Texas: Round 1

MANAGING HEALTH REFORM TEXAS: ROUND 1 State-Level Field Network Study of the Implementation of the Affordable Care Act August 2014 Rockefeller Institute of Government State University of New York The Brookings Institution Fels Institute of Government The Public Policy University of Pennsylvania Research Arm of the State University of New York 411 State Street Albany, NY 12203-1003 (518) 443-5522 www.rockinst.org Managing Health Reform Texas: Round 1 Field Research Associates Students and faculty from the Lyndon B. Johnson School of Public Affairs Policy Research Project 2013–2014 Students and faculty from the Lyndon B. Johnson School of Public Affairs Pol- icy Research Project 2013–2014 Affordable Care Act Health Insurance Exchange Implementation: A Case Study in Austin and across Texas First row: Taylor Woodard, Victoria Walsh, Erin McManus, Mollie Bradlee, Emily Hoffman, and Camille Jackson. Second row: Jane Ross, Jane Vance, Ben Murguia, and Alison Simister. Third row: Dr. Samuel Richardson, Dr. David Warner, Daniel Kibert, Elizabeth Colvin, Mark Woodard, John Dinning, Jason Wible, and Chris LeSuer. Not pictured: Ruqiyyah Abu-Anbar David C. Warner, Professor of Public Affairs and Wilbur J. Cohen Professor in Health and Social Policy, Lyndon B. Johnson School of Public Affairs, University of Texas at Austin [email protected], (512) 471-6277 David Warner’s major research and teaching interests are in health finance, health policy and economics. A graduate of Princeton University and with a Syracuse University M(I)PA and Ph.D. in economics, he formerly taught at Wayne State University and Yale University and was deputy director of the Office of Program Analysis at the New York City Health and Hospitals Cor- poration. Samuel Richardson, Assistant Professor of Public Affairs, Lyndon B. John- son School of Public Affairs, University of Texas at Austin [email protected], (512) 232-3687 Samuel S. Richardson received his Ph.D. in Health Policy at Harvard Univer- sity and holds a B.A. in Human Biology from Stanford University. A health economist by training, his research broadly addresses when and how government should intervene in health care markets. His current work focuses specifically on how health care providers respond to payment incentives, and how to set up payment policies that lead to efficient provision of high-quality care. His research has been published in JAMA and Health Services Research. Elizabeth Colvin, Director, Insure Central Texas at Foundation Communities [email protected], (512) 554-4409 Elizabeth Colvin directs Insure Central Texas, a program of Foundation Com- munities. She received a J.D. from the University of Texas School of Law and holds a B.A. in math and history from Rice University. Rockefeller Institute Page ii www.rockinst.org Managing Health Reform Texas: Round 1 Contents Part 1 – Setting the State Context ...................1 1.1 Decisions to Date ........................1 1.2 Goal Alignment ........................11 Part 2 – Implementation Tasks ....................12 2.1 Exchange Priorities ......................12 2.2 Leadership – Who Governs? .................15 2.3 Staffing .............................22 2.4 Outreach and Consumer Education.............23 2.5 Navigational Assistance ...................26 2.6 Interagency and Intergovernmental Relations .......30 2.7 QHP Availability and Program Articulation........33 2.8 Data Systems and Reporting .................41 Part 3 – Supplement on Small Business Exchanges ........43 3.1 Organization of Small Business Exchanges ........43 Part 4 – Summary Analysis . .....................44 4.1 Policy Implications ......................44 4.2. Possible Management Changes and Their Policy Consequences ................47 Appendix A. Letters from Texas Governor Rick Perry Regarding Implementation of ACA in Texas ..........51 Appendix B. Organizational Charts for HHSC ...........59 Appendix C. Number of Health Insurance Companies Offering Coverage Through the Marketplace by Texas County ...........................61 Appendix D. Regional Variation in Premium Rates ........62 Endnotes ................................ 