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Thursday, October 27, 2016

by Tracy Weber and Charles Ornstein, ProPublica.

It wasn’t just President Barack Obama who won Tuesday. His signature health care plan did as well. But while the Affordable Care Act remains alive, less clear is how its various mandates will proceed and who will participate.

To a large extent, the success of the health care overhaul lies in how many of the nation’s uninsured get coverage. And that is largely in the hands of the states, which have been all over the map in their willingness to cooperate.

We mean that literally. The maps here show the lack of consensus on two key parts of the act: creating insurance exchanges and expanding Medicaid.

Here’s why each map matters.

Map 1: Where Will We Buy Insurance?

Source: Kaiser Family Foundation

The health care act requires all Americans who aren’t already insured to buy coverage. But where? That’s where insurance exchanges come in.

States have to decide whether to set up these online marketplaces, where individuals can choose among different insurance plans. Setting up an exchange allows states to customize the offerings to the needs of their residents.

States can also partner with the federal government on exchanges. But if they elect not to, the federal government will take over with its one-size-fits-all exchange. States are supposed to decide which course to take by Nov. 16.

Along the West Coast, legislatures have already voted to set up exchanges. Other states, including Texas, Maine and Alaska, have decided to punt.

But many states in the Midwest and South haven’t committed either way. Some governors, such as New Jersey’s Gov. Chris Christie, have held off setting up a state insurance exchange until after the election.

A health care consultant group predicted yesterday that 20 states will elect to operate exchanges.

Map 2: Will States Cover More Poor People?

Source: The Advisory Board Company

Obamacare hopes to expand coverage to 30 million of the country’s 48 million uninsured residents. A big part of that would come though Medicaid.

States must also decide whether to expand Medicaid to all residents under 133 percent of the federal poverty line (about $14,893 for an individual and $30,657 for a family of four).  Medicaid currently covers poor children, pregnant women, seniors and some disabled adults. The federal government will pay the full cost of the expanded coverage for three years, and then gradually reduce its contribution to 90 percent over the next three years.

As passed in 2010, the Affordable Care Act required states to expand Medicaid or risk losing all federal matching funds for the program. But the U.S. Supreme Court ruled in June that it was coercive to force states to expand their program just to keep money they were already getting.

Now, states that don’t opt in will keep their current funding, but residents who might have qualified under an expansion will likely remain uninsured. There isn’t a deadline for the expansion, but the federal government says states will receive less federal help if they decide to expand later, according to The New York Times.

As with exchanges, the states are divided.

So far, a handful — including California, Washington and Illinois — have already embraced the expansion. Florida, South Carolina, Mississippi and Louisiana and Wisconsin have opted out.

Too Murky to Map  

Not everything is left to states. Other issues remain murky about the law, perhaps because the deadlines are further in the future.

The requirement for individuals to either buy insurance or pay a fee to the IRS begins Jan. 14, 2014. But the federal government has not made clear how vigorously it plans to pursue those who don’t comply.

Here’s a flowchart showing who has to pay and who doesn’t.

Also unclear is the impact on employers, who will be required to provide health insurance to full-time workers beginning in 2014. Some, according to The Wall Street Journal, are responding by moving employees to part-time positions.

Finally, the Act’s opponents in Congress and on the grassroots level will likely do what they can to delay or dilute these requirements, which are among its most unpopular.


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Copyright 2012 The National Memo
  • I feel sorry for the citizens of those states that have decided to not participate in the expanded programs. Not setting up state run exchanges in favor of letting the feds do the job, seems a self-directed prophecy of big government in health care. You would think that the states would want to care for their less fortunate citizens themselves in a manner that gives local control. It is beyond me why the richest nation in the world has so much trouble handling the issue of health care for its citizens. Our economic competitors don’t spend nearly as much of their national wealth on care and for the most part have better results.

    • Sand_Cat

      Before you cry too hard, remember that they are the ones who elected the governors and legislatures who are opting out!

    • Tom_D44

      The states are going broke and the local governments have been tasked with getting their fiscal houses in order. Remember, it is the states and local governments who pay for policeman, firefighters and teachers – not the federal government and when they look at their budgets, a term kind of foreign to Washington, they realize they don’t have the money. AND, the states know that they can’t print money.

  • nobsartist

    It looks like republiCON governors are going o fuck the populations of the states that they govern simply to make a point that is of NO consequence.

    Time to open up the two federally backed insurance plans and simply put the for profit health care insurance cabal out of business.

    since reagun was able to destroy our health care system by signing one bill that made for profit health care legal and ordered all taxpayer built and owned health care facilities sold to the for profit health care cabal for pennies on the dollar, its time to put the health care business out of business.

    • Tom_D44

      Careful what you wish for snob, or nob or whatever you call yourself. There are a whole lot of people employed by the healthcare system. Unless of course you don’t think those jobs are all that important. And, oh, by the way……….how, exactly, are you going to pay for that federally backed system. Oh that’s right – we’re monitarily sovereign so we’ll just print what we need. Or better yet, when all the dope smokers start really lighting it up, now that it’s legal, we’ll just tax the hell out of them. Wait a minute, those people aren’t really the rich people and can’t afford that. So we’ll tax the rich people, until they all move away, and subsidize the dope smokers AND federalize the healthcare system.

