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States have been waiting years to return to fixing how health care is delivered. But they got delayed in the process.

The ACA tasked every state with making major changes to Medicaid eligibility technology – a federally imposed mandate for all states, regardless of whether they chose to expand Medicaid. To comply with the ACA’s new eligibility rules and policies, some states attempted to build state marketplaces for private insurance plan shopping while retooling their separate Medicaid eligibility systems to accommodate the new rules for the under-65 population. This siloed approach often lead to cost overruns and lack of coordination between technology teams at each of the state marketplaces and their partner Medicaid agencies. Other states adopted marketplace systems that included an integrated “single door” for providing eligibility determinations for all state health care programs and benefits, while another set of states – the majority— wound up on HealthCare.gov.

Every state regardless of their decisions on marketplace implementation were forced to divert resources and expertise away from reforming health care and instead focusing on the changing ACA eligibility rules and associated IT systems. This often meant delaying planned work to transform how public programs like Medicaid pay for health care – one of the long-envisioned successes of health reform that hasn’t succeed on a large scale or in the private sector.

Last month, health care and hospital executives told a Washington, D.C. panel event hosted by POLITICO about their organizations’ work to return to the longer-term goal for transforming how health care is paid for and provided to patients. For example, a leader at one of New York City’s major hospital systems told the panel that his group ties almost all its patient care with value – including use of electronic medical records and emphasis on care coordination and outcomes and lowering costs. As expected, New York policy makers embraced the ACA and the state runs its own state marketplace with a single door eligibility system.

California and Massachusetts also run state based marketplaces – and similar to New York, Massachusetts has embraced an integrated single door to health coverage eligibility determinations for both private coverage and Medicaid. With state marketplaces, states retain local control over enrollment and policy decisions and their relationships with carriers and provider groups, allowing the states coordinate with these key stakeholders to influence the design and provision of health benefits and health coverage.

When states closely link health coverage with patient care, the full set of the ACA’s goals can be accomplished in ways that meet states’ unique needs, on their own terms.

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