Now that there are renewed doubts about the workability of the private-insurance exchanges set up under the Affordable Care Act, the president must again take the blame if things don’t work out as intended, right?
Well, at most, that is half-right or maybe one-third right. The U.S. Supreme Court bears some responsibility for thwarting the original design of the ACA by insisting on a state opt-in for the Medicaid expansion that was so integral to the overall effort. And that enhanced the residual power of the states — many under hostile management — to frustrate the implementation of Obamacare by active or passive resistance.
It is not a coincidence that nearly all the states suffering from a lack of competition of private plans under Obamacare are states that did not bother to create their own exchanges or undertake the kind of public-education measures that might have encouraged broader enrollment and that have made the ACA successful in places like California.
And as Paul Krugman points out, many of the states fighting Obamacare implementation are the very states that made a federal solution necessary by using their power under the preexisting Medicaid program to shirk health-care access for poor people with serious health problems.
The much-quoted characterization of the states by Louis Brandeis as the “laboratories of democracy” is almost invariably used by those promoting the utility of greater freedom for sub-federal jurisdictions in domestic governance, even if the federal government is footing the bills. But it’s the nature of true laboratories to sponsor failed as well as successful experiments. Letting the states — and yes, particularly the states of the former Confederacy — call the shots on indigent health care has been an ongoing disaster. Blaming the latest stage of that disaster on Barack Obama — who sought to mitigate the risk via a mandatory Medicaid expansion and a public option for insurance purchases — is a bad joke.