For much of the past week, the Supreme Court has been issuing opinions at a dizzying pace. Four cases in particular impact states directly. Rulings on same-sex marriage and Affordable Care Act cases affect everyday life and have incited much discussion in Congress and among the public. Other rulings on what license plates may say and access to hotel registry information have not garnered as much attention, but have important impacts on states as well.

Long-term care and supports were the focus of the 2015 CSG Medicaid Policy Academy, held in Washington, D.C., June 17-19, 2015. The 30 registered CSG members came from 19 states. Home states are marked in purple in the map below. Over the four years CSG has convened the Medicaid Policy Academy, legislators from 42 states have participated. 

The program concluded with a plenary session featuring Dr. Jeffrey Brenner, medical director of the Urban Health Institute at the Cooper University Healthcare as well as the founder and executive director of Camden (N.J.)  Coalition of Healthcare Providers. In 2013, Dr. Brenner was named a MacArthur Fellow for his work on addressing the health care needs of the chronically ill in impoverished neighborhoods. 

In 6-3 decision the Supreme Court ruled today that health insurance tax credits are available on the 34 Federal Exchanges. The Court’s opinion focused largely on the consequences of ruling to the contrary:  the destruction of health insurance markets.

Chief Justice Roberts, writing for the majority, began his opinion by pointing out that the Affordable Care Act relies on three reforms:  making sure health insurance is available to everyone regardless of their heath and not charging higher premiums depending on health, requiring everyone to be insured, and offering tax credits to those with low-income so they can afford insurance. If only the first reforms were implemented a well-documented economic “death spiral” occurs, where health insurance premiums skyrocket, because only the sick buy insurance.

Last week Pennsylvania and Delaware moved toward a Plan B in case the Supreme Court rules against the Obama administration in the pending King v. Burwell lawsuit that questions whether tax subsidies can be provided in those states that did not opt to operate their own state health exchanges.

With a special session of the Florida legislature underway to adopt a state budget for the next fiscal year that begins July 1, federalism questions abound. Florida Gov. Rick Scott filed a lawsuit against the Obama administration in April, challenging what Florida Attorney General Pam Bondi characterized in an April 28 press release as “the federal government’s attempt to coerce Florida into expanding Medicaid” by withholding federal funding for hospitals that provide care to the uninsured. The federal government had notified Florida it would withhold $2.2 billion in funding for Florida hospitals in fiscal year 2016.

Depending on how the Supreme Court rules in King v. Burwell this summer, eight million residents of states now using the healthcare.gov exchange may lose federal insurance subsidies unless their state creates its own exchange. Some existing state exchanges have struggled with implementation over the last year. Others have been more successful.

During a CSG-East webinar on May 20th, Peter VanLoon, from Connecticut’s health insurance exchange, will describe how Access Health CT avoided most problems. Building on its success, Access Health CT is offering technical assistance and business services to states wishing to create or enhance their state-based exchange.

Today the federal government announced that it would be taking grant applications for $67 million for navigators to link consumers to federally-facilitated and state-based health insurance exchanges. 

The speakers on the conference call characterized the announcement and posting as part of the "regular grant process" but one has to wonder if this is a sign of the administration's confidence that the Supreme Court will find in their favor in the King v. Burwell case.

The Cleveland Clinic, one of the nation’s largest hospitals, reported a 40 percent drop in charity care and credited the good news to Ohio’s Medicaid expansion, according to Kaiser Health News. Free care costs fell from $171 million in 2013 to $101 million in 2014.

Approximately 7.7 million people living in states with a federally run health insurance exchange purchased health insurance and qualified for monthly premium tax subsidies during the 2014-15 open enrollment period, according to newly released data. The estimated annual value of those tax subsidies tops $24 billion, according to calculations by The Council of State Governments. These premium subsidies are at risk in the King v. Burwell case currently before the U.S. Supreme Court.

I learned a few things last week when I was visiting with Indiana Rep. Ed Clere, one of the new co-chairs of CSG’s Health Public Policy Committee.

  • That week, the state announced the 100,000th person enrolled in the Medicaid expansion waiver, called HIP 2.0 in Indiana, after the program opened less than a month before. Indiana had three Medicaid managed care organizations already engaged in the state and the state Medicaid office and the
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