In a July 30 editorial opposing the implementation of the Affordable Care Act, the Wall Street Journal opined that planning for the new health insurance marketplaces called Exchanges belongs on a “fiasco list.” However, the editorial misrepresented the pace of exchange planning, downplayed the catalyst of Republican “civil disobedience” in implementation slow-downs, and obscured the role that right-wing media and advocates have in this intransigence.

States That Have Attempted Exchange Implementation Are Actually “Well Underway”

Many of the nation's leading health policy organizations are closely monitoring implementation of health care reform and exchange progress is one of their metrics. The National Academy for State Health Policy (NASHP) is one such example, and the WSJ editorial cited them for the proposition that “by and large the states aren't” building exchanges. However, the editorial did not mention NASHP's most recent report on exchange implementation that instead notes in the opening paragraph that “many states are well underway in planning for and establishing their exchanges.” Rather, without indicating the source, the WSJ used NASHP's "State Refor(u)m" project that is a user-generated “online network.” That is, the metrics that the WSJ cited for the alleged “fiasco” of exchange implementation is a measurement of documents voluntarily uploaded to a wiki. State Refor(u)m does not claim to be a comprehensive progress measurement, but rather a clearinghouse reliant on user submissions.

Thus, the editorial's listing of “liberal leader” states who score low on this “milestone” measure of State Refor(u)m does not support its thesis. These “milestones” are not an accurate barometer of the difficulties in exchange planning - or even of completion of these actual metrics -  but rather of the success of this network at attracting policy documents. Indeed, several of the states that the WSJ specifically lists as laggards - Massachusetts, California, Oregon, West Virginia, Colorado, Washington, Vermont, New York  - actually have fully established exchanges, the first two of which were established by Governors Mitt Romney and Arnold Schwarzenegger, respectively.

Conservative Politicians' Refusal to Implement Health Care Reform is a Significant Obstacle

The WSJ mentions that "[m]any states run by Republicans are refusing to cooperate as a kind of civil disobedience."  This is an understatement. Nearly thirty states have engaged in litigation against the Affordable Care Act, and even states with Republican Governors who have acquiesced to the constitutionality of health care reform still find themselves stymied by state legislatures who have moved from waiting for the Supreme Court decision, to waiting out the presidential election. Furthermore, whereas the president exercising standard policy shifts is considered "lawless" in the pages of the WSJ, conservative politicians pushing for state obstruction of a constitutional federal law are egged on in the right-wing media. From a July 9 American Spectator article by David Catron:

[Rick] Scott isn't the only governor to balk at moving forward on state-based exchanges. Scott Walker of Wisconsin, Sam Brownback of Kansas, and Mary Fallin of Oklahoma have all pushed back as well. And the momentum seems to be building. In May, Alabama's governor Robert Bentley thwarted his legislature when it tried to create an exchange and Chris Christie vetoed a bill passed by the New Jersey legislature to set one up. In June, after the Supreme Court handed down its decision, Louisiana Governor Bobby Jindal also joined the movement: “Absolutely, we're not implementing the exchanges. We're not implementing Obamacare.”

Meanwhile, conservatives in Congress are ramping up an effort to enlist more governors in the cause. Seventy-three senators and representatives have signed a letter to the National Governors Association urging its members to stay in the fight against Obamacare: “As members of the U.S. Congress, we are dedicated to the full repeal of this government takeover of healthcare and we ask you to join us to oppose its implementation.” The letter goes on to specifically implore the governors “to oppose any creation of a state health care exchange mandated under the President's discredited health care law.” [The American Spectator, 7/9/12]

This Conservative Intransigence Has Been Fueled by Right-Wing Media, Including the WSJ

The editorial recognizes that although its “prior advice to anti-ObamaCare states” was to create state exchanges based on a Republican model, it is “too late” for that now, despite the pleas of more moderate Republicans.  Back in 2010 the WSJ did publish an op-ed by American Enterprise Institute fellows Scott Gottlieb and Tom Miller, which called for states to “offer[] their own market-friendly versions of exchanges.” That cooperative spirit of federalism was quickly lost as the WSJ decided by 2011 that "[t]he states are concluding that the more they get to know about ObamaCare, the less they think they can afford it," an alarming sentiment echoed by Karl Rove in another 2011 op-ed that intoned "[w]e are now, to our horror, finding out how harmful this measure is. More Americans are realizing that unless repealed, ObamaCare will sink America in a sea of red ink."

This messaging about the dangers of exchange implementation and praise for obstructionist Republican Governors was reinforced by the right-wing media, and was further supported and amplified by conservative third-party groups such as the Koch-backed Americans for Prosperity. This synergy is effective and won't be slowing down any time soon. As reported by Dan Eggen in the Washington Post on July 10:

Americans for Prosperity (AFP), a conservative group that has strong ties to the billionaire brothers who run Koch Industries, launched a $9 million anti-Obamacare ad campaign that began after the Supreme Court ruling and ran through mid-July. The ads ran in 12 swing states, including new targets for the group such as Minnesota.

“There's going to be a lot more,” said AFP President Tim Phillips. “There's nothing more important than repealing the health-care legislation in 2013. We want to be sure the public gets a sense of how important this is.” [The Washington Post, 7/20/12]