Doing Obamacare

Should conservatives help implement the Affordable Care Act, the health-care law they detest?

For months, it seemed that Republican state leaders hoped they would not need to decide. Perhaps the Supreme Court would overturn the law. It didn't. Then perhaps Mitt Romney would beat President Obama and slow or halt the application of the law. Romney will get no such opportunity. Now conservative governors are facing their first deadline to decide how much they will cooperate with a federal government that will push forward. States must tell the Department of Health and Human Services (HHS) whether they will set up their own health-insurance "exchanges" — markets on which the uninsured will be able to buy coverage — or punt some or all of that responsibility to the federal government.

According to the Kaiser Family Foundation, more than a dozen states have already said that they will not participate in building the exchanges, which means HHS will do it for them. A similar number of states have yet to decide. Those that procrastinated might not have much choice; HHS has been at work since the law passed in 2010, and they haven't been. But anti-Obama politics and simple aversion to the law also no doubt tug conservative governors and state legislatures away from cooperating with any part of it.

They will have to step up, eventually. The Affordable Care Act envisions a thick web of state-federal interactions that is impossible to untangle. If states refuse to build their own exchanges, for example, their Medicaid offices and others will have to coordinate with HHS to hook the two systems together. Otherwise they court bureaucratic disaster, harming their people, their budgets or both.

The law also gives states wide latitude on many big decisions. What minimum benefits will insurance companies be required to provide? Will health-care markets be relatively open to any insurance company that meets certain basic requirements, as in Utah, or will they be highly structured, as in California? What information will consumers shopping for insurance see, when will they see it and how will it be presented?

When Congress opted to give states a central role in health-care reform, it did so at a cost. Lawmakers declined the opportunity to build a big, efficient national health-care market. Instead, they created a near-universal health-care system in which states are empowered to experiment, in coordination with the federal government and, if they so choose, with other states. The more states that take an active role in this experimentation, the more likely that Congress' bet on America's laboratories of democracy will pay off.