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The ACA: Sailing America to Maybe from

the Seas of Yes and No.

Abstract: This paper will analyze the effect political polarization has on legislation from

the federal government, using the Patient Protection Affordable Care Act or (ACA) as an

example. The paper will analyze ACA’s progress from a historical perspective

considering the various political atmospheres of several states across the country

including Nevada. The paper will measure the success of the ACA by the number of

insured persons in each state. Next, the paper will measure the likelihood of the state’s

result based upon that state’s politician’s affiliation with of its source. e.g. Republican or

Democrat. Finally, the paper will reconcile the successes and failures of other states and

propose a workable solution for Nevada and then America as a whole.

By: Reginald S. Thomas

1

The ACA in America: Guiding the ship to

Maybe from the Seas of Yes and No

I. Introduction

The Patient Protection Affordable Care Act1 (ACA) is one of the most divisive topics in

America today.2 The American political system has a substantial influence on this law.3 To casual

onlookers the general rule is liberal Democrats generally support the changes, but conservative

Republicans view the law unfavorably.4 Both sides do have merit. While the ACA as a whole

remains divisive, the majority of the population views many of its major changes favorably.5 This

paper will explore the root cause of this paradoxical dynamic, which is Political Polarization.6

Political Polarization7 caused individuals to favor or disfavor the ACA because of their

identification with a particular political party e.g., Democrat or Republican or ideology e.g., liberal

or conservative. To explore this thesis, this paper will acknowledge the views of both major

political parties. Instead of choosing a side to either justify or invalidate the ACA, this paper will

1 Pub. L. No. 111-148, 124 (2010), amended by Health Care and Reconciliation Act of 2010, Pub. L. No. 111-152,

124 Stat. 1029 (2010) (to be codified primarily in scattered sections of 42 U.S.C.). (*commonly called Obamacare).

[hereinafter ACA] 2 Shane Marks, Ten Most Controversial Topics for 2014 , VISUAL.LY,

http://visual.ly/10-most-controversial-topics-2014 (last visited Nov. 22, 2014, 2:52 PM). 3 Inside Story Team, What’s in the legal future for Obamacare as midterm elections come?, AL-JAZEERA AMERICA,

http://america.aljazeera.com/watch/shows/inside-story/articles/2014/7/23/what-is-the-

legalandpoliticalfutureofobamacare.html (last visited Nov. 26, 2014 2:32 PM). 4 Steve Benen, About that ACA ‘repeal’ poll…,MSNBC,

http://www.msnbc.com/rachel-maddow-show/about-aca-repeal-poll (last visited Nov. 22, 2014, 2:46 PM). 5 Infra Ezra Klein, Poll: Republicans hate ‘Obamacare,’ but like most of what it does, THE WASHINGTON POST ,

http://www.washingtonpost.com/blogs/wonkblog/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-

what-it-does/ (last visited Nov. 27, 2014 11:21 PM). 6 See Paul DiMaggio, Have American’s Social Attitudes become more polarized? AMERICAN JOURNAL OF

SOCIOLOGY, stating (“The term ‘Political polarization’ refers to cases in which an individual's stance on a given

issue, policy, or person is more likely to be strictly defined by their identification with a particular political party

e.g., Democrat or Republican or ideology e.g., liberal or conservative) (available at

http://www.jstor.org/discover/10.2307/2782461?uid=3739824&uid=2&uid=4&uid=3739256&sid=21105272770593

). 7 Id.

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measure how examine how divergent stances influence the success of the law despite what the

majority of citizens favor. One of the ACA’s primary goals was to reduce the number of uninsured

citizens by providing affordable healthcare to more Americans.8 Accordingly, this paper will

assess the law’s achievement of that goal by measuring the number of uninsured residents in the

state. To provide some context, first, this paper will recap the cause for reform, then detail the

history of the ACA, and describe the changes the law made to America’s health care system. Next,

the paper assess of how members from the two political parties currently view the changes. Then,

the paper will analyze the different results the ACA has had in traditionally politically divergent

states by considering the following factors: the political history of the state before the ACA, the

extensiveness of the states’ Medicaid program Pre-ACA, and the states’ politician’s response to

the ACA. However, when considering Nevada, the paper will reconcile the successes and failures

of other states to propose a realistic solution to the health care problems in the state. Afterward,

the paper will propose a solution to the problem of Political Polarity in America.

