Yesterday, Politico had a story whose headline read, "Tea Party Finds Success Blocking Reform." The story told about how in many states with Republican governors and legislators, conservatives are undermining the Affordable Care Act, "blocking the law's implementation" by refusing to get started establishing the exchanges through which people without employer health insurance will get their coverage after 2014. Victory for the Tea Party, right? They're blocking implementation! Well, no.
Under the ACA, if a state doesn't set up its own insurance exchange, the federal government does it for them. So the Tea Partiers who think they've struck a blow for freedom by refusing to establish an exchange in their state are actually just expanding the federal government's power. Their citizens are still going to go through an exchange to get their insurance; it's just that it'll be one built by the feds, not built by the state of South Carolina or Montana or Georgia.
As Jonathan Cohn says, "The irony here is that, throughout the health care debate, liberals like me wanted federal exchanges, in part because we feared states with reluctant or hostile elected officials would do a lousy job." If you were living in South Carolina, whom would you trust to construct an exchange that works well: the Obama administration's Department of Health and Human Services, which is desperate to see this reform succeed, or your state government, run by Republicans who think the whole thing is a vile socialist plot?
That isn't to say an exchange set up by reluctant Republicans might not work well, even better than one set up by the federal government. It's possible. But there are incentives pushing against it. In fact, if the Republicans were really Machiavellian, they would take the federal money set aside for states to establish their exchanges, then create the crappiest possible system, work to undermine it at every turn, then say, "See? We told you this wouldn't work." (There are safeguards in the law to prevent that, but I'm sure if you were creative, you could find a way to make the exchange as unfriendly to consumers as possible.)
So the current situation seems like a win-win. In states where legislators and governors want to make an earnest effort to make the exchanges work as well as possible for their citizens, they will. In states dominated by Tea Partiers, they'll refuse to have anything to do with it, and the federal government will step in. The Tea Partiers get to pretend they're standing up to big government, and the reforms of the ACA become more likely to succeed.
