State officials are pushing back hard against what they view as shortcomings in the healthcare reform law for fear they'll be barraged with complaints when people have trouble affording insurance.
Federal regulators are writing the rules governing key aspects of the law, including the guidelines to determine who's eligible for subsidies to buy private insurance.
Those benefits will be delivered through state-based exchanges, however, leaving state officials on the receiving end of angry phone calls if glitches in the law aren't ironed out by 2014.
One key shortcoming is found in the law's subsidies for people who don’t have access to affordable coverage through their employer. As The Hill first reported in July, the law links the subsidies to the cost of coverage for a single employee. If that coverage is found to be affordable, the individual does not qualify for subsidies in the state health exchanges.
But the determination is based on the single-employee rate regardless of whether the individual has a spouse and/or children — meaning that someone could end up disqualified from the federal assistance yet unable to afford the family coverage that an employer offers.
"Such an outcome would undermine Maryland's goal of reducing the number of uninsured residents," Maryland Health Benefit Exchange officials wrote in comments to the Department of Health and Human Services that were due Monday.
"It could also engender significant frustration with the Exchange among affected families."
Some states are worried about a particularly powerful constituency: state workers.
North Carolina, for example, fully subsidizes healthcare coverage for its employees, but doesn't pay a cent of their dependents' health insurance costs. The average cost of basic family coverage is $516 per month, which is out of reach for many state workers.
"Because employee-only coverage for this plan is provided at no cost to the employee, based on the proposed regulations all family members would be prohibited from accessing subsidies through the Exchange," North Carolina Commissioner of Insurance Wayne Goodwin wrote to HHS. "This rule puts state employees at a disadvantage as compared to other workers in the state."
Michigan, which is a party to the 26-state lawsuit seeking to overturn the healthcare law, told HHS that federal officials — not states — should be responsible for hearing appeals from people who are denied subsidies.
And Tennessee points out that states without an individual income tax have no data source to determine who's eligible for the income-based subsidies in the first place.
The deluge of comments over the past week wasn't the only sign of increased attention by the states.
The new president of the National Association of Insurance Commissioners (NAIC), Florida Republican Kevin McCarty, vowed Friday to defend state powers threatened by federal intrusion.
"Whether it is Dodd-Frank or the Affordable Care Act, the federal government has become increasingly involved in the insurance arena," McCarty said. "As your president, I intend to vigorously defend the role of state-based regulation, highlight our accomplishments, and continue to work for regulatory modernization and national uniformity to create an insurance framework that benefits both consumers and the insurance industry."
NAIC consumer advocate Tim Jost this past week urged the group to take a "leadership role" in pressing states to address potential gaps in the healthcare law's consumer protections.
Self-insured plans are exempt from most of the law's regulations, Jost pointed out, and policies offered by large employers also don't have to meet certain requirements.
Jost also said small businesses are shifting toward self-insurance, so employees will be stuck without benefits Congress intended to provide.