A Conversation With ... Andrea Croley

Missouri is part of the federal health care exchange under the Affordable Care Act after lawmakers did not establish a state-based exchange. Is there hope of a state-run marketplace in the future?
It is possible. Our neighbor Kentucky has actually run a successful exchange. However, if you look at it, many of the states that facilitated their own private exchanges have had a lot of trouble. It was hard to connect with the federal exchange. You have to use the federal exchange because it extracts your income information, which then goes to the Internal Revenue Service to validate it. What the states then did, is linked up with the first portion, like a step two.

Some exchanges, such as Massachusetts first started under Gov. (Mitt) Romney, and others who have had them in place for a while, such as California – have had success. Oregon, on the other hand, has had a very different experience. That exchange isn’t prospering.

Missouri has a Republican House and Senate and a Democratic governor. It’s going to fall along party lines. Right now, I don’t foresee Missouri creating an exchange. The majority of states use the federal exchange.

Missouri is among 17 states with federally run marketplaces that enacted legislation imposing requirements on navigators. However, a federal judge recently granted a preliminary injunction against the law. Why was the law enacted, and where does it stand now?
Although the issuance of this preliminary injunction is somewhat, for the insurance industry, frustrating, they feel as if there should be some sort of requirement for navigators, the people who assist others with enrollment on the federal website.

Fraud is a big concern. What if the navigator isn’t licensed? This person is dealing with people’s personal information. What if he steals that person’s social security number? This is a national concern. In some states, there are no background checks required.

We are the first state to initiate this, and they are all going to be watching us to see what happens here. The judge ruled since we are a federally facilitated exchange, the laws we should abide by are federal. The judge’s order eliminates oversight for navigators and creates a regulatory vacuum that leaves navigators outside the jurisdiction of state officials and the insurance codes. That means local regulators lack the authority to take enforcement action when navigators engage in improper conduct.

This is not going in the direction (legislators) wanted it to go. Now, because of the preliminary injunction, everybody is watching Missouri. The order has broader repercussions as well because it challenges the state’s ability to regulate the conduct of any entity that offers health plans via the exchange.

Is Missouri setting the stage for a national battle regarding navigators?
This order flies in the face of states’ rights. It does somewhat contradict the Affordable Care Act. There is no provision in the ACA that prohibits policymakers from licensing, certifying and regulating individuals or entities who seek to operate as navigators.

Because this issue was first taken up in a smaller court in Missouri, what’s happening now is moving up the ladder. We don’t know yet how it’s going to progress, but it’s an example for other states moving forward.

Many of Missouri’s Republican lawmakers currently oppose Medicaid expansion legislation, despite its endorsement from Gov. Jay Nixon, the Missouri Chamber of Commerce and Industry and many other local chambers. Will lobbyists such as the state chamber’s recent hire of former U.S. Sen. Kit Bond, turn the tide this session?
Kit is a very effective and well-known legislator, and they picked a very important person to tackle the issue. I think Medicaid expansion could go both ways. We have seen it in our office where people are in a doughnut hole, or in other words they have fallen through the cracks. If you are not eligible for Medicaid and are in between that area – the 100 to 133 percent of poverty level – you are not going to qualify for a subsidy in the marketplace. You don’t get Medicaid and you don’t get a subsidy on the exchange. Those people have fallen through the cracks, and I have great empathy for those people.

The other side to it is once we have Medicaid expansion, guess what’s going to happen? Again, after a few years, the state picks up the cost of it. I think that’s why if you are looking at the fiscal side, that is the biggest reason to oppose it. I don’t think it has anything to do with thinking we don’t want those people to have coverage, we are just afraid of what’s going to happen to the state when the federal government pulls away the funding.