The Patient Protection and Affordable Care Act remains a polarizing issue for many—and that becomes even more apparent when you look at how states are reacting to it.
After the Supreme Court upheld the law, about a third of the states told the Department of Health and Human Services they intended to create an exchange. Several states moved full-steam ahead with compliance even before the ruling. Some hailed the PPACA as a way to distribute health care to millions of uninsured and underinsured Americans.
But not everyone did.
Despite the positive ruling in June, it isn't all good news for the Obama administration. Health reform still lags in several states. Half now face a federally run health care exchange, the default for states that haven't made progress or declined involvement in setting up a state run marketplace for health insurance coverage.
Officials at the National Association of Insurance Commissioners even warn it's too late to start a state-based exchange if work hasn't already been under way for a while.
That's in large part due to the fact that many of those states are just not that into reform. These states—led largely by Republicans—aren't rushing to comply.
Though there's a number of states that fall under both of these categories, here are five clear examples of each.
Five states resisting reform
1) Texas
Texas is among a chorus of states rejecting the two key proposals of the PPACA. Gov. Rick Perry—whose GOP presidential bid fell short earlier this year—said his state won't establish an exchange for patients to shop for insurance or expand Medicaid.
In a letter to Health and Human Services Secretary Kathleen Sebelius, Perry rejected both proposals.
“If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under Obamacare,” Perry stated. “I will not be party to socializing health care and bankrupting my state in direct contradiction to our constitution and our founding principles of limited government.
“I stand proudly with the growing chorus of governors who reject the Obamacare power grab. Neither a 'state' exchange nor the expansion of Medicaid under this program would result in better 'patient protection' or in more 'affordable care.' They would only make Texas a mere appendage of the federal government when it comes to health care,” Perry continued.
According to a Commonwealth Fund report, individual Texas health insurance premiums increased by almost 50 percent in the past eight years while the increase in family and group Texas health insurance plan premiums was even larger. The number of people uninsured in Texas is the largest in the nation, at 25 percent
2) New Jersey
Republican Gov. Chris Christie says he won't rush into setting up a New Jersey health insurance exchange just because the Supreme Court upheld the PPACA.
He says the state should wait until at least November's election before taking steps to comply with the law.
After the Supreme Court announcement June 28, Christie made a statement reiterating his views against Obama's law.
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“I've been clear from the very beginning that I do not believe a one-size-fits-all health care program works for the entire country and that each governor should have the ability to make decisions about what works best for their state. Today's Supreme Court decision is disappointing and I still believe this is the wrong approach for the people of New Jersey who should be able to make their own judgments about health care. Most importantly, the Supreme Court is confirming what we knew all along about this law—it is a tax on middle class Americans.”
3) Wisconsin
With regard to health reform, Wisconsin Gov. Scott Walker has vowed not to do anything until after the general election.
Walker's been an outspoken critic of the law, and originally said he wouldn't do anything with the law until after the Supreme Court ruled. But now he says he's waiting until November.
Based on 2010 U.S. Census Bureau data, 90.6 percent of people in Wisconsin had insurance coverage. That tied with Maine for the third-highest rate of any state, after Hawaii at 92.3 percent and Massachusetts at 94.4 percent.
4) Florida
Florida Gov. Rick Scott has said that his state will continue to resist implementing both the expansion of Medicaid and the state exchange.
He's argued against setting up exchanges, saying they won't make health coverage cheaper and might not even give people coverage they want.
Scott's indicated he hopes the November election will undo the PPACA.
Scott, a former health care corporation CEO, doesn't have the best approval rates. They hover around the 31 percent range right now, but back in December he was the least popular governor in the country with a 26 percent approval rating.
That might be in part because of this poor statistic: Florida is right behind Texas with the nation's highest rate of uninsured residents, at 21 percent.
5) Virginia
Gov. Bob McDonnell says before Virginia policymakers make any moves, they need more answers from the Obama administration.
Writing on behalf of fellow Republican governors, McDonnell outlined a long list of questions about state-based health insurance exchanges and Medicaid expansion in a July 10 letter to the president.
