For nearly two years, Republicans have railed against the Affordable Care Act (ACA), with many a state-level politician going so far as to call for nullification. But even after the Supreme Court voted to uphold the ACA on June 29, state legislatures and governors in states from Florida to Wisconsin are refusing to implement the law's health-care exchange provisions, while other states are running far behind schedule.
The deadline for states to submit their exchange blueprints to the Department of Health and Human Services (HHS) is only four months away, and several states are scrambling to draft them. Fewer than 20 states have even legislatively authorized health-insurance exchanges. Several state governments decided to wait until the Supreme Court ruled on the law to move forward with the exchanges, and now their legislatures will have to convene in special sessions to decide what path to take before the year is out.
HHS has announced that it would begin implementing “federally facilitated exchanges” for uncooperative or unprepared states, a gargantuan task that HHS seeks to avoid at all costs—which in this case amounts to $1 billion in grants. HHS has also offered multiple blueprints with degrees of federal assistance for states that request them. Documents also mention the potential for “conditional approval” for states whose blueprints aren’t fully fleshed out by January 2013.
But some politicians, like Wisconsin Governor Scott Walker, remain defiant. After originally delaying action until the Supreme Court’s decision, Walker has now decided to wait until November, saying in a statement that that his state “will not take any action” to implement the law. Louisiana's governor struck a similar tone, refusing to act and predicting that a Romney victory would result in the ACA’s repeal. Virginia House Speaker Bill Howell stated after the Court’s ruling that the legislature would go forward to implement a health-insurance exchange, in accordance with previous statements by Virginia’s governor. But both politicians have since changed their stance, with the Governor Bob McDonnell not calling a special session and Speaker Howell following his lead.
Five of the eight members of the Republican Governors Association’s executive committee have refused to create a state insurance exchange. Only one member, Susana Martinez of New Mexico, has led her state in carrying out the Affordable Care Act’s requirements. Even states that have legislatively approved the creation of a health-insurance exchange—from Connecticut to Illinois to Washington—are still hashing out the details, more than two years after the ACA was signed.
With so many states behind schedule, officials and insurers alike anticipate that HHS will push back its deadline. But as Patty Connor, the director of Utah’s exchange, said in October, the federal government hasn’t made clear “what exactly their expectation is.” Let’s hope they aren’t waiting until the election to clear things up.