8 Health Care, UNITED STATES SENATOR FOR NEVADA HARRY REID, http://www.reid.senate.gov/healthcare (last

visited Nov. 23, 2014, 5:24 PM).

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I. American Health Care

Before the ACA, the previous health care system did not reach a large proportion of

Americans.9 To understand the ACA in a nationwide context, you must understand the previous

healthcare scheme in America. People by their nature, periodically get ill and require healthcare

in some form.10 So health care is a necessity, which at some point, nearly all must participate in.11

To aid with the eventual cost of health care there are different schemes.12 America is the only

industrialized nation without universal public healthcare.13 (See Graphic A below)

Compared to other industrialized nations, at the time, America was behind in important metrics

such as number of insured persons and healthcare cost.14 Health care was a substantial cost to some

9 Health Care Facts: Why we need Health Care Reform, OBAMACARE FACTS,

http://obamacarefacts.com/healthcare-facts/ (last visited Nov. 23, 2014, 2:19 PM) [hereinafter Health Care Facts]. 10 Evan Horowitz, Everyone gets sick. Should everyone get sick days? , THE BOSTON GLOBE,

http://www.bostonglobe.com/metro/2014/07/31/everyone-gets-sick-should-everyone-get-sick-

days/PgZjuY7v3UQpXHDCFUkTTK/story.html (last visited Nov. 23, 2014PM). 11 Id. 12 Max Fisher, Here’s a map of the countries that provide Universal Health Care (America’s still not on it), THE

ATLANTIC, http://www.theatlantic.com/international/archive/2012/06/heres -a-map-of-the-countries-that-provide-

universal-health-care-americas-still-not-on-it/259153/ (last visited Nov. 23, 2014, 2:32 PM). [hereinafter Health

Care Around the World]. 13 Id. 14 Health Care Facts, supra note 9.

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Americans,15 causing great hardship in many cases.16 To compare, the United States, as a country,

then and currently spends more on healthcare than Japan, Germany, France, China, the U.K., Italy,

Canada, Brazil, Spain, and Australia combined.17 Services that are paid for by compulsory taxes

in other countries, instead, are an individual cost here in the United States.18 That individualized

cost could reach substantial levels,19especially, when families were considered.20 For example, the

average premium in 2009 for a family of four was $20,728.21 This great cost caused many average

Americans to see healthcare as a luxury they could not afford.22 The nation did have Medicaid to

cover low income individuals.23 Generally, low income residents must qualify for state run

Medicaid programs24 and the requirements to qualify for those programs differ from state to state.25

However, vast majority of citizens do not qualify for those programs26 and must either purchase

coverage individually from private insurer27 or obtain insurance through an employer.28 So, to

provide more insurance to the nation’s people, the nation needed an option to bring down the cost

of healthcare for the average American.29

15 Id. 16 Id. 17 Id. 18 Id. 19 Id. 20 Id. 21 Id. 22 Id. 23 Infra Joesph F. Mathews, How Medicaid Works, CARING.COM,

https://www.caring.com/articles/how-does-medicaid-work (last visited Nov. 23, 2014, 5:33 PM). 24 Id. 25 Id. 26 Id. at 3. 27 Health Care Facts, supra note 9. 28 Employer-Provided Health Coverage Informational Reporting Requirements: Questions and Answers, IRS,

http://www.irs.gov/uac/Employer-Provided-Health-Coverage-Informational-Reporting-Requirements:-Questions-

and-Answers (last visited Nov. 23, 2014, 5:24 PM). 29 Id.

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II. History of the ACA

The ACA aimed to bring down the cost for the average American, but passed with the

support of only one political party.30 To understand subsequent sections analysis on why the

ACA has vastly divergent results across the country,31 you must understand the events leading up

to the passage starting with the election of its principle advocate Barack Obama.32

Barack Obama’s campaign caused a substantial political wave.33 In 2008, regardless of

political affiliation, one must say that times were unprecedented, in America. The country was

stuck fighting two unpopular wars,34 the economy was the worst since the Great Depression,35

and affordable health care was distant to many Americans.36 The Bush administration rightly or

wrongly took most of the blame for these events.37 This caused an anti-Republican sentiment to

sweep across the country.38 To the casual onlooker, Obama was emblematic.39 Obama ran on a

