Amicus Curiae Brief — King v. Burwell, 135 S. Ct. 475 (2014) (No. 14-114)
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Supreme Court, U.S.
FILED
JAN 28 205
No. 14-114
CLERK
IN THE
SHupreme Court of the Anited States
DAVID KING, ET AL.,
Petitioners,
Vv.
SYLVIA MATTHEWS BURWELL,
SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.,
Respondents.
On Writ of Certiorari to the
United States Court of Appeals
for the Fourth Circuit
BRIEF AMICI CURIAE OF
MARILYN RALAT-ALBERNAS, R.N.,
MARCUS SANDLING, M.D., MICHELE
EVANS, SERVICE EMPLOYEES
INTERNATIONAL UNION, ET AL.,
SUPPORTING RESPONDENTS
CLAIRE PRESTEL JUDITH A. SCOTT
DANIEL M. ROSENTHAL Counsel of Record
JAMES & HOFFMAN, P.C. NICOLE G. BERNER
1130 Connecticut Ave., NW, SERVICE EMPLOYEES
Suite 950 INTERNATIONAL UNION
Washington, D.C. 20036 1800 Massachusetts Ave., NW
(202) 496-0500 Washington, D.C. 20036
cpprestel@jamhoff.com (202) 730-7383
judy.scott@seiu.org
WALTER KAMIAT
7305 Alaska Avenue, NW
Washington, D.C. 20012
January 28, 2015
EID DESTIN L DLAI LED EEE LT IEEE LE LEP LE TEED YELL EAL E LE_ELE EIEN ELL LEE LDL Oe
WILSON-EPES PRINTING CO. Inc. — (202) 789-0096 — WaSHmGTON, D.C. 20002
IT.
ITI.
TABLE OF CONTENTS
PETITIONERS’ CARROTS-AND-STICKS
THEORY RAISES SERIOUS CONSTI-
TUTIONAL AND FEDERALISM QUES-
TIONS THAT DEMAND A CLEAR
STATEMENT OF CONGRESSIONAL
INTENT, WHICH IS NOT PRESENT
UII tienesictnshidtntnuneduichbpatienisamedhceoaieiadasascdess
PETITIONERS’ CARROTS-AND-STICKS
THEORY IS NOT SUPPORTED BY,
AND INDEED CONTRADICTS, THE
EE SUPINE iiisiitenphisecnd uitisestincanuneiidedsicasasiuoce
A. When Congress Incentivizes State
Action, It Does So In Clear Terms And
Not At All As In The ACA....................
B. Congress’s Provision For FFEs Makes
No Sense Under Petitioners’ Theory ..
C. Other ACA Provisions Make No Sense
Under Petitioners’ Theory...................
PETITIONERS’ THEORY CONTRA-
VENES CONGRESS’S PURPOSES IN
ENACTING THE ACA ...0..0 oo ccccccceeeeeeee
PETITIONERS’ THEORY IS CON-
TRARY TO THE ACA’S LEGISLATIVE
IEEE dditrtpencseniipnencinnndtiesembindatensmenn
13
20
21
il
TABLE OF CONTENTS—Continued
Page
V. THE STATES DID NOT INTERPRET
THE ACA AS PETITIONERS DO NOW... =. 25
VI. EVEN PETITIONERS’ SUPPORTERS
DO NOT BELIEVE THE CARROTS-
AND-STICKD THB ...222.20020200.s0000eee- 34
GENIE iccavnrcpssnsindaninnmcssdeinnienerssenssararvi 36
APPENDIX:
STATE DOCUMENTS REVIEWED ........... la
til
TABLE OF AUTHORITIES
CASES Page(s)
Bond v. United States,
oe Be eg | een 7,8
Fargo Packing Corp. v. Hardin,
312 F. Supp. 942 (D.N.D. 1970)................ 15
Gregory v. Ashcroft,
Bt Rt REE ee eee ee 7,13
Halbig v. Burwell,
758 F.3d 390 (D.C. Cir. 2014),
vacated, No. 14-5018 (Sept. 4, 2014)........ 18
Hall v. United States,
ge ee Be, eens 18
Leocal v. Ashcroft,
I ce LN a ba 19
Maracich v. Spears,
Be is Cc EE CIR cca cnrotetdnarescicnavensas 18
Nat'l Fed’n of Indep. Bus. v. Sebelius,
> | £e |... RR RRs passim
New York v. United States,
ns 7, 8, 13, 14
Nixon v. Missouri Mun. League,
Be Pe, Bt ID iii csssiccteniscdeinanenescsdtcsnass 8
Pennhurst State Sch. & Hosp. v.
Halderman, 451 U.S. 1 (1981).................. 8, 34
Ransom v. FIA Card Servs.,
Fe | ae Sey |, |) | ee 18
Rewis v. United States,
Oe es CI I adcnces ikcdncenéntedabasetsenssdes Re
iV
TABLE OF AUTHORITIES—Continued
Page(s)
United States v. Bass,
IG re MU AT Banca a iccsitsstcnacesscbasssaccnce 7
Whitman v. American Trucking Ass’ns,
es gd) _ | ene 11
STATUTES AND REGULATIONS
Oy nn 11
Fe REESE ima, Pease se Se ane 11
Be Ns WIE eitieda.sidicctcsaiticiadtstsitvaceicaudenaaneas 11
ee ns I oie td clk, 0 11
ee A icone nat scce a ceecinaeaadonnitns 15
RE 5 EAR SIRES Sie Sgt nc SR 12
a isk da cehcornisicibieeipsteslsonunaiaoienndn 12
Be Ie aisha stestcirnesndaansndicceccasactonneie 12
ERATE rare Cereneete narvia un SPE sw 10
Be ee ID iis sdicichsscanbsicdaccobhusededatietconeniniis 12
Ss fk” Eee Otani 12
Be ee I sic cntsccsmicionabiceetnteeesenianbes 12
ET hE PRN We comer eran 12
Be ee ia I iinet caicisticnicestehensnpcliclonetinen 16
Fa es SID sicitincinesencennesdonasnebescnace 16
BL SII datehasdilatncscphaanancecanieacituminconsionage 15
Oe ae ED cnercncncancssésixesiccessssnbonpin 11
Se es IIR oniveriicienaceateceosusieimeigunas 24
ey eens IEE vacrndacipeenisacinnntdntrsenendevtaumenctcans 11
v
TABLE OF AUTHORITIES—Continued
Page(s)
Oe RE, SED dscidciniciadncacemncimnincinnicnicedicnstasteishanie 11
Re I tr diccisdcateaeiwianinnnuntyenonniebieibiaavanaiicnns 11
I er I oi nicacicciodseicsacnecenssabnendenidladdelens 11
42 U.S.C. $655(aN4)A(5) ...............cccccrcsrrcooees 11
ga Oe 10, 11
ei II siinirincsecetssccnnsenntnusonsnssns 11
Oe a IED iin tnnssicnictnhtnncidomniccnbipeninednts 11
Oe as I ciiskinicetnihaescrctnnapcnccinitenseesonas 11
es IDE BI icsencsicissacecansccsnassecenseiaies 15
Be i I sc cansniicnancdiinnienssanindiinicatiocanes 19
is i iitnitsstecccntirestpanninccssonens 19
Ee, Be Rivtenrinnscnsnisecrcsséncantacaren 19
42 U.S.C. §18021(aX 1M Ci) ...............seeeeeee 24
es IB iviincctinnnicanscacosonsbssstanans 24
i BI cesncccsnestlsaccetninrdacsncerintncennas 10
Oe iia: SE eri cénhtictnsntdinmanestivnansecnaes 11
BE TE Fa. BIE ccc psnesisevsessiscenessasesouns 18
ee, BE eicccintarinbicstannnccinsnesesechiene 20
Oe SIE scccicivasipasancncunanienenteateinaanehsinies 10, 16
Ie cesstsstierencetoens. 11
TT FG Be vines etn cc isscinsecicassenccoessss 18
IF Pe eR csctiinnicsscsesccctesctasinntnnnniatie 19
42 U.S.C. §18061(c)1)(A)
SSSR Oe eC eee Ee ee ee
19
vi
TABLE OF AUTHORITIES—Continued
Page(s)
43 U.S.C. GIBBS IMEN UMA) ......200sesscerecocccesesss- 19
42 U.S.C. $180BU(2XD) ............0cc.cccccesscesseees 21
Os I iii asricrennsngebeiscnnioncinen 15
71 Fed. Reg. 25,328 (Apr. 28, 2006)............. 15
79 Fed. Reg. 49,465 (Aug. 21, 2014)............ 15
OTHER AUTHORITIES
34 House Record 18 (N.H. Mar. 7, 2012),
available at http://www.gencourt.
state.nh.us/house/caljourns/calendars/
2012/houcal2012_18.html, archived at
http://perma.cc/BTZ2-NDXSG..................... 32
155 Cong. Rec. $12,356 (daily ed. Dec. 4,
SII: scgustuaddiasssenseasaasunicaiaaien uciauaa aakcuon 22, 23
155 Cong. Rec. $13,345 (daily ed. Dec. 17,
SIA so cashes taeiiactouss aks sasuabieae wane aneseoeasasde 23
155 Cong. Rec. S13,714 (daily ed. Dec. 22,
RU csiddae asecacoecicnsicncnuccamacsieinsabanaimencticasasese: 22
155 Cong. Rec. $13,796 (daily ed. Dec. 23,
I parern ee eer 22
156 Cong. Rec. H1854, 1871, 1888 (daily
a 23
Affordable Health Choices Act, S. 1679
Be I, Ci renesccscdsnnececemincocetsecscasas 23, 24
Alaska Health Care Comm'n,
Transforming Health Care in Alaska
(Jan. 2011), available at http://dhss.
alaska.gov/ahcc/Documents/2010_ report.
pdf, archived at http://perma.cc/5R6C-
Vil
TABLE OF AUTHORITIES—Continued
Page(s)
America’s Healthy Future Act, S. 1796,
111th Cong. (2009)..............:scsessereresseseees 23, 24
Ariz. Health Care Cost Containment Sys.,
Notice of Request for Info. (Aug. 15,
2011), available at http://www.azahcccs.
gov/commercial/Downloads/
Solicitations/Open/RFIs/YH 12-0013/
YH12-0013.pdf, archived at
http://perma.cc/W9BN-PE668 ..............-..--. 27
Austin Bordelon et al., The Stage is Set:
Predicting State and Federal Reactions
to King v. Burwell (Jan. 2015), available
at http://www. healthreformgps.org/wp-
content/uploads/the_stage_is_set_
federal_and_state_planning_ahead_of_
king_v_burwell.pdf ............:..ssccserseeseree 35
Carrie Budoff Brown, Nelson: National
exchange a dealbreaker, Politico, Jan.
QE, BOVO .......crseccrscrersorersesersrensecroossccessseres 24
Daniel Tyson, W.Va. man plaintiff in
health care case, Register-Herald, Jan.
12, 2015, available at
http://www.register-herald.com/news/w-
va-man-plaintiff-in-health-care-
case/article_991503a3-3024-539 1-b5a8-
28d2e4a59347 html................cccceeeeeeeeeeeeees 35
Vili
TABLE OF AUTHORITIES—Continued
Page(s)
Fed. Healthcare Reform: Exchange
Planning Symposium, Background
Information and Requested Stakeholder
Input (Feb. 14, 2011), available at
www.politico.com/pdf/PPM170_symposi
um_background.pdf, archived at http://
perma.cc/R4GA-LE®@F ............. ccc. ceeeeeeeeee es 28
Ga. Health Ins. Exchange Advisory
Comm., Report to the Governor (Dec. 15,
2011), available at https://
www.statereforum.org/system/files/
1797658 13ghix_final_report_to_the_gov
ernor.pdf, archived at
http://perma.cc/9PNY-NXBL..................... 30
Greg Sargent, Mitch McConnell: We can’t
repeal Obamacare, but Supreme Court
may ‘take it down’ instead, Wash. Post:
Plum Line (Dec. 2, 2014),
http://www. washingtonpost.com/
blogs/plum-line/wp/2014/12/02/mitch-
mcconnell-we-cant-repeal-obamacare-
but-supreme-court-may-take-it-down-
GODIN o.oo ccovcsossccionvsecesnbasasiiaiuantensenn ae 34
H.R. 3962, 111th Cong. (2009) ........cescccsee0e-. 24
Health Care Reform Review Comm.,
Minutes (July 25, 2012), available at
http:/Jegis.nd.gov/assembly/62-
201 1/interim-info/minutes/hc
072512minutes.pdf, archived at
http://perma.cc/2DE4-CVB2................0000 32
ix
TABLE OF AUTHORITIES—Continued
Page(s)
Health Ins. Exchange Working Grp.,
Findings (Oct. 30, 2012), available at
http://www.doi.idaho.gov/Health
Exchange/Final_report.pdf, archived
at http://perma.cc/S285-UQWG................. 32
HTMS, Health Benefit Exchange Planning
Services: Narrative Summary (Dec. 2,
2011), available at http://www.nd.gov/
ndins/uploads/18/finalhbeplanningnarr
ative.pdf, archived at http://perma.cc
a Te 30
Humberto Sanchez and Niels Lesniewski,
Cornyn: Obamacare Repeal Vote Should
Wait, Roll Call: #WGDB (Jan. 8, 2015,
11:16 AM), http://blogs.
rolicall.com/wgdb/obamacare-repeal-
vote-should-wait-cornyn/ ......................... 34, 35
In re Starpower Commc’ns, LLC,
es BEETS F GUD vecccscccccevvescceccscees 15
Ind. Family & Social Servs. Admin..,
Comment on Proposed Rule: Health
Insurance Premium Tax Credit (Oct. 31,
2011), available at http://www.
regulations.gov/#!document
Detail; D=IRS-2011-0024-0133 ................. 30
Kaiser Family Foundation, State Exchange
Profiles: Kansas (Mar. 21, 2013),
http://kff.org/health-reform/state-profile/
state-exchange-profiles-kansas/ ............... 26
x
TABLE OF AUTHORITIES—Continued
Page(s)
Karen Langley, Council Backs Off Health
Exchange, Concord Monitor (Apr. 14,
2011), available at http://www.concord
monitor.com/ article/251216/council-
backs-off-health-exchange, archived at
http://perma.cc/KT8Y-RXZH ....................
Letter, Bruce D. Greenstein to Kathleen
Sebelius (Nov. 16, 2012), available at
http://www.dhh.louisiana.gov/assets/
media/LA_Declaration_HealthInsurance
Exchanges.pdf, archived at http://perma.
Maureen Michael, M.G.A., e¢ ai.,
Stakeholder Views about the Design of
Health Ins. Exchanges for N.J.: Volume
II i, 19-25 (Aug. 2011), available at
http://www.cshp.rutgers.edu/Down
loads/9000.pdf, archived at http://perma.
IED cetitnitenssistirinssiadbecieniiteenise
Me. Joint Select Comm. On Health Care
Reform Opportunities and Implemen-
tation, Health Ins. Exchanges: Written
Comments Submitted by Stakeholders
(Sept. 21, 2010), available at
http://www.maine.gov/legis/opla/health
reformstakeholdercomments.pdf,
archived at http://perma.cc/2DWM
32
32
29
29
xi
TABLE OF AUTHORITIES—Continued
Page(s)
Milliman, Inc., N.C. Health Benefit
Exchange Study (Mar. 31, 2011),
available at http://www.nciom.org/wp-
content/uploads/2010/12/Health-Be
nefits-Exchange-Study-DRAFT-4-2011-
03-31-FULL-REPORT.pdf, archived at
http://perma.cc/Y6FF-64XxX .....000...
N.C. Inst. of Med., Examining the Impact
of the [ACA] in N.C. (Jan. 2013),
available at http://www.nciom.org/wp-
content/uploads/2013/0 /FULL-
REPORT-2-13-2013.pdf, archived at
http://perma.cc/5X5C-HNSS .....................
Okla. Health Care Authority, Comments
on IRS Proposed Rule REG-131491-10
(Oct. 31, 2011), available at http://www.
regulations.gov/#!documentDetail;D
eS BS GE oo cccccsccsnncccasoseccescesss.
