President Obama has similar ambitions for the Affordable Care Act, which launches this coming week with “marketplaces” that will allow Americans to choose among competing insurance plans. Obamacare certainly will increase access to health care across racial and class lines. Yet the program’s success relies on the cooperation of two dozen conservative-leaning states that are home to half of the nation’s 50 million uninsured. In many of these states, the public tends to oppose the law, and politicians are doing all they can to undermine it. If they succeed, the dawn of the Affordable Care Act may create new disparities in health coverage between the states that embrace Obamacare and those that resist it.
“We had illusions that the ACA represented universal health care,” Theodore Marmor, a Yale University professor who is one of the nation’s top scholars of health policy, told me. But because coverage will vary so much from state to state for poor and working-class people, he said, “you will see a great divergence in the experience of lower-income Americans.”
GOP lawmakers in Washington are trying to defund and delay Obamacare, but those efforts are all but certain to fail. In Obama’s words, the strategy is an attempt to “mess with me.” In the states, however, Republicans do have the power to mess with the law — and they are wielding it.
For starters, about half of the states, almost all run by Republican governors and legislatures, have decided not to expand Medicaid, the joint state-federal health insurance program for the poor, as the Affordable Care Act was supposed to do. (The Supreme Court ruled that states could choose whether to expand Medicaid.) As a result, about 6 million low-income people will not have coverage, according to the Kaiser Family Foundation. That’s compared with 4 million people who will gain coverage in the remaining states and the District of Columbia under the expansion, all paid for with federal dollars.
What’s more, almost all the states refusing to expand Medicaid, plus a few more, have decided against setting up their own health insurance marketplaces, a critical feature of the law. That’s forced federal officials to organize far more of the “exchanges” than they had anticipated. The remaining states are working hard to set up and advertise their exchanges, which experts think will lead to more Americans signing up for health coverage in those places.
While millions of Americans in states that are not setting up their own exchanges are still eligible for coverage, many local government leaders are making it as difficult as possible for residents to find out about their options under the law. For example, Florida, with almost 4 million uninsured people, has banned federally hired workers from setting up shop in state health centers to help people understand their new choices. That means it’s going to be a lot harder for uninsured Floridians to sign up for the exchanges.