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On Health Care, Conservatives Protest Too Much

Lately conservatives have been feeling like losers in health care and complaining loudly about it. They don’t like Obamacare or the increase in the government’s role in health care or the federal spending it brings with it, even if those things result in coverage for more than 30 million uninsured Americans and new protections from the worst abuses in the health insurance industry.

Actually, conservatives are winning at least as much as they are losing in health care, even if they don’t know it or won’t say it, because out in the real world of health insurance, beneath the politicized debate about Obamacare, the vision of health insurance they have always championed — high deductible plans that give consumers lots of “skin in the game” — is steadily prevailing in the marketplace. Moreover, the conservative vision of “skin in the game” insurance could actually get a boost from the health reform law.

Half of all workers in small firms now pay deductibles of $1,000 or more a year, and the percentage of workers in all firms paying big deductibles has tripled in the last six years. In the last five years the average deductible for single coverage has gone from $616 to $1,097 in all firms that have deductibles, and from $852 to $1,596 in small firms. Estimates are that in the basic plan offered in the health insurance exchanges under the Affordable Care Act, deductibles could be over $4,000 for individual policies and over $8,000 for family policies. These are big deductibles by any standard. Yes, the minimum coverage people will have to buy under Obamacare will be just the kind of “skin in the game” insurance that conservatives have always favored.

But from start to finish, the health care reform debate has not been about facts but about ideology and partisanship. Conservatives are certainly not happy that the Affordable Care Act has survived a Supreme Court challenge and an election and will now be implemented and will not be repealed. But even as they continue to vilify the law, they must take solace in the fact that many states are still balking at implementing major provisions that conservatives do not like, such as the law’s insurance exchanges or its Medicaid expansion, which the Supreme Court made optional. Only 18 states and D.C. have chosen to implement their own insurance exchanges, and only seven are planning exchanges that are active purchasers, the more aggressive kind of exchange that liberals and consumer advocates would like because they weed out plans with high premiums.

The success of the Affordable Care Act now hinges on implementation, and more than any other single factor, the fate of the law will depend on what states do and how well they do it. The federal government will step in and operate exchanges in states that choose not to do so, but there is no federal fallback on Medicaid; if a state like Texas or Florida does not opt to expand coverage under the ACA, it will not happen.

It will behoove the Obama administration and advocates of the law to actively nurture pacesetting states so that they have tangible success stories to point to in 2014 and models that other states can learn from and emulate. If even a relatively small number of states can show that uninsured people are being covered in large numbers, that federal funding is flowing as promised to the states and to individuals who qualify for insurance subsidies, that the new health insurance reforms are working as planned and that coverage is affordable and, as in Massachusetts, the public is accepting the individual mandate, then other states will take notice, whatever the ideological predispositions of their governors or legislators. It is already clear that the test in 2014 will not be whether the law is working perfectly everywhere (there isn’t time for that to happen, and it won’t be) but whether it can work as intended. If a handful of states can demonstrate that, then the others will want to follow.