WASHINGTON – Half a century ago, the creation of Medicare and Medicaid was a triumph of American egalitarianism. Within a decade, the United States went from a country where 1 in 3 people lacked health insurance to a nation where just 1 in 10 went without coverage.
President Barack Obama has similar ambitions for the Affordable Care Act, which launches this week with marketplaces that will allow Americans to choose among competing insurance plans.
“Obamacare,” as it is known, 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 (ACA) 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,” said Theodore Marmor, a Yale University professor who is one of the nation’s top scholars of health policy. 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. As a result, about 6 million low-income people will not have coverage, according to the Kaiser Family Foundation. That is 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 is 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 has 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 is going to be a lot harder for uninsured Floridians to sign up for the exchanges.
The story is similar in a number of other states hostile to Obamacare, and those states are getting outside help in undermining the law. Republicans in Congress are demanding reams of information from some of the organizations contracted by the administration to help implement the program, in what a spokesman for the Department of Health and Human Services called “a blatant and shameful attempt to intimidate” them. Meanwhile, activist groups have spent $400 million running television ads disparaging the law since its passage three years ago, compared with $75 million spent by organizations supporting it.
As a result, the next few years are likely to see a big gap between the states that embrace Obamacare and those that oppose it. States that welcome the program will probably have far fewer uninsured people. States that resist may see a more modest drop in the number of uninsured. And the psychological and financial risks associated with being without coverage — the worry about paying for a doctor if you feel sick and the costs of getting care if you need it — will probably fall in states that favor the law, compared with states that do not.
The irony is that the states fighting Obamacare arguably will benefit more than those that are embracing it. States friendly to the program already have a much lower percentage of uninsured residents, and they are healthier than states that are hostile to the law.
Of the 11 states with the highest rates of uninsured adults, led by Texas at 31 percent, seven are fighting Obamacare. By contrast, some of the states with the fewest health care challenges, such as Vermont, Hawaii and Connecticut, are doing their best to implement the program.
What is more, states supportive of Obamacare have lower rates of obesity, diabetes and heart disease deaths, as well as higher life expectancy, compared with the places fighting the law.
The geographic divide over Obamacare usually follows the political leanings that dominate in the states. According to the Kaiser Family Foundation, between 50 and 70 percent of Democrats have generally favored the law, while only 10 to 20 percent of Republicans have. As a result, “blue” states generally show enthusiasm for Obama-care — and are doing much to implement it — and “red” states are not.
It is safe to conclude, then, that politicians are not just crusading against Obamacare in conservative states, they are following public opinion.
Over time, it is possible that the disparities at the onset of the Affordable Care Act will diminish if the law works well and reluctant states embrace it. After all, Medicare and Medicaid faced early political resistance, but both programs eventually expanded coverage and became less controversial. Every state was immediately part of Medicare, while it took four years for almost every state to join Medicaid; Alaska joined in 1972, and Arizona in 1982.
From 1963, before the passage of the Medicare and Medicaid law, to 1976, the number of uninsured Americans fell from a high of 33 percent of the population to 11 percent. Obamacare hopes to accomplish a similar feat; the Congressional Budget Office estimates that the law will reduce the uninsured population from 18 percent today to 8 percent in a decade.
But meeting even the diminished expectations could be an uphill climb. If people in states resistant to Obamacare find that it isn’t working very well — in part because of local governments’ efforts to obstruct the law — their already-negative views may intensify.
Moreover, in many places, opposition to Obamacare is not based on a substantive concern — that the program will, for example, increase premiums or reduce consumer choice — but on a philosophical objection.
As Texas Gov. Rick Perry, a Republican, said in September, Texas has not expanded Medicaid because Texans believe that most people should not receive government-sponsored insurance, even if they cannot afford coverage on their own.
The TV host, former White House adviser Stephanie Cutter, pointed out that if people cannot afford health insurance, they will just go to an emergency room.
Perry’s response: “Fine with me. And you know what? The people of the state of Texas have made the decision that that is how they would rather run their health care system, rather than allow for Washington” to do it.