In the letter, he also maintained his stance that the PPACA will have disastrous effects: “The PPACA remains seriously flawed both conceptually and technically. It favors dependency over personal responsibility and will ultimately destroy the private insurance market. In its current form, the law will increase health care costs and likely lead to the disruption or discontinuation of millions of Americans' insurance plans.”
McDonnell said he was not pleased with his response letter from the Centers for Medicare & Medicaid Services acting administrator Marilyn Tavenner, arguing his questions were not answered.
He said his health policy advisors, led by Health and Human Resources Secretary Bill Hazel, must learn more before Virginia retools its Medicaid program, already among the leanest in the nation.
State officials say Medicaid expansion will cost Virginia $2.2 billion over 10 years, starting in 2014.
Five states embracing reform
1) Hawaii
Before the Supreme Court ruling, Gov. Neil Abercrombie (pictured below) announced in June Hawaii was the first state to declare its intent to develop a state-based insurance exchange. Abercrombie says the 50th state's exchange will be called the Hawaii Health Connector.
After the ruling, Abercrombie praised the law: “Here in Hawaii, we already have our Prepaid Health Care Act, which enables a vast majority of our residents to be insured. The U.S. Supreme Court's decision supports President Obama's initiative to make health care availability a national policy,” he said. “What is most important for Hawaii to know is that your state government will continue to support a health care system that ensures high quality, safety and sustainable costs. The Affordable Care Act is our ally in this effort.”
2) Washington
According to The Olympian, Washington state is moving ahead with plans to cover low- to moderate-income people following the Supreme Court decision.
State officials are working to put a health insurance exchange in place by October 2013. They also are bracing for an influx of as many as 500,000 new enrollees in the Medicaid health program for the poor in January 2014.
Longer term, some 800,000 of the state's roughly 1.1 million uninsured residents could be covered starting in January 2014, according to state insurance commissioner Mike Kreidler's office. Roughly 477,000 of them would receive subsidized care through the new health care exchange. Another 328,000 could be covered by a future expansion of Medicaid to include low-income adults who have no dependent children.
3) Maryland
Maryland has been moving aggressively to implement the PPACA since President Obama signed it in 2010. The state expects to hit all the federal deadlines in January 2014.
An estimated 730,000 Maryland residents do not have health insurance, according to Joshua M. Sharfstein, secretary of the state's department of health and mental hygiene and chairman of the board the state created to implement its public exchange. Sharfstein expects half of those people will be insured under the PPACA—half through commercial policies bought in the state exchange and the rest through Medicaid.
4) Massachusetts
It's easy to say Massachusetts has embraced health reform—because they did it before everyone else. The state laid the groundwork for the 2010 federal health law with its 2006 health care initiative and is the only state with an individual mandate requiring residents to have insurance or face tax penalties.
Gov. Deval Patrick hailed the court's ruling as a victory for the role of government in helping people help themselves. He said the law gives families more security while holding insurers accountable. Some saw the Supreme Court ruling June 28 as vindication for Massachusetts.
The Democratic governor also praised former Massachusetts Gov. Mitt Romney, right, for signing the state law while at the same time faulting him for his opposition to the PPACA.
5) California
California was the first state in the nation to set up an exchange under a Republican governor—Arnold Schwarzenegger, pictured—and a Democratic-controlled Legislature.
California has nearly 7.5 million residents without coverage, more than half of the 12.7 million uninsured in the states with a plan. An estimated 3 million Californians would gain coverage, according to the Urban Institute's research, funded by the nonpartisan Robert Wood Johnson Foundation.
A study by the Bay Area Council Economic Institute even suggests the law will create nearly 100,000 jobs and bump up economic output by $4.4 billion. Most of the anticipated job gains would be in Southern California with nearly 58,000 new jobs, the study finds. The Sacramento area would have the second most jobs with 13,500 new positions, followed by the Bay Area with 7,600 jobs and San Diego County with 6,500 jobs. The remaining 10,000 jobs would be spread throughout other counties.
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