The Robert Wood Johnson Foundation and the Urban Institute continue their series of reports on how states are implementing policies of the Affordable Care Act (ACA). The latest reports look at Minnesota, New Mexico, and Virginia.

The sections below include a few points of comparison from the briefs about how each state is doing in key areas. Overall, the reports show Minnesota making “remarkable progress” compared to the other two states, thanks to motivated executive leadership and existing policies that give Minnesota a head start in implementing the health reform law.

Exchange Governance
While the Kaiser Family Health Foundation lists all three states as “studying options” to create exchanges, these three reports depict Minnesota as farther along than New Mexico and Virginia. None of the state’s legislatures has passed legislation to create a state-run Health Insurance Exchange (HIX).

Officials in Minnesota’s executive branch have begun setting up the infrastructure for the exchange–such as a call center and website–despite the absence of certain policy guidance from the federal government and the lack of state legislation to authorize the exchange. “This pragmatic approach should serve the state well in the future, since it will result in a flexible exchange structure that can be adapted as the policy environment experiences future changes, which are surely inevitable,” the brief notes.

The Virginia report commends the state’s health reform initiative for engaging stakeholders and for publishing recommendations about how Virginia’s exchange should be run. However, the discussion has become mired in controversy over whether the exchange should be run as a quasi-governmental agency or should be house in the State Corporation Commission, an agency that includes the state Bureau of Insurance. The Virginia legislature has taken no action to establish an exchange.

In New Mexico, Governor Susana Martinez vetoed legislation in 2011 to create an exchange. The legislature demurred when another exchange bill was introduced in 2012. Since the Urban Institute report was written in May, the state has established a task force to consider establishing an insurance exchange, which met in late July.

Exchange Planning Grants
All three of these states received federal exchange planning grants, awards of up to $1 million to help states establish new insurance exchanges under the ACA. All but one state–Alaska–received a planning grant. Minnesota and New Mexico received subsequent funding through Level One Exchange Establishment grants, which were for states who had made some progress in establishing an exchange using the $1 million planning grants. Virginia is one of 17 states so far that have not taken advantage of the exchange establishment grants.

Overhaul of Eligibility and Enrollment Systems
Virginia has, however, taken advantage of a 90-percent federal funding match to develop new enrollment systems in anticipation of the ACA’s Medicaid expansion. Virginia released a Request for Proposals (RFP) in May for the new system, whose first goal is to determine Medicaid eligibility and facilitate enrollment under the ACA’s new rules: up to 138 percent of federal poverty level, using a new metric called modified adjusted gross income (MAGI). The system eventually will handle eligibility and enrollment for all social service benefits, such as Medicaid, Supplemental Nutrition Assistance Program (SNAP, aka food stamps), Family Access to Medical Insurance Security (FAMIS), and Temporary Assistance for Needy Families (TANF).

Minnesota also is drawing down federal matching funds for a new enrollment and eligibility system for Medicaid and CHIP, and for premium and cost-sharing subsidies through the exchange. The state has released an RFP to develop and oversee the project, and has created a joint team of Medicaid and exchange staff to integrate their IT systems.

Medicaid eEpansion
Minnesota’s Medicaid program is closest to meeting the ACA Medicaid expansion’s parameters. Under the ACA, states that choose to participate in the expansion must cover all people with incomes up to 138 percent of federal poverty level. Minnesota already covers children, parents, and pregnant women with incomes up to 275 percent of the federal poverty level, and childless adults with incomes up to 250 percent of federal poverty level.

Although those policies generally ease the transition to the ACA, they do present some problems. The ACA allows states to reduce Medicaid coverage for adults above the new threshold of 138 percent of poverty level. Whether to drop adults above that threshold who are currently on Medicaid is of particular concern in Minnesota, the brief notes.

Neither New Mexico or Virginia’s current Medicaid program is as generous as Minnesota’s, and both would see large increases in the number of people covered by Medicaid if they choose to expand under the ACA.


Kip Piper is a Medicaid, Medicare, and health reform consultant, speaker, and author.  For more, visit  Follow on Twitter at @KipPiper and connect with Kip on LinkedIn.