One signature consequence, perhaps the leading consequence, of last night’s electoral victory for Democrats is that the implementation of Obamacare will now proceed unfettered. At least at the federal level. But as we’ve noted for many months, the law’s facility will rise or fall on the willingness of the states to carry it out. After the Supreme Court ruling in June, states can now decide on whether or not to expand Medicaid to their populations. There are now 30 Republican governors, one more than before last night (North Carolina flipped to the Republicans), which in my book means 30 potential land mines for the Medicaid expansion. 24 of those states have Republican legislatures, making the potential for rejecting the expansion even more acute. This is the largest potential expansion of coverage in the law, a difference of close to 16 million beneficiaries, and it’s critically important to the working poor and the elderly. Pre-election, Administration officials and allies have been very circumspect about how to nudge states into accepting the expansion, outside of the deal they’re offering on picking up 100% of the costs initially and over 90% of the costs eventually. But there doesn’t seem to yet be a plan to get states to comply. Gridlock here would be a very bad thing for millions of families.
In addition, states have the wherewithal to decide whether or not to set up exchanges, and that deadline is coming up directly:
States have to decide whether to set up a health insurance exchange, the marketplace where individuals will shop for health insurance benefits. If they decide against it, the federal government will take over the task [...]
The timeline to get this all done, meanwhile, is tight. States are supposed to let the Obama administration know by Nov. 16 whether they plan to set up their own health insurance exchange. Only 10 states have passed laws or had governors sign executive orders that commit to doing so.
We know that at least seven states will kick the exchanges up to the federal government: Texas, Maine, New Hampshire, South Carolina, Louisiana, South Dakota and Alaska. That leaves 33 others undecided at this point, with less than 10 days to the deadline. I doubt we’ll get much clarity from ANY state before this deadline; most legislatures aren’t even in session. A federal exchange has advantages and disadvantages for residents, but the lack of clarity is worst of all.