Okla. Legislature, Final Report of the
Joint Comm. on Fed. Health Care Law
(Feb. 22, 2012), available at http://www.
oksenate.gov/news/press_releases/
press_releases_2012/pr20120222b. pdf,
archived at http://perma.cc/99UF-
CORRE EEE OEE RH REE He eT eee ee
Press Release, Miss. Health Ins. Exchange
Op-Ed from Comm’r of Ins. Mike
Chaney (Nov. 20, 2012), available at
https://www.mid.ms.gov/pdf/hc-exchange
-oped.pdf, archived at
http://perma.cc/ZEB5-H9PP .....................
xii
TABLE OF AUTHORITIES—Continued
Page(s)
S.C. Dep’t of Ins., The ACA’s Impact on
Ins. Regulation, Presentation to Senate
Banking & Ins. Comm. (Mar. 23, 2011),
available at http://doi.sc.gov/Document
Center/View/2472, archived at
http://perma.cc/4PHV-E4R8 ..................... 27
S.C. Health Planning Comm., Improving
the Health Care Marketplace in S.C.
(Nov. 2011), available at
http-//doi.sc.gov/DocumentCenter/View/
2534, archived at http://perma.cc/LD8A-
Tl ciciisstntacenbeniitininatsnntsbbniadanaianaananineshins 30
S.D. Health Insurance Exchange Planning
Effort: Report for Governor Dennis
Daugaard (Nov. 3, 2011), available at
http://federalhealthreform.sd.gov/docum
ents/exchange_planning_effort_report.p
df, archived at http://perma.cc/223F-
ei necanssbocueusacicecsiactinnansgsivciptnaisiinectataiinnncian 31
State of Colo., Stakeholder Perspectives:
Health Ins. Exchange Governance and
Structure (Dec. 2010), available at
http://www.nahu.org/legislative/
exchange/HIE%20Governance%
20Structure%20Brief%20Final%201_7_
11.pdf, archived at
http://perma.cc/2HLG-68XxX ................-..+ 29
Xili
TABLE OF AUTHORITIES—Continued
Page(s)
Tom Howell Jr., House Budget chairman:
Supreme Court could unravel
Obamacare ‘pretty darn quickly’, Wash.
Times, Jan. 12, 2015, available at
http://www.washingtontimes.com/news/
2015/jan/12/tom-price-supreme-court-
could-unravel-obamacare’ ......................+: 35
U.S. Rep. Doggett: Settling for Second-Rate
Health Care Doesn’t Serve Texans, My
Harlingen News (Jan. 11, 2010),
http://www.myharlingennews.
com/?p=6426, archived at
http://perma.cc/2K3C-CFP6...................... 25
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INTERESTS OF AMICI CURIAE
Marilyn Ralat-Albernas, R.N., of Miami, Florida,
is a member of the Service Employees International
Union (SEIU) and a nurse in the postpartum division
of a hospital maternity unit.' Ms. Ralat-Albernas has
seen improved health outcomes for mothers and
infants since enactment of the Patient Protection and
Affordable Care Act (ACA). With improved access to
affordable healthcare, more soon-to-be mothers are
able to obtain prenatal care and education.
Marcus Sandling, M.D., is a third-year medical
resident in Jersey City, New Jersey, and a member of
SEIU. Dr. Sandling has noticed positive benefits of the
ACA for the low-income patients he treats at an
internal medicine clinic. More affordable healthcare
and better access to health insurance have made it
easier for Dr. Sandling to maintain relationships with
his patients and refer them to necessary specialists.
Michele Evans is a small business owner in
Bozeman, Montana, who has worked with SEIU and a
coalition of organizations to advocate for better
healthcare for all. In 2009, Ms. Evans was diagnosed
with Lyme disease. Because she could not afford
health insurance at the time, she had to pay out of
pocket for her treatment. At one point, Ms. Evans’s
husband was forced to leave his job so that he could
stay home to care for her. Ms. Evans was able to
purchase insurance in December 2014 because of the
availability of a premium tax credit. She can now
! Letters of consent from all parties are on file with the
Clerk. No counsel for a party authored this brief in whole or in
part, and no person or entity other than amici curiae made a
monetary contribution to the preparation or submission of this
brief.
2
receive regular checkups and _ routine health
screenings.
Healthcare workers in addition to
Ms. Ralat-Albernas and Dr. Sandling
Robert Blair, R.N., lives in Port St. Lucie, ‘orida,
and is a member of SEIU. He has been a nurse for
more than 15 years. Mr. Blair enjoys helping others
and believes access to healthcare is a basic human
right. In his view, the ACA’s expansion of insurance
coverage and its tax-credit provisions have helped
extend that right to all Floridians.
Michelle Boyle, R.N., is a member of SEIU and a
nurse in the Level I Trauma Center at a Pittsburgh,
Pennsylvania, hospital. Ms. Boyle’s mother-in-law
died in 1999 as the result of a chronic illness for which
she struggled to receive proper treatment because of
her lack of insurance. Ms. Boyle has noticed that since
enactment of the ACA, patients are more likely to go
to the doctor when ill rather than wait until
emergency-room care is necessary.
Mary Brooks is a member of SEIU from Portland,
Oregon. She has worked as a clinical scheduler for a
hospital’s mental-health department for 30 years. Ms.
Brooks witnessed the devastating consequences of
inadequate insurance coverage when a family member
nearly went bankrupt after falling down stairs. Ms.
Brooks believes that the ACA has not only expanded
access to affordable health insurance for all Americans
but also forced private insurance companies to cover
better quality care.
Chryseandra Roland of Atlanta, Georgia, is a
secretary in a hospital neonatal intensive care unit.
Ms. Roland believes the ACA is one of the most
significant and positive improvements to the
3
healthcare system to occur during her 41 years
working in the industry.
Healthcare consumers in addition to Ms. Evans
Rita Adamski is a member of SEIU and a home-
care worker in Salem, Oregon. Prior to enactment of
the ACA, Ms. Adamski could not afford health
insurance and was uninsured in 2013. Ms. Adamski
suffers from depression and had to turn to her church
for help paying for the therapy she needed. In 2014,
because of a premium tax credit, Ms. Adamski was
able to purchase health insurance. She now sees a
therapist regularly and, as a result, is able to lead a
more productive and meaningful life.
Jay Joshi lives in Richardson, Texas, and is part
of the Texas Organizing Project, a community
organization that works in partnership with SEIU.
After Ms. Joshi lost her job as a travel agent, she
began working part-time as a yoga instructor for
children in an after-care program. Prior to enactment
of the ACA, Ms. Joshi was able to purchase individual)
health insurance on the private market. However, her
husband, who is retired, could not buy insurance
because of his preexisting diabetic condition and, as
a result, could not afford insulin. Because of the
availability of a premium tax credit, Ms. Joshi can now
afford health insurance for herself, her husband, and
her two sons, and her husband is able to get the
treatment he needs.
Deborah McBee is a retired educator from Tilton,
New Hampshire. Her husband is an adjunct professor
and a member of SEIU. Ms. McBee’s husband is
covered by Medicare, but Ms. McBee is not yet eligible.
Before enactment of the ACA, Ms. McBee struggled to
afford health insurance and often had to reduce her
+
spending on necessities like food in order to pay for
insurance. Because of a tax credit available under the
ACA, Ms. McBee’s monthly insurance premium was
significantly reduced.
Claudette Newsome lives in Houston, Texas, and
is part of the Texas Organizing Project. Before
enactment of the ACA, Ms. Newsome and her family
were uninsured. Ms. Newsome’s husband received
cancer treatment through an experimental trial
because the trial was his least costly option, not
because it was his preferred choice. He passed away in
2010. Ms. Newsome was recently able to purchase
health insurance with a premium tax credit. She feels
that health insurance is critical to her family’s welfare
and financial stability.
Janet Wolfe is an SEIU member from Springfield,
Oregon, who works as a healthcare aide in both a
private home and in an adult foster home for the
developmentally disabled. Prior to enactment of the
ACA, Ms. Wolfe was uninsured and was unable to
afford treatment for proble ~s with her hip. Ms. Wolfe
purchased health insurance with a tax credit after
enactment of the ACA, got a hip replacement, and now
walks without pain.
Service Employees International Union
SEIU is the largest healthcare union in the United
States. More than half of SEIU’s two million members
work in the healthcare industry. SEIU supports the
ACA because it helps to ensure accessible, quality
healthcare for all Americans, including SEIU
members and their families.
5
SUMMARY OF ARGUMENT
As healthcare workers, healthcare consumers, and
the largest healthcare union in the country, amici
have witnessed first-hand the ways in which the ACA
has vastly improved access to care, health outcomes,
and overall quality of life for millions of Americans.
Amici file this brief supporting respondents to
address petitioners’ argument that their reading of the
statute gives effect to Congress’s true intent to use tax
subsidies as “carrots” (or “sticks”) to encourage states
to operate their own exchanges. As explained below,
petitioners’ carrots-and-sticks theory, developed post-
hoc for purposes of litigation, should be rejected
because it turns the ACA into a statute that is
arguably coercive and, at a minimum, disruptive of
ordinary federal-state relations, and also because it is
contrary to the ACA’s text, Congress’s stated purposes
in enacting the statute, the ACA’s legislative history,
and evidence of what the states understood when
deciding whether to set up their own exchanges, and
is not even believed by petitioners’ supporters.
ARGUMENT
To shore up their purported “plain meaning”
argument, which in fact contravenes the ACA’s text,
Respondents’ Br. 19-35, and has been anything but
“plain” to either the statute’s proponents or its
detractors, infra Parts IV-—VI, petitioners have
developed a post-hoc theory that Congress intended to
use subsidies as “carrots” (or “sticks”) to encourage
state-operated exchanges. Petitioners’ carrots-
and-sticks theory raises serious constitutional and
6
federalism questions such that it should not be
accepted unless supported by unmistakably clear
evidence of congressional intent, which is not present
here. Petitioners’ theory in fact is contradicted by the
statute, its legislative history, the record of ACA-
related state decision-making, and even the public
statements of petitioners’ supporters.
I. PETITIONERS’ CARROTS-AND-STICKS
THEORY RAISES SERIOUS CONSTITU-
TIONAL AND FEDERALISM QUESTIONS
THAT DEMAND A CLEAR STATEMENT
OF CONGRESSIONAL INTENT, WHICH IS
NOT PRESENT HERE.
Petitioners’ theory raises serious constitutional and
federalism questions because it turns the ACA into an
arguably coercive statute that disrupts ordinary
federal-state relations. The Court should not accept a
statutory construction that raises unnecessary
constitutional questions and disturbs normal federal-
state relations absent clear evidence that the proffered
construction is consistent with Congress’s intent, and
there is no such evidence here.
As an initial matter, Congress may not constitution-
ally compel states to participate in a federal program
by presenting them with what appears to be a free
choice but is in fact a choice “so coercive as to pass the
point at which pressure turns into compulsion.” Nat'l
Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2604
(2012) (NFIB) (Roberts, C.-J., joined by Breyer and
Kagan, JJ.) (internal quotation marks omitted).
Construed as petitioners urge, the ACA would present
significant questions of unconstitutional compulsion
because states, by refusing to create exchanges, would
not only forfeit subsidies but would also subject their
7
insurance markets to the “death spiral” caused by
the ACA’s market reforms in the absence of subsidies.
See, e.g., Respondents’ Br. 3-8. The doctrine of
constitutional avoidance requires rejecting such an
interpretation unless doing so would be “plainly
contrary to the intent of Congress,” which is not the
case here, as demonstrated below. New York v. United
States, 505 U.S. 144, 170 (1992) (internal quotation
marks omitted).
Moreover, even if petitioners’ view of the statute
did not raise serious questions of unconstitutional
compulsion, this Court in construing federal statutes
relies on “background principles . . . grounded in the
relationship between the Federal Government and the
States,” Bond v. United States, 134 S. Ct. 2077, 2088
(2014), that are contravened by petitioners’ reading.
Among those principles, which apply even when no
specific constitutional federalism restriction is
implicated, see, e.g., id. at 2087-94, is that the Court
will not adopt a construction that “upsetis] the usual
constitutional balance of federal and state powers”
unless its correctness is “unmistakably clear.” Gregory
uv. Ashcroft, 501 U.S. 452, 460 (1991) (internal
quotation marks, citations omitted). This rule “assures
that the legislature has in fact faced, and intended to
bring into issue, the critical matters involved in the
judicial decision.” United States v. Bass, 404 U.S. 336,
349 (1971).
Before construing statutes to “alter sensitive
federal-state relationships,” Rewis v. United States,
401 U.S. 808 (1971), and to determine whether the
legislature has in fact made its intent “unmistakably
clear,” Gregory, 501 U.S. at 460, this Court has
examined whether the overall statutory policies and
context are consistent with the proffered construction,
8
see, e.g., Bond, 134 S. Ct. at 2090; the degree to which
the construction conforms to traditional statutory
approaches taken by Congress, see, e.g., New York, 505
U.S. at 167-68; whether legislative history validates
the construction, see, e.g., Nixon v. Missouri Mun.
League, 541 U.S. 125, 140—41 (2004); and whether the
statute puts states on clear notice of the consequences
of their choices, especially of possible “massive
financial” costs. See, e.g., Pennhurst State Sch. &
Hosp. v. Halderman, 451 U.S. 1, 16-17, 24-25 (1981);
cf. NFIB, 132 S. Ct. at 2602 (Roberts, C.J., joined by
Breyer and Kagan, JJ.) (Pennhurst requirement that
states be given clear statement of potential costs “is
critical to ensuring that Spending Clause legislation
does not undermine the status of the States as
independent sovereigns in our federal system”).
As shown below, petitioners’ reading of the ACA
represents a severe deviation from the presumed
relationship between the federal government and the
states but is not supported by any of the expected
indicia of congressional intent. On petitioners’ view,
Congress coerced state decisions about their internal
operations by threatening the states with severe
injury. Yet we are to believe that Congress did so in a
manner never before seen in a federal statute, i.e., by
promising to establish intentionally ineffective and
destructive federal institutions within those states
that do not do what Congress wants, and legislated
that unprecedented scheme using language buried in
a technical provision not directed to the states’
attention, which is surrounded by other provisions
indicating that the language does not mean what
petitioners claim, and which failed to give the states
full and fair notice of the serious consequences they
faced.
9
ff. PETITIONERS’ CARROTS-AND-STICKS
THEORY IS NOT SUPPORTED BY, AND
INDEED CONTRADICTS, THE ACA’S
TEXT.
A. When Congress Incentivizes State
Action, It Does So In Clear Terms And
Not At All As In The ACA.
Petitioners’ theory is that Congress intended the
ACA’s tax subsidies to be “carrots” (or their potential
unavailability, and ensuing death spiral, a “stick”) to
encourage state-operated exchanges. If petitioners’
theory were correct, one would expect to find that
subsidy-as-incentive scheme articulated clearly in the
statute’s text, but the ACA defies such expectations: It
contains none of the clear language one would
anticipate if petitioners’ theory were true, and its
provisions seem, if anything, designed to hide the
incentive petitioners claim to have identified. The
illogic of this approach undermines petitioners’ theory,
as does the fact that Congress has always spoken
clearly in the past when it has incentivized state
action.
If Congress in fact intended to use tax subsidies as
carrots or sticks to encourage states to set up their own
exchanges, one would expect to find that incentive
scheme articulated clearly in the ACA’s text because
just as a threat is effective only if communicated, an
incentive to the states is effective only if state officials
understand what they are being encouraged to do and
what their states’ citizens stand to gain or lose
depending on their decisions. In short, Congress has
every reason, if it intends to use a carrot or stick to
incentivize the states, to make that intention
unmistakably clear.
10
The ACA’s exchange provisions, however, contain
none of the clear language one would expect if
petitioners’ theory were true. For example, if Congress
had actually intended to use subsidies as an incentive
for state-operated exchanges, it could and would likely
have made that intention clear by stating, as part of
ACA §1321, 42 U.S.C. §18041, that “tax credits under
section 36B of the Internal Revenue Code shall not be
available to anyone purchasing insurance on an
Exchange operated by the Secretary.” Cf, e.g., 42
U.S.C. §1396c. Or in the tax credit provision itself,
Congress could have defined an “eligible taxpayer” to
exclude anyone who purchases insurance on an
“exchange operated by the Secretary.” Cf, e.g.,
26 U.S.C. §223. Contra Petitioners’ Br. 20 (claiming
that Congress “could not have chosen clearer
language”).