30 Inside Congress, THE NEW YORK TIMES, http://politics.nytimes.com/congress/votes/111/senate/1/396 (last visited

Nov. 23, 2014, 5:57PM). 31 Infra, Sarah Varney, Mississippi, Burned: How the poorest, sickest state got left behind by Obamacare , POLITICO

MAGAZINE,

http://www.politico.com/magazine/story/2014/10/mississippi-burned-obamacare-112181.html#.VG012cmKYn4

(last visited Nov. 24, 2014 11:00 PM) [hereinafter Mississippi Burned]; see contra Chad Terhune, Rate of uninsured

Californians is halved under Obamacare, survey finds, LATIMES, http://www.latimes.com/business/healthcare/la-fi-

health-law-uninsured-california-obamacare-20140709-story.html (last visited Nov. 23, 2014, 3:09 PM) [hereinafter

California Halved]. 32 Quin Hilyer, Obamacare’s Hideous History Recounted , SPECTATOR.ORG,

http://spectator.org/articles/35226/obamacares -hideous-history-recounted, (last modified Jul. 3, 2012). 33 Id. 34 Peyton Craighill, Poll: Iraq war still unpopular, divisive on 10 th Anniversary, THE WASHINGTON POST ,

http://www.washingtonpost.com/blogs/worldviews/wp/2013/03/17/poll-iraq-war-still-unpopular-divisive-on-10th-

anniversary/, (last modified Mar. 17, 2013). 35 The Great Recession, INVESTOPEDIA,

http://www.investopedia.com/terms/g/great-recession.asp (last visited Nov. 24, 2014, 8:27PM). 36 Health Care Facts, supra note 9. 37 Morgan Whitaker, Bush still getting blame for economic woes, MSNBC

http://www.msnbc.com/politicsnation/poll-economy-bush-obama (last visited Nov. 24, 2014, 8:32 PM). 38 Jim VandeHei, Bush, GOP Congress losing core supporters, THE WASHINGTON POST ,

http://www.washingtonpost.com/wp-dyn/content/article/2006/05/10/AR2006051002040.html (last visited Nov. 24,

2014 8:34 PM). 39 See Ben Smith, Why Obama won, POLITICO,

http://www.politico.com/news/stories/1108/15301.html (last visited Nov. 24, 2014, 8:40 PM).

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campaign of “hope” and “change” to the previous ideals promoted in America.40 This political

movement, along with the anti-Republican sentiment of the time brought a wave of political

change to America.41 After those events, Obama won election by a wide margin42 and his

Democratic party saw substantial wins in both the House and the Senate.43 After the election,

Democrats held a nearly filibuster proof 60 members in the senate and a controlling margin in

the House.44 With this new found political power, Democrats essentially could enact legislation

without any need to compromise with the other side.45 While seemingly beneficial for the

Democrats, these events created a noticeable trend.46 Save Florida, Barack Obama had lost all

traditionally conservative states.47 (See Graphic B below)

40 Aaron Blake, President Obama: A man of many slogans, THE WASHINGTON POST ,

http://www.washingtonpost.com/blogs/the-fix/post/president-obama-a-man-of-many-

slogans/2012/07/10/gJQAf8UlaW_blog.html (last visited Nov. 24, 2014, 8:39 PM). 41 Ben Smith, supra note 39. 42 Id. 43 See Kevin Drum, About That Filibuster Proof Majority, MOTHER JONES,

http://www.motherjones.com/kevin-drum/2010/09/about-filibuster-proof-majority (last visited Nov. 24, 8:45 PM). 44 Shailagh Murray, House passes health-care reform bill without Republican votes, THE WASHINGTON POST ,

http://www.washingtonpost.com/wp-dyn/content/article/2010/03/21/AR2010032100943.html (last modified Mar. 22

2010). 45 See id; see also Drum, supra note 43. 46 Election of 2008, THE AMERICAN PRESIDENCY PROJECT ,

http://www.presidency.ucsb.edu/showelection.php?year=2008 (last visited Nov. 24, 2014, 9:01PM). 47 Id.

