Katie Keith of Georgetown University Health Policy Inst says:
February 4, 2013

These are both great comments and thank you for your feedback!

John - you're exactly right that consumers get the same protections from federal regulation and you pose a great question about the incentives for state enforcement of these reforms. We were interested in the same question and heard consistently from state insurance regulators that they want to limit direct federal enforcement in their state because 1) they have long-standing experience in regulating their insurance markets, 2) they know the key players and appreciate the complexity of their markets, and 3) they feel they are in the best position possible to respond to consumer complaints. The experience with implementation of the Health Insurance Portability and Accountability Act (which uses a similar framework to the ACA) is consistent with this idea and shows that nearly all states eventually passed new laws or issued new regulations implementing the federal requirements.

Randall - thank you for your comments and suggestion about population data! This is a great idea and something we will certainly consider in our future reports. Beyond the state's total population, perhaps we will look to how many people are in the individual and small group markets in those states. Thank you for this idea!

While it is certainly true that five states implemented guaranteed issue prior to the ACA, we limited our analysis to new state action, in part, because even states with existing laws that are similar to the ACA may not fully conform to the ACA's requirements. For example, states with guaranteed issue may still need to amend their requirements regarding open and special enrollment periods or align these periods with the exchange. Another example is in the coverage of young adults: while some states allow dependents to enroll even above age 26, these laws often have restrictions that the ACA does not have (i.e., the young adult must be a full-time student, unmarried, etc.).

With many state standards that are similar to the ACA, we felt that determining whether existing state law complies with the ACA should be left to the state and federal governments and instead focused on new state action specific to the ACA. I hope that helps explain our approach and am happy to discuss further, if helpful. Thanks again!

John Hatch of John D. Hatch, P.C. says:
February 1, 2013

If consumers can get the same protections from federal regulation, why would states want authority to do the same thing? Short of expanding government for the sake of expanding, there seems to be no incentive for the states to take on this burden.

Randall P Ellis of Boston University says:
February 1, 2013

Congratulations on a useful report and interactive map. I feel it is unfair and misleading that you do not recognize, other than in a footnote to the map, the various states that have ALREADY implemented the required coverage and guaranteed issue, even before the ACA. Further refinement of your interactive map would be useful.

Also, instead of just narrowly counting 11 states that have passed NEW legislation (to which I would add the five who had PREVIOUSLY PASSED such legislation), you should also show the percent of the US population in the states that have acted. By my quick calculation, 37 percent of the US population lives in states that have passed legislation (before or since the ACA) that moves that state towards compliance with the ACA. It is easy to imagine that by the end of this year, when the new regulations take effect, 80 percent of the US population, but only about half of the states, may have passed such legislation. The former statistic is more relevant for policy discussion, and more likely to move the rest of the states forward.