Either of these formulations would have been much
clearer than the language on which petitioners rely,
yet the ACA, rather than using any of the above
language, seems if anything designed to obscure
petitioners’ imagined incentive scheme. Not only
did Congress fail to mention any subsidy-related
difference between state-operated exchanges and
federally facilitated exchanges (FFEs) in the statutory
sections that provide for exchanges, see 42 U.S.C.
§§18031, 18041, but also Congress (accepting petition-
ers’ theory) hid its threat to withhold subsidies from
FFEs in at-best ambiguous language in a definition of
“coverage month” where no one would expect to find it.
And Congress (again accepting petitioners’ theory)
further disguised its threat with language assuring
states that they have the “flexibility” to “elect”
whether to set up their own exchanges, without even
hinting at any significant consequences flowing from
11
those decisions. Jd. §18041(c); see also Respondents’
Br. 22-23.
Of course it makes no sense for Congress to have
hidden a key incentive (indeed, a threat of serious
harm) in such a way. Nor, in this Court’s words, does
Congress usually “hide elephants in mouseholes.”
Whitman v. American Trucking Ass’ns, Inc., 531 U.S.
457, 468 (2001).
Furthermore, if Congress did hide its key incentive
as petitioners claim, then the ACA stands in sharp
contrast to other federal statutes. When Congress has
in the past conditioned receipt of federal funds on
particular state action, it has done so in clear terms.
For example, the Medicaid statute provides that if a
state plan fails to meet federal requirements, “the
Secretary shall notify such State agency that further
payments will not be made to the State.” 42 U.S.C.
§1396c. And the other federal-funding programs cited
by petitioners’ amici as comparators contain similarly
clear language, unlike the language in the ACA on
which petitioners rely.2 Even the ACA itself is clear
about offering grants to states to set up their own
exchanges; the statute’s plain grant language, see 42
U.S.C. §18031(a), is entirely unlike the buried subsidy
incentive petitioners claim to find in the statute’s
definition of “coverage month.”
2 See 7 U.S.C. §§2013(a), 2020(g) (Supplemental Nutrition
Assistance Program); 20 U.S.C. §6311(g) (No Child Left Behind);
42 U.S.C. §280g-15(c) (medical malpractice program); 42 U.S.C.
§§602, 603, 609 (Temporary Assistance for Needy Families); 42
U.S.C. §§8654, 655(a)(4)-(5) (child support program); 42 U.S.C.
§§1397aa(b), bb, ff (Children’s Health Insurance Program); 20
U.S.C. §1412 (Individuals with Disabilities Education Act).
12
As is true of the other statutes just discussed, the
health coverage tax credits (HCTC) statute cited as a
comparator by amici Adler and Cannon is more unlike
the ACA than like it. The health-coverage credits are
stand-alone tax provisions, not part of a complex,
interconnected statutory scheme like the ACA. Thus,
while it may have made sense given the HCTC
statute’s structure for Congress to put the conditions
on those credits in the tax provisions alone, that does
not support amici’s claim that it made sense for
Congress to hide petitioners’ purported subsidy
incentive in 26 U.S.C. §36B in the very differently
structured ACA without mentioning that incentive in
the statute’s exchange provisions.
Congress also used much clearer language in the
HCTC statute. In providing credits for certain kinds
of “state-based insurance plans,” among others,
Congress introduced its “state-based” language not in
a definition of “coverage month” but in a section titled
“[qjualified health insurance”—a logical location. 26
U.S.C. §35(e)(1). And Congress did not rely on the
phrase “state-based” alone: it described qualified
state-based plans with specificity and devoted a sub-
section to explaining what qualified “state-based”
plans must be. See id. §35(e)(2). All very much unlike
the ACA language on which petitioners rely.*
3 Cf. also 26 U.S.C. §223(a), (c) (a health-savings-account
deduction will be “allowed” to “eligible individual|s],” defined to
mean, inter alia, individuals enrolled in high-deductible plans);
26 U.S.C. §§3302(a), 3305(j) (Federal Unemployment Tax Act,
providing credit for money paid “into an unemployment fund .. .
under the unemployment compensation law of a State which is
certified” as meeting certain requirements, and for the “[djenial
of credits” in states without certified laws).
13
In sum, accepting petitioners’ theory means
accepting that Congress hid and disguised its key
incentive (indeed, a threat of serious harm)—an
approach that is illogical and contrary to Congress’s
past practice and that falls far short of the
requirement that a statute be “unmistakably clear”
before it may be construed to alter the federal-state
balance of power. See Gregory, 501 U.S. at 460.
B. Congress’s Provision For FFEs Makes
No Sense Under Petitioners’ Theory.
Petitioners’ theory is also inconsistent with the
ACA’s provisions calling for the creation of FFEs.
If petitioners’ theory is correct, then FFEs, which
appear on the ACA’s face to be an effective federal
“backup” for states that choose not to set up their own
exchanges, are in fact not effective at all but infected
with a fatal flaw, i.e., the unavailability of subsidies.
Congress has never created that kind of false fallback
before, and doing so makes no sense even under
petitioners’ theory. A federal backup that appears
legitimate to the states (and even to members of this
Court) will blunt any incentive to the states to set up
their own exchanges, not encourage state-operated
exchanges.
Congress has in the past employed two different
strategies for encouraging states to implement federal
programs. Congress sometimes encourages state
action by conditioning federal grants on state
implementation of a federal regime, see New York, 505
U.S. at 167, as in the Medicaid statute. See 42 U.S.C.
§1396c. Congress has also encouraged state action by
giving states a choice between regulating an activity
themselves and having the federal government
regulate instead, in essence providing alternative
14
federal and state means for furthering the federal
government’s policy objectives. See New York, 505 U.S.
at 167-68.
The ACA’s provision for FFEs appears on its face to
be an example of the latter, federal-fallback approach.
As explained in a dissenting opinion in NFIB:
“[Blecause Congress thought that some States might
decline federal funding for the operation of a ‘health
benefit exchange,’ Congress provided a _ backup
scheme; if a State declines to participate. ., the
Federal Government will step in and operate an
exchange in that State.” NFIB, 132 S. Ct. at 2665
(Scalia, Kennedy, Thomas and Alito, JJ., dissenting).
Petitioners’ carrots-and-sticks theory, however, leads
to the conclusion that the ACA’s exchange system is
not the federal “backup” everyone has understood it to
be but is instead an entirely new scheme, previously
unknown: A coercive choice masquerading as a federal
fallback. Without subsidies, FFEs will never function
as effective exchanges, leaving FFE states worse off
than before the ACA’s enactment by exposing their
individual insurance markets to “death spiral”
pressures. See, e.g., Br. Amicus Curiae of Am.’s Health
Ins. Plans (AHIP). Thus, although ACA Title I appears
to give states a classic choice between setting up their
own exchanges or having an equally effective federal
“backup” set up for them, under petitioners’ theory
the ACA’s federal-fallback option is essentially a
sham disguising a “set-up-exchanges-or-else” coercive
choice.
Petitioners do not cite any examples of similar false-
fallback regimes in other statutes, and amici are
not aware of any. Petitioners’ amici do cite some
prototypical federal “backup” provisions, but in all
15
those statutes the federal fallbacks are real: If
states decline to regulate themselves, the federal
government steps in in a manner that achieves
Congress’s policy goals and ensures no state’s citizens
are “left out in the cold.” NFIB, 132 S. Ct. at 2665
(Scalia, Kennedy, Thomas and Alito, JJ., dissenting);
see 42 U.S.C. §7410(c)(1) (Clean Air Act); 47 U.S.C.
§252(e)(5) (Telecommunications Act); 21 U.S.C.
§661(c) (Wholesome Meat Act (WMA)); 29 U.S.C. §667
(OSHA).‘ In none of the cited statutes does the federal
government leave a state’s citizens unprotected and
outside of the federal scheme—or, indeed, worse off—
as a consequence of the state’s allowing for federal
regulation.
Nor do petitioners explain why Congress would have
acted so illogically—and would have wasted its time—-
by creating a false federal fallback. For one thing, it is
an inefficient and confusing waste of resources to
legislate an at-best useless institution. For another, a
federal backup, like an FFE, that appears effective
will blunt any incentive for states to set up their own
exchanges: if states believe there is a federal-fallback
option on which they can rely, they have less reason to
incur the cost and responsibility of implementing the
federal regime themselves. Thus, if Congress’s goal
was, as petitioners claim, to use subsidies as an
incentive, it was illogical for Congress to provide a
* See also, e.g., Fargo Packing Corp. v. Hardin, 312 F. Supp.
942, 945 (D.N.D. 1970) (federal government subjected state to
regulation under WMA); In re Starpower Commc’ns, LLC, 15
F.C.C.R. 11277 (2000) (FCC asserted jurisdiction under Telecom-
munications Act after state failed in its responsibility); 79 Fed.
Reg. 49,465 (Aug. 21, 2014) (proposed rejection of Arizona safety
standard “to allow OSHA to enforce Federal. . standards”); 71
Fed. Reg. 25,328 (Apr. 28, 2006) (federal emissions regulation
following states’ failure to regulate).
16
federal fallback, especially one that appeared even to
members of this Court to play an effective operational
role. See NFIB, 132 S. Ct. at 2664—65.
C. Other ACA Provisions Make No Sense
Under Petitioners’ Theory.
Several more of the ACA’s provisions are
inconsistent with petitioners’ theory.
First, ACA $1321 informs the states that they have
the “flexibility” to “elect” whether to set up their own
exchanges and indicates as well, using the word “such”
to refer back to “required Exchange,” that states
will not face adverse consequences for deciding
against state-operated exchanges. 42 U.S.C. §18041.
Under petitioners’ theory, however, these references to
“flexibility,” state “electlion],” and equally effective
FFEs are false and misleading: FFEs are not equally
effective, and the “flexibility” to choose between a
functioning healthcare system and an insurance-
market death spiral is no real flexibility at all.
Second, the ACA’s employer mandate is at odds with
petitioners’ theory.
If petitioners’ argument is correct, then the ACA
gives many large employers an incentive to lobby
against state-operated exchanges, which makes no
sense if Congress so strongly preferred them. As
petitioners point out, under their theory penalties
for violating the ACA’s employer mandate will not
apply in FFE states because the penalties are imposed
only if a “tax credit or cost-sharing reduction is allowed
or paid” to an employee. 26 U.S.C. §4980H(a), (b).
This gives employers an incentive to lobby for
FFEs and against state-operated exchanges, and
petitioners never explain why Congress would
17
have created that incentive if it in fact wanted to
encourage such exchanges.
And the way petitioners’ theory interacts with the
employer mandate is even more irrational and
counterproductive than that. For an employer will still
face penalties for its entire operation if even one of
its employees receives a subsidy. This means, under
petitioners’ theory, that an FFE-state employer
employing anyone who resides in a state that operates
its own exchange risks substantial penalties (i.e., if
that out-of-state employee receives a subsidy), while
another employer in the same state risks no penalties
if it employs only in-state residents. This outcome
makes no sense in relation to any imaginable policy
goals, and Congress cannot be assumed to have
intended such a bizarre result, which would present
employers with irrational competitive advantages
or disadvantages based on location within a state
(i.e., near or far from state borders) and on the
happenstance of where employees reside, and would
undermine efficient operation of interstate labor
markets by promoting job discrimination on the basis
of state residence.*
Third, the ACA’s provisions regarding “qualified
individualls]” provide more _ evidence against
petitioners’ theory, as demonstrated by the fact
that petitioners abandon any effort at consistent
statutory construction in explaining those provisions.
Petitioners’ leading argument on the qualified-
individual issue is that the term “Exchange” should be
5 Cf. Rewis, 401 U.S. at 812 (rejecting idea that Congress would
“produce situations in which the geographic origin of customers,
a matter of happenstance” would define significant federal
liabilities given “the ease . . . [of] travel and the existence of mar y
multi-state metropolitan areas”).
18
equated with “state established” for purposes of the
qualified-individual definition, see Petitioners’ Br. 48,
but not equated with “state established” in the
statutory provision for FFEs. Jd. 12. Contra, e.g.,
Maracich v. Spears, 133 S. Ct. 2191, 2205 (2013)
(statutory terms should be read consistently with one
another). And petitioners’ next argument—that non-
qualified individuals may purchase insurance on the
exchanges—flies in the face of ACA §1331(eX2), 42
U.S.C. §18051(e)(2), which equates being “treated as a
qualified individual” with being “eligible for
enrollment . . through an Exchange.” Contra, e.g.,
Maracich, 133 S. Ct. at 2205.
Fourth, ACA §1311(d)(1) must be re-written to
accommodate petitioners’ theory. Section 1311(dX1)
“require[s}” that “[a]n Exchange shall be a governmental
agency or nonprofit entity that is established by a
State.” 42 U.S.C. §18031(d\1) (emphasis added). That
requirement is consistent with §1321(c)(1)’s provision
for FFEs if, as respondents argue, FFEs are
“established by a State” for purposes of the statute
such that creation of an FFE complies with
§1311(d\1)’s_ state-establishment requirement. For
§1311(d\1) to make sense under petitioners’ theory,
however, the section’s reference to “established by the
State” must be deleted entirely and (d\1)’s verb
changed from “shall be” to “shall operate.” See Halbig
v. Burwell, 758 F.3d 390 (D.C. Cir. 2014), vacated, No.
14-5018 (Sept. 4, 2014) (re-writing §1311(d)(1) to
require only that “[aJn Exchange shall operate as a
governmental agency or nonprofit entity”). Contra,
e.g., Hall v. United States, 132 S. Ct. 1882, 1893 (2012)
(“[I]t is not for us to rewrite the statute.”); Ransom v.
FIA Card Servs., N.A., 131 S. Ct. 716, 724 (2011)
(“(Wle must give effect to every word of a statute
19
wherever possible.”) (quoting Leocal v. Ashcroft, 543
U.S. 1, 12 (2004)).
Fifth, the ACA’s interim high-risk pool for
consumers with pre-existing conditions is yet another
statutory provision that makes no sense under
petitioners’ theory. To ensure “[ijmmediate access” to
insurance for consumers with pre-existing conditions,
Congress created a temporary high-risk pool for that
group. 42 U.S.C. §18001. Congress provided that the
pool would sunset in January 2014 when consumers
could “[t]Jransition to exchange” coverage and in-
structed the Secretary to adopt transition procedures
to “ensure . . . no lapse in coverage.” Jd. §18001(gX3).
Congress’s plan for high-risk consumers works if
subsidies are available in all states because consumers
with pre-existing conditions can use subsidies to
transition to affordable exchange coverage everywhere.
But Congress’s plan falls apart under petitioners’
theory because if subsidies are unavailable in FFE
states, then the cost of insurance in those states will
skyrocket, effectively guaranteeing the “lapse in
coverage” Congress promised to prevent. See also 42
U.S.C. §18002(a)(1) (similar January 1, 2014 sunset
for temporary reinsurance program for early retirees).
Sixth, the ACA’s “[t]ransitional” reinsurance, risk
corridor, and risk adjustment programs cannot
operate as intended under petitioners’ reading.
Congress created those programs to help “stabilize
premiums .. during the first 3 years of operation of
an Exchange.” 42 U.S.C. §§18061(a), (c)(1A). The
programs operate identically in every state, which
makes sense if subsidies are available everywhere but
not if subsidies are unavailable in FFE states such
that insurance markets will function and premiums
20
fluctuate much differently in FFE states than in states
with their own exchanges.
Finally, ACA §1311(f), which provides for regional
or interstate exchanges, further undercuts petitioners’
theory that the phrase “established by the State” in
the tax-subsidy provisions excludes FFEs. Section
1311(f) provides that one exchange may operate in
multiple states if the states agree and the Secretary
approves. See 42 U.S.C. §18031(f). But if petitioners’
understanding of “established by the State” is correct,
then the citizens of some member states in interstate
exchanges will likely have no access to subsidies, e.g.,
if their states joined already-established exchanges.
Since that result makes no sense, the better reading of
§1311( is that Congress intended all exchanges
created under the ACA to be “established by the State”
for purposes of the tax subsidy provisions.
To say the least, petitioners’ carrots-and-sticks
theory runs counter to myriad ACA terms.
lil. PETITIONERS’ THEORY CONTRAVENES
CONGRESS’S PURPOSES IN ENACTING
THE ACA.
