By Joe Touschner

Even as the media is focusing on the high-profile debate over court challenges to the Affordable Care Act and efforts to repeal and defund it in the House of Representatives, many states continue to move steadily forward with implementation.  California was a leader in enacting legislation to create its exchange last year, and many other states will consider exchange legislation this year.  The federal government has offered to states another round of exchange planning and establishment grants and the funding announcement envisions that states will have the legal authority to operate exchanges in 2011.   So many Say Ahhh! readers will be working during the current session of their state legislatures to support the establishment of exchanges that provide quality coverage for kids and families.

Where should those who care about kids and families focus their exchange efforts?  There are a variety of exchange-focused resources available.  Be sure to check out the National Academy of Social Insurance toolkit on state exchange legislation – it’s based on the model legislation from the National Association of Insurance Commissioners, but adds a number of alternatives that states may want to choose.  There are also exchange briefs from us here at Georgetown CCF as well as Community Catalyst,  Families USA  and the Center on Budget and Policy Priorities. 

But for the time-crunched (and who isn’t?), it’s important to gauge which decisions will be made this year and which can be put off until later.  The state exchange legislation we’ve seen so far focuses mostly on establishing the legal structure, governance, and overall goals of exchanges.  The details will come later and they will depend on the formative decisions made this year.  Three key provisions to look for in early exchange legislation include:

• Strong representation for families in the governance structure.  A wide variety of stakeholders will be competing for influence over each state’s exchange:  small businesses, insurers, insurance commissioners, providers, the state’s administrative and political leadership, and others.  Consumer representation should be strong enough to hold their own with these interests, through direct seats on any governing or advisory board.  And those who represent consumers should protect the interests of all consumers–including the children who will be covered in the exchanges but who won’t be able to make purchasing decisions for themselves. Moreover, the legislation should have strong provisions to protect against conflict of interest on the exchange board.
• Strong connections between the exchange and the state Medicaid and CHIP agency.  Exchanges will need to screen applicants for Medicaid and CHIP and enroll them when eligible.  And exchanges will provide coverage to many family members of those on CHIP and Medicaid and to individuals leaving public coverage.  Therefore, exchange legislation should ensure close collaboration–if the exchange is not operated by the Medicaid agency, the law should direct it to enter into agreements with the state’s Medicaid and CHIP agencies so that these important functions are carried out seamlessly from the beginning.
• Make necessary insurance market adjustments outside the exchange.  Exchanges won’t work for kids and families if they only attract enrollees with high health needs, sending costs out of reach.  The exchange law should direct the state’s insurance regulator to take steps to minimize adverse selection in the exchange.  This will require aligning health insurance regulations outside of the exchange with those inside the exchange and more. 

Are these three considerations the only ones that kids advocates should focus on this year?  Not necessarily, but three seems like a manageable number for a blog post – see the reports mentioned above for more issues to watch out for, or leave your own in the comment section below.  Health insurance exchanges represent a new and complex idea for many of us, so as exchange legislation comes up in legislatures across the country, we’d love to hear from readers on promising ideas for kids and families as well as potential trouble spots.