For much of 2012, it seemed just about every major issue confronting states and the federal government was put on hold in anticipation of the impending election. With that process finally over, lawmakers will settle in to try and solve a myriad of thorny problems in 2013. Over the next few issues, SNCJ will review some of the most pressing matters facing states in the New Year. HEALTH INSURANCE EXCHANGES - With the Affordable Care Act having been upheld by both the U.S. Supreme Court and, in effect, the voters, many states will now turn their full attention to determining how they will implement the health reform law's many tenets. Chief among them is the creation of health insurance exchanges, online portals where individuals and small groups will in theory be able to comparison shop for affordable health policies. To date, 17 states and the District of Columbia have opted to run their own exchanges, while six more have indicated they will partner with the federal government on a hybrid state-federal model. Seventeen states have said they will defer entirely to the federal government on their exchanges. The remaining 10 are still undecided. Last month, the U.S. Department of Health and Human Services (HHS) extended the deadlines for states to inform them of which direction they plan to go: Dec. 14 for states that wish to run their own exchange or Feb. 15 for those who opt for a partnership. One major roadblock has been the failure by HHS to release final proposed rules for defining the 10 "essential health benefits" the law requires each insurance policy to cover. The law allows states to determine for themselves which benefits they will require within each of the categories, but until last month HHS had only provided states with guidelines, not the actual final rules. The agency finally issued them on Nov. 20, and some of the law's most vocal critics, including New Jersey Gov. Chris Christie (R) and Florida Gov. Rick Scott (R), have indicated they are now more willing to consider a state-run exchange. But a plethora of other challenges exist in getting the exchanges up and running in time to begin enrolling people by the deadline of Oct. 1, 2013, including massive technical hurdles that virtually necessitate each exchange be customized to fit its state's specific needs. Regardless of which option states choose, the creation of health exchanges is sure to dominate legislative agendas for the foreseeable future. MEDICAID EXPANSION - While the Supreme Court decision last June upheld the ACA's individual mandate to have health insurance, it nixed the law's other major directive, which required states to increase Medicaid eligibility to everyone at or below 138 percent of the poverty line. With expansion now voluntary, at least eight states have said they will not grow their Medicaid roles beyond current levels. How long they can remain steadfast, however, remains to be seen. The federal government will initially foot the entire bill for new Medicaid recipients in 2014, 2015 and 2016 before gradually dropping to 90 percent by 2020 and beyond. A new report released last week by the non-partisan Kaiser Family Foundation said that while states would spend an additional $76 billion over the next decade to expand their Medicaid rolls, that would mark only a 2.9 percent increase over what they would spend anyway without the law. The federal government, meanwhile, would cover over $950 billion in expanded Medicaid costs. That is likely to be a temptation many lawmakers and perhaps even some currently reluctant governors find too much to resist. PHARMACY OVERSIGHT - This year's deadly meningitis outbreak caused by tainted drugs distributed by a Massachusetts compounding pharmacy has already spurred action in several states and Congress. While many observers are urging Congress to increase federal oversight of the pharmacies, the bulk of regulation currently falls primarily to the states. Since the outbreak - which has killed 36 people nationwide and sickened hundreds more -Ohio and Texas are among several states that have ramped up inspections, while others have put together task forces to study oversight changes. Legislation has also been introduced in New Jersey (AB 3453/SB 2365) to toughen the rules for accreditation for compounding pharmacies, and some states, including California and Maryland, are considering requiring out-of-state pharmacies that sell drugs in their states to be regularly inspected by an independent agency. FRACKING - According to State Net, over 130 bills dealing with the natural gas and oil extraction process known as hydraulic fracturing, or fracking, are currently pending in statehouses. Ohio Gov. John Kasich (R) signed sweeping legislation last summer to regulate the process in the Buckeye State, and Colorado Gov. John Hickenlooper (D) and Michigan Gov. Rick Snyder (R) have expressed strong support for the process in their states. But fracking - which entails injecting large amounts of water deep into the ground to break up Marcellus shale deposits that contain oil and natural gas - continues to draw strong opposition from environmental groups, which claim it contaminates drinking water supplies and causes other environmental damage. The most notable conflicts continue in New York, which has had a moratorium on fracking since 2010. New York Gov. Andrew Cuomo (D) is now considering a proposal to allow fracking in a five-county region bordering Pennsylvania. But Cuomo has so far been reluctant to embrace that proposal and recently ordered another environmental review before acting on proposed new fracking regulations that would lift his state's moratorium. THE FISCAL CLIFF - The ongoing conflict in Washington D.C. over an impending combination of across-the-board sequestration cuts and tax hikes, a.k.a. the "fiscal cliff," could have a dramatic impact on states. If the cuts are allowed to go forward, states would lose billions of dollars in federal funding for education, health care, law enforcement and a host of other services. Worse, the nation's fragile economy could possibly slide back into recession, losing two million jobs along the way. As of this writing, President Obama and Congressional leaders continue to negotiate a solution for avoiding that possibility. But as the Wall Street Journal reports, many state budget chiefs have started setting aside money and targeting programs that can be quickly scaled back if no resolution is reached. INTERNET GAMBLING - In 2011, the U.S. Department of Justice issued an opinion that declared the 1961 Federal Wire Act did not specifically ban online gambling, only sports betting. Since then, a growing number of states have introduced a variety of bills to regulate some aspect of online gaming and lotteries. But now, draft legislation in Congress would effectively strip states of that power by barring all online gaming except for poker. This does not sit well with most states, which feel they are perfectly equipped to regulate online gaming on their own. With the fiscal cliff issue dominating the agenda, many observers doubt Congress will pass the measure during the current lame duck session. If that turns out to be the case, states will almost assuredly introduce a wealth of their own bills next session to either legalize or bar Internet gaming. Congress will also not have seen the last of the issue, as the gaming industry is overwhelmingly in favor of federal legislation over a litany of differing state statutes. SOCIAL NETWORK ACCESS - Lawmakers have considered a plethora of workplace and hiring issues in recent years. A trend has developed to bar employers from asking current workers and potential hires for log-in information for their personal social networking accounts, such as Facebook and Twitter. Illinois, California and Maryland have barred the practice, and California and Delaware have extended that prohibition to colleges and universities as well. Variations of these measures are pending in over a dozen states, with more likely in the coming session.
- By RICH EHISEN
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