Petitioners’ theory runs counter to Congress’s stated
purposes in enacting the ACA as well. Congress passed
the ACA to “increase the number of Americans covered
by health insurance and decrease the cost of health
care.” NFIB, 132 S. Ct. at 2580. Yet, under petitioners’
theory, the ACA will lead to fewer insured Americans
and more expensive healthcare in FFE states.
As described by respondents and amicus AHIP, the
ACA’s market reforms, which apply in all states,
tend to encourage adverse selection if they stand
alone. When individuals are guaranteed the ability to
purchase insurance at a set price not based on their
21
individual health, many will “wait to purchase
health insurance until they need[} care.” 42 U.S.C.
§18091(2)(1). The remaining pool of insureds will then
skew toward the less healthy.
Adverse selection, in turn, will lead to higher
premiums for the entire pool, and higher premiums
will drive even more relatively healthy consumers
from the insurance market. The dynamic will feed on
itself, forcing premiums ever higher and the insured
population ever lower.
When the ACA functions as intended, its individual-
mandate and tax-subsidy provisions work to prevent
this “death spiral.” By requiring individual insurance
coverage and subsidizing that coverage, the mandate
and tax subsidy provisions work together to keep
healthy consumers in the market. They curb adverse
section and protect states from its adverse
consequences.
Under petitioners’ carrots-and-sticks theory, how-
ever, FFE states are left with unchecked adverse
selection. FFE states must abide by the ACA’s market
reforms but without subsidies and an effective
individual mandate. Inevitably, FFE states will
experience what Washington State and others
experienced in the 1990s, namely, fewer insureds and
higher premiums—making the ACA a tool, in FFE
states, for achieving the exact opposite of Congress's
stated goals.
IV. PETITIONERS’ THEORY IS CONTRARY
TO THE ACA’S LEGISLATIVE HISTORY.
Nor can petitioners’ carrot-and-sticks theory be
reconciled with the ACA’s legislative history, which
contains no mention of petitioners’ posited design,
much less the kind of controversy one would expect to
22
accompany such a novel and heavy-handed effort at
state coercion. Rather, the ACA’s legislative history
shows that Congress both thought it possible that the
federal government would set up exchanges and,
notwithstanding that possibility, expected subsidies to
be available in every state.
On the Senate side, Senators Orrin Hatch and Max
Baucus spoke in December 2009 about the ACA’s
provision for FFEs and made clear that they viewed
FFEs as a very real possibility. Senator Hatch objected
in strong terms to what he expected to be the federal
government’s role in operating FFEs and described
that federal role as a reason to reject the statute. See
155 Cong. Rec. $13,714, 13,726 (daily ed. Dec. 22,
2009). Senator Baucus, on the other hand, emphasized
the statute’s provision for FFEs as ensuring its
constitutionality. 155 Cong. Rec. $13,796, 13,832
(daily ed. Dec. 23, 2009).°
Simultaneous with this discussion of FFEs as a very
real possibility, various senators made clear their
understanding that tax subsidies would be available
in each state. E.g., 155 Cong. Rec. $12,356, 12,358
(daily ed. Dec. 4, 2009) (statement of Sen. Bingaman)
(ACA creates a “new health insurance exchange in
each State which will provide Americans
refundable tax credits to ensure that coverage is
® Senator Hatch’s December 2009 statement also drew a sharp
contrast between the ACA’s exchange provisions and the type of
conditional-grant legislation that petitioners claim those
provisions to be. Senator Hatch noted that in the past Congress
had “encouraged States to pass legislation,.. bribed them, .. .
even extorted them by threatening to withhold federal funds.” See
155 Cong. Rec. at 13,726. But he described the ACA as different
in that it provides for FFEs as a federal fallback. Jd.
23
affordable”); 155 Cong. Rec. $13,345, 13,375 (daily ed.
Dec. 17, 2009) (statement of Sen. Johnson) (the ACA
“will. . form health insurance exchanges in every
State” that will “provide tax credits to significantly
reduce the cost of purchasing .. coverage.”). That
understanding makes sense only if the senators
expected subsidies to be available via FFEs.
The House record is similar. In March 2010,
Representative Phil Roe noted that “[t)hirty-seven
States” were “proposing legislation to opt out” of
implementing ACA provisions if the statute were to
pass. 156 Cong. Rec. H1854, 1888 (daily ed. Mar. 21,
2010). At the same time, House members stated their
understanding that citizens would be able to “shop for
more affordable coverage on exchanges set up by
states or the Federal Government.” Jd. at 1871
(statement of Rep. Maloney). Of course insurance
would be “more affordable” only with subsidies.
Petitioners and their amici cite ACA precursor bills
as legislative history supporting their theory, but
those bills, too, aid the government’s position. For
example, when the Affordable Health Choices Act
(AHCA), passed by the Senate HELP Committee,
conditioned subsidies on states adopting certain
protections for their public employees, it did so in clear
language entirely unlike the ACA language on which
petitioners rely. See AHCA, S. 1679 111th Cong. 3142
(2009) (adding §3104 to the Public Health Service Act).
In the same section of the bill that called for “federal
fallback” exchanges, AHCA provided that citizens in
federal fallback states “shall be eligible for credits .
if the State agrees to make employers that are State
or local governments subject to sections 162 and 163 of
the [AHCA].” Id. (§3104(d)(1D)) (emphasis added).
Moreover, neither AHCA nor America’s Healthy
24
Future Act of 2009 (AHFA), passed by the Senate
Finance Committee, drew any distinction between
state-operated exchanges and FFEs with respect to
subsidies, so neither is a model for petitioners’ vision
of the ACA. See AHCA, S. 1679; AHFA, S. 1796, 111th
Cong. (2009) (not providing for FFEs at all).
Against this legislative history supporting
respondents’ view, petitioners and their amici cite two
irrelevant documents.
Senator Ben Nelson’s statement that he opposed a
“national exchange” that might “start us down the
road of.. a single-payer plan,” Carrie Budoff Brown,
Nelson: National exchange a dealbreaker, Politico,
Jan. 25, 2010, says nothing at all about support for
conditioning subsidies on state-operated exchanges.
Senator Nelson plainly opposed a policy solution akin
to that found in an earlier House bill, which would
have created a single national exchange through
which the federal government could “negotiate and
enter into contracts with [qualified insurance plans)”
on a nationwide basis. H.R. 3962, 111th Cong. §301
(2009) (as introduced in House). But the ACA, unlike
that House bill, requires separate state-by-state
exchanges, prevents the federal government from
negotiating with insurers on a nationwide basis,
grants states the first opportunity to create exchanges,
and defers to state policies in important areas even in
FFE jurisdictions, see 42 U.S.C. §§300gg(a)(2),
18021(aX1C)i), 18023(a)(1). Thus, Senator Nelson’s
opposition to a solution like that found in the earlier
House bill provides no insight into his position
regarding the very different ACA.
Indeed, it is counter-intuitive to think that Senator
Nelson, who opposed a single national exchange
because he feared federal over-reaching, would have
25
supported a federal power to coerce states to set up
their own exchanges by threatening to destroy their
insurance markets if they did not.
Petitioners’ second document, a letter from
Representative Lloyd Doggett and other Texas
Democrats, is equally irrelevant. The Doggett letter
expresses concern that the Senate version of
healthcare reform, unlike the House version that
created a “single, national health insurance
exchange,” would allow “indifferent state leadership”
to “administer” “weak, state-based exchanges,” which
would “fracture the market. . especially .. if the
state sets up multiple exchanges.” U.S. Rep. Doggett:
Settling for Second-Rate Health Care Doesn’t Serve
Texans, My Harlingen News (Jan. 11, 2010),
http://www.myharlingennews.com/?p=6426, archived
at http://perma.cc/2K3C-CFP6. The authors explained
that when “states face difficult budget years,” they
sometimes cut funding for healthcare programs, and
the “same result” could befall exchanges. Jd.
As the text of the letter reflects, Representative
Doggett and his co-signatories sought to ensure
effective operations even where state officials might
not want to operate effective exchanges; their letter
supports the need for effective FFEs. The letter, like
Senator Nelson’s statement, says nothing about the
idea of limiting subsidies to states’ operating their own
exchanges, and its one reference to FFEs implies no
difference between them and __state-operated
exchanges. Id.
V. THE STATES DID NOT INTERPRET THE
ACA AS PETITIONERS DO NOW.
If, as petitioners claim, the ACA’s tax subsidies are
“obvious[ly]” not available in FFE jurisdictions,
26
Petitioners’ Br. 20, one would expect the states to have
discussed that important fact at length when deciding
whether to set up their own exchanges. Instead, the
record of state decision-making indicates that most
states never considered the possibility that subsidies
might be unavailable in FFE states, and there is no
evidence showing that any state made its decision on
the basis of petitioners’ theory.
Under the ACA, each state had to decide whether to
operate its own exchange or to opt for an FFE, and
state officials, legislators, and contractors created a
written record of their decision-making processes.
Most states created committees to consider their
options, and in at least 20 States, a comprehensive
report was prepared for the governor, state
legislature, or other responsible entity. Some state
governments also or alternatively published partial or
tentative reports, statements to their citizens
regarding the state’s decision, or other documents
related to the exchange issue. See App.
The authors of this brief reviewed more than one
hundred documents created during the states’
decision-making processes, including documents
linked to on the “State Exchange Profiles” created by
the Kaiser Family Foundation, see, e.g., Kaiser Family
Foundation, State Exchange Profiles: Kansas (Mar. 21,
2013), http://kff.org/health-reform/state-profile/state-
exchange-profiles-kansas/, and documents we found
by searching state web domains. In total, we reviewed
190 relevant documents from 46 States (plus the
District of Columbia). See App. (listing reviewed
documents).’
’ Specifically, we reviewed all Kaiser-linked documents created
by or on behalf of state governments before January 1, 2013 that
27
Fifty of the documents we reviewed pre-date August
17, 2011, when IRS first proposed the rule at issue.
Not one of those documents mentions that subsidies
might be available only via state-operated exchanges,
while many suggest the opposite.
For example, in March 2011, the South Carolina
Department of Insurance presented to a state
legislative committee about the ACA, and in doing so,
explained both that the federal government would
establish an exchange if the state did not and, without
drawing any distinction between state-operated
exchanges and FFEs, identified as a “Minimum
Exchange Function|[]” the transmission of information
about individuals “eligible for a tax credit.”*
Similarly, an August 15, 2011 Arizona document
calling for contract proposals explains that the ACA
requires creation of an exchange in “each state, either
by the state or by the federal government, [which)
would perform a variety of functions, including
offering residents of each state the means to... receive
subsidies if eligible.”
discuss creation of individual exchanges. We then searched each
state’s web domain for additional documents (e.g., by searching
for pages containing “exchange,” “insurance,” and “subsidy”
within kansas.gov) and reviewed those additional documents
that appeared most likely to be relevant.
® S.C. Dep't of Ins., The ACA’s Impact on Ins. Regulation,
Presentation to Senate Banking & Ins. Comm., 8, 15 (Mar. 23,
2011), available at http://doi.sc.gov/DocumentCenter/View/2472,
archived at http://perma.cc/4PHV-E4R5.
® Ariz. Health Care Cost Containment Sys., Notice of Request
for Info. 3 (Aug. 15, 2011), available at http://www.azahcccs.
gov/commercial/Downloads/Solicitations/Open/RFIs/YH 12-
0013/YH12-0013.pdf, archived at http://perma.cc/W9BN-PE68.
28
And in January 2011, Alaska’s healthcare
commission wrote:
A Health Insurance Exchange will be
established for every state by 2014.
The federal government will establish
Exchanges for the states in which the State
government chooses not to participate. .
The premium credits will be advanceable and
available for purchase of insurance through
the Exchange. In addition to premium credits,
cost sharing subsidies will be provided to
individuals and households whose income is
between 100% - 400% FPL."®
The Alaska report makes no mention of what would
have been, if petitioners are correct, the salient point
that subsidies would be available only on state-
operated exchanges."’
‘© Alaska Health Care Comm'n, Transforming Health Care in
Alaska 15-16 (Jan. 2011) (emphasis added), available at
http://dhss.alaska.gov/ahcc/Documents/2010_report.pdf,
archived at http//perma.cc/5R6C-23M7.
'! See also Milliman, Inc., N.C. Health Benefit Exchange Study
19 (Mar. 31, 2011), available at http://www.nciom.org/wp-
content/uploads/20 10/12/Health-Benefits-Exchange-Study-
DRAFT-4-2011-03-31-FULL-REPORT.pdf, archived at http://per
ma.cc/Y6FF-64XX (also mentioning FFEs without discussing the
asserted unavailability of subsidies); Fed. Healthcare Reform:
Exchange Planning Symposium, Background Information and
Requested Stakeholder Input 1 (Feb. 14, 2011) (same), available
at www.politico.com/pdf/PPM170_symposium_background. pdf,
archived at http://perma.cc/RAGA-LE2F.
29
Some states consulted business and employer
groups during this period, and although such groups
were presumably well advised and would have been
interested in the issue petitioners raise, none of their
comments reflect any understanding that subsidies
might be unavailable in FFEs jurisdictions. In New
Jersey, for example, employers participated in a
series of fora ending in April 2011 and “agreed
that New Jersey should create its own exchange” in
order to retain “regulatory authority” without
mentioning that subsidies might be limited to state-
operated exchanges.'* The same employer perspective
is reflected in similar compilations from other
states, including statements from the Denver
Chamber of Commerce and the National Federation of
Independent Businesses."
And the same pattern continues in later state
documents. Several states, including amici Indiana
and Oklahoma, submitted comments after IRS
proposed the regulation at issue. None of those
comments doubt the proposed regulation’s correctness
12 See Maureen Michael, M.G.A., et al., Stakeholder Views
about the Design of Health Ins. Exchanges for N.J.: Volume II i,
19-25 (Aug. 2011), available at http//www.cshp.rutgers.edu/
Downloads/9000.pdf, archived at http://perma.ce/3HN8-NE68.
'3 See State of Colo., Stakeholder Perspectives: Health Ins.
Exchange Governance and Structure 7, 12-13 (Dec. 2010),
available at http://www.nahu.org/legislative/exchange/HIE%20
Governance%20Structure%20Brief%20Final®201_7_11.pdf,
archived at http://perma.cc/2HLG-68XX; Me. Joint Select Comm.
On Health Care Reform Opportunities and Implementation,
Health Ins. Exchanges: Written Comments Submitted by
Stakeholders 24-32 (Sept. 21, 2010), available at http://
www.maine.gov/legis/opla/healthreformstakeholdercomments
_pdf, archived at http://perma.ce/2DWM-2JUS.
30
with respect to subsidy availability.‘ Other state
documents either note that subsidies will be available
on both state-operated exchanges and FFEs" or imply
that they will be available on both without suggesting
that the statute supports any other reading."
4 See Ind. Family & Social Servs. Admin., Comment on
Proposed Rule: Health Insurance Premium Tax Credit (Oct. 31,
2011), available at http//www.regulations.gov/#!document
Detail;D=IRS-2011-0024-0133; Okla. Health Care Authority,
Comments on IRS Proposed Rule REG-131491-10 (Oct. 31, 2011),
available at http//www.regulations.gov/#!documentDetail;D
=IRS-2011-0024-0064.
'S See Ga. Health Ins. Exchange Advisory Comm., Report to
the Governor 13 (Dec. 15, 2011), available at https-/
www.statereforum.org/system/files/1797658 13ghix final_report_
to_the_governor.pdf, archived at http://perma.cc/9PNY-NX6L
(“Georgians will be eligible for . subsidies whether the
lexchange] in Georgia is established by the state or federal
government.”); HTMS, Health Benefit Exchange Planning
Services: Narrative Summary 5, 46—47 (Dec. 2, 2011), available
at http://Awww.nd.gov/ndins/uploads/18/finalhbeplanningnarr
ative.pdf, archived at http://perma.cc/PSY7-37L6 (report by
private firm, contracted by North Dakota Insurance Department,
stating that in a “federally-run exchange,” the federal
government will “transmit[] information necessary to initiate
advance payments of the premium tax credit and cost-sharing
reductions”).
