President Obama and his Democratic allies should enjoy the moment. This was a hard-fought victory, one not years but decades in the making.
Still, there is work to be done. And some of it must begin soon. In the new issue of Time, Karen Tumulty and Kate Pickert with Alice Park sketch out the major challenges ahead. Among them are action at the state level:
The most important challenge for the states will be setting up health insurance exchanges--marketplaces where small businesses and individuals will be able to shop around, choosing from a selection of insurance policies, much as federal government employees (including members of Congress) do now. ...
But to work right, each exchange will need to have enough enrollees and enough insurance-plan offerings to assure vigorous competition. That's no small challenge, given the near monopoly power insurers have in many states. For instance, Republican Vermont Governor Jim Douglas notes that while there were 75 major insurers competing for business in his state a decade ago, there are now only three. The rest were driven away, he says, when Vermont instituted many of the same reforms that are envisioned under the federal law.
While some states will be able to operate these exchanges on their own, others are likely to join with their neighbors in regional operations. "The borders don't separate where the care might be given, and I have five borders," says West Virginia Governor Joe Manchin, a Democrat. "We're going to work in conjunction with our fellow states, with our fellow governors, to make the best delivery system and the best economy that we can."
And some states may well return to an idea that generated a lot of controversy during the yearlong battle over health reform: a government-run public option for the uninsured, similar to Medicare. Oregon is already studying the feasibility of including a public option as part of its state exchange. Says Manchin: "All of us are going to have to look at that ... What we've got to do is make [insurance companies] compete--and a public option is probably the only way."
The odds of creating a public option at the state level might seem longer than the odds of getting one at the national level. But if a state really does have a lack of competition, I don't see why determined lawmakers there couldn't add one--or, at the very least, arrange for some kind of Medicare access.