In conservative states, especially those with Republican governors, the pushback against implementation of the Affordable Care Act (ACA), perhaps better known as “ObamaCare,” has been quite notable. In fact, these were the states that joined with Florida in challenging the law before the Supreme Court. Unfortunately for them, they lost their case, at least for the most part. The Court did say that they don’t have to participate in the Medicaid expansion, and most of the GOP governors have declared that that is precisely the path they will take. On another issue, however, the federal government can act if the states do not.
The issue at hand is the establishing of the so-called “health insurance exchanges”–a marketplace for consumers to shop for health insurance coverage on the basis of more transparent premium cost and benefit design. The ACA was written to provide states with flexibility to design their exchanges within broad federal guidelines, with the assumption that state policymakers are more familiar with the specific needs of their state’s residents. This, in fact, is precisely the way that the Medicaid program operates.
However, unlike Medicaid, the ACA put in place a “stop-gap” measure. In the event that states failed to establish their own exchanges, the federal government would establish one for them. In other words, states can design their own exchanges however they would like, provided they meet federal guidelines with respect to minimal acceptable coverage and tiered plan levels. But, if a state says no, Uncle Sam says “Fine. We’ll do it ourselves.” And the state gets no say in the design of that exchange.
And therein lies the irony: Democratic governors in liberal states have gone ahead and established–or are in the process of establishing–their own, state-designed health insurance exchanges. They’ve been able to set up a system that will work best for their residents, and they have been in charge of the entire process. Meanwhile, the Republican governors in conservative states have been defiantly refusing to set up their own exchanges as best they see fit, which, in turn, is an open invitation for the federal government to impose its will on those states. That, of course, is the very thing that they opposed from the outset. You just can’t make this stuff up.