There were signs almost from the start that the great unknown about the Affordable Care Act was how effectively individual states would implement the law. The question got more complicated after the Supreme Court turned one of the key provisions, the expansion of Medicaid, into a state option.
Now, as the evidence starts rolling in from the states, it is even more clear that their policies make all the difference in the world. Let's start with Kentucky, a weird case. Its congressional delegation is 7 to 1 Republican, with Rep. John Yarmuth of Louisville the only Democrat; the others are all firmly committed to the GOP hard line of repealing Obamacare.
But under Democratic Gov. Steve Beshear, Kentucky has been one of the most enthusiastic and effective implementers of the ACA -- so much so that Sen. Mitch McConnell, the Senate minority leader, who is facing a tough Democratic challenge, has suggested that Kentucky's state insurance exchange can live on even if Obamacare dies. Experts say he's wrong about that, by the way.
How effective is Kentucky's effort? Examine the accompanying charts, which show the state's population of uninsureds, county by county, before (left) and after (right) the ACA. Some of the state's poorest counties, including the infamous Harlan County, went from recording the highest levels of uninsured residents to the lowest. According to Larry Kissner, a top state health official, Medicaid reimbursements, which help keep hospitals running, have moved higher, too.
In California, another firmly pro-ACA state, premium increases for 2015 in the individual market have come in at a modest average of 4.2%. So much for predictions of double-digit increases for next year.
As my colleagues Stuart Pfeifer, Chad Terhune, and Soumya Karlamangla observe, there may be some complexities underlying this figure. These derive from Proposition 45, an initiative on this November's ballot that for the first time would give the state Insurance Commissioner authority to regulate health insurance rates.
Insurance Commissioner Dave Jones had predicted that the 2015 rate increases would come in low because insurers would be wary of giving the Proposition 45 campaign ammunition. Rates for this year were typically higher than 2013's by double-digit percentages, he announced earlier, though most buyers on the individual market paid less than the posted rates because of government subsidies.
Either way, the rationale for Proposition 45 is strong. Regulators in 38 states have prior-approval authority over at least some forms of health insurance; in California the Insurance Commissioner has such authority over property and casualty, auto, medical malpractice, and many other insurance lines, but not health insurance. Rate review is a big gap in the ACA, which ceded such authority to the states.
Such regulation is an important corrective to the tendency of health insurers to push the boundaries of what they can charge. In Connecticut, for example, regulators pared one company's 2015 rate increase request from 12.8% to 3.1%, and rejected outright requests for 12.5% increases from Blue Shield and Anthem Blue Cross.
So that's how the ACA works when state officials fulfill their responsibilities. On the other side of the coin is Mississippi, which apparently wishes to turn itself into a laboratory for making its residents miserable.
There, the Republican administration under Gov. Phil Bryant refused to expand Medicaid, leaving nearly 138,000 residents without coverage. According to the personal finance site WalletHub, Mississippi is unique in the nation in actually having more residents uninsured after Obamacare than before -- 21.46% of its residents are uninsured, an increase of 3.34 percentage points from the pre-ACA figure.
Confronted with this statistic, Bryant made his bid for the chutzpah-of-the-year trophy. "If statistics show that the ill-conceived and so-called Affordable Care Act is resulting in higher rates of uninsured people in Mississippi," he asserted, "I’d say that’s yet another example of a broken promise from Barack Obama." Well played, governor.
One of five Mississippians lives in poverty, the highest rate in the nation. Now you know one reason why residents of other states shamefully indifferent to their fellow citizens' plights often say, "Thank God for Mississippi."