WASHINGTON President Barack Obamas health-care overhaul is unfolding as a national experiment with American consumers as the guinea pigs: Who will do a better job getting uninsured people covered, the states or the feds?
The nation is about evenly split between states that decided by Fridays deadline they want a say in running new insurance markets and states that are defaulting to federal control because they dont want to participate in Obamacare. That choice was left to state governments under the law: Establish the market or Washington will.
With some exceptions, states led by Democrats opted to set up their own markets, called exchanges, and Republican-led states declined.
Only months from the official launch, exchanges are supposed to make the mind-boggling task of buying health insurance more like shopping on Amazon.com or Travelocity. Millions of people who dont have employer coverage will flock to the new markets. Middle-class consumers will be able to buy private insurance, with government help to pay the premiums in most cases. The poor will be steered to safety-net programs such as Medicaid.
Its an experiment between the feds and the states, and among the states themselves, said Robert Krughoff, president of Consumers Checkbook, a nonprofit ratings group that has devised an online tool used by many federal workers to pick their health plans. Krughoff is skeptical that either the feds or the states have solved the technological challenge of making the purchase of health insurance as easy as selecting a travel-and-hotel package.
Whether or not the bugs get worked out, consumers will be able to start signing up Oct. 1 for coverage that takes effect Jan. 1. Thats also when two other major provisions of the law kick in: the mandate that almost all Americans carry health insurance, and the rule that says insurers can no longer turn away people in poor health.
Barring last-minute switches that may not be revealed until next week, 23 states plus Washington, D.C., have opted to run their own markets or partner with the Obama administration to do so.
Twenty-six states are defaulting to the feds. But in several of those, Republican governors are trying to carve out some kind of role by negotiating with federal Health and Human Services Secretary Kathleen Sebelius. Utahs status is unclear. It received initial federal approval to run its own market, but appears to be reconsidering.
Its healthy for the states to have various choices, said Ben Nelson, CEO of the National Association of Insurance Commissioners. And theres no barrier to taking somebody elses ideas and making them work in your situation. A former U.S. senator from Nebraska, Nelson was one of several conservative Democrats who provided crucial votes to pass the overhaul.
States setting up their own exchanges are already taking different paths. Some will operate their markets much the way major employers run their health plans, as active purchasers offering a limited choice of insurance carriers to drive better bargains. Others will open their markets to all insurers that meet basic standards, and let consumers decide.
Obamas Affordable Care Act remains politically divisive, but state insurance exchanges enjoy broad public support. Setting up a new market was central to former Republican presidential candidate Mitt Romneys health-care overhaul as governor of Massachusetts. There, its known as the Health Connector.
A recent AP poll found that Americans prefer to have states run the new markets by 63 percent to 32 percent. Among conservatives the margin was nearly 4-1 in favor of state control. But with some exceptions, including Idaho, Nevada and New Mexico, Republican-led states are maintaining a hands-off posture, meaning the federal government will step in.
There is a sense of irony that its the more conservative states yielding to federal control, said Sandy Praeger, the Republican insurance commissioner in Kansas, a state declining to run its own exchange. First, she said, the laws opponents put their money on the Supreme Court, then on the election. Now that its a reality, we may see some movement.
Theyre not budging in Austin. Texas is not interested in being a subcontractor to Obamacare, said Lucy Nashed, spokeswoman for Gov. Rick Perry, who remains opposed to mandates in the law.