Everybody knows that red state officials aren’t enthusiastic about Obamacare. Some of them are even trying to undermine it. But are they succeeding? Are they actually holding back the law? Here are two reasons to think the answer is yes—one relatively ambiguous, one relatively clear.
The first—the ambiguous one—is some information that became a little more than a week ago, when the federal government released new information about the people enrolling in private Obamacare insurance plans. The data doesn’t reveal a lot of things. It doesn’t say how many people have actually paid premiums, for example. And it doesn’t say how many people had insurance before. But it does break down the numbers by state. For each one, plus the District of Columbia, you can see exactly how many people have signed up for a private insurance plan through one of the new marketplaces.
Analysts at the Kaiser Family Foundation have since taken those numbers, state by state, and compared them to the number of people eligible to get private insurance through the marketplaces. The result, in each case, is a percentage—the proportion of eligible residents who have signed up for private Obamacare plans. The analysts at Kaiser, a carefully non-partisan foundation, didn't take into account state political environments. The graph below, which I constructed, does.
Of the ten states that have the higher percentages, eight are solidly “blue,” in the sense that they voted for the Democratic president in the last three presidential elections. Of the ten states that have the lowest percentages, six are solidly red. What does this mean exactly? Technology would appear to be the big factor. States running their own exchanges tended, with a few exceptions, to be more successful than states that are relying on healthcare.gov, which had so many problems for the first two months. And the states running their own exchanges have tended to be blue states, because those are the states where officials were eager to implement the program. The one red state that’s gotten high enrollment is Kentucky, which has a Democratic governor who has been an outspoken Obamacare supporter.
Of course, a few blue states have had trouble enrolling people—Oregon, Maryland, Hawaii, and Massachusetts. In all four, officials attempted to run their own websites but ran into technological problems as bad, if not worse, than those that plagued the Department of Health and Human Services. (Massachusetts is something of a special case: Because its coverage system was already in place, most people already have insurance anyway.) And it's possible the numbers will even out over the next few weeks and months, now that healthcare.gov is working and outreach campaigns in those states are underway. But a red-blue divide in health insurance coverage is going to remain, thanks to a more familiar and ultimately more significant distinction between the states.
The architects of Obamacare assumed that all states would expand their Medicaid programs, so that all people with incomes below or just above the poverty line would qualify. But the Supreme Court in 2012 made it easier for states to opt out of the expansion and about half the states have done just that. You can see the pattern in the map below, which comes from the Advisory Board. And you’ll notice it looks pretty similar to a map of the last presidential election, with—again—just a few exceptions.
The end result will almost surely be fewer people in Republican-leaning states getting health insurance. And this is a familiar pattern. As a general rule, income supports and public services in red states are a lot less generous than they are in the blue states. Conservatives consider this a virtue—because, among other things, it means those states can get away with lower taxes. That’s certainly true. But exposing more people to financial hardship because of illness, making it harder for them to get medical care—those things extract a price, too.
P.S. From a policy standpoint, you could actually make a solid case that the private insurance figures actually vindicate the argument for greater state flexibility—a cause that conservatives have traditionally championed. After all, it was such flexibility that allowed some states to develop their own websites and escape the problems of healthcare.gov. Then again, it’s also possible that the burden of running so many state exchanges made it at least marginally more difficult for federal officials to do their jobs.
Update: At the Reality-Based Community blog, James Wimberly looked more closely at the private insurance numbers than I did—and actually thinks state policies are a bigger factor than I had assumed. His take is worth a read.