days ago, the Wall Street Journal chimed in documenting a further effort on behalf of private employers to alter the ACA requirement of employer pay or play for all employees at 30 hours a week and up. Those of you who kow anything about the demographics of part time work will not be surprised to see the National Restaurant Association as part of the leadership in opposition to the statutory requirement.

And no lesser lights than the folks at NPR and Sarah Kliff are busy documenting the move to part time workers. But will this necessarily last?  Or, will employer-sponsored health insurance benefits be used — as they have been from their WWII wage freeze origins — as a way to tie quality employees to the employer, offered by quality service emphasizing employers as a way to skim the best employees  for themselves?  If not, will enforcing the employer pay or play mandate not free those highest quality service sector employees from job lock and free the market to reward them more appropriately for what they bring to the table?

I suppose how you feel about freeing employees in labor markets all depends upon whether you're a buyer or seller in those labor markets.

The funny thing about Medicaid expansion is that it is like endless soup — that recipe where tomorrow you take on yesterday's leftovers, build in a few new ingredients, and serve it up. Don't like today's soup? You could always hold out for tomorrow's.   By this, I mean that optional Medicaid expansion under the ACA is never a yes or no thing, only a "not now" or "not on those terms" thing.  And so it has always been with Medicaid state buy-in since its very inception and so it is, I would argue, with American-style health care reform.  We are rarely all in or all out.

That's what I say when people ask me about the Missouri legislature's apparent failure to address ACA optional Medicaid expansion this session.

Anybody for yesterday's soup?

Earlier this month, President Obama submitted a budget proposal offering to delay the implementation of DSH cuts by twelve months. I have dished on the significance of DSH before and will merely note here that this is a proposal — a bargaining chip if you will — and that twelve months is not an extraordinarily long time in the acute care hospital budget cycle.

DSH's re-invention is inevitable, it seems to me. Forestalling the 75%  DSH cuts that bind while states move toward Medicaid expansion makes sense so long as progress is being made. Otherwise, it is hard to rationalize the continuation of such a troubled federal subsidy system.

The battle over DSH or Medicaid expansion highlights the irony, of course, that it is federal dollars that keep some acute care hospitals alive — whether those dollars come to the hospital through the back door (DSH) or through the front door (through expanded Medicaid enrolled patients). Ironically — given the gaming of DSH payments — significant numbers of rural low income facilitites would do better under the federal dollars through the front door model than the current gamed-DSH through the back door system, where the majority of dollars go to suburban hospitals in only a few regions of the country.

I tell my students there are always cross-subsidizations in health care, some of them perverse. I also tell them we can learn a great deal about health care payors and players by looking at how the cross subsidization works.  And then I talk about DSH.

The AP is reporting that Washington state is considering a proposal to move part time state government employees eligible for employer sponsored health insurance out of state health coverage and into Exchange health insurance purchases.  This latest proposal focuses on Washington state government employees who work 20-30 hours per week only. Washington, unusually generous in this regard, has historically extended state health coverage to those who work for state government for as few as 20 hours a week.

Many other states are not so generous, but they also struggle with the budgetary significance of the ACA's requirement that those who work a minimum of 30 hours a week be offered employer sponsored health insurance. Virginia  is reportedly requiring that all part-time state employees work less than 30 hours a week, to dodge the ACA coverage requirement. This move parallels reports of similar conduct in the private sector.

Washington state's circumstances are distinguishable, of course.  These matters are a subject of collective bargaining in Washington state.  A revised collective bargaining agreement sweetening the deal for individual state workers in the 20-30 hours per week category to move to the Exchnage is reportedly under discussion.

But, as far as I can tell, noone is offering to sweeten the deal for Virginia's part time state employees.  Florida, taking another tack, is moving to extend state coverage to its 30-39 hours per week employees, a group that has traditionally not been offered health insurance in that state.

Where you end up, on this, depends on where you started, of course.  Each state has its own state employee insurance coverage and state government employment system. Each state starts with its own profile of coverage and non-coverage in the state employee population and must determine for itself how generous it chooses to be to less than full time state employees. I will note that, in some states, part time state employees are the majority of employees in some state agencies.  You may, for example, read about the predominance of part-time state employees in Virginia's ABCD here http://www.timesdispatch.com/news/state-regional/virginia-politics/general-assembly/state-grapples-with-insurance-rules-for-part-time-workers/article_03136cab-9eab-5295-9359-89a19fae4a15.html.

Tradeoffs will have to be made.  Just as commercial employers must struggle with employer sponsored health insurance for part time employees, so must state and local governments. State and local governments, in fact, are the largest single employees in some places in the United States. State government employee wages have long been discussed as a fraction of total state employee compensation.  In tax parlance, compensation includes wages and benefits.  And anyone who has ever been involved in payroll knows that the tail can wag the dog in this regard.

Is it a good or a bad thing that state government employees below 40 hours or 30 hours a week employment status are moved to the Exchanges?  The answer to that will depend on what sweeteners, if any, these state employees bring to their Exchange purchases and to the prices of the plans in the Exchanges — particularly the prices of those plans that most closely mimic the scope and depth of the state health insurance offered to 30 hour a week or 40 hour a week state employees. The biggest sweetener for low wage workers — whether employed by the state government or in the private sector — is the potential expansion of Medicaid, of course.

It will come as no surprise to some that Arizona — several decades late to the party on original Medicaid — worked hard for approval of a plan to extend Arizona Medicaid to all Arizona state employees. This plan fell short of implementation.  But everyone should know that this idea is not new.