Mary Feldblum of the Health Security for New Mexicans Campaign visited Silver City to meet with proponents of the New Mexico Health Security Plan, as well as with physicians to explain the program to them.

She has been working to promote a one-payer health coverage system in New Mexico since 1992, she told the Beat.

The passage of the Affordable Care Act, and the upholding of some of its provisions by the U.S. Supreme Court has aided and in some ways confused the proposals Feldblum and her campaign have put in front of the New Mexico Legislature every few years.

The 2013 Health Security Act, to be presented to legislators, assumes the state will have a health insurance exchange by Jan. 1, 2014. The Health Security Alliance wants to transfer any exchange that is set up so that it belongs to the state.

"We want the exchange to fold into the Health Security Plan," Feldblum said. "We got it endorsed by the Interim Health and Human Services Committee. This way the Democrats can vote for an exchange and also the Health Security Plan."

The legislation for the Health Security Plan will include that all resources from an exchange will transfer to the Health Security Alliance to support the Health Security Plan. A timeline to set up the Health Security Plan was discussed later in the meeting.

The ACA creates state-based health insurance exchanges administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. In 2014 and beyond most Americans who work for small businesses or obtain their coverage in the individual health insurance market will do so through health insurance exchanges, according to http://insurance.about.com/od/reformresources/a/Health-Insurance-Exchange-101.htm .

The ACA includes State Innovation Waivers, which provide an opportunity for states to develop alternative health coverage systems that do not have to rely on private insurance systems.

States may set up their own exchanges, or they can opt out of creating the exchanges and let the federal government develop them for the states, with the federal government doing it by itself or in partnership with the states. Most southern states, as well as some states with Republican governors, who like states' rights, have already opted to let the federal government do it. Feldblum said the federal government intended for states to set up their own exchanges.

For the poor—anyone up to 400 percent of the poverty line—the ACA proposes a federal subsidy to purchase insurance. States must decide by Dec. 14 of this year, whether they will have an exchange.

On Nov. 15, 2012, New Mexico Gov. Susana Martinez announced the state would create and administer its own health insurance exchange.

According to Feldblum, Martinez wants the New Mexico Health Insurance Alliance to set up the exchange. Feldblum said the board of the NMHIA is controlled by insurance companies. She also said Martinez wants to do the exchange by executive order. However, some members of the Legislature contend it is a violation of the constitution. The same members say an exchange is a "different animal," from what Martinez is proposing. Lawsuits over the issue are already being filed.

Critical issues for the exchanges, according to Feldblum, include positive provisions of the ACA that protect consumers from insurance abuses, help to develop more efficient health delivery systems and invest in preventive care. She also supports the state taking advantage of all federal grants monies available to help build a good health care system for New Mexico.

Deadlines for aspects of setting up the exchanges, include by Jan. 1, 2013, the U.S. Secretary of Human Services will determine whether a state will be "ready" to have a state-run exchange up and running by Jan. 1, 2014. In addition, by Jan. 1, 2015, state-run exchanges must generate adequate operating funds to be self-sufficient.

The latter brings up the question of whether an exchange is economically viable in New Mexico. If revenues are not sufficient, funding will have to be pulled from the state general fund.

Feldblum cited a study by Alain Enthoven, who was President Bill Clinton's managed-competition guru. Enthoven stated that for an exchange to be economically viable, it must provide insurance to at least 20 percent of the insured population, excluding Medicare and Medicaid recipients."

Based on New Mexico Office of Health Care Reform estimates, by June 2015, the maximum participation rate would by about 10.7 percent, increasing to 14 percent by 2019. The number is critical, Feldblum said, because by Jan. 1, 2015, state-based exchanges can no longer count on federal subsidies and must be able to general sufficient revenues to be self-supporting.

A little-known provision of the ACA allows those states where exchanges are not viable to apply for a waiver to develop an alternative plan, but not until Jan. 1, 2017. Although Obama supported, in 2011, getting rid of the 2017 date, it was in the federal budget, which has not been passed.

Feldblum said it is estimated that, in New Mexico, there would still be 100,000 uninsured by 2019.

She discussed the Health Security Act implementation if it passes in the 2013 legislative session. It is a phased plan.

In 2015, at the legislative session, the Legislature would approve appropriation of funds to the Legislative Finance Committee to conduct Health Security Plan financing analysis. By Nov. 2, 2015, LFC's report would be presented to interim committees.

By March 14, 2016, a nominating committee would be created, and by no later than June 12, 2016, a geographically diverse citizens' commission selected by the governor from a list of candidates submitted by the nominating committee would be named. In the fall of 2016, the commission would begin the process of setting up the plan and preparing and submitting the waiver for state innovation application, which would be eligible for consideration by the U.S. Department of Human Services on Jan. 1, 2017.

During the winter/spring of 2017, the waiver would authorize the transfer of exchange property and customers to the Health Security Plan and make them subject to is rules.

Plan implementation date is scheduled for July 1, 2017.

If the 2017 date disappears, Feldblum said the HAS would seek funding for the financial analysis as soon as 2014.

Feldblum said she has met with many citizens and municipal officials over the years, and for most, it is a bi-partisan decision to support the Health Security Plan. "What we want legislators to know is the Health Security Act is the best program for New Mexico."

Insurance Coverage Status* 2014 2015 2016 2019
Population 2,206,121 2,242,856 2,278,407 2,385,061
Medicaid 679,675 741,530 750,926 810,360
Medicare 358,033 370,711 387,209 436,703
Champus/Tricare 50,000 50,000 50,000 50,000
Commercial 732,440 754,769 764,865 777,944
Exchange 52,055 96,718 106,958 134,796
Uninsured 339,698 235,006 224,422 181,509
Dual Coverage Adjustment -5,782 -5,878 -5,972 -6,251
Total Coverage, 2,211,903 2,248,734 2,284,379 2,391,312
including Dual Coverage

Riemer/Enthoven 20% Threshold for Exchange Sustainability
Total Insured Population (Total Population excluding Uninsured)
1,866,423 2,007,850 2,053,985 2,203,552
Total Medicare/Medicaid 1,037,708 1,112,241 1,138,135 1,247,063
recipients
Total Medicare/Medicaid 1,031,926 1,106,363 1,132,163 1,240,812
recipients,adjusting for dual coverage
Insured Population 834,497 901,487 921,822 962,740
(excluding adjusted Medicare/Medicaid recipients)
Exchange participation 2.8% 4.8% 5.2% 6.1%
as % of total number of insured
Exchange participation 6.2% 10.7% 11.6% 14.0%
as % of total number of insured(excluding adjusted Medicaid/Medicare recipients)

*Data Source: New Mexico Health Care Reform Fiscal Analysis, May 2, 2012, The Hilltop Institute, UMBC, Baltimore, Maryland