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From this political situation, Democrats from traditionally liberal states48 held the all the politica l

power in government: the Senate, House, and the Presidency.49

Now, working with only members of their own political party, the three governmenta l

bodies could pass binding legislation to affect all states, including those who had voted for the

traditionally conservative Republican Party.50 Controversial legislation here could divide the

country along party lines.51 Left leaning legislation favoring a bigger federal government,52 might

disturb those on the right who traditionally adhere to the ideals of bigger business and smaller

government.53 The ACA’s call for bigger government and additional expenses on business made

the law one of the most controversial bills in modern times.54 The Democratic party, for the better

part of 60 years, has attempted to pass universal healthcare.55 Presidents Franklin Roosevelt, Harry

Truman, John Kennedy, Lyndon Johnson, Jimmy Carter, and William Clinton attempted for

decades to pass health care reform in America, all attempts ended in failure because of opposition

from conservatives.56 However, with the new political surge brought by the Obama campaign, the

ACA passed both houses of congress, thus becoming the law of the land.57 Probably, the most

notable thing about the ACA, is that the law passed without a single Republican vote.58 Despite

not voting for the change states such as: Mississippi, Georgia, and Texas would have to adhere or

risk violating federal law.59

48 Id. 49 Id. 50 Id. 51 Id. 52 Democrat vs. Republican, DIFFEN,

http://www.diffen.com/difference/Democrat_vs_Republican (last visited Nov. 24, 2014 8:58PM). 53 See id. 54 See Marks, supra note 2. 55 The history of the US health care reform, FOX NEWS, http://www.foxnews.com/us/2012/06/27/us-health-care-

reform-efforts-through-history/, (last visited Nov. 24, 2014, 9:34 PM). [hereinafter Health Care Reform History] 56 Id. 57 See Inside Congress, supra note 30; see also Murray, supra note 44. 58 See Inside Congress, supra note 30; see also Murray, supra note 44. 59 See Inside Congress, supra note 30.

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N.F.I.B. v. Sibelius

Almost immediately after the passage, a nationwide lawsuit showed how drastically

polarized the country stood as a whole.60 After the passage of the ACA, twenty-seven states, all

with Republican governors, and the National Federation of Independent Business brought suit in

Federal Court suing the federal government challenging the constitutionality of the Affordable

Care Act.61 The consensus was that the law was going to fail because even at our Supreme Court

were judges whom are termed conservative.62 Those justices appointed by Republican Presidents

held a majority on the Supreme Court.63 Perhaps surprisingly, the Court held the Affordable Care

Act to be constitutional.64 With a 5-4 ruling, usual conservative and Bush appointee, Chief

Justice Roberts sided with the liberal justices.65 This moved shocked many court observers, who

predicted a vote split along purely ideological lines.66 In a winding opinion, Justice Roberts held

that congress had the power to pass the law under the power to tax.67 While the Court struck

down the portion of the ACA requiring states to comply,68 the court held, the federal government

instead could incentivize state government into complying with the law.69 From that day, the

clock began to run on the states to comply or risk losing loss of incentives.70

60 See Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2572, 183 L. Ed. 2d 450 (2012); see also Brandon

Stewart, List of 27 states suing over Obamacare, THE DAILY SIGNAL, http://dailysignal.com/2011/01/17/ list-of-

states-suing-over-obamacare/ (last visited Nov. 27, 2014, 11:44 PM). 61 Id. 62 See id. 63 Id. 64 Id. 65 Id. 66 Avik Roy, The inside story on how Roberts changed his Supreme Court Vote on Obamacare , FORBES,

http://www.forbes.com/sites/theapothecary/2012/07/01/the-supreme-courts-john-roberts-changed-his- obamacare-

vote-in-may/ (last visited Nov. 24, 2014 9:49 PM). 67 Nat'l Fed'n of Indep. Bus., 132 S. Ct. 2566, (2012). 68 Nat'l Fed'n of Indep. Bus., 132 S. Ct. 2566, (2012) at 2598. 69 Id. 70 Id.

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III. ACA Requirements

The ACA’s progressive requirements brought sweeping changes to the American health

care scheme.71 Among other things the ACA: created an individual mandate, an employer, new

insurance regulations, expanded Medicaid, and also incentivized states to create healthcare

exchanges.72 States would have to conform with all of the standards set forth in the ACA or risk

loss of incentives.73

A. Mandates

The most drastic change the ACA made to the United States health care policy is the

individual and employer mandates.74 The individual mandate imposes a duty on every citizen to

obtain health insurance that meets minimum standards set by the federal government.75 Further,

employers with over 50 employees are required to provide insurance to their employee. The

consequences for failure to conform include monetary penalties.76

B. Exchanges

To ease the implementation the ACA’s employer and individual mandates, The ACA

created Health Care Exchanges. Exchanges are websites designed to streamline the process of

businesses providing insurance to individuals. Each Exchange needed to provide information on

all available health insurance options,77 coordinate eligibility determinations for advance able

premium tax credits and cost-sharing subsidies available to individuals with incomes below 400%

of the Federal Poverty Level and Medicaid,78 and provide an analytical tool,79 to provide

71 See id. 72 ACA, supra note 1 at Stat. 163. 73 See Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2598, 183 L. Ed. 2d 450 (2012). 74 ACA, supra note 1. 75 Id. 76 Id. 77 Id. 78 Id at Stat 177. 79 Id.