      And the tea party people are the extremists………….

      • nobsartist

        there are many manufacturing people that actually used to do something for a living that lost their jobs. Did that concern you?

        Funny, since we are the only “advanced” nation on earth without a national “not for profit” health care system, perhaps we can ask Canada how they do it.

        You sound like a soe loser that voted for willard the rat.



          Buy your own health insurance like WE do!!!!!

          Get the Coverage YOU want—-NOT the one the Govenment makes you have.

          Be able to pick the Doctors YOU want not the Goverment telling you where to go.

          WHY would anybody want this??

          Everyone should buy their own insurance—it shouldn’t be put on the Government!!!!! WHAT DO THESE PEOPLE THINK—


          • nobsartist

            as we all know, you are a simple asshole. you already pay for medicare, dick.

            by the way dumb fuck, canada started their “socialized” medicine program by charging each citizen $600 for the first year of coverage. now it is paid for with a 2% sales tax and for shitforbrains assholes like you, you can still buy your own additional health insurance.

            you are one stupid fuck.


            I don’t know why you are sooooo angry???

            We don’t have Medicare—-

            We have Health insurance
            that we buy for our whole entire family of 6!!!!!!

            Why does that make you soooo angry–LIB

          • Tokopol

            He didn’t say you have Medicare. He said you PAY for Medicare—which you do, in payroll taxes. Get it, dimbulb?

          • Ed

            Have you taken your meds today?

          • beaumisty

            Allllamerican.You have brian damage,remmeber This healthcare law was a Republican Idea that Willard implemented while he was the wosrt govenor of a state and statisics prove.I love people in denial.Sorry for your mental brakedown!!!!!!:)

          • “mark of the beast chip”…… I must have missed that part of the bill. And these rightwing maniacs wonder why their outlandish agenda was rejected in a general election.

          • I just love reading the comments by these right wing religous crazies. I’m on medicare and have all of the same doctors I had before I sgned up for medicare. As for picking your own doctors on private insurance, think again. If your doctors are not in the insurance providers network, you can only go to them if you pay them. All compassionate conservative how will the people making minimum wage or slight more afford health insurance. Who is the “WE” the veterans who use the VA for their medical needs? You “WE’s” are so full of bs anger that you forget what the gov’t gives you. If you live in a red state you state gov’t gets more Federal money than your state sends to the Federal gov’t, if you are so self sufficient why not have the excess Fed money returned. I just laugh when you religious freaks predict doom and gloom.

      • William Deutschlander

        Ignorance is BLISS and GREED is pathetic!

        What truly is in order is to put EVERYONE in MEDICARE and get on with life!

      • beaumisty

        Hay Tom The notion that this counrty is broke is flat out bullshit, thats just what they want you to belive .Take the Fed out of private hands and make it a Federal institution like Japan and things would get alot better .Why does our government borrow from a privatly run institution.We don’t need a middle man, most are just purely ignorant.As far as your pure ignorants about the so called dope smokers,watch what happens in Colorado it will become a very rich state and marijuana is 100% safer than alcohol yet it is legal.You seem to live in the passed or your just another extremist nut job. This is a progressive counrty get used to it my friend or move out of this counrty!!!!!!

        • Tom_D44

          Beau, I can’t even begin to figure out how you come to these conclusions.

          First of all if this country was not flat broke then why are we running deficits, borrowing money to pay for them, and why is our debt skyrocketing out of control. Where is all the money that is sitting around which could pay all this off? So is the notion that this country is flat broke really bullshit or are you off your rocker? Do you know exactly how much the rich make in this country and do you realize that you could tax the rich people, the millionaires and billionaires, 100% of their income and not even make the smallest dent in the national debt. That’s how big the debt is. And since the wars were all paid for with borrowed money you can’t get any savings from stopping them. So please tell me where all this money is?

          The next absoltely insane comment is that about the Fed. Why does the country borrow money from a private institution? Where do you borrow money from when you need a house or a car? When you say we don’t need a middle man to get the money we need, where are you proposing we get it from? Print all we need for ourselves? And exactly how much money do you think we can print without consequences? I am curious to know. Do you know what inflation is? And do you understand that it is a tax on every citizen rich or poor – and there is no ducking and hiding from it as it effects the costs of everything you buy?

