The ACA brings unprecedented challenges to our states, and day one of the National Health Policy Conference focused on the key issues facing state policy professionals. There’s no question that states are under immense pressures from a variety of stakeholders. This morning’s opening plenary featured representatives from some of the agencies at play, including health department leadership, a health insurance commissioner, and an exchange commissioner, who shared their own experiences as they move forward. After moderator Robert St. Peter rattled off an overwhelming list of obstacles in his own state of Kansas, Kim Belshe of the California Exchange Board followed up by pointing out what most participants already know: implementation at the state level is really hard.

“Transforming policy and practice is not for the faint of heart. It’s not for sissies,” she said.
Each of the panelists focused mostly on issues surrounding exchange implementation, noting that we’re in uncharted waters and navigation requires intricate collaborations among stakeholders. But defining and maintaining that collaboration often leads to additional challenges. As Iowa Insurance Commissioner Susan Voss explained, every interest group wants to have a say in the process, but none are willing to concede. She even joked that the only way to get anything done is to sit everyone down in a room with some tequila shots. The exchange discussion carried over into one of the breakout sessions, with AcademyHealth Vice President Enrique Martinez-Vidal, who directs the Robert Wood Johnson Foundation’s State Coverage Initiatives program, leading a panel of state policy representatives.  As daunting as the exchange work is for states right now, it's also an extraordinary opportunity to be innovative, and the panelists agreed, specifically citing their own work in engaging consumers.  Blue Cross Blue Shield Association's Kim Holland highlighted the organization's focus on consumer education with regard to exchanges, stating that transparency and consumer engagement will be keys to exchange success. Rhode Island Lt. Governor Elizabeth Roberts also agreed that transparency is invaluable, noting that her state's exchange advisory board has been having public conversations about their plans. And Christine Barber, of Community Catalyst, stated that consumer advocates are excited for exchanges, as long as they include high quality health plans options, easy to understand comparisons, and assistance in choosing a plan. Complicating the implementation process for states are the constitutional objections to the ACA. With the Supreme Court set to rule on the 26 legal challenges this summer, state policy professionals are still moving forward in their own ways to meet the aggressive deadlines. There's no question that the court's ruling will have a huge impact on health policy this year, and panelists in a session on the constitutional challenges broke down the elements of the controversy.
"Everything about the ACA is unique, and that's why it's before the Supreme Court," said Washington and Lee University's Tim Jost. "The future of the Medicaid program and the future of our federalism rides on this case."
Finally, attendees heard from Alabama Governor Robert Bentley about his state's experiences with innovation and exchange implementation.
"Is the Affordable Care Act the answer? Only time will tell," the governor stated. "As we've begun to develop our insurance and information exchanges, we've seen how extremely complicated it will be, and I'm not sure it can be done. Maybe that's why the federal government wants us states to do it."
Overall, the governor stressed that his ultimate goal is to make Alabama a healthier state. To do that, he's proposing the Alabama Health Alliance to bring together stakeholders in health departments, government, universities, and the clinical settings to foster innovation and share ideas that can improve the lives of Alabama residents. He said that physicians need to be more invovled in the policy process. So, what IS the state we’re in? A dizzying state, it seems, from the overall discussion in today's sessions. But with all the uncertainty and obstacles comes an opportunity for innovation and a commitment from the administration to assist when possible. For states, it’s going to be an eventful 2012 for sure.  
The State Coverage Initiatives program has wealth of reform implementation resources for policy professionals, available at www.statecoverage.org.