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specification about, marketing, quality, and affordability.80 States that elected to operate their own

state-based exchanges or partnered exchanges were expected to assist the federal government to

determining whether state participants were complying with the mandates.81 States had until

January 1, 2014, to elect whether they would establish a state-based Exchange, partnership with

the federal government, or not establish an exchange at all.82

C. Insurance Regulation

The ACA calls for the states to change some practices by insurers.83 Previously, insurers

could exclude an individual from coverage because of poor health.84 Under the ACA, insurers must

cover all individuals regardless of preexisting conditions.85 Further, the ACA called for monetary

caps for healthcare costs.86 Payments paid like deductibles are also capped annually at $6000

dollars and insurers are forbidden from capping their contribution under a plan.87 Furthermore,

health plans may not rescind health coverage for any reason other than fraud.88 Finally, dependents

are allowed to remain on their parents' health insurance policies until age 26.89

D. Medicaid Expansion

In an effort to provide even more coverage to citizens, the ACA mandates that states expand

their Medicaid programs.90 The ACA incentivized states to expand coverage to people with

incomes up to 133% of the Federal Poverty Level by linking the expansion to the states’ existing

ability to receive federal matching funds toward the state's entire Medicaid program.91 The

80 Id. 81 Id at Stat 182. 82 Id. 83 Id at Stat 131. 84 Id at Stat141. 85 Id. 86 Id. 87 Id. 88 Id. 89 Id at Stat.131. 90 Id at Stat.776 91 Id.

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expansion of Medicaid eligibility is now essentially optional based on the Supreme Court's

decision.92

IV. Opinion of the Changes

Despite the radical changes, most people on either side actually agree with most of the

law but define their opinion based upon their affiliation with the source.93 While the general rule

is that Democrats favor the law and Republican generally disfavor the law, the law’s provisions

themselves have fans from some unlikely sources.94 While a recent poll says 52% of Americans

disapprove of “Obamacare,”95 and another poll found the majority of Americans both Democrats

and Republicans favored the law’s provisions.96 For example, 80 percent of Republicans favor

creating an insurance pool where small businesses and uninsured have access to insurance

exchanges, 54% of Republicans support requiring companies with more than 50 employees to

provide insurance for their employers, 78% of Republicans support banning insurances

companies from denying coverage for preexisting conditions, and 86% of Republicans support

banning insurance companies from cancelling policies because a person gets ill.97 The

favorability of these provisions is even higher among citizens identifying as Independents.98 In a

separate study, researchers asked people whether they agree with “Obamacare” or the ACA.99

These results often were comical.100 Here’s an excerpt of one of the exchanges:

92 Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, (2012). 93 James Hamblin, Some say they support the Affordable Care Act but not Obamacare , THE ATLANTIC,

http://www.theatlantic.com/health/archive/2013/10/some-americans-say-they-support-the-affordable-care-act-but-

not-obamacare/280165/ (last visited Nov. 28, 2014 12:56PM). 94 Public Approval of Health Care Law, REAL CLEAR POLITICS,

http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan -1130.html (last visited Nov.

26, 2014 12:00PM). 95 Id. 96 Hamblin, supra note 93. 97 Id. 98 Id. 99 Id. 100 Framing Works Affordable Care Act more popular then “Obamacare”, FSTV,

https://www.youtube.com/watch?v=76Sh-fjrgzU (last visited Nov. 28, 2014 1:04 PM).

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Q: So you disagree with Obamacare? A: Yes, I do.

Q: Do you think insurance companies should be able to exclude people with preexisting conditions?

A: No. Q: Do you agree that young people should be able to stay on their parents' plans until they're 26?"

A: They should be able to, yes. Q: "Do you agree that companies with 50 or more employees should provide healthcare?