64 TEXAS ROUND 1 State-Level Field Network Study of the Implementation of the Affordable Care Act August 2014 Rockefeller Institute Page iii www.rockinst.org MANAGING HEALTH REFORM TEXAS: ROUND 1 State-Level Field Network Study of the Implementation of the State University of New Affordable Care Act York 411 State Street Albany, New York 12203 (518) 443-5522 www.rockinst.org Part 1 – Setting the State Context Carl Hayden Chair, Board of Overseers 1.1. Decisions to Date ince the Patient Protection and Affordable Care Act (ACA) Thomas Gais was signed into law on March 23, 2010, Texas has reviewed Director Sand debated the different policy directives of the legislation. In 2011, Texas decided against administering a state-run health in- Robert Bullock surance exchange and opted in to a federally run exchange. This Deputy Director for decision occurred prior to the Supreme Court decision on the con- Operations stitutionality of ACA provisions. In 2013, after the 2012 Supreme Patricia Strach Court decision allowed states to decide whether to expand Deputy Director for Research Medicaid, Texas chose not to expand Medicaid eligibility and enrollment. Michael Cooper The Texas Legislature has visited these decisions over the last Director of Publications two legislative sessions with Governor Rick Perry providing his perspective on the ACA and its position in Texas. Although there Michele Charbonneau have been both supporters and opponents of a state-run health in- Staff Assistant for surance exchange and Medicaid expansion, the decision to not Publications support either of these policies ultimately came down to the governor and the Texas legislature. This section describes the actions of influential officials in Texas over the four years from the passage of the ACA to the launch of the online marketplace on October 1, 2013. Actions in 2010 After passage of the ACA, political leaders in Texas reviewed the legal and fiscal implications of the federal legislation. On March 23, 2010, Texas Attorney General Greg Abbott joined twelve attorney generals from other states in a lawsuit challeng- Nancy L. Zimpher ing the constitutionality of the ACA, particularly the requirement Chancellor Rockefeller Institute Page 1 www.rockinst.org Managing Health Reform Texas: Round 1 of an individual mandate, the requirement of states to expand Medicaid standards, and the imposition of a tax that these twelve states considered to be unconstitutional.1 In April 2010, Perry wrote a letter to notify the U.S. Depart- ment of Health and Human Services (HHS) Secretary Kathleen Sebelius that Texas would not participate in one of the ACA provisions, specifically the operation of a second high-risk health insurance pool in Texas. In his letter, Perry wrote, “¼ the State of Texas cannot today commit to operating the new high-risk pool due to the lack of program rules or reliable federal funding.” Fur- thermore, Perry questioned the adequacy of the $5 billion in federal funding available for the implementation of the program.2 Due to Perry’s decision, HHS set up the federally funded Pre- Existing Condition Insurance Plan in Texas beginning in August 2010.3 The main state insurers of Texas requested funding for reimbursements under the Early Retiree Reinsurance Program (ERRP) also established by the ACA with $5 billion in federal funds available nationwide. The Employees Retirement System, Teacher Re- tirement System of Texas (TRS), The University of Texas System, and Texas A&M University System received a total of $69 million in fiscal year 2010 in reimbursements, with the majority provided to the TRS. The ERRP federal funding continued into 2011 and 2012, resulting in a total of approximately $106 million in federal funds provided to the state insurance plans over the three years of the program’s existence and an approximate grand total of $444 million provided in Texas across all eligible entities in the state.4 The state’s insurance regulator, the Texas Department of In- surance (TDI), under the direction of Commissioner Mike Geeslin, reviewed actions that would be needed to implement ACA provisions. Appointed by Perry in 2005, Geeslin was a former deputy commissioner of policy at TDI and previous advisor to Perry while Perry was lieutenant governor and governor.5 During 2010, TDI applied for and received three different grants from the federal government related to the ACA: 1. State Consumer Assistance Program: TDI applied for a grant related to the State Consumer Assistance Program in September and was awarded approximately $2.8 million in October. TDI used these funds for a variety of activities and created the Consumer Health Assistance Program (CHAP), a hotline for consumers to receive in- formation about health insurance.6 2. Premium Rate Reviews: TDI received a $1 million grant to expand the agency’s premium rate review capabili- ties. TDI used the funds to hire additional temporary legal and actuarial staff to perform premium rate reviews.7 3. Exchange Planning Grant: TDI and the Texas Health and Human Services Commission (HHSC) received a $1 Rockefeller Institute Page 2 www.rockinst.org Managing Health Reform Texas: Round 1 million grant to review the feasibility of operating a state-run exchange. Using $100,000 of the federal grant, TDI worked with the Milliman actuarial firm on the market impact of the federal health

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