As the U.S. Congress enters its final push to enact health care reform legislation, state legislators working with Progressive States Network have been raising their voices to make sure key state concerns are addressed in final negotiations.
On top of the more than 1000 state legislators who have joined PSN's network of legislators  urging key reforms, a subset of legislators supported by PSN and working with the White House has been meeting with White House officials and Capitol Hill leaders during the last six months. Just before the holidays, they shared a white paper produced by the group  with D.C. leaders, which details the working group’s concerns, priorities, and recommendations for provisions to be included in the final bill.
Supporting Federal and State Public Option Efforts: Among the key priorities highlighted in the white paper , Suggestions for Strengthening Health Care Legislation from State Legislators , is the highly debated creation of a public option. While the prospect for inclusion of a national public option in the final bill appears close to non existent, some opportunity does remain for expansion of the federal employees health program (the OPM provision) to a wider public. But an even more significant step forward would allow federal funds to flow to states that wish to establish a state public option or expand an existing public insurance program.
Bridge Funding During the Implementation Phase: Another critical recommendation made in the paper speaks to the all-important need for states to receive both short-term and long-term funding. Without such funding, it is difficult to conceive how comprehensive health care reform can be successful.
- Bridge financing during the transition to a new health care system will jump start reform and avoid financial penalties to states that have moved forward to insure low income individuals.
- The paper recommends policies such as continuing an additional Medicaid match with ARRA or TARP funds, providing temporary funding for state public plans and using high risk pool funds for low income subsidies and early Medicaid expansions.
- Along those same lines, the paper explicitly calls for maintenance of effort language that will require states to maintain existing levels of eligibility in their Medicaid programs and the need for Medicaid beneficiaries to have access to a “full” benefit package, not a “slimmed down” plan which will result in worse health outcomes.
Strengthening Affordability Provisions: The paper highlights the need for strong affordability measures in the final bill, stating that the Senate bill falls short in helping low income people afford access to health coverage. While support is given to the requirement that individuals purchase insurance, this mandate is only feasible if the subsidies are pegged at a level that recognizes fiscal reality, with exceptions for significant hardships. The recommendation is to adopt most of the cost sharing protections in the House bill, including the subsidy structure and out of pocket caps for people with income below 250% of the federal poverty level and the actuarial values for all populations with incomes below 400% the federal poverty level (FPL). However, the subsidies and out-of-pocket limits for families with incomes at 300% and 400% FPL are stronger in the Senate bill than the House bill and should be retained.
Promoting Real Insurance Options in the Exchanges: With respect to the Insurance Exchange, recommendations include a requirement for a sufficient number of participating insurers and covered lives to present multiple options to individuals and small businesses. The paper calls for retaining the language in the House bill, creating a national Exchange with the option for states to administer a state exchange. In addition, insurance consumer protections and non-discrimination provisions to all insurance plans and providers need to be in place as well as transitional support to states - regardless of whether they have a high risk pool - to provide access to uninsured individuals with pre-existing conditions.
Promoting Cost Containment: Lastly, the paper addresses a series of acceptable methods for cost containment. These include:
1) payment reform with an emphasis on primary care;
2) incentivizing coordinated care such as medical home models;
3) the use of data to promote evidence-based medicine with strict conflict of interest standards;
4) administrative simplification and electronic record keeping; and,
5) banning prescription drug and medical equipment manufacturers from providing gifts of any kind to providers.
Over the next few weeks, the Working Group of State Legislators for Health Reform will continue to meet with and communicate their messages with Congressional members and House/Senate leadership.
Comparisons of the House and Senate health reform bills - These side by side comparisons are from Politico , the Kaiser Family Foundation  and the New York Times .
Working Group of State Legislators for Health Reform - Suggestions for Strengthening Health Care Legislation from State Legislators  / Executive Summary 
Progressive States Network - Over 1000 Legislators Sign Letters Supporting Federal Health Care Reform