'6 See, e.g.,S.C. Heaith Planning Comm., Improving the Health
Care Marketplace in S.C. 17 (Nov. 2011), available at
http://doi.sc.gov/DocumentCenter/V iew/2534, archived at
http://perma.cc/LD8A-ZRX6 (“[A]n exchange will be established
in each state; if a state chooses not to create its own exchange,
the federal government will operate one in that state. The
exchanges will provide. premium and cost-sharing subsidies
to make health insurance coverage more affordable. ”); Okla.
Legislature, Final Report of the Joint Comm. on Fed. Health Care
Law 18-20 (Feb. 22, 2012), available at http//www.
oksenate.gov/news/press_releases/press_releases_2012/pr2012
0222b.pdf, archived at http://perma.cc/99UF-VW9M (listing
31
By contrast, the states did speak bluntly and often
about other perceived advantages and disadvantages
of state-operated exchanges, suggesting they would
have discussed the subsidy issue as well if they
had agreed with petitioners’ reading. For example,
Mississippi's Insurance Commissioner advocated for a
state-operated exchange, while acknowledging that
subsidies would be available even on an FFE, so that
Mississippi could avoid “ced[ing] the regulation of a
large portion of [the] health insurance market to the
federal government.”"’
Only four of the 190 state government documents
we reviewed mention that subsidies might not be
available in FFE states, and none of those documents
aids petitioners’ argument. Two post-date litigation of
the issue so may reflect knowledge of the litigation
rather than any independent statutory assessment,
many reasons for recommending a state-operated exchenge
without any mention of the subsidy issue); N.C. Inst. of Meu .
Examining the Impact of the [ACA] in N.C. 37 (Jan. 2013),
available at http://www.nciom.org/wp-content/uploads/2013/01/
FULL-REPORT-2-13-2013.pdf, archived at http://perma.cc/
5X5C-HN59 (mentioning reasons state-operated exchange was
recommended, without mentioning subsidies); South Dakota's
Health Insurance Exchange Planning Effort: Report for
Governor Dennis Daugaard 19 (Nov. 3, 2011), available at
http-//federalhealthreform.sd.gov/documents/exchange_planning
_effort_report.pdf, archived at _ http://perma.cc/223F-G7C3
(describing benefits and advantages of an FFE without
mentioning subsidies).
'’ Press Release, Miss. Health Ins. Exchange Op-Ed from
Comm’r of Ins. Mike Chaney 1-3 (Nov. 20, 2012), available at
https://www.mid.ms.gov/pdf/hc-exchange-oped.pdf, archived at
http://perma.cce/ZEB5-H9PP.
32
and those two documents are of no help to petitioners
in any event.'®
The two documents that pre-date litigation are
equally beside the point. One North Dakota legislator
mentioned a “claim” that subsidies might not be
available in FFE states but did not indicate whether
he agreed with the claim."® And a single New
Hampshire legislator mentioned the idea in a speech
railing against the ACA, long after the New
Hampshire Executive Council effectively had ended
planning for a state-operated exchange.”
'® One, an Idaho report, mentions “talk” about the issue
without expressing a view. Health Ins. Exchange Working Grp.,
Findings 48 (Oct. 30, 2012), available at http://www.
doi.idaho.gov/HealthExchange/Final report.pdf, archived at
http://perma.cc/S285-UQWG. Another, a letter from a state
official to Secretary Sebelius, mentions the issue but notes that
the author’s state already had decided not to create an exchange
18 months earlier. Letter, Bruce D. Greenstein to Kathleen
Sebelius 1-2 (Nov. 16, 2012), available at http://Awww.dhh.
lovisiana.gov/assets/media/LA Declaration HealthInsuranceExch
anges. pdf, archived at http://perma.cc/PPS6-AP6Z.
'? Health Care Reform Review Comm., Minutes 7 (July 25,
2012), available at http:/Aegis.nd.gov/assembly/62-201 L/interim-
info/minutes/hc072512minutes.pdf, archived at http://perma.cc/
2DE4-CV52 (“[I)f there is truth to the claim that a federally
administered health benefit exchange would not allow subsidies,
this would be very serious. If this claim is accurate, the State may
need to reconsider state administration.”).
*° Compare 34 House Record 18, 28-29 (N.H. Mar. 7, 2012),
available at http//www.gencourt.state.nh.us/house/caljourns/
calendars/2012/houcal2012_18.html, archived at http://perma.
cc/BTZ2-NDXS, with Karen Langley, Council Backs Off Health
Exchange, Concord Monitor (Apr. 14, 2011), available at
http://www.concordmonitor.com/article/251216/council-backs-off-
health-exchange, archived at http://perma.cc/KT8Y-RXZH.
33
In short, we did not find any documents
demonstrating that any state made its decision about
whether to set up an exchange on the basis of
petitioners’ theory.
Petitioners’ amici’s arguments regarding the state
record do not alter the analysis. Six states have
submitted a brief claiming, after the fact, that “the
States were well aware” of the asserted subsidy
incentive, but the brief cites nothing to support the
claim. See Br. of Amici Curiae Oklahoma, et al., 15.
Other amici cite statements made by Idaho’s and
Wisconsin’s governors, which make no mention of the
subsidy issue. See Br. of Amici Curiae Galen Institute,
et al., 13. Missouri Liberty Project’s (MLP’s) claim that
Missourians voted against a state-operated exchange
with full knowledge that they were declining tax
subsidies is also unpersuasive. See. Br. of Amici
Curiae, et al., MLP 14-15 (citing only one article
published after the vote and one op-ed published nine
months earlier in a local publication).*'
The states’ ignorance of the threat supposedly made
to them undercuts petitioners’ claim that the statute
is clear, while demonstrating that petitioners’ theory
would deprive states, retroactively, of the ability to
“exercise their choice knowingly, cognizant of the
2! MLP’s brief makes similar claims about several other states,
but those claims are also not supported by the evidence MLP
cites. See id. 15—17 (citing a newspaper article pertaining to New
Jersey that makes no mention of subsidies being prohibited in
FFE jurisdictions, a New Hampshire article citing only the
president of a local think tank, and a Maine article that describes
it as at-best unclear whether the state’s decision was motivated
by petitioners’ reading of the statute, even after a review of 2,000
pages of administration documents).
34
consequences of their participation.” Pennhurst, 451
USS. at 17.
VI. EVEN PETITIONERS’ SUPPORTERS DO
NOT BELIEVE THE CARROTS-AND-
STICKS THEORY.
Although petitioners claim that Congress intended
to make subsidies available only through state-
operated exchanges, and that a ruling for petitioners
will ensure that the ACA operates as planned, many
of petitioners’ supporters and the statute’s opponents
have described a ruling in petitioners’ favor as a body
blow for the ACA that will “take it down” and from
which it will never recover—hardly a victory for
congressional intent.
Indeed, the death-blow understanding of peti-
tioners’ theory seems to be widespread, and it is
striking that in discussing a statutory-construction
case, petitioners’ supporters and ACA opponents
describe petitioners’ theory (which they did not
advance during earlier debate) as a way to destroy the
statute, rather than as a way to effectuate Congress’s
intent. For example, one senator said recently that a
victory for petitioners would “take [the ACA] down.””
Similarly, Senator John Cornyn said that if the Court
accepts petitioners’ theory, it will deal “a body blow to
Obamacare from which I don’t think it will ever
recover.” And Representative Tom Price, Chairman
22 Greg Sargent, Mitch McConnell: We can’t repeal Obamacare,
but Supreme Court may ‘take it down’ instead, Wash. Post: Plum
Line (Dec. 2, 2014), http://www.washingtonpost.com/blogs/plum-
line/wp/20 14/12/02/mitch-mcconnell-we-cant-repeal-obamacare-
but-supreme-court-may-take-it-down-instead/.
23 Humberto Sanchez and Niels Lesniewski, Cornyn:
Obamacare Repeal Vote Should Wait, Roli Call: #WGDB (Jan. 8,
35
of the House Budget Committee, has said that this
case presents a “great opportunity”—not to fulfill
Congress’s original intent—but to “unravel [] Obamacare
pretty darn quickly.””
That many of the people who want this Court to
accept petitioners’ theory as being consistent with
Congress’s intent describe it publicly as a way to
destroy the statute and undo wha‘ Congress intended
casts further doubt on petitioners’ post-hoc theory.
2015, 11:16 AM), http://blogs.rollcall.com/wgdb/obamacare-
repeal-vote-should-wait-cornyn/.
* Tom Howell Jr., House Budget chairman: Supreme Court
could unravel Obamacare ‘pretty darn quickly’, Wash. Times,
Jan. 12, 2015, available at http//www.washingtontimes.
com/news/2015/jan/12/tom-price-supreme-court-could-unravel-
obamacare/. See also, e.g., Austin Bordelon et al., The Stage is
Set: Predicting State and Federal Reactions to King v. Burwell 5
(Jan. 2015), available at http//www.healthreformgps.org/wp-
content/uploads/the_stage is_set_federal_and_state_planning_
ahead_of_king v_burwell.pdf (white paper prepared by Leavitt
Partners, the firm of former Health and Human Services
Secretary Michael Leavitt, stating that “[elimination] of
consumer subsidies through the marketplace in 34 states will
deliver a crippling blow to the healthcare law”); Daniel Tyson,
W.Va. man plaintiff in health care case, Register-Herald, Jan. 12,
2015, available at http://www.register-herald.com/news/w-va-
man-plaintiff-in-health-care-case/article_991503a3-3024-539 1-
b5a8-28d2e4a59347.html] (statement by one of the petitioners
that “courts seem to be the only way we are going to eliminate
[the ACA]”).
36
CONCLUSION
Petitioners posit a congressional plan that, if
accepted, would raise constitutional questions and
have deeply serious consequences for federal-
state relations, and thus should be rejected unless
supported by clear congressional intent. Given that
there is no evidence of such clear intent here, the
Fourth Circuit’s decision should be affirmed.
Respectfully submitted,
CLAIRE PRESTEL JUDITH A. SCOTT
DANIEL M. ROSENTHAL Counsel of Record
JAMES & HOFFMAN, P.C. NICOLE G. BERNER
1130 Connecticut Ave., NW, SERVICE EMPLOYEES
Suite 950 INTERNATIONAL UNION
Washington, D.C. 20036 1800 Massachusetts Ave., NW
(202) 496-0500 Washington, D.C. 20036
cpprestel@jamhoff.com (202) 730-7383
judy.scott@seiu.org
WALTER KAMIAT
7305 Alaska Avenue, NW
Washington, D.C. 20012
January 28, 2015
APPENDIX
la
APPENDIX
STATE DOCUMENTS REVIEWED
An * indicates a report authored by state officials, or
created at their direction, as part of the state’s deci-
sion-making process regarding exchanges.
ALABAMA
Ala. Office of Consumer Info. and Ins. Oversight, State
Planning and Establishment Grants for the ACA’s
Exchanges, Quarterly Report 2 (Apr. 7, 2011),
available at http://www.aldoi.gov/PDF/Consumers/
SQReport.pdf, archived at http://perma.cc/CUZA4-
2T4G
*Robert Carey, Ala.’s Ins. Exchange Roadmap (June
2011), available at http://Awww.insurance.alabama.
gov/PDF/Consumers/Exchange%20Roadmap%20BM
A10T1.pdf, archived at http://perma.cc/BY2P-XPX7
Press Release, Governor Bentley Signs Executive
Order Creating Ala. Health Ins. Exchange Study
Comm’n (June 2, 2011), available at http://
governor.alabama.gov/newsroom/20 1 1/06/governor-
bentley-signs-executive-order-creating-alabama-
health-insurance-exchange-study-commission/,
archived at http://perma.cc/N588-ULR2
Executive Order No. 17 (Ala. June 2, 2011), available
at https://web.archive.org/web/201 1080816010 1/
http://governor.alabama.gov/news/news_detail.aspx
?ID=5 164, archived at http://perma.cc/A2ZAF-8CTR
Press Release, Ala. Health Ins. Exchange Study
Comm’n Holds Organization Meeting (Sept. 14,
2011), available at https://web.archive.org/web/
20111205201 702/http://governor.alabama.gov/news
/‘news_detail.aspx?ID=5603, archived at http://
perma.cc/VMK4-3HK,J
2a
*Ala. Dep’t of Ins., Ala. Health Ins. Exchange
Study Comm’n Recommendations (Nov. 2011),
available at https://web.archive.org/web/2012111
6202704/http//www.governor.alabama.gov/pdfs/HIX
StudyCommissionReport.pdf, archived at https://
perma.cc/3D3S-RQLR
State of Ala., Request for Information (Feb. 23, 2012),
available at http://www.aldoi.gov/PDF/Consumers/
RFI-Alabama-HIX-14.pdf, archived at http://perma
.cc/BG2S-VAQ6
State of Ala., Request for Proposal for the Ala. Health
Ins. Exchange Sys. (June 7, 2012), available at
http://www.aldoi.gov/PDF/Consumers/FINAL-Alab
ama-HIX-RFP-v47_acceptedchange. pdf, archived at
http://perma.cc/R6EA-XS9L
Press Release, Governor Bentley Announces Ala.
Will Not Set Up State Ins. Exchange (Nov. 13,
2012), available at http://governor.alabama.gov/
newsroom/20 12/1 1/governor-bentley-announces-ala
bama-will-not-set-up-state-insurance-exchange/,
archived at http://perma.cc/2Y9H-3XE2
ALASKA
Deborah Erickson, Overview of Fed. Health Care Re-
form Legis. (May 27, 2010), available at
http://dhss.alaska.gov/Commissioner/Documents/
FederalHealth/5-27-10%200verview%200f%20Fed
%20HC%20Reform%20Law.pdf, archived at http://
perma.cc/F6HS-7CG9
*Alaska Health Care Comm’n, Transforming Health
Care in Alaska (Jan. 2011), available at http://
dhss.alaska.gov/ahcc/Documents/2010_report.pdf,
archived at http://perma.cc/5R6C-23M7
3a
*Mark A. Foster, Estimated Economic Effects in
Alaska of the PPACA, as Amended (June 30,
2011), available at http://dhss.alaska.gov/ahcc/Docu
ments/MAFA_PPACA AK Estimates _Junellc.pdf,
archived at http://perma.cc/8Z8R-V2NC
Press Release, Alaska Won’t Fund Exchanges (June
17, 2012), available at https://web.archive.org/web/
20130823 160607/http://www.gov.state.ak.us/parne!
