There were three very interesting nuggets of news in the past couple of months that highlight the continual entrenchment of the ACA into baseline expectations of the national political system. The biggest one is the least likely to immediately occur:
Texas GOP Rep Seeks To Create State-Based Exchange https://t.co/jflnrbRUpN
— InsideHealthPolicy (@InHealthPolicy) March 7, 2023
Texas is thinking about launching a state based marketplace. The concept of operations is that Texas can run their own Lone Star Health website cheaper/better than Healthcare.gov. The wedge of money that otherwise would have been spent on Healthcare.gov could be used for other, local priorities. This was basically the motivation for Pennsylvania to move to a state based marketplace. Running Pennie cheaper than Healthcare.gov basically funds a reinsurance waiver for Pennsylvania. The second big argument for a state based marketplace is that it gives a state way more flexibility for other waiver programs.
In 2010-2011, the Obama administration expected to see most of the individual market to be insured through state based marketplaces. The federal government had a fire hose of grants to help states set up state based marketplaces with the expectations that governors would want local autonomy and a local credit for helping their residents get insurance. The expectation was even in red states, lots of people would get insurance and like their insurance from the state based exchange with state relevant branding while hating Obamacare — this is what we saw in Kentucky.
However as part of deep, broad and pervasive conservative resistance to the ACA, conservative advocates argued that red states should do nothing to support the ACA and rely on Healthcare.gov so they could rally against out of touch Washington bureaucrats. Idaho was the only Republican trifecta state that ran its own marketplace on the thought that the “ACA is here, we’re not thrilled with it, but we can locally control it…”
But that dam seems to be breaking. Georgia has filed to stand-up their own state based marketplace for the Fall of 2023. Texas is thinking about a state based marketplace. It seems like acceptance and modification of the ACA is occurring.
Finally, North Carolina looks like it will expand Medicaid. It will expand Medicaid by regular order in a Republican dominated legislature with a bill that is likely to be signed by a Democratic governor. This is important as the last gasp of Repeal and Replace in 2017 was known as the 26 governor strategy— craft a bill that sends a lot of money to 26 governors and get money from mostly Blue states with low uninsurance rates — primarily Massachusetts, New York, and California —. The big component of the opposition to repeal and replace that was likely decisive was the bipartisan governor coalition where the common thread was that the states had expanded Medicaid.
So if we’re thinking about entrechment and embedding, this has been a very good quarter for the ACA.