In the timeline for implementation of the Affordable Care Act, today is a fairly important day.
After two years of political battles and a Supreme Court case, many if not most states are expected to tell the federal government Friday if they're willing carry out a key part of President Barack Obama's health care overhaul.
At issue is the creation of new health insurance markets, where millions of middle-class households and small businesses will shop for private coverage. The so-called exchanges will open for business Jan. 1, 2014, and most of their customers will be eligible for government subsidies to help pay premiums. The exchanges will also steer low-income people into expanded Medicaid programs, if states choose to broaden their safety net coverage.
In some cases, governors decided to gamble that President Obama would lose his re-election bid, and when he didn't, they sought an extension on the deadline. The White House has been happy to accommodate, handing out extensions on today's deadline to any state that asks for one.
But for several governors, they've already decided not to act -- they're aware of the deadline, but have decided not to create an exchange of their own.
Of course, the policymakers who created the law suspected this might happen, so states that refuse to create exchanges of their own will instead find Washington doing it for them. The irony is rather remarkable, since some of the same folks who decried more federal control over health care are choosing more federal control over health care.
Among them are Govs. Scott Walker (R) of Wisconsin and Rick Perry (R) of Texas, both of whom weretold by national far-right groups that Republican governors who went along with the implementation of Obama's health care law would struggle in future presidential primaries.
Looking ahead, there a couple of angles to keep in mind.
The first, as we discussed in July, is how pointless the far-right opposition to this policy really is. Exchanges, like the individual mandate, used to be a Republican idea. As recently as 2008 -- hardly ancient history -- Marco Rubio, Mitt Romney, and many throughout the Republican Party thought exchanges made a lot of sense, since they give consumers choices, spur competition, create a new private marketplace, etc.
Now, the fact that Obama likes the idea leads Republicans to oppose it.
The second is a practical concern: setting up exchanges isn't easy, and the more governors decide not to bother, leaving it to DC to do all the word, the harder the task becomes. Sarah Kliff had a good piece on this the other day.
"These are systems that typically take two or three years to build," says Kevin Walsh, managing director of insurance exchange services at Xerox. "The last time I looked at the calendar, that's not what we're working with." [...]
A health exchange's first task is ensuring that those who are eligible for benefits know about them — right now, research suggests three-quarters have no idea.
That suggests a huge outreach challenge — and one the federal government may not be ideally suited to completing.
So, when governors balk at doing the work, they're inviting more federal control over health care, but they're also making matters deliberately more difficult for consumers and small businesses in their states.