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Missouri casts symbolic vote against state-based HIX, may get one anyway

Now that the federal government is set to run Missouri's health insurance exchange, after voters passed a proposition banning state creation of an exchange without legislative or voter approval, lawmakers say they'd actually like to create their own.

Missouri Gov. Jay Nixon, a Democrat, recently said the federal exchange isn't "ideal" and Republican lawmakers agree.

"I'm not overly excited about the prospect of setting up an exchange," Republican Tim Jones, the Missouri house speaker, told the St. Louis Post-Dispatch. "But I think we're going to have to talk to the stakeholders. I'm not interested in giving the federal government any more power or say in what we do here."

The U.S. Department of Health and Human Services has extended the deadline for states to submit HIX blueprints, to December 14, and the Missouri legislature has adjourned until January, so the federally-facilitated option is currently expected.

The current governors of Kansas, Texas, Florida and a few other states have said they will not implement an exchange, and dozens more are undecided and likely to jointly manage the exchanges with CMS's CCIIO, the Center for Consumer Information and Insurance Oversight.

With 13 state currently committed to creating their own exchanges, federal health officials have suggested that state governments may be able to take control of federally-facilitated exchanges sometime after 2014, when they're set to be live marketplaces. But some looming deadlines in 2013 are weighing heavy on HHS and the states.

"Standing up a health benefit exchange is an enormous and complex undertaking," Claudia Page, co-director of the technology and policy at non profit Social Interest Solutions told Government Health IT. "Even for states that already have the ball rolling, meeting the aggressive deadlines is going to be an enormous challenge."

[See also: Everett Clinic, Group Health to launch Medicare ACO]

As the ACA's political controversy diminishes, voter provisions like Missouri's -- and ones in Alabama, Wyoming and elsewhere adding constitutional amendments opposing the individual mandate -- are probably not going to have a large practical impact, said Dick Cauchi, a policy analyst from the National Conference on State Legislatures.

In 2010, Missouri voters adopted a constitutional ammendment opposing the individual mandate, and this year's vote requiring legislative approval for HIX creation is likely to have as little an impact, Cauchi said. Only in Minnesota has the governor acted unilaterally to establish an exchange body; everywhere else, exchange authorities were created by legislative approval.

And while some state governments may find efficiencies in integrating the HIX into other public programs, for consumers, the federal exchange may not be very different than a state exchange, Cauchi said.

Rob Schaaf, the Missouri state senator who sponsored the HIX ballot initiative, told the Associated Press that he is still waiting for the outcome of a lawsuit filed by the Oklahoma attorney general, which claims the ACA restricts the administration of insurance subsidies under the individual mandate to state exchanges alone.

Filed in U.S. District Court in Muskogee, Oklahoma, the lawsuit challenges an Internal Revenue Service ruling permitting subsidies through both state and federal exchanges.Conservative activists are hailing it as a last best hope for weakening the individual mandate and also think it could allow employers to escape penalties for not providing health insurance.

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