\/press-room/full-press-release.html?pr=6195,
archived at http://perma.cc/PPD8-XPZR
*State of Alaska Dep't of Health and Human Servs.,
Health Ins. Exchange Planning: Final Report (June
21, 2012), available at http://dhss.alaska.gov/
Documents/Pdfs/AKHealthExchangeReport2012.pd
f, archived at http://perma.cc/GG8P-KGYU
ARIZONA
S.B. 1305, 49th Leg., 2nd Reg. Sess. (Apr. 24, 2010),
available at http://www.azleg.gov/legtext/49leg/2r/
bills/sb1305h.pdf, archived at http://perma.cc/EB9Z-
WS7M
Ariz. Health Cost Containment Sys., Notice of Request
for Info. (Aug. 15, 2011), available at http://www.
azahcccs.gov/commercial/Downloads/Solicitations/O
pen/RFIs/YH12-0013/YH12-0013.pdf, archived at
http://perma.cc/W9BN-PE68
Ariz. Governor’s Office, Level One Grant Application
(Sept. 2011), available at https://web.archive.org/
web/20130920185929/http://www.azgovernor.gov/hi
x/documents/Grants/L1EstGrantApp_SubmittedN
OTApproved.pdf, archived at http://perma.cc/SDS3-
BESN
4a
Ariz. Office of Consumer Info. and Ins. Oversight,
Quarterly Report (Oct. 15, 2011), available
at https://web.archive.org/web/20120413001627/
http://www.azgovernor.gov/hix/documents/QuickLi
nks/ExchangePlanningGrantReportQ4.pdf,
archived at http://perma.cc/CWP8-F7QW
H.B. 2783, 50th Leg., 2nd Reg. Sess. (Ariz. 2012),
available at http://)www.azleg.gov/legtext/50leg/2r/
bills/hb2783p.pdf, archived at http://perma.cc/
DPD5-YFEX
Ariz. Office of Consumer Info. and Ins. Oversight,
Quarterly Report (Jan. 5, 2012), available at
https://web.archive.org/web/20130920190252/http:/
www.azgovernor.gov/hix/documents/QuickLinks/Ex
changePlanningGrantReportFinal.pdf, archived at
http://perma.cc/V32U-RM2Y
State of Ariz., Health Ins. Exchange: Request for Pro-
posal (Feb. 2, 2012), available at http://www.
azahcccs.gov/commercial/Downloads/Solicitations/Y
H12_0023/AZ_HIX_RFPSoliticationNoYH 12-
0023.pdf, archived at http://perma.cc/B2V4-9533
Beth Lazare, Ariz. Health Care Cost Containment
Sys., Health Ins. Exchange and ACA Update
(Aug. 23, 2012), available at http://www.azdhs.gov/
diro/documents/forums/2012/health-insurance-
exchange-affordable-care-act.pdf, archived at
http://perma.cc/45VK-9W2D
Letter, Janice K. Brewer to Gary Cohen (Nov. 28,
2012), available at https://web.archive.org/web/
20130122090103/http://azgovernor.gov/dms/upload/
PR_112812_CohenLetter.pdf, archived at
http://perma.cc/D67M-E3FE
5a
ARKANSAS
Ark. Ins. Dep’t, Request for Proposal (Jan. 30, 2012),
available at https://web.archive.org/web/20131012
144029/http://hbe.arkansas.gov/RFQ_ID-12-0001.
pdf, archived at http://perma.cce/RRD6-6R8J
Jay Bradford & Cynthia Crone, Ark. Ins. Dep't,
Update on Federally-Facilitated Health Benefits
Exchange Partnership Planning in Ark. (July 18,
2012), available at http://hbe.arkansas.gov/Present
ation.pdf, archived at http://perma.cc/A2R4-ETLH
Arkansas Federally-Facilitated Exchange Partnership
Open Marketplace/Active Purchaser Recommenda-
tions (Sept. 17, 2012), available at http://www.
hbe.arkansas.gov/FFE/Plan/Recommendations/9-
17-2012. pdf, archived at http://perma.cc/784G-VV8F
CALIFORNIA
Assembly Bill 1602, 2009-2010 Reg. Sess. (Cal. Sept.
30, 2010), available at http://www.leginfo.ca.
gov/pub/09-10/bill/asm/ab_1601-1650/ab_1602_bill
_20100930_chaptered.html, archived at http://
perma.cc/C3ZY-5J47
Senate Bill 900, 2009-2010 Reg. Sess. (Cal. Sept. 30,
2010), available at http-//www.leginfo.ca.gov/pub/
09-10/bill/sen/sb_0851-0900/sb_900_bill_20100930_
chaptered.html, archived at http://perma.cc/J92R-
JZ7F
Cal. Health Benefit Exchange Bd., Minutes (Sept.
18, 2012), available at http://board.coveredca.com/
meetings/2012/10%200ct-30%20Meeting%20Mater
ials/PDFs/TV_HBEX_091812BoardMeetingMinutes
_103012.pdf, archived ot http://perma.cc/9CX8-
C5P7
6a
Cal. Health Benefit Exchange, 2012-2013 Initial
Qualified Health Plan Solicitation to Health
Insurers (Nov. 16, 2012), available at http://
www.oal.ca.gov/res/docs/pdf/emergencies/recent%2
Oaction,%20moved%20emergencies/2013-0703-03
EE _2App.pdf, archived at http://perma.cc/Y2D2-
6UDH
COLORADO
*State of Colo., Implementing Health Care Reform:
A Roadmap for Colo. (Dec. 2010), available at
http://www.colorado.gov/cs/Satellite%3Fblobcol%3D
urldata%26blobheader%3Dapplication%252F pdf%2
6blobkey%3Did%26blobtable%3DMungoBlobs%26b
lobwhere%3D1251682472168%26ssbinary%3Dtrue,
archived at https://perma.cc/5M5S-ATQ6
State of Colo., Stakeholder Perspectives: Health Ins.
Exchange Governance and Structure (Dec. 2010),
available at http://www.nahu.org/legislative/exch
ange/HIE%20Governance%20Structure%20Brief%
20Final%201_7_11.pdf, archived at http://perma.cc/
2HLG-68XX
Senate Bill 11-200, 68th Gen. Assembly (Colo. June
1, 2011), available at http://www.leg.state.co.us/
clics/clics201 1a/csl.nsf/fsbillcont/7233327000DC9A
078725780100604CC4?0pen&file=200_ren. pdf,
archived at http://perma.cc/LJ2D-JLQS
CONNECTICUT
An Act Establishing a State Health Ins. Exchange,
Pub. L. No. 11-53 (Conn. July 1, 2011), available at
http://www.cga.ct.gov/2011/ACT/PA/2011PA-00053-
ROOSB-00921-PA.htm, archived at http://perma.cc/
Q8WY-MK3E
Ta
*Conn. Health Ins. Exchange, Exchange Plan: Rec-
ommendations for the Successful Implementation of
the Conn. Health Ins. Exchange (Feb. 1, 2012),
available at http://www.healthreform.ct.gov/ohri/
lib/ohri/exchange/1-19-12/exchange_plan_-_draft1
_19_12.pdf, archived at http://perma.cc/9VJG-72EF
Conn. Health Ins. Exchange, Bd. of Directors Meeting
(Sept. 27, 2012), available at https://jwww.state
reforum.org/sites/default/files/postingbod_meetings
lides_92712 final_pvl-5ii.pdf, archived at http://
perma.cc/GEX8-LHDS
Conn. Health Ins. Exchange, Plan Mgm’t Overview
(Oct. 10, 2012), available at http://www.ct.gov/
hix/lib/hix/Memo_Plan_Management_Overview_ 10
1512.pdf, archived at http://perma.cc/RU5C-S8E2
DELAWARE
Del. Health Care Comm’n, Del. QHP Certification
Standards (Nov. 1, 2012), available at http://
dhss.delaware.gov/dhss/dhcc/files/certificationstand
ardsNovl.pdf, archived at http://perma.cc/6L2D-
U626
Letter, Jack A. Markell to Kathleen Sebelius (Nov. 14,
2012), available at https://web.archive.org/web/
20130115185927/http://www.healthcare.gov/law/res
ources/letters/de-exchange-letter.pdf, archived at
http://perma.cc/7M4B-CQMQ
DISTRICT OF COLUMBIA
D.C. Act. 19-269 (D.C. Jan. 17, 2012), available at
http://www.dcregs.dc.gov/Notice/DownLoad.aspx?N
oticeID=1889092, archived at https://perma.cc/
ZY2J-W7DF
8a
GEORGIA
Executive Order (Ga. June 2, 2011), available at
https://web.archive.org/web/20120813174313/http://
gov.georgia.gov/vgn/images/portal/cit_1210/21/41/1
7217485106_02_11_01.pdf, archived at http://perma
cc/9YJH-8NCH
*Ga. Health Ins. Exchange Advisory Comm., Report to
the Governor (Dec. 15, 2011), available at
https://www.statereforum.org/system/files/1797658
13ghix_final_report_to_the_governor.pdf, archived
at http://perma.cc/9PNY-NX6L
Press Release, Ga. Will Not Set Up State Exchange
(Nov. 16, 2012), available at http://gov.georgia.gov/
press-releases/2012-11-16/deal-georgia-will-not-set-
state-exchange, archived at http://perma.cc/NFS5-
QW5L
HAWAII
Act 205 (Haw. July 8, 2011), available at http://www.
capitol. hawaii.gov/session201 1/bills/GM1309_.pdf,
archived at http://perma.cc/TB4K-N6AZ
Press Release, Governor Affirms Commitment to a
State-Based Health ins. Exchange (June 13,
2012), available at http://archive2014.abercrom-bie
-hawaii.gov/blog/governor-affirms-commitment-to-
a-state-based-health-insurance-exchange/, archived
at http://perma.cc/3.J94-56NE
IDAHO
S.B. 1115, 61st Leg., Ist Reg. Sess. (Idaho Apr. 1,
2011), available at http://www.legislature.idaho.
gov/legislation/2011/S1115.pdf, archived at
http://perma.cce/73LN-3KBA
9a
Executive Order 2011-03 (Idaho Apr. 20, 2011),
available at http://gov.idaho.gov/mediacenter/exec
orders/eol l/eo_2011_03.html, archived at http://
perma. cc/K42R-MR82
Press Release, Governor Opts to Seek Fed. Funding
for Implementing State-Based Health Exchange
(Sept. 20, 2011), available at http://gov.idaho.gov/
mediacenter/press/pr201 1/prsept11/pr_053.html,
archived at http://perma.cc/BRFQ-9AXY
Draft Legis. Regarding Idaho Health Ins. Exchange
(Nov. 9, 2011), available at http://www.legis
lature.idaho.gov/sessioninfo/20 1 1/interim/healthcar
e1117_deal2.pdf, archived at http://perma.cc/L9QT-
CMZB
Press Release, Idaho’s Next Steps on Obamacare Re-
quire Further Study, Careful Consideration (July
10, 2012), available at http://gov.idaho.gov/media
center/press/pr2012/7Jul/pr_32.html, archived at
http://perma.cc/Y48G-J9K7
*Idaho Health Ins. Exchange Working Grp.,
Findings (Oct. 30, 2012), available at http://www.
doi.idaho.gov/HealthExchange/Final_report. pdf,
archived at http://perma.cc/S285-UQWG
Press Release, Governor Opts for State-Based Ex-
change; Legislature Still Must Weigh in on
Health Ins. Issue (Dec. 11, 2012), available at
http://gov.idaho.gov/mediacenter/press/pr2012/12D
ec/pr_64.htm!, archived at http://perma.cc/J292-
5GSK
10a
ILLINOIS
Pub. Act 097-0142 (Ill. July 14, 2011), available ai
http://www.ilga.gov/legislation/publicacts/97/PDF/0
97-0142.pdf, archived at http://perma.cc/GV24-
NBPM
Iii. Dep’t of Ins., Performance Progress Report (June
30, 2012), available at http://insurance.illinois.gov/
hiric/ILLevelOneExEstGrantRpt073012.pdf,
archived at http://perma.cc/7E4T-RGHB
INDIANA
Executive Order 11-01 (Ind. Jan. 3, 2011), available at
http://www.in.gov/legislative/iac/20110119-IR-GOV
110047EOA.xml.pdf, archived at http://perma.cc/
3GW4-Y98Q
State of Ind., Ind. Ins. Market Level One Funding
Solicitation (2011), available at http://www.
statecoverage.org/files/IN_InsuranceMarketGrant]
TGAPSummary_2011.pdf, archived at
http://perma.cc/D7GW-677G
State of Ind., Quarterly Report: Performance Progress
Report, Ind. Ins. Market, Level One Solicitation
(Oct. 30, 2011), available at http://www.in.gov/
aca/files/HIX_Level_One_Quarterly_Report.pdf,
archived at http://perma.cc/2T27-BHJL
Letter, Michael A Gargano & Stephen P. Robertson to
Kathleen Sebelius (Jan. 10, 2012), available at
http://www.in.gov/aca/files/Indiana_Exchange_Cert
ification_Application_Comments.pdf, archived at
http://perma.ce/J49T-WTYE
lla
IOWA
lowa Dep’t of Human Servs., lowa Design Review Evi-
dence: State Partnership Model (Nov. 14, 2012),
available at http://www.iid.state.ia.us/sites/default/
files/press_release/2013/02/15/ia_hbe_design_revie
w_section_4_plan_managementl_pd_20878.pdf,
archived at http://perma.cc/32EL-BPRU
Letter, Terry E. Branstad to Kathleen Sebelius
(Dec. 14, 2012), available at http://Awww.cms.gov/
CCI1O/Resources/Technical-Implementation-Letter
s/Downloads/ia-exchange-letter.pdf, archived at
http://perma.cc/26VK-TKGY
KANSAS
Kan. Dep't of Ins., Ins. Benefits Exchange: Steering
Committee Notes (Oct. 20, 2011), available at
http://www.ksinsurance.org/hbexplan/files/2011102
4 gpid2 Edited_Steering Committee_10-20-11_not
es.pdf, archived at http://perma.cc/Z498-9EUD
Testimony of Ins. Comm’r Sandy Praeger before Spe-
cial Comm. on Fin. Inst. and Ins., Overview of the
PPACA Requirements for the Development and
Implementation of a Health Insurance Exchange,
Exchange Options, and Planning Status Report
(Oct. 24, 2011), available at http://www.ksin
surance.org/hbexplan/files/slcfi/Exchange_Require
ments.pdf, archived at http://perma.cc/628R-XM9G
KENTUCKY
Ky. Office of Health Policy, Stakeholder Perspectives
on Health Benefit Exchanges (June 2012),
available at http://healthcarereform.ky.gov/grants/
Documents/Stakeholder®%20Report%2020 12. pdf,
archived at http://perma.cc/5SGG-V2S6
12a
Executive Order 2012-587 (Ky. July 17, 2012),
available at http://apps.sos.ky.gov/Executive/Jour
nal/execjournalimages/2012-MISC-2012-0587-2229
43.pdf, archived at http://pe rma.cc/W8JP-FUR6
Press Release, Gov. Beshear Appoints Members to
Health Exchange Bd. (Sept. 18, 2012), available at
http://migration.kentucky.gov/Newsroom/gover
nor/20120918healthboard.htm, archived at http://
perma.cc/SA68-Z5DR
Ky. Health Benefits Advisory Bd., Meeting Minutes
(Dec. 20, 2012), available at http://healthbenefit
exchange.ky.gov/Documents/KHBE%20Advisory%2
OBd%20Mtg%20Minutes%20 12-20-12.pdf, archived
at http://perma.cc/3D5U-9QWL
LOUISIANA
Senate Bill 744, 2012 Reg. Sess. (La. introduced Apr.
3, 2012), available at http://www.legis.la.gov/legis/
View Document.aspx?d=794947, archived at
http://perma.cc/RL69-PQ25
Letter, Bruce D. Greenstein to Kathleen Sebelius,
(Nov. 16, 2012), available at http://www.dhh.louisi-
ana.gov/assets/media/LA_Declaration_HealthInsur
anceExchanges.pdf, archived at http://perma.cc/
PPS6-AP6Z
MAINE
H.P 1165—L.D. 1582, 125th Leg., lst Reg. Sess. (Me.
July 6, 2011), available at http://www.mainelegis
lature.org/legis/bills/getPDF .asp?paper=HP1165&it
em=2&snum=125, archived at http://perma.cc/
WW8M-R4C6
13a
Comm’r Anne L. Head, Me. Dep’t of Profl and Fin.
Reg., Memorandum Regarding Admin. Rec. on
Structure/Governance (Sept. 13, 2011), available
at http://www.dirigohealth.maine.gov/Documents/
Health®%20Exchange%20recommendation. pdf,
archived at http://perma.cc/R94U-JW2P
*Advisory Comm. on Me.’s Health Ins. Exchange, Rec.
