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Marc Kilmer: What now for health care reform in Maryland?

The Supreme Court found no constitutional objections to most of the Affordable Care Act (ACA, or, as some prefer, “Obamacare”).

The constitutional question may be settled, but the policy debate remains, at least on the state level. State policymakers are still tasked with implementing this law. In light of the court decision, what should they do?

The U.S. health care system has a few different but interrelated problems. One issue, access to care, affects a proportion of the population. The other issues — such as rapidly increasing health care costs and the strain that these costs place on taxpayers – affect us all.

ACA dealt with the first issue. Its Medicaid expansion and its mandate that every person buy insurance or pay a tax penalty were the primary ways of trying to decrease the number of uninsured. No doubt the legislation will succeed at this goal.

The other two issues, relating to health care costs and their effects on taxpayers, will only be worsened by ACA. Any honest analysis of the ACA’s long-term impact shows that it expands both state and federal government spending and does nothing to address decreasing the health care cost curve.

These problems will have to be addressed at the federal level, which is unlikely to happen any time soon, so state policymakers need to consider the problems that ACA has exacerbated.

Health care exchanges

Even though the federal government is now regulating far more of our health care sector than previously, there are still tools state governments can use to help improve care and control costs.

For instance, the state is establishing a health insurance exchange to comply with ACA. This exchange will be an online clearinghouse where individuals and small businesses can purchase health insurance.

The federal subsidies for insurance purchases established by ACA will only be able to be used in this exchange.

Buying health insurance in Maryland is expensive, consumers cannot find policies that meet their needs and there is little choice in the companies that sell policies.

All of these issues are directly related to heavy state regulation on insurance sales and the numerous mandated benefits that the state government imposes on insurance.

These mandates and regulations prevent insurance companies from tailoring policies to meet consumer need and force insurance buyers to purchase coverage for a variety of procedures they don’t want or need. Not only does this stifle consumer choice, but it also increases consumer cost.

Eliminate Certificate of Need

While the ACA places strict parameters on the type of insurance that can be sold in an exchange, the state has some leeway in which policies can be offered. The state could impose minimal restrictions on the insurance sold through the exchange, giving consumers more options than they possess in today’s insurance market.

State laws that interfere with health care professionals looking to serve their patients better could also be loosened or eliminated.

Eliminating the state’s Certificate of Need law, for instance, would end the requirement that owners of health care facilities seek state permission before building or expanding. These laws have been proven to raise costs and decrease health care access, and many states have repealed them. Maryland should do the same.

Expanding the scope of practice for health care professionals would also give Marylanders more options at lower prices. Bipartisan movement at the state level in recent years has attempted to allow dental hygienists, nurse practitioners and others greater freedom to provide health care services. These initiatives should be continued and expanded.

The state can help reform the health care marketplace in many other ways to better serve patients and health care providers. It is vital Maryland does so.

The ACA did not fix our health care system, and arguably it worsened existing problems. State policymakers have a vital role to play in dealing with the problems that still exist. They must choose good policies that maximize consumer choice and support market mechanisms to lower costs.

Marc Kilmer is a senior fellow at the Maryland Public Policy Institute, a nonpartisan public policy research organization based in Rockville. His email address is