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Published by Jeffrey Young

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Published by: Jeffrey Young on Nov 14, 2012
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 November 14, 2012The Honorable Barack ObamaPresident of the United StatesThe White House1600 Pennsylvania Avenue, NWWashington, DC 20500Dear President Obama:Congratulations on your election victory. The American people have made their decisionand Republican governors stand ready to work with your Administration on issues of criticalimportance to our states and the nation. Our American political system once again showed theworld democracy in action, where policy differences are debated in the public arena and settledwith one vote per person. We wish you well and are hopeful that you and the Congress willpromptly address the crushing problems of debt, unemployment, and spending reform by the endof the year to create certainty for the states and businesses.We write today on behalf of the 29 Republican governors and two governor-electsrepresenting 60 percent of the states, with an urgent matter related to implementation of thePatient Protection and Affordable Care Act (PPACA). It is clear that putting in place the newprograms you championed will be an enormous strain on state governments and budgets, as wellas the federal government. From the financial obligations and complex technicalities to ensuringthe healthcare workforce and infrastructure will be in place to meet the new demand, thetimeframe and many of the provisions in the PPACA are simply unworkable. With the pendingdeadline of November 16 for governors to make a decision on state based health insuranceexchanges, we ask you to push back the date until your team has answered the numerous
previous questions for governors and other groups, and promulgated the final regulations, so thatall stakeholders have had the opportunity to comment, and those comments have beenincorporated into a final rule. The guidance Friday from Secretary Sebelius extends the dateonly for the election of a partnership exchange, and subsequently for the federal exchange.The PPACA, as written, requires many changes, but most immediate are theimplementation deadlines for the health insurance exchange models. While the January deadlineto certify if a state is prepared to implement a state based exchange is statutory, most otherdeadlines are written within the discretion of the United States Department of Health and HumanServices (HHS). Other than the minor amendments made last Friday, to date, HHS has beenunwilling to establish a more manageable timeline. The rulemaking process has been undulycondensed, and in some cases, important rules have not been promulgated at all. Rather, theadministrative guidance that has been shared holds limited legal authority for states or the federalgovernment.States are struggling with many unanswered questions and are not able to makecomprehensive far-reaching decisions prudently. In the past months, we have sent letters withmany specific questions to help us make an informed choice, and our letters have been generallyignored. Many important questions remain unanswered as the deadlines loom. We include ourprevious letters as an attachment.Also, the clear truth is that the PPACA does not contain much-needed Medicaid orMedicare reform designed to control costs. As you correctly
told Senate Democrats, “[a]s we
move forward on health reform, it is not sufficient for us to simply add more people to Medicareor Medicaid to increase the rolls, to increase coverage in the absence of cost controls and reform.And let us repeat this
 principle: If we don’t get control over costs, then it is going to be very
difficult for us to expand coverage. These two things go hand in hand. Another way of putting it
is we can’t simply put more people into a broken system that doesn’t work.”
We governors,facing crushing Medicaid budget pressure from Medicaid before PPACA implementation,wholeheartedly agree with your statement. Expansion without reform is not responsible andwould bust the state budgets. With the Supreme Court striking the punitive provisions of PPACAto penalize states that do not expand, we renew our pleas for an honest discussion on reform,flexibility, and waivers to allow governors to manage Medicaid costs better.As has been stated many times, before making any final policy decisions, governors mustcarefully consider the short and long-term implications of an expanded entitlement program andthe consequences of significantly increasing the size of government to manage these programs.In the near term, we need to better understand how the federal government will implement afederal exchange as it is clear most states will not be ready on their own. We also have concernsabout future cost shifting to states, and need certainty as we prepare our budgets, many of whichare biennial budgets. We also remain very apprehensive about the unsustainable deficits and
national debt, and the reality that imprudent implementation of PPACA will contributedramatically to an increase in both.Lastly, we respectfully request that you meet as soon as possible with a group of concernedgovernors, Republicans and Democrats. We wish to discuss our specific proposals for Medicaidreform that we sent you in August 2011, as you work with the Congress to address the fiscal cliff the country faces. We hope you can appreciate the real challenges all states face in implementingthe PPACA under compressed schedules with insufficient information to make good decisions.Mr. President, again, congratulations on y
our team’s impressive victory.
We all look forward to working together.Sincerely,Governor Bob McDonnell Governor Bobby JindalCommonwealth of Virginia State of LouisianaEnclosureCC: Republican Governors

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