Few states have been as enthusiastic about the Affordable Care Act as Maryland. It has the scaffolding in place for a marketplace in which small businesses and individual consumers can purchase coverage beginning in 2014.
Virginia, which was at the forefront of the legal challenge, has done extensive planning but has yet to implement any of it — and may not even now, although continued inaction means it could be forced to accept an insurance marketplace dictated by Washington.
“We’ll see,” Virginia Gov. Robert F. McDonnell (R) said shortly after the court decision.
McDonnell, who has frequently been mentioned as a possible running mate for Republican presidential challenger Mitt Romney, indicated that he may be willing to gamble on the results of the November election: “I think there’s a fair bet that if there’s a new president — and I hope there will be — that this policy will not stand.”
The District of Columbia, meanwhile, is not as far along as Maryland in its planning, but it intends to come up with its own exchange — an ambitious undertaking given its small size but one that would build on the extraordinary progress that the District has made over the past decade in providing coverage to the uninsured.
How well the health-care law works will hinge in large part on how willing and successful the states are in carrying out the two major challenges it presents.
The first is in setting up individual state exchanges. If they work as intended, the systems would be the equivalent of shopping malls for health coverage, bringing together the purchasing power of large numbers of small businesses and consumers, who ideally would be able to select among a variety of health plans vigorously competing for their business.
It is a new role for states, said Maryland Lt. Gov. Anthony G. Brown (D), who is spearheading the effort in Annapolis. “We regulate markets,” he explained. “We have never created markets.”
The second big role for the states — one that was thrown into greater question by the Supreme Court ruling — is in the expansion of Medicaid programs to cover people earning up to 133 percent of the federal poverty level,
which for a family of four would be those making $30,656 or less.
As the law was written, states that fail to cover those people, 17 million in all, would lose all their federal funding for Medicaid, which for most states is the second-largest program after elementary and secondary education. But the court ruled that Washington could not put “a gun to the head” of the states to force them to expand their rolls.