Progress Report: 2014 ACA Legislation Filed & Enacted
** A note on legislation counts: The computer-generated counts are fully reliable for totals of distinctly numbered legislative records. In some states, identical bills carry separate numbers and records, or may be assigned a new number as a result of amendments or combining of multiple bills.
Guide to 2014 Health Reform Database Topics
The explanations of topics provided below are brief highlights of filed legislation contained in the database and are not intended to include all features or provisions. Users also can search text for examples and specific key words.
State legislatures and governors continue to amend the state infrastructure to implement provisions of the law. To date, some of the most common efforts include changing provisions related to health insurance exchanges, insurance reforms, and Medicaid expansion. State legislatures have also authorized state agencies with responsibilities for implementation to perform certain duties, including applying for funding available to states through the Affordable Care Act and authorizing fees paid by health insurers to make exchanges self-sufficient.
Challenges, Opt-Outs and Alternatives
So far in 2014 legislators in at least 37 states proposed to block, oppose, not participate in or design alternatives for elements of the Affordable Care Act through statutes, constitutional amendments and joint resolutions. Between 2010 and 2013 at least 21 states had passed legislation that opposes elements of health reform. For 2014, these include measures to prohibit state agencies or employees from implementing or enforcing requirements that individuals or employers purchase insurance or face fines for non-participation. Other measures would restrict state government involvement generally or seek authority to join an interstate compact for multiple states opposing enforcement. Others propose overall nullification of the federal law, would reject specific federally defined benefits or would separately regulate or restrict the federally mandated navigators. Several states have measures related to single-payer health alternatives that would supplant commercial insurance policies. Some alternative mechanisms are compatible with the federal law; others are intended not to be. Click here for more details on this topic.
Health Insurance Exchanges
Exchanges are the newly established entities that function as a marketplace for buyers of health insurance, giving them choices for health coverage. The Affordable Care Act required health insurance exchanges to be established and working in every state by October 2013. The ACA still gives states the option to replace a federally-run exchange with a state-run exchange or to partner with the federal government to operate the exchange. If a state does not establish an exchange, the federal government will continue to operate the exchange(s) in that state. Seventeen states and D.C. run their exchange or at least the small-business segment, seven are partnering with the federal government and the federal government runs the exchange in the remaining states (as of September 2014). In almost all states, there are two separate exchange programs—one for the individual market and another for the small group employer market (SHOP). This topic includes legislation to create or prohibit an exchange as well as legislation that addresses specific functions of the exchange, such as navigators, grants, interoperability, privacy, etc.
> Click here for more information on State Actions to Address Health Insurance Exchanges.
> NEW: "2014 State Legislation to Establish a State-Based Exchange" - NCSL health reform report, October 2014.
Health Insurance Reform
The Affordable Care Act established a series of uniform, requirements and additional options for states that build on existing state regulation of health insurance policies. These include standard-price insurance coverage for individuals with pre-existing conditions, family coverage that includes dependent members up to age 26, expanded review of premium rates, required ratios of insurer expenditures on health services, consumer assistance or ombudsman offices, reduced employer shares for retirees ages 55 to 64, and patients’ rights to appeal denied coverage. In 2011-13 at least 48 states considered related bills resulting in more than 200 enacted into law. Major focuses for 2014 include more uniform mandated "essential health benefits" and conforming state laws with ACA provisions such as premium rate review, preventive screenings and services with no co-payments, no lifetime or annual limits on standard policies and options for multi-state or out-of-state health insurance purchasing. "Health Insurance Exchanges" are a central element of insurance reform, but are identified and listed separately—database users can obtain a single list that combines both groups of bills. Also see "Challenges and Alternatives" bills which also affect insurance policy. Click here for more insurance reform information, including a report on enacted and signed laws specific to ACA health insurance implementation.
The Affordable Care Act as signed expanded eligibility for Medicaid as of Jan. 1, 2014, to cover Americans with family incomes up to 133 percent of the federal poverty level. As a result of the U.S. Supreme Court ruling on June 28, 2012, states have the option to participate or not in the expansion. The Centers for Medicare and Medicaid Services clarified in a letter that there are no deadlines for states to make a decision concerning the expansion of their Medicaid programs. As of March 2014, about 25 states have increased eligibility or taken steps toward increased eligibility; this topic includes bills that would authorize a Medicaid expansion. Bills that propose an alternative and bills that would prohibit such an expansion are listed separately under "Other Revisions".
Medicaid Other Revisions
In related or separate actions, states continue to create policies about specific eligibility, coverage and enrollment options, enrollment systems, compatibility with the exchanges, among other issues. Click here for more information.
Outreach and Enrollment
The Affordable Care Act requires and facilitates efforts for outreach and enrollment aimed at the public, including populations traditionally underserved or more frequently not enrolled in health coverage. State measures include the roles, regulation or restriction of health navigators and use of marketing and enrollment through other state programs. This topic is newly added for 2014; in previous years, similar measurers were included in the Primary Care category.
Other ACA Issues
The Affordable Care Act includes many provisions and may affect many state laws, including income taxes, small business taxes, labor and employment law, pharmaceuticals, and much more. This topic is intended to capture examples of key legislation that does not fit into other topic areas.