A: I do. Q: And so, by that logic, you would be for the Affordable Care Act? A: Yes.101

If we take these polls, as true, identifying with or against the source of the ACA has a noticeable

effect on your opinion of the law.102

Progress around the country

If the majority of American’s actually agree with the changes, the true test comes when the

ACA is implemented in the various states. If the provisions are favored by the majority of the

citizens, in isolation of the source, the law should have strong support by the politicians elected to

represent their constituents. The ACA is federal legislation regulating state functions, so the

legislation needs compliance from the state officials to work efficiently.103 Given the divergent

political climates of the states, one probably could guess, this dynamic would lead to equally

divergent results. To analyze the cause of these effects, each section will briefly determine the

political landscape in the state before the ACA, assess the number of uninsured before the ACA,

and the states’ political response to the ACA. Then, determine the law’s success by assessing

enrollment numbers after the ACA .

101 Hamblin, supra note 93. 102 See id. 103 Id.

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A. Massachusetts

Massachusetts’ usually progressive policies, and existing healthcare infrastructure made

adhering to the ACA fairly easy. In 2006, unhampered by the constitutional restrictions prescribed

to the federal government, Massachusetts, passed An Act Providing Access to Affordable, Quality,

Accountable Health Care, (APQHC), a full 4 years before the ACA..104 The act required: every

individual possess healthcare, created a state run organization to police the program, subsidized

coverage for individuals below the poverty line and created a tax for individuals who could not

prove they possessed healthcare.105 This legislation radically changed the health care landscape

and seemed like a step in the right direction. Both Republicans and Democrats lauded the act as a

bipartisan triumph of 21st century healthcare.106

Even at its worst level, many viewed Massachusetts as the nationwide leader for quality

health care.107 Massachusetts was the first state to pass comprehensive healthcare reform with

mandatory enrollment in 2006.108 The passage of the law came in response to a high number of

uninsured residents.109 In 2006, the number of uninsured residents the state estimated the number

to ranged from 372,000 to 618,000,110 out of the states estimated 6,349,097 population.111 While

that number seemed large, that number accounted for only 5 to 10% of the state’s population.112

104 Chapter 58 of the Acts of 2006, An Act Providing Access to Affordable, Quality Accountable Health Care. 2006

Mass. Act Chp. 58, sec. 47, [hereinafter APQHC] 105 Id. 106 Mike Pridmore, The Real Reason Republicans hate “Obamacare,” DAILY KOS,

http://www.dailykos.com/story/2012/06/29/1104398/-The-Real-Reason-Republicans-hate-Obamacare (last modified

Jun. 29, 2012 10:54 PM). 107 See id. 108 Id. 109 Id. 110 How many uninsured in Massachusetts?, A HEALTHY BLOG, https://www.hcfama.org/pt-br/blog/how-many-

uninsured-massachusetts (last modified Aug. 29, 2006, 2014). 111https://www.census.gov/popest/data/historical/2000s/vintage_2006/state.html 112 Population Estimates Vintage 2006: State Tables, UNITED STATES CENSUS BUREAU,

http://quickfacts.census.gov/qfd/states/25000.html (last visited Nov. 26, 2014 11:15 PM).

14

After, the passage of the APQHC, at one point, that number fell all the way to 3.8%, by far the

lowest in that nation.113

Since the state already had a system similar to the ACA in place, Massachusetts’ response to

the law was favorable. After the ACA passed in 2010, Massachusetts did not join the nationwide

lawsuit, by the N.F.I.B.114 Massachusetts did not need to change much for the ACA.115 The state

already had a healthcare exchange program116 and had one of the lowest uninsured rate in the

country.117 So, the state should have continued to have stellar results. However, the APAQHC

recently failed.118 As of May 2014, Massachusetts scrapped its state run health care exchange.119

The exchange’s failure is attributed to many things including wide reports that the regulat ions

caused premiums to go up in the state and the prices were too much for the market.120 For example,

the typical family of four’s premium was nearly $13,788, the highest in the country. Further,

people could not sign up for the plans they needed, as many plans were too expensive for

individual’s needs. Massachusetts then enrolled into the federal healthcare exchange.121

While the exchange failed, Massachusetts still has the lowest uninsured rate in the nation. 122

The uninsured rate hovers around 3.1% currently.123 It seems the scrapping of the health care