Regarding the Maine Health Benefit Exchange
(Sept. 20, 2011), available at http://www.dirigo
health.maine.gov/Documents/Advisory%20Committ
ee%20Report%200n%20Health%20Insurance%20E
xchange%20%28F inal%209-20-11%29. pdf, archived
at http://perma.cce/UQ75-H32X
State of Me., Level One Establishment Grant—
Project Narrative (Sept. 29, 2011), available
at http://www.dirigohealth.maine.gov/Documents/
ME_L1 Project_Narrative_09292011_FINAL.pdf,
archived at http://perma.cc/E4RX-CL8J
Press Release, Me. Issues Letter to Fed. Health
Officials Opting Out of Health Ins. Exchanges
(Nov. 16, 2012), available at http://content.
govdelivery.com/bulletins/gd/MEGOV-5cfe96#.UKZ
voA8Yogk, archived at http://perma.cc/PGJ9-H5K7
MARYLAND
House Bill 166 (Md. Apr. 12, 2011), available at
http://mlis.state.md.us/201 1rs/chapters_noln/Ch_2_
hbO166T pdf, archived at http://perma.cc/UQH4-
EKA2
Maryland Health Benefits Exchange Bd., Meeting
Minutes (Feb. 14, 2012), available at http://dhmh.
maryland.gov/exchange/pdf/Health%20Benefit%20
Exchange%20Board%20minutes_Feb2012. pdf.
archived at http://perma.cc/6E4K-5PJ8
l4a
House Bill 443 (Md. May 2, 2012), available at
http://mlis.state.md.us/2012rs/bills/hb/hb0443t. pdf,
archived at http://perma.cc/VTW7-Q8U4
State of Md., Md. Health Benefit Exchange Level Two
Establishment Grant Application (June 12, 2012),
available at http://dhmh.maryland.gov/exchange/
pdf/Level2_site.pdf, archived at http://perma.cc/
BAZ2-SNEW
Joint Comm. on Md. Health Benefit Exchange
Financing, Options for Financing the Md. Health
Benefits Exchange (Dec. 1, 2012), available at
http://www.healthreform.maryland.gov/wp-content
/uploads/2012/12/Options-for-Financing-the-Maryla
nd-Health-Benefit-Exchange.Joint-Committee-
Report-and-Recommendations.pdf, arched = at
http://perma.cc/KT98-VPXA
MICHIGAN
Rick Snyder, A Special Message from Governor Rick
Snyder: Health and Wellness (Sept. 14, 2011),
available at _ http://www.michigan.gov/snyder/
0,4668,7-277--262254--,00. html, archived at
http://perma.cc/BUZ2-D5VD
Press Release, Mich. Moves Towards State-Fed. Part-
nership Health Exchanges, Leaves Door Open for
MI Health Marketplace (Nov. 16, 2012), available at
http://www. michigan.gov/snyder/0,4668,7-277-5757
7-290046--,00.html, archived at http://perma.cc/
LUS4-MAC9
MINNESOTA
Executive Order 11-30 (Minn. Oct. 31, 2011), available
at http://mn.gov/governor/images/EO- 1 1-30.pdf,
archived at http://perma.cc/8PB6-XMGN
15a
*Jonathan Gruber, et al., The Impact of the ACA and
Exchange on Minn. (Apr. 2012), available at
http://mn.gov/commerce/insurance/images/Exch
GruberGormanFinalReport4-12.pdf, archived at
http://perma.cc/5UPE-R6ZH
MISSISSIPPI
Miss. Ins. Dep't, Application for Cooperative
Agreement to Support Establishment of State-
Operated Health Ins. Exchange (June 29, 2011),
available at http:/Awww.mid.ms.gov/pdf/MS_Exch
ange_Establishment_Grant_Application.pdf,
archived at http://perma.cc/E4JA-Q95T
Mike Chaney, Miss. Comm’r of Ins., Bulletin Regard-
ing Application Requirements and Appointment
Procedure for Establishment of Health Ins.
Exchange Advisory Bd. and Subcomm. (Oct. 18,
2011), available at http://www.mid.ms.gov.bullet
ins/20119bul.pdf, archived at http://perma.cc/B5ZB-
WV32
Miss. Comprehensive Health Ins. Risk Pool Ass’n, Re-
quest for Proposals for a Health Ins. Exchange
Portal (Phase 1) (Nov. 16, 2011), available at
http://www.mshie.org/images/user_files/files/MS%2
OCHIRPA%20EXCHANGE%20PORTAL%20RFP%
2011-16-2011.pdf, archived at _ http://perma.cc/
K63A-WPZS
Presentation, Inaugural Meeting of the Miss.
Health Ins. Exchange Advisory Bd. (Jan. 31, 2012),
available at http://www.mid.ms.gov/pdf/ExcMtg
SlideShow 013112.pdf, archived at http://perma.cc/
K63A-WPZS
16a
Miss. Comprehensive Health Ins. Risk Pool Ass’n,
Request for Proposals for a Health Ins. Exchange
Portal (Phases 2 and 3) (May 22, 2012), available
at http:/Awww.mshie.org/images/CHIRPA-Associa-
tion_HIX_RFP_002-FINAL-5-22-12_BEF.docx,
archived at http://perma.cc/HP9E-RSCE
Miss. Health Ins. Exchange Advisory Bd., Meeting
Minutes (Nov. 14, 2012), available at http://
www.mid.ms.gov/pdf/ExcAdvBoardMtgMinutes111
42012.pdf, archived at http://perma.cc/TF9T-CEE6
Presentation, Miss. Health Ins. Exchange Advisory
Bd. (Nov. 14, 2012), available at http://(www.mid.ms.
gov/pdf/ExchAdvisoryBoadMtgPresentation111420
12.pdf, archived at http://perma.cc/6R3M-3NRR
Letter, Mike Chaney to Gary Cohen (Nov. 14,
2012), available at https://www.mid.ms.gov/pdf/
ExchDecLtr.pdf, archived at http://perma.cc/FL6W-
ACLE
Press Release, Miss. Health Ins. Exchange Op-Ed
from Comm’r of Ins. Mike Chaney (Nov. 20, 2012),
available at https://www.mid.ms.gov/pdf/hc-exchan
ge-oped.pdf, archived at http://perma.cc/ZEB5-
H9PP
MONTANA
House Bill 124, 62nd Leg. (Mont. introduced Dec. 15,
2010), available at http:/Aeg.mt.gov/bills/2011/
hb0199/HB0124 1.pdf, archived at http://perma.cc/
ZS9A-4ZTQ
House Bill 620, 62nd Leg. (Mont. introduced Mar. 18,
2011), available at http://leg.mt.gov/bills/2011/
hb0699/HB0620_1.pdf, archived at http://perma.cc/
DC9G-4HR9
17a
Senate Bill 176, 62nd Leg. (Mont. vetoed Apr. 4, 2011),
available at http:/Mleg.mt.gov/bills/2011/sb0199/
SB0176_x.pdf, archived at http://perma.cc/VMC9-
FNVR
Senate Bill 228, 62nd Leg. (Mont. vetoed Apr. 13,
2011), available at http:/Meg.mt.gov/bills/2011/
sb0299/SB0228 x.pdf, archived at http://perma.cc/
XEE4-DBRG
House Joint Resolution 33, 62nd Leg. (Mont. Apr. 29,
2011), available at http://leg.mt.gov/bills/2011/
billpdf/HJ0033.pdf, archived at http://perma.cc/
TVVS-K4N7
NEBRASKA
Legislative Bill 835, 102nd Leg. (Neb. introduced Jan.
5, 2012), available at http://nebraskalegislature.gov/
FloorDocs/102/PDF/Intro/LB835.pdf, archived at
http://perma.cc/T95W-4VB2
Legislative Bill 838, 102nd Leg. (Neb. introduced
Jan. 5, 2012), available at http://nebraska
legislature.gov/FloorDocs/102/PDF/Intro/LB838. pdf,
archived at http://perma.cc/H2Y6-6Y3E
State of Neb., Request for Proposal (Mar. 12, 2012),
available at http://www.doi.nebraska.gov/rfp/RFP _
12-002Z /RFP_12-002Z1.pdf, archived at
http://perma.cc/5U4K-LANZ
Neb. Dep’t of Ins., Presentation to the Banking, Fin..,
and Ins. Comm. (Sept. 14, 2012), available at
https://www.statereforum.org/sites/default/files/neb
raska_public_meetings_9-14-12.pdf, archived at
http://perma.cc/2G5D-2WJR
18a
Neb. Dep’t of Ins., State of Neb.’s Health Ins. Ex-
change: A Presentation to the Public (Sept. 2012),
available at https://www.statereforum.org/sites/
default/files/nebraska_public_meetings_9-14-
12.pdf, archived at http://perma.cc/NTH9-JYVP
NEVADA
Senate Bill 440, 76th Sess. (Nev. June 16, 2011),
available at http://Awww.leg.state.nv.us/Session/
76th2011/Bills/SB/SB440_EN.pdf, archived’ at
http://perma.cc/D86C-PAL9
Silver State Health Ins. Exchange, Plan Certification
and Management (Apr. 12, 2012), available at
http://exchange.nv.gov/uploadedFiles/exchangen-
vgov/Content/Meetings/CommitteeRecommendatio
nsApprovedbytheBoard%20April%2012%202012%2
OPCM.pdf, archived at http://perma.cc/AGX3-EHE7
Silver State Health Ins. Exchange, Summary of
Recommendations Approved by the Bd. (June 14,
2012), available at https://www.statereforum.
org/sites/default/files/09a-board_approved_recomm
endations.pdf, archived at http://perma.cc/XZ8H-
4B53
Silver State Health Ins. Exchange, Design Review Sec.
2.0 Consumer Stakeholder Engagement and Sup-
port (Oct. 4, 2012), available at http://exchange.
nv.gov/uploadedFiles/exchangenvgov/Content/Repo
rts/Design_Review_Evidence_Matrix_2_2012_ 10 0
4. pdf, archived at http://perma.cc/2LG3-2FWG
19a
*Silver State Health Ins. Exchange, Advisory
Comm. Recommendations (Dec. 24, 2012), available
at http//exchange.nv.gov/uploadedFiles/exchange
nvgov/Content/About/Board%20Approved%20Reco
mmendations.pdf, archived at http://perma.cc/
MUL2-M5VA
NEW HAMPSHIRE
HB 601, 2011 Sess. (N.H. June 22, 2011), available
at http://www.gencourt.state.nh.us/legislation/201 1/
HBO0601.html, archived at http://perma.cc/LW8D-
HMG9
Press Release, Governor Lynch’s Statement on Allow-
ing HB 601 to Become Law Without His Signature
(July 14, 2011), available at https://web.archive.org/
web/20110719035104/http://www.governor.nh.gov/
media/news/2011/071411-hb601.htm, archived at
http://perma.cc/T37U-4DDF
34 House Record 18 (N.H. Mar. 7, 2012), available at
http:/Awww.gencourt.state.nh.us/house/caljourns/
calendars/2012/houcal2012 18.html, archived at
http://perma.cc/BTZ2-NDXS
HB 1297, 2012 Sess. (N.H. June 21, 2012), available af
http://www.gencourt.state.nh.us/legislation/2012/H
B1297.html, archived at http://perma.cc/Y46D-
XYT2
Press Release, First Meeting of Health Exchange
Advisory Bd. (Oct. 31, 2012), available at
http://www.nh.gov/insurance/media/pr/2012/docum
ents/pr_103112.pdf, archived at http://perma.cc/
RFC7-ALBJ
20a
State of N.H., The ACA in N.H. (Nov. 9, 2012),
available at http:/www.nh.gov/insurance/consume
rs/documents/aca_bullets-faq.pdf, archived at
http://perma.cc/3W2F-9PE8
NEW JERSEY
Joel C. Cantor, et al., Stakeholder Views about the De-
sign of Health Ins. Exchanges for N.J.: Volume [
(Aug. 2011), available at http://www.cshp.rut-
gers.edu/Downloads/8980. pdf, archived at
http://perma.cc/74KV-K8VE
Joel C. Cantor, et al., Stakeholder Views about the
Design of Health Ins. Exchanges for N.J.: Volume
II (Aug. 2011), available at http://www.cshp.
rutgers.edu/Downloads/9000. pdf, archived at
http://perma.cc/3HN8-NE68
Joel C. Cantor, et al., Stakeholder Views about the De-
sign of Health Ins. Exchanges for N.J.: Volume II
(Aug. 2011), available at http://www.cshp.rutgers.
edu/Downloads/8990.pdf, archived at http://perma.
cce/Z.CK8-5C9Z
*Joel C. Cantor, et al., Health Ins. Status in N.J. After
Implementation of the ACA (Aug. 2011), available
at http://www.cshp.rutgers.edu/Downloads/8970.
pdf, archived at http://perma.cc/Z6XA-MB4B
*John V. Jacobi, Health Ins. Exchanges: Governance
Issues for NJ. (Sept. 2011), available at
http://www.cshp.rutgers.edu/Downloads/9020. pdf,
archived at http://perma.cc/PG9H-KHYC
Rutgers Center for State Health Policy, Summary of
Proceedings: Stakeholder Forums to Discuss Gov-
ernance Options for a N.J. Health Ins. Exchange
(Dec. 2011), available at http://www.cshp.rutgers.
2la
edu/Downloads/9160.pdf, archived at http://perma.
cc/X882-K88A
Assembly Bill 2171, 215th Leg. (N.J. vetoed May 10,
2012), available at http:/Awww.njleg.state.nj.us/
2012/Bills/A2500/2171_R1.HTM, archived at http://
perma.cc/P2KT-VKQN
*John V. Jacobi, Active or Passive: The Role of a New
Jersey Health Ins. Exchange (Aug. 2012), available
at _—http://www.cshp.rutgers.edu/Downloads/9530.
pdf, archived at http://perma.cc/3USQ-ZBUE
*Joel C. Cantor, Preventing Adverse Risk Selection in
N.J.’s Health Ins. Exchange and the Outside Indi-
vidual and Small-Group Markets (Aug. 2012),
available at http//www.cshp.rutgers.edu/Downloads/
9510.pdf, archived at http://perma.cc/ZZS6-NQ6V
*Kate Greenwood, The Health Ins. Exchange, the
Medicaid Program, and the Apportionment of
Responsibility for Determining Eligibility and
Effectuating Enrollment in N.J. (Aug. 2012),
available at http://www.cshp.rutgers.edu/Down
loads/9500.pdf, archived at http://perma.cc/4DV7-
3X8T
Chris Christie, Message to the Senate Regarding Veto
of Senate Bill No. 2135 (Dec. 6, 2012), available at
http://www.state.nj.us/governor/news/news/552012
/pdf/20121206b_S-2135AV.pdf, archived at http://
perma.cc/7 DG7-JDR4
Senate Bill 2135, 215th Leg. (NJ. vetoed Dec. 17,
2012), available at http://www.njleg.state.nj.us/
2012/Bills/S2500/2135_R1.HTM, archived at http://
perma.cc/R2WN-N849
22a
NEW MEXICO
N.M. Dep’t of Human Servs., N.M. Level 1 Health
Ins. Exchange Establishment Grant (Sept. 2011),
available at https://Aweb.archive.org/web/20111116
2029 15/http://www.hsd.state.nm.us/pdf/hcr/NM%20
Health%20Insurance%20Exchange%20Establishm
ent%20Grant.pdf, archived at http://perma.cc/C7T2-
5B23
Press Release, Governor Susana Martinez Announces
Award of Health Ins. Exchange Grant (Nov. 29,
2011), available at http:/Awww.governor.state.
nm.us/uploads/PressRelease/191a415014634aa896
04e0b4790e4768/health®20insurance%20grant%20
11.29. pdf, archived at http://perma.cc/S2ZE-NGQY
*The Hilltop Inst., N.M. Health Care Reform Fiscal
Model: Detailed Analysis and Methodology (Mar.
2012), available at https://web.archive.org/web/
20130319081803/http://www.hsd.state.nm.us/pdf/h
cr/New%20Mexico%20Health%20care%20Reform%
20Fiscal%20Model%20Report.pdf, archived at
http://perma.cc/WX56-U8Y7
Letter, Susana Martinez to Kathleen Sebelius (Dec.
13, 2012), available at https://web.archive.org/
web/20130115181149/http://cciio.cms.gov/Archive/T
echnical-Implementation-Letters/nm-declaration-
letter.pdf, archived at http://perma.cc/BAEL-5MCW
NEW YORK
Press Release, Governor Cuomo Issues Executive Or-
der Establishing Statewide Health Exchange (Apr.
