2013 will be a critical year for health policy, particularly at the state level where officials continue to adapt to states’ changing roles as health care providers, purchasers, and market regulators. State policy experts took the podium at the National Health Policy Conference to discuss some of the challenges they face and the opportunities to to work together to improve health and health care. Obviously, the ACA has put new pressure on states. In a plenary session on challenges for states, National Academy for State Health Policy (NASHP) Executive Director Alan Weil explained that most of the focus at the state level is on the coverage provisions instead of the delivery system transformations. The tight deadlines and available funding keep coverage expansions at the top of the priority list for state officials. Julie Weinberg, division director for Medicaid in New Mexico, talked about her state's plans to expand Medicaid eligibility to individuals earning up to 138 percent FPL and the added challenges that come along with that decision. She said that the ACA has had an impact on almost every area of business that Medicaid runs: eligibility, how to determine it, enrollment, exchange interaction, worries about churn between exchange and medicaid, access worries, and maintenance of effort. With all those moving parts, state Medicaid programs are really under a time crunch to make some hard decisions. "There's a lot on our plates," Weinberg said. "While we're doing all of this, guess what: we're also running a program. All Medicaid agencies are running the programs that they currently have. And some of them...are trying to revamp their programs to prepare for the influx of newly eligible persons." [NASHP's State Refor(u)m website has a nice chart tracking Medicaid expansion decisions by state.] The second major coverage challenge facing states is defining and implementing an exchange. Colorado Health Benefit Exchange Executive Director Patty Fontneau shared her experiences in building one of the 18 state-based exchanges and the importance of customer service and navigators. She described the exchange as a "shop and compare website and support network" to guide individuals and small businesses in choosing health insurance. "Ultimately, we're selling commercial insurance," she said. "People are going to have to buy something and make that commitment." The panelists in the session on exchanges and consumer assistance needs expanded on the role of navigators and some general best practices for messaging around exchanges. Alison Betty of the communications firm GMMB shared results from a study of 1,800 adults at or below 400 percent FPL, showing that 45 percent of respondents said they want help from a state government worker whose job it is to provide customer service. Betty noted that the newly eligible population will be looking for a trusted relationship when dealing with the exchanges. Of course, each state is different and not all exchanges or Medicaid programs will look the same. That's why Fontneau stressed the importance of getting public feedback at all different stages of the process to ensure that people are engaged and that the final program/product addresses the population's needs. Panelists also agreed that these unprecedented coverage expansions will require extensive coordination among the key stakeholders within the states.  Rhode Island Health Insurance Commissioner Christopher Koller said that in order to make this work, insurance commissioners, exchange directors, and Medicaid directors should spend a lot of time planning privately and delegating to the appropriate staff who can execute the shared goals. As we continue to move toward the 2014 deadlines, activity in the states is only going to increase. For additional resources, refer to the State Coverage Initiatives federal reform resources page.   weilnhpc2013 A full recording of the plenary session is available from C-SPAN