113 Massachusetts, AMERICA’S HEALTH RANKINGS, http://www.americashealthrankings.org/MA (last visited Nov.

24, 2014 11:54 PM). 114 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 115 See APQHC, supra note 104; see also Massachusetts, supra note 113. 116 See, See APQHC, supra note 104. 117 Massachusetts, supra note 113. 118 Jon Kamp, Massachusetts scraps its health insurance exchange , THE WALL STREET JOURNAL,

http://online.wsj.com/articles/SB10001424052702303417104579544350496443052 (last visited Nov. 25, 2014

11:54PM). 119 Id. 120 Michael Tanner, Lessons from the fall of RomneyCare, CATO INSTITUTE, http://www.cato.org/policy-

report/januaryfebruary-2008/lessons-fall-romneycare (last visited Nov. 26, 2014 11:59 PM). 121 Jim Landers, How has the Massachusetts health insurance law worked out?, DALLASNEWS BUSINESS,

http://www.dallasnews.com/business/headlines/20140503-how-has-the-massachusetts-health-insurance-law-

worked-out.ece (last visited Nov. 28, 2014 9:00 AM) [hereinafter Mass. Health Progress]. 122 Id. 123 Id.

15

exchange did not affect the state at all in maintaining their record of providing their citizens with

affordable healthcare. So, we can take from this when the federal legislation from one politica l

source meets a state with similar policies, that legislation is more likely to succeed.

B. California

Like Massachusetts, California’s liberal politics124 and history of progressive policies

regarding healthcare125 made adhering to the ACA relatively easy. Before the ACA, California

had a 40 year history of providing healthcare to low income uninsured Californians funded by

local and county taxes.126 So, the ACA was not a radical change. In 2010, California had

Republican Governor Schwarzenegger,127 but his tenure is largely seen as very liberal.128

Schwarzenegger ideals confused liberals and conservatives alike because while supported

traditionally conservative causes like smaller government, he also appeared liberal when it came

to social issues such as abortion rights, gun control, and gay marriage.129 The state under his lead,

did not fight the ACA.130

Before the ACA, California had a high rate of uninsured residents.131 In 2009, the rate of

uninsured was 33.3%.132 California has long had the highest number of residents in the nation133

124 Alex Rodgers. These are the most Democratic and Most Republican states, TIME,

http://time.com/3536420/republican-democratic-states/ (last visited Nov. 26, 2014 5:07 PM). 125 Cal. Welf. & Inst. Code § 14005.4 (West) 126 Id. 127The governor’s gallery, ARNOLD SCHWARZENEGGER, http://governors.library.ca.gov/38-schwarzenegger.html

(last visited Nov. 26, 2014 5:10 PM). 128 Mark Sandalow, Schwarzenegger;’s liberal views leave GOP Flummoxed/Actor is pro-choice, pro-gun control

and pro-gay rights, SFGATE, http://www.sfgate.com/politics/article/Schwarzenegger-s-liberal-v iews-leave-GOP-

2596346.php (last visited Nov. 26, 2014 5:15 PM). 129 Id. 130 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 131 Sandra Shrewry, Close-Up on California: A look at the Medi-Cal Program, THE COMMONWEALTH FUND,

http://www.commonwealthfund.org/publications/commentaries/2005/oct/close-up-on-california--a-look-at-the-

medi-cal-program (last visited Nov. 25, 2014 5:31 PM). 132 Duke Helfand, About 1 in 4 in California lack health insurance study finds, LA TIMES,

http://articles.latimes.com/2010/mar/16/business/la-fi-uninsured16-2010mar16 (last modified Mar. 16, 2010). 133 Id.

16

at an estimated 36 million plus residents.134 In 2009, the uninsured accounted for roughly 8.2

million residents.135 But, all was not bad in California. The state had one of the most substantia l

Medicaid programs in the nation. Medi-Cal as it is commonly called did cover a great amount of

the state’s citizens.136 However, many were still left out.137 For example, adults without children

who made more than $15,400, or families of four making more than $32,000 were excluded.138

So, while California was not on the same level as a progressive state like Massachusetts, the state

still had much to work with for the ACA.

California’s willingness to compromise allowed the state’s ACA goals to be realized.

Despite having a member of the opposing party as the state’s governor, California did not join the

initial nationwide lawsuit.139 The state instead embraced the changes the federal law prescribed by

creating a statewide exchange,140 and promoting the new law through an informational marketing

campaign.141 Under the ACA, from 