The real battle over Obamacare isn't on a website, it's in the states. And there, the political map has been redrawn in perhaps surprising ways.
This is what the political Obamacare map looks like.
There are three factors included to grade each state.
- Did the state establish its own health care exchange? Under the Affordable Care Act (Obamacare's official name), states were tasked with either establishing their own insurance exchange to offer coverage or to rely on the federal government's. Many Republican-led states declined to establish their own exchanges; those that did are having better luck with the roll-out. (This was worth 2 points, or one if the state is partnering with the government.)
- Did the state expand Medicaid coverage? Part of the ACA lifted the income cap for Medicaid coverage, allowing more low-income people to enroll in the federal program. Since the states would eventually have to cover a small part of the cost, some (mostly Southern) states declined to do so. (This was worth 2 points, or one if the expansion is still under consideration.)
- Did voters in the state vote to reelect Barack Obama? The legislature in a state doesn't often entirely reflect the state's voting population. In some places — Pennsylvania, Wisconsin, Florida — Obama won reelection even while the state's leadership declined to implement his signature policy. (This was worth 1 point.)
|State||State exchange?||Medicaid expansion?||Supported Obama?|
|Arkansas||Partnered with federal gov't||Yes||No|
|Illinois||Partnered with federal gov't||Yes||Yes|
|Iowa||Partnered with federal gov't||Yes||Yes|
|Michigan||Partnered with federal gov't||Yes||Yes|
|New Hampshire||Partnered with federal gov't||Considering expansion||Yes|
|West Virginia||Partnered with federal gov't||Yes||No|
The portrait is of a country that doesn't break down entirely along red-blue lines. The Northeast, for example, has been slower to embrace the state-based components of the health care law. And some red states have shown more readiness to participate.
Take Idaho. The governor of the deeply conservative state, Butch Otter, chose to establish an exchange for the state. Its roll-out, like (and in part because of) the federal one, hasn't been flawless. And that's opened the door to political pressure for Otter. On Saturday, the Idaho Statesman reported that the governor would face a primary challenger — specifically because of Otter's choice to establish a state exchange. The challenger, state Senate Republican caucus chair Russ Fulcher, identified Otter's "regrettable decision to voluntarily thrust Idaho into Obamacare” as a key component of his decision.
In Ohio, the Republican governor of a pro-Obama state took a slightly less politically fraught approach to the Medicaid decision. Gov. John Kasich tasked an independent panel with evaluating whether or not the state would expand coverage. On Monday, as Reuters reports, the panel recommended that the state do so. An estimated 275,000 Ohioans will get coverage under the program.
Meanwhile, Colorado, which has fully embraced the Affordable Care Act, is expanding its outreach to young people, in creative ways.
Guess this is what happens when the governor of your state got his start in the beer-brewing business: pic.twitter.com/eXAVMVVhC4— Alec MacGillis (@AlecMacGillis) October 22, 2013
As we've noted, getting young people to participate in the health exchanges is important to keeping costs down, as insurers will get more income from people who get sick less often.
But there's a big state-based obstacle looming for the program. On Tuesday, the Wall Street Journal reports, a judge allowed a lawsuit against the Affordable Care Act to move forward. That suit argues that the subsidies that are part of the program — money provided by the government in order to reduce the cost of insurance plans for lower-income individuals — can't be given to participants in the federal exchange. The argument is that the law specifically stipulates that subsidies apply to insurance purchased through an exchange "established by the state." Since many states didn't establish exchanges, the suit argues, there should be no subsidy.
It's not clear if the lawsuit will succeed. If it does, the map above will even more accurately depict two Americas: one in which states provide an exchange offering subsidized insurance plans for residents and expanded coverage for the very poor; another in which residents are forced to buy unsubsidized insurance through the federal system — and the very poor are left with no coverage at all.