12, 2012), available at http://www.governor.ny.gov/
news/governor-cuomo-issues-executive-order-estab
lishing-statewide-health-exchange, archived at
http://perma.cc/77R8-PFLD
23a
NORTH CAROLINA
*Milliman, Inc., N.C. Health Benefit Exchange Study
(Mar. 31, 2011), available at http://www.nciom.org/
wp-content/uploads/2010/12/Health-Benefits-
Exchange-Study-DRAFT-4-201 1-03-31-FULL-
REPORT.pdf, archived at http://perma.cc/Y6FF-
64XX
*N.C. Inst. of Med., Examining the Impact of the
PPACA in N.C. (May 2012), available at
http://www.nciom.org/wp-content/uploads/2013/01/
FULL-REPORT-2-13-2013.pdf, archived at
http://perma.cc/5X5C-HN59
N.C. Dep’t of Ins., Level 1 Establishment Cooperative
Agreement Application (Dec. 19, 2012), available at
http://www.ncdoi.com/Smart/Documents/November
%202012%20Level%200ne%20Exchange%20Estab!
ishment%20Cooperative*%20Agreement%20Applica
tion.pdf, archived at http://perma.cc/97Z4-GNML
NORTH DAKOTA
House Bill 1126, 62nd Leg. (N.D. May 20, 2011), avail-
able at http:/Awww.legis.nd.gov/assembly/62-2011/
documents/11-8110-05000. pdf?20 150123172423,
archived at http://perma.cc/Q5L5-8KZ8
House Bill 1474, 62nd Leg. (N.D. introduced
Nov. 7, 2011), available at http://www.legis.nd.gov/
assembly/62-201 1/documents/11-8110-05000. pdf
720150123172423, archived at http://perma.cc/RBM
6-L7SY
*HTMS, Health Benefits Exchange Planning Services:
Narrative Summary (Dec. 2, 2011), available at
http://www.nd.gov/ndins/uploads/18/finalhbeplan-
ningnarrative.pdf, archived at http://perma.cc/PSY
7-37L6
24a
N.D. Health Care Reform Comm., Minutes (July 25,
2012), available at http:/Negis.nd.gov/assembly/62-
201 1/interim-info/minutes/hc0725 12minutes.pdf,
archived at http://perma.cc/2DE4-CV52
OHIO
Ohio Health Care Coverage and Quality Council,
Health Benefits Exchange Task Force (Oct. 22,
2010), available at http://www.healthcarereform.
ohio.gov/Documents/HBE%20federal%20req%20an
d%20timeline%2010_22 10%20-%20final. pdf,
archived at http://perma.cc/57EB-YFZY
*Milliman, Inc., Assist With the First Year of Planning
for Design and Implementation of a Federally Man-
dated Am. Health Benefits Exchange (Aug. 31,
2011), available at http://Awww.healthtransform
ation.ohio.gov/LinkClick.aspx?fileticket=bAXaVW0
HZQA%3D&tabid=150, archived at http://perma
.cc/PZ6N-7QP9
*KPMG, State of Ohio Health Ins. Exchange Planning:
Strategic Architecture Blueprints Report (Sept. 13,
2011), available at http://www.healthtransform
ation.ohio.gov/LinkClick.aspx?fileticket=O046c4hg0
AQM%3D&tabid=150, archived at http://perma.cc/
TQR7-PQ62
*KPMG, State of Ohio Health Ins. Exchange Planning:
Strategic Architecture Roadmap and Budget
Report (Sept. 14, 2011), available at http://www.
healthtransformation.ohio.gov/LinkClick.aspx?filet
icket=8SDAQ4Y-enE%3D&tabid=150, archived at
http://perma.cc/Y3PM-6EWK
25a
Press Release, Ohio Says No to an Obamacare
Health Exchange (Nov. 16, 2012), available at
http://governor.ohio.gov/exchange.aspx, archived at
http://perma.cc/4466-65UG
OKLAHOMA
Press Release, Health Care Law to be Studied Over
Interim (May 18, 2011), available at https://
web.archive.org/web/20110519201724/http://www.o
khouse.gov/OkhouseMedia/ShowStory.aspx?Media
NewsID=4000, archived at http://perma.cc/M6F2-
M2LA
Summary of the Meetings of the Joint Comm. on
Fed. Health Care Law (Sept. 14 and Nov. 3, 2011),
available at http://garystanislawski.net/okhealth
care.info/Presentations/Joint®20Comm%20Fed%20
Health%20Care%20Laws%20summ.pdf, archived
at http://perma.cc/T4WN-GTJE
*Okla. Legislature, Final Report of the Joint Comm.
on Fed. Health Care Law (Feb. 22, 2012), available
at _http://www.oksenate.gov/news/press_releases/
press_releases_2012/pr20120222b.pdf, archived at
http://perma.cc/99UF-VW9M
Letter, Mary Fallin to Kathleen Sebelius (Nov. 19,
2012), available at http://www.bartlesvilleradio.
com/caffeine/uploads/files/images/Oklahoma%20Let
ter%20to%20Secretary%20Sebelius 1}.pdf, archived
at http://perma.cc/SDD7-H9UC
Press Release, Gov. Fallin: Okla. Will Not Pursue a
State-Based Exchange or Medicaid Expansion
(Nov. 19, 2012), available at http://services.ok.gov/
triton/modules/newsroom/newsroom_article.php?id
=223&article_id=9750, archived at http://perma.cc/
A8NJ-V68T
26a
OREGON
Senate Bill 99, 76th Leg. (Or. June 17, 2011), available
at https://olis.leg.state.or.us/liz/2011R1/Downloads/
MeasureDocument/SB99/Introduced, archived at
http://perma.cc/3ZCQ-3PZV
PENNSYLVANIA
*KPMG, Pa. Ins. Dep’t, Ins. Exchange Planning Over-
view (Nov. 21, 2011), available at https://
www.portal.state.pa.us/portal/server.pt/document/1
209620/kmpg_report_pdf, archived at
http://perma.cce/F4FV-7Q5T
Pa. Ins. Dep’t, Conceptual Draft of Commonwealth
Health Ins. Marketplace and Exchange Access
Act (Jan. 30, 2012), available at http://www.
phlp.org/wp-content/uploads/2012/03/Draft-exch
ange-bill-1-31-12.pdf, archived at http://perma
.cc/BETF-4VMS
Pa. Ins. Dep’t, Request for Quotations for Pa. Ins. Ex-
change Planning and Implementation (May 2,
2012), available at http:/Awww.emarketplace.state.
pa.us/FileDownload.aspx?file=6 100022192/Solicitat
ion_0.pdf, archived at http://perma.cc/9LKE-JW22
Press Release, Governor Corbett Announces State-
Based Ins. Exchange Decision (Dec. 12, 2012),
available at https://www.portal.state.pa.us/portal/
server. pt/document/1305763/governor_corbett_ann
ounces_state-based_insurance_exchange_decision_
pdf, archived at http://perma.cc/4EJL-H5A6
RHODE ISLAND
Executive Order 11-09 (R.I. Sept. 19, 2011), available
at http://Awww.healthcare.ri.gov/documents/Exec%
200rder%2011-09%20as%20Signed.pdf, archived at
http://perma.cc/J3NS-6G9L
27a
State of R.I., Request for Proposals: Health Ins. Ex-
change Establishment Technical Assistance (Nov. 9,
2011), available at http://www.purchasing.ri.gov/
RIVIP/StateAgencyBids/7449222.PDF, archived at
http://perma.cc/8PP5-JDHV
Letter, Lincoln D. Chafee to Kathleen Sebelius (July
5, 2012), available at http://www.cms.gov/CCIIO/
Resources/Technical-Implementation-Letters/Down
loads/ri-exchange-letter.pdf, archived at http://
perma.cc/DCA5-6Z8L
SOUTH CAROLINA
Executive Order 2011-09 (S.C. Mar. 22, 2010),
available at http://www.scstatehouse.gov/reports
/executiveorders/exor1109.htm, archived at http://
perma.cc/6HB6-A2KG
S.C. Dep’t of Ins., Presentation to Senate Banking &
Ins. Comm., The ACA’s Impact on Ins. Regulation
(Mar. 23, 2011), available at http://doi.sc.gov/
DocumentCenter/View/2472, archived at http://
perma.cc/4PHV-E4R5
Letter, Nikki D. Haley to Jim DeMint (July 2, 2011),
available at http://governor.sc.gov/Documents/
Letter%20to%20Senator%20DeMint.pdf, archived
at http://perma.cc/T42W-9Y74
*S.C. Health Planning Comm., Improving the
Health Care Marketplace in S.C. (Nov. 2011),
available at http://doi.sc.gov/DocumentCenter/View/
2534, archived at http://perma.cc/LD8A-ZRX6
Letter, Nikki D. Haley to Kathleen Sebelius (Nov.
15, 2012), available at http://governor.sc.gov/
Documents/Gov%20Nikki%20Haley%20Letter%20
to%20HHS%20Secretary. pdf, archived at
http://perma.cc/7B29-HUTP
28a
SOUTH DAKOTA
State of S.D., Quarterly Report (Oct. 28, 2011),
available at https://web.archive.org/web/20130221
202359/http://healthreform.sd.gov/documents/4thQ
uarterlyExchangePlanningGrantsReport_000.pdf,
archived at http://perma.cc/BV48-3V7L
*South Dakota’s Health Insurance Exchange
Planning Effort: Report for Governor Dennis
Daugaard (Nov. 3, 2011), available at http://
ederalhealthreform.sd.gov/documents/exchange_p!
anning_ effort_report.pdf, archived at http://perma
.cc/223F-G7C3
Press Release, S.D. Will Not Build Health Ins. Ex-
change (Sept. 26, 2012), available at http://
news.sd.gov/newsitem.aspx7id=13607, archived at
http://perma.cc/8BYA-YBTC
S.D. Div. of Ins., Newsletter (Fall 2012), available at
http://dir.sd.gov/insurance/publications/newsletter_
fall12.pdf, - -chived at http://perma.cc/U6FF-LR45
TENNESSEE
State of Tenn., Quarterly Report (May 2, 2011),
available at https://web.archive.org/web/201110141
644 13/http//www.tn.gov/nationalhealthreform/forms
/planninggrant2ndatr.pdf, archived at http://perma
ce/ 34JT-GG9S
Brian Haile, Ins. Exchanges: What Makes Sense
for Tennessee? (May 24, 2011), available at
https-//web.archive.org/web/20111014164356/http://
www.tn.gov/nationalhealthreform/forms/HC21.pdf,
archived at http://perma.cc/KG2R-DSS4
29a
State of Tenn., Level 1 Establishment Grant Applica-
tion (Sept. 30, 2011), available at http://www.state
coverage.org/files/TN_level lestablishmentgrant. pdf,
archived at http://perma.cc/PBG5-6ZNZ
Tenn. Ins. Exchange Planning Initiative, Best
Alternatives to a Fed. Ins. Exchange in Tennessee:
A Summary of Stakeholder Feedback (Oct. 21,
2011), available at https:/Awww.statereforum.org/
system/files/white_paper_-_final.pdf, archived at
http://perma.cc/3HZ6-2667
State of Tenn., Request for Information: Ins. Exchange
Planning Initiative (Oct. 2012), available at
http://tn.gov/generalserv/cpo/sourcing_sub/
documents/RF131865-00709. pdf, archived at http://
perma.cc/MQ43-3GWG
Press Release, Haslam Announces State Will Not Run
Health-Care Exchange (Dec. 10, 2012), available at
https://news.tn.gov/node/10017, archived at
http://perma.cc/L442-KNB4
TEXAS
Fed. Healthcare Reform: Exchange Planning Sympo-
sium, Background Information and Requested
Stakeholder Input (Feb. 14, 2011), available at
http://www.politico.com/pdf/PPM170_symposium_
background.pdf, archived at http://perma.cc/R4GA-
LE2F
Letter, Rick Perry to Kathleen Sebelius (July 9, 2012),
available at http://gov.texas.gov/files/press-office/O-
SebeliusKathleen201207090024 pdf, archived at
http://perma.cc/2QWN-FMBV
30a
Press Release, Gov. Perry: Texas Will Not Expand
Medicaid or Implement Health Benefit Exchange
(July 9, 2012), available at https://web.archive
org/web/20141117112510/http://governor.state.tx.u
s/news/press-release/17408/, archived at http://
perma .cc/HS84-MBYU
VERMONT
Act 48 (Vt. May 26, 2011), available at
http://www.leg.state.vt.us/docs/2012/Acts/ACT048.p
df, archived at http://perma.cc/5MZ3-P45D
*Senate Comm. on Health and Welfare; Senate Comm.
on Fin.; House Committee on Health Care, Act 48
Integration Report: The Exchange (Jan. 17, 2012),
available at http://hcr.vermont.gov/sites/hcr/files/
RJL%20Final%20Integration%20Report%20Act%2
048%20Exchange.pdf, archived at http://perma.cc/
4FU7-GCHY
Presentation, Planning Review: Vt. Health Benefit
Exchange (May 10-11, 2012), available at http://
dvha.vermont.gov/administration/hbe-powerpoint-
presentation-for-vermonts-planning-review-with-
hhs-05-2012.pdf, archived at http://perma.cc/PF2F-
UUAE
Vt. Exchange Advisory Grp., Minutes (May 14,
2012), available at http://dvha.vermont.gov/admin
istration/hbe-advisory-group-minutes-05-14-12.pdf,
archived at http://perma.cc/DBB7-RH2V
Presentation, The Vt. Health Benefit Exchange: An
Update for Small Business Owners (Nov. 28, 2012),
available at http://dvha.vermont.gov/administra-
tion/exchange-update-small-biz-11.28.12-final.pdf,
archived at http://perma.cc/5GBG-3QCD
3la
VIRGINIA
*Va. Health Reform Initiative Advisory Council,
Report (Dec. 20, 2010), available at http://www.na-
hu.org/legislative/exchange/VHRIFINAL122010.pd
f, archived at http://perma.cc/Z935-9USK
House Bill 2434, 2011 Sess. (Va. Apr. 6, 2011),
available at http://lis.virginia.gov/cgi-bin/legp604.
exe?111+ful+CHAPO823+pdf, archived at http://
perma.ce/JC2W-WSJ4
Cindi B. Jones, The Va. Health Reform Initiative
(Nov. 16, 2011), available at http://hac.virginia
.gov/Committee/files/2011/11-16-11/DMAS_ Virginia
HealthcareReformInitiative.pdf, archived at http://
perma.cc/N8SF-RT42
*Sec. of Health and Human Servs., Report Pursuant
to House Bill 2434: Va. Health Reform Initiative
Advisory Council Recommendations for a Health
Benefit Exchange (2011), available at https://www.
statereforum.org/system/files/report_-_2011_- vhri
_-_health_benefit_exchange -_december_2011.pdf,
archived at http://perma.cc/8B39-CBFY
Letter, Robert F. McDonnell to Kathleen Sebelius
(Dec. 14, 2012), available at https://delegated
avealbo.files.wordpress.com/2012/12/letter-to-secret
ary-sebelius.pdf, archived at http://perma.cc/JD22-
2WVQ
WASHINGTON
Senate Bill 5445, 62nd Leg., 2011 Reg. Sess.
(Wash. May 11, 2011), available at http://
lawfilesext.leg.wa.gov/biennium/201 1-12/Pdf/Bills/
Session%20Laws/Senate/5445-S.SL. pdf, archived at
http://perma.cc/BD2R-CHU5
32a
House Bill 2319, 62nd Leg., 2012 Reg. Sess. (Wash.
Mar. 23, 2012), available at http://lawfilesext.leg.
wa.gov/biennium/201 1-12/Pdf/Bills/Session%20Law
s/House/2319-S2.SL.pdf, archived at http://perma
.cc/EH98-VZY9
WEST VIRGINIA
Senate Bill 408, 2011 Reg. Sess. (W. Va. Mar. 18,
2011), available at http://www.legis.state.wv.us/
Bill_Text_HTML/2011_SESSIONS/RS/bills/SB408
%20SUB2%20ENR.pdf, archived at http://perma
.cc/42G2-K6VF
WISCONSIN
Executive Order 10 (Wis. Jan. 27, 2011), available at
https://docs.legis.wisconsin.gov/code/executive_orde
rs/2011_scott_walker/2011-10.pdf, archived at http:
//perma.cc/D2EJ-SSKK
Press Release, Wis. Office of Free Market Health
Care Releases Report on PPACA (Aug. 24, 2011),
available at https:/;www.statereforum.org/system/
files /press_release_gruber_study_august_2011.pdf,
archived at http://perma.cc/M5XN-TEZJ
Press Release, Governor Walker Turns Down
ObamaCare Funding (Jan. 18, 2012), available at
http://walker.wisconsin.gov/newsroom/press-release
/governor-walker-turns-down-obamacare-funding,
archived at http://perma.cc/GQ9K-7F3P
Letter, Scott Walker to Kathleen Sebelius (Nov. 16,
2012), available at https://web.archive.org/web/
20130214040913/http://www.walker.wi.gov/Docume
nts/11.16.12%20Letter%20to%20Secretary%20Sebe
lius.pdf, archived at http://perma.cc/E5JG-UQSG
33a
WYOMING
Act 102, 61st Leg., 2011 Reg. Sess. (Wyo. Mar. 10,
2011), available at http://legisweb.state.wy.us/2011/
Enroll/HB0050.pdf, archived at http://perma.cc/
ST9B-LK4M
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.