The meaning of that number is, to be sure, a little fuzzy. To begin, it’s a gross, not a net, increase. Some of the 2.1 million who purchased insurance on exchanges did so after their previous plans were altered or canceled. In some states, the increase in those insured through Medicaid does not distinguish between those not eligible previously and those who are simply renewing coverage.
All that said, whether the total is 9 million or 7 million, it’s a big number and it’s rising rapidly: December sign-ups far exceeded those in November, and the number is expected to continue growing through 2014.
Whether you can access the benefits of the ACA, however, depends on where you live. In states that set up their own exchanges and accepted federal funding for Medicaid expansion, the increase in the number of insured vastly exceeds that in states that declined to do either.
Theda Skocpol, a Harvard professor of government and sociology, has compared state totals of those who gained insurance through the exchanges and Medicaid with Congressional Budget Office projections of the number of enrollees in each state for the first year the ACA is in effect, as well as with the Kaiser Medicaid Commission’s projections of new Medicaid recipients in that first year.
In the three months since the exchanges opened, she wrote this week, the 14 states that established their own exchanges and accepted Medicaid funding reported increases amounting to 37.2 percent of the projected yearly exchange purchases and 42.9 percent of the projected Medicaid enrollments. In the 23 states that refused to establish insurance exchanges, refused to cooperate in making the federal Web site easily accessible and declined to expand Medicaid, exchange purchases were just 5.6 percent of the projected increase and Medicaid enrollments just 1.5 percent. (The 13 states that partially embraced the programs generally had increases lower than the 14 full implementers but higher than the 23 refusniks.)
Which is to say, the ACA is working as planned, perhaps a little better, in the states where governors and legislatures chose to implement it, such as California and New York. It is barely working in those states where governors and legislators have refused to implement it, such as Texas. Although the number of states declining any participation probably will diminish over time, as the tea party’s grip on the Republican Party wanes or as older white conservative voters die off, the resulting red-blue division between the states probably will be a feature of the nation’s political economy for some time.
Consider the implications: A larger share of Californians will be able to afford regular medical check-ups than Texans. A smaller share of Californians is likely to be bankrupted by the expense of major medical treatment than Texans. When the law’s tax penalties take effect, a smaller share of Californians will be subject to the penalties that come with the individual mandates than will Texans. In the coming years, a smaller share of California hospitals will face financial risk for indigent care than hospitals in Texas, where fewer of the sick and poor will be covered by Medicaid.
The conservative argument that the ACA is a disaster is true only when it’s a self-fulfilling prophecy: Most of the negative consequences that right-wingers have warned against have occurred only in those places where right-wingers have subverted implementation of the law. What supporters of the ACA must keep in mind, however, is that Americans who live in states where implementation has been stymied may continue to see the act as a failure and continue to blame President Obama and his party.
Only by publicizing the act’s manifest success in states where it has been implemented can supporters begin to change the public’s verdict.
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