As you no doubt remember, much of the Affordable Care Act doesn't go into effect until 2014. In order to deal with the problem of people whose pre-existing conditions make insurance companies uninterested in giving them coverage, the act provides for the creation of high-risk pools for people who have been uninsured for over six months. States can establish the high-risk pools themselves (some states already have them), or they can let the federal government do it for them.
So what have they chosen? The Washington Post tells us that 18 states have said they won't do it, which means the federal government will be taking care of citizens in those states who need to be in a high-risk pool. They are: Alabama, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Texas, Virginia, and Wyoming.
Notice anything about that list? Fifteen out of the 18 are ruled by Republican governors (the exceptions are Delaware, Tennessee, and Wyoming), and two of the remaining three are conservative states where conservative Democrats managed to get elected. And you've got the entire Deep South in there.
You might remember that the House version of reform, which liberals liked, contained one federal insurance exchange, while the Senate version, which centrists liked, contained 50 state-based exchanges. One of the issues liberals raised was that states run by Republicans who don't care much about effective government or government involvement in health care were likely to create crappy exchanges that don't serve people well. But in the case of the temporary high-risk pools, those Republicans are opting out altogether, which means that the federal government will have to take care of it. It's a victory for progressives! After all, if you're one of the people who can't get insurance now, who would you trust to put in place an insurance program that would treat you right: Barack Obama's HHS department run by Kathleen Sebelius or Mississippi governor Haley Barbour, former tobacco lobbyist and vehement opponent of government provision of social services?
We should note that high-risk pools are usually a pretty bad option for people. They tend to be expensive and offer limited coverage, but there are safeguards in the Affordable Care Act meant to deal with those problems, and they're better than nothing. But this might point the way toward better implementation of health-care reform. Maybe Republican governors should start a movement to federalize the exchanges when they come on line in 2014 so they can wash their hands of any involvement in health care. They could maintain their principled stand against creeping socialism, and their constituents could get an exchange that works.
-- Paul Waldman
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