The latest versions of health care reform legislation in the U.S. House (H.R. 3962) and Senate (S. 1796) continue to show that states will be in the forefront of implementation of reform within broad federal requirements.  The House could pass H.R. 3962 as soon as November 7. Senate action on S. 1796 is uncertain but may occur by December 15.  If each chamber passes a bill, a House/Senate conference committee will try to bridge, or choose between, differences in the two bills, perhaps by December 31.   The still-evolving Senate bill offers an especially wide scope of opportunities and challenges for states. 

It would, for example, authorize each state to:

• Establish its own health insurance exchanges, decide which insurers can participate, and decide which groups of low-income uninsured persons would obtain coverage through the exchanges (at state option, uninsured persons with incomes from 133% to 200% of the Federal poverty level could be served through a choice of plans under a separate insurance pool);
• Negotiate premiums with insurers seeking to provide coverage through health insurance exchanges, separate insurance pools, and certain high-risk pools for persons needing immediate coverage;
• Consider participation in regional health insurance exchanges across state lines and even recruit out-of-state insurers to spur price competition on insurance premiums;
• Decide if uninsured persons may enroll in group health plans for state employees;
• Implement other insurance market reforms such as requiring acceptance of all persons seeking to purchase coverage and prohibiting premium variations based on health status;
• Promote development of non-profit, member operated health insurance cooperatives (a substitute for the "public option" for consumers in the House bill);
• Develop Accountable Care Organization (ACO) pilots, participate in bundled Medicaid payment rate demonstration projects, and offer "medical home" options designed to promote better coordination and continuity of care;
• Offer a "Community First Choice Option" with personal attendant services and supports for disabled persons.