          And finally, when you libs all talk about global warming, it’s always about the science and why people don’t buy into the studies and research that has been put forth. And when you want to challenge God and religion, again its always about the science and the research and evolution. Yet when it comes to leagalizing drugs, who cares about science and research, you’ll just make up your own facts. If smoking filtered cigarettes is bad for you, and for our country’s healthcare costs, how is smoking unfiltered joints somehow not worse? And when people are happily impaired, we now have to enforce the abusers, just like alcohol, when they decide somehow that they are just fine to get in the car and drive somewhere. And, of course, breathalizers don’t work so how do we enforce all of this and at what costs to local municipalities? Not to mention that if pot is legalalized, then what is next? Ectasy? Cocaine? Hydrocodone? Hell, why don’t we just legalize all drugs? I mean we can handle it right? Really? I don’t know who you are or how old you are, but try raising 2 young kids in this world with the presence of date rape drugs, meth, crack and other ridiculously dangerous drugs available. This world is incredibly more dangerous than when I was a kid and you free thinkers never look at this side of it. You talk about saving the world with all your government benefits as if you really care about people, but what about that young family who is killed by the drunk driver or worse yet by that high driver now? Do you care for them or do you somehow believe that there will not be abusers to the point that it would become a problem. I went to college and I know what we all did. I know the risks we all took and it was stupid looking back at it today. But try telling that to us back then – we would have brushed you off. The law, however, kept us in line because we always knew there was a possibility of getting caught, and arrested, and that kept us from taking things too far. Fortunately for me I grew up and became an adult. You talk as if you are a happy go lucky college kid with nothing to worry about except your next buzz – but you write more like a high school drop out. Maybe you are a good scientific case study of what happens when your brain cells die from doing too many drugs.

          And finally, this is not a progressive country, it is a center right country and always has been. And I will do everything in my power to fight to maintain the sanity in this country from fools like yourself. You libs all seem to think that because you won the election this was some kind of mandate. But lets be real – the election was very close and 50% of the country, give or take 1% voted against all of this.

      • Ground Control to Major Tom, you are go for landing. Come on back to Earth, son.

      • beaumisty

        Tom all I have to say is your just a nut <you have no idea what the Fed really is and alcohol is the worst drug on earth and the most abused.You are the problem with this counrty, piont blank!!!!!!!

      • Your notions on taxation label you as another rightwing idealogue in what initialy seemed like a reasonable post. Matijuana should be legal for a host of reasons. It’s ridiculous that we waste so many tax dollars on it’s criminalization and miss a tax revenue bonanza. The idea that the rich would be taxed more because the poor can’t afford to pay taxes on legal marijuana is just plain rightwing ranting. Who pays for the high cigarrette taxes? The smokers do, and I believe that group is made up of mostly lower income people.

      • Tokopol

        “There are a whole lot of people employed by the healthcare system. Unless of course you don’t think those jobs are all that important.”

        LOL. And think of all those poor numbers runners, card dealers, drug dealers, prostitutes, fences, and corrupt union stewards put out of business by crackdowns on the Mafia. Can’t those nosy feds just let the market flourish?!

        Seriously, if you’re going to consider every line of work valid regardless of its merits, you’re heading down a slippery slope. Much of the size of the health insurance industry is consequence of parasitism. We KNOW this. Compassion for those poor shysters inevitably has to be balanced with compassion for all the people they’re fleecing out of money.

    • tampajim

      We got along before health insurance companies dominated the marketplace and we will get along fine with ACA, Medicaid, VA Care and Medicare. Let the fat-cats buy whatever suits them and let the government provide, for a small fee, coverage for the remaining Americans.

      • nobsartist

        another failed republiCON policy, health care created by reagun with his failed health care bill of 1982. that bill made “for profit” health care legal and ordered all taxpayer built and owned, county hospitals sold to the “for profit” health care system for pennies on the dollar.

        prior to 1982, doctors RENTED space at hospitals. Once “for profit” took over the hospitals and controlled everything, prices skyrocketed.

        republiCON policies have been ruining America for 50 years.

  • Sand_Cat

    Hey, let the lunatics screw up their health care and kill off their aging supporters even faster!

  • commserver

    The problem is with many states don’t want to pay for Medicaid or to have any pools of insurance plans.

    In the long run it is the people of those states who will pay for the costs. Medicaid is to be evenly split between the states and the feds. Those cost are going up and thus there will be a climax that will be catastropic.

    • I have gotten so many replies from many companies to come with them at only $20.00 a month

  • beaumisty

    Obama will now be able to change the Supreme Court.Instead of having a wright wing activist Supreme Court we may now have a chance to have a Superme Court that is listening to the people.We are a progressive counrty.The Republican party will never change whitch mean they will never regain power.Democrats are the real party of liberty and allowing people to make thier own decissions on how to run thier lives .The Republicans want government to to make your decissions for, they flat out lie about small government and staying out of your life and the people got to see that in this election.The only way the Republicans will ever win anything again is to try to rig or steal elections. If this courty really wants to take control of deficits the Fed has to be taken out of private hands and actually be a federal institution like Japan. Most people are completely ignorant about the Fed and this is probably the biggest problem in this counrty.

    • My wife and I decide which doctor to go to, which hospital. There are no complications in anything, just a $10 co-pay per visit. We can go to any hospital for $25.00.

  • nobsartist

    follow the money. all of the republiCON governors are getting kickbacks from the “for profit” health care industry. when is the government going to start putting some effort into investigating the corruption in the health care industry, wall street and the banks?

    single payer health care with NO states involved is the only way to go.

  • In NJ we have insurance. If one is a State worker, like myself a retired teacher, we are fully protected. My medicine comes to $1.67 per month or $5.00 for three months.