Journalism in the Public Interest

The Outlook for “Obamacare” in Two Maps

How states handle Medicaid and new insurance exchanges will determine if President Obama’s re-election victory gives his healthcare overhaul a boost.

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 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?

State insurance exchanges

Source: Kaiser Family Foundation, current as of Sept. 27, 2012.


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?

Medicaid Expansion

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 for 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 have opted out.

(The states marked with scales participated in litigation against the Act that culminated in June’s U.S. Supreme Court decision.)

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 flow chart 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.

If you’re interested in comparing the politics further, here’s a link to the final presidential election results by state.

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Can we please stop calling it a “health care” plan?  Health insurance is NOT health care, and is only barely related to the extent that an insurance company puts its long-term profits (keeping customers paying premiums) ahead of its short-term profits (not paying for care).

A real health care reform would have broken up the cartels and guilds that keep care prices so high, either by literally breaking them up for competitive purposes or by taking them over (capitalist or socialist solutions, basically).  Instead, we’re forced to do business with companies that have proven, time and time again, that they don’t care about their customers and are forced to raise prices for all of us to protest having to cover the terminally ill.

There’s a reason this was laughed out of Congress when Hillary Clinton presented it.  I can’t imagine the reason it made it through this time around other than Romney’s support.

I also have serious concerns about the exchanges.  It’s only a matter of time before some Wall Streeter figures out how to make bets on people’s health like they did on mortgages.  And then you have a bunch of rich people who have a vested interest in your remaining ill.

Barry Schmittou

Nov. 8, 2012, 1:21 p.m.

Obama Manslaughter and Bribery Evidence !! Two MetLife executives gave Obama huge Contributions !! One year later they both signed page 5 of the DOJ agreement where no one was prosecuted for rigging multimillion dollar bids!!

You’ll see overwhelming evidence that proves MetLife is still ignoring life threatening medical conditions when patients file claims on the policies MetLife rigged bids to sell. This evidence could have destroyed Obama’s Chance to win but Republican leaders Blackburn, Issa and Grassley continue to do nothing even though many citizens and prominent regional community leaders and business persons have requested immediate action !!

On the following website you’ll also see links to evidence I’ve filed with two Congressional Committees and handed to Congresswoman Blackburn personally that prove Obama is protecting ten deadly patterns of corporate crimes :

Has a study of all the waivers been done yet?  I would like to know more about that…please point me in the right direction.

Where is the actual number of uninsured to be found? (and I don’t mean in Obama’s campaign literature).  Please advise.

I totally agree with John. This whole thing reeks of crony capitalism and has nothing to do with health care.  Look for costs to go up and increased delays for care. 

And, the corruption will explode with this much money and power at stake.

We should all have our heads examined for putting up with this.

The exchanges were supposed to ‘keep the insurance companies honest.’ But instead the Obama Admin has outsourced that function. So now all health insurance is moving farther and farther towards unaffordable underinsurance - with an IRS penalty if you don’t buy it.

The Medicaid subsidies are basically a $500 Billion transfer of money from the Treasury directly into the bank accounts of the insurance companies.

Of every dollar we spend on health insurance premiums, co-pays, deductibles, conditions not covered, etc., 80 cents goes to pay the salaries of private insurance bureaucrats whose main job is to deny you health care.

Even under the most optimistic assumptions, over 30 million Americans will still be without health insurance under Obamacare. It is not a universal health care plan and it is not affordable to the majority of Americans.

Obama said at the beginning of the ‘debate’ that all voices got a seat at the table. He lied. Single Payer was never heard and those that tried to talk about it in those hearings were literally thrown in jail.

Single Payer is the only answer. It is universal, will reduce overall health care costs, put employers on a level playing field with their competitors overseas who have some form of govt. sponsored health care, to name just a few of its advantages.

See PNHP dot org.

John, you are a tard. For most insurance companies, 70-80 cents of every dollar is paid out in claims. They simply administer the plan that your company has purchased. If you don’t like the plan, complain to your company so they will shop around for a different plan. If your company buys a plan that covers facelifts, they will pay for a facelift.

I love to hear the tune you whistle when the private companies are soley the reserve of the rich, and you and I are stuck on a govt. plan that is inefficient, bloated and provides terrible service. The US govt. couldn’t run an ice cream stand effectively.

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