How the Obamacare fight could create new health disparities

Joe Raedle/Getty Images – Ruby Edwards, rear left, Juan Gonzalez, rear right, and other protesters gather in the office of Florida State Rep. Manny Diaz on Sept. 20 to protest his opposition to expanding health-care coverage.

BY Zachary A. Goldfarb,


Zachary A. Goldfarb covers economics and the White House for The Washington Post. 

A half-century ago, the creation of Medicare and Medicaid was a triumph of American egalitarianism. Within a decade, the United States went from a country where one in three people lacked health insurance to a nation where just one in 10 went without coverage.


President Obama has similar ambitions forthe Affordable Care Act, which launches this coming week with “marketplaces” that will allow Americans to choose among competing insurance plans. Obamacare certainly will increase access to health care across racial and class lines. Yet the program’s success relies on the cooperation of two dozen conservative-leaning states that are home to half of the nation’s 50 million uninsured. In many of these states, the public tends to oppose the law, and politicians are doing all they can to undermine it. If they succeed, the dawn of the Affordable Care Act may create new disparities in health coverage between the states that embrace Obamacare and those that resist it.


“We had illusions that the ACA represented universal health care,” Theodore Marmor, a Yale University professor who is one of the nation’s top scholars of health policy, told me. But because coverage will vary so much from state to state for poor and working-class people, he said, “you will see a great divergence in the experience of lower-income Americans.”

GOP lawmakers in Washington are trying to defund and delay Obamacare, but those efforts are all but certain to fail. In Obama’s words, the strategy is an attempt to “mess with me.” In the states, however, Republicans do have the power to mess with the law — and they are wielding it.

For starters, about half of the states, almost all run by Republican governors and legislatures, have decided not to expand Medicaid, the joint state-federal health insurance program for the poor, as the Affordable Care Act was supposed to do. (The Supreme Court ruled that states could choose whether to expand Medicaid.) As a result, about 6 million low-income people will not have coverage, according to the Kaiser Family Foundation. That’s compared with 4 million people who will gain coverage in the remaining states and the District of Columbia under the expansion, all paid for with federal dollars.

What’s more, almost all the states refusing to expand Medicaid, plus a few more, havedecided against setting up their own health insurance marketplaces, a critical feature of the law. That’s forced federal officials to organize far more of the “exchanges” than they had anticipated. The remaining states are working hard to set up and advertise their exchanges, which experts think will lead to more Americans signing up for health coverage in those places.

While millions of Americans in states that are not setting up their own exchanges are still eligible for coverage, many local government leaders are making it as difficult as possible for residents to find out about their options under the law. For example, Florida, with almost 4 million uninsured people, has banned federally hired workers from setting up shop in state health centers to help people understand their new choices. That means it’s going to be a lot harder for uninsured Floridians to sign up for the exchanges.

It’s a similar story in a number of other states hostile to Obamacare, and those states are getting outside help in undermining the law. Republicans in Congress are demanding reams of information from some of the organizations contracted by the administration to help implement the program, in what a spokesman for the Department of Health and Human Services called “a blatant and shameful attempt to intimidate” them. Meanwhile, activist groups have spent $400 million running television ads disparaging the law since its passage three years ago, compared with $75 million spent by organizations supporting it.

As a result, in the next few years we’re likely to see a big gap between the states that embrace Obamacare and those that oppose it. States that welcome the program will probably have far fewer uninsured people. States that resist may see a more modest drop in the number of uninsured. And the psychological and financial risks associated with being without coverage — the worry about paying for a doctor if you feel sick and the costs of getting care if you need it — will probably fall in states that favor the law, compared with states that don’t.

The irony is that the states fighting Obamacare arguably would benefit more than those that are embracing it. States friendly to the program already have a much lower percentage of uninsured residents, and they’re healthier than states that are hostile to the law.

Of the 11 states with the highest rates of uninsured adults, led by Texas at 31 percent, seven are fighting Obamacare. By contrast, some of the states with the fewest health-care challenges, such as Vermont, Hawaii and Connecticut, are doing their best to implement the program.

What’s more, states supportive of Obamacare have lower rates of obesity, diabetes and heart disease deaths, as well as higher life expectancy, compared with the places fighting the law.

The geographic divide over Obama­care usually follows the political leanings that dominate in the states. According to the Kaiser Family Foundation, between 50 and 70 percent of Democrats have generally favored the law, while only 10 to 20 percent of Republicans have. As a result, “blue states” generally show enthusiasm for Obamacare — and are doing much to implement it — and “red states” are not.

It’s safe to conclude, then, that politicians aren’t just crusading against Obamacare in conservative states, they’re following public opinion.

Over time, it’s possible that the disparities at the onset of the Affordable Care Act will diminish if the law works well and reluctant states embrace it. After all, Medicare and Medicaid faced early political resistance, but both programs eventually expanded coverage and became less controversial. Every state was immediately part of Medicare, while it took four years for almost every state to join Medicaid; Alaska joined in 1972, and Arizona in 1982.

From 1963, before the passage of the Medicare and Medicaid law, to 1976, the uninsured fell from a high of 33 percent of the population to 11 percent. Obamacare hopes to accomplish a similar feat; the Congressional Budget Office estimates that the law will reduce the uninsured population from 18 percent today to 8 percent in a decade (excluding undocumented immigrants). That is down from the CBO’s projections two years ago, when the nonpartisan office said only 5 percent of the population would be left without coverage.

But meeting even the diminished expectations could be an uphill climb. If people in states resistant to Obamacare find that it isn’t working very well — in part because of local governments’ efforts to obstruct the law — their already-negative views may intensify.

Moreover, in many places, opposition to Obamacare is not based on a substantive concern — that the program will, for example, increase premiums or reduce consumer choice — but on a philosophical objection.

As Texas Gov. Rick Perry (R) said this month, Texas has not expanded Medicaid because Texans believe that most people should not receive government-sponsored insurance, even if they can’t afford coverage on their own.

“We never thought in the state of Texas that you judge success by the number of people that are on public assistance,” Perry said on CNN.

The TV host, former White House adviser Stephanie Cutter, pointed out that if people can’t afford health insurance, they’ll just go to an emergency room.

Perry’s response: Fine with me.

“And you know what?” he said. “The people of the state of Texas have made the decision that that is how they would rather run their health-care system, rather than allow for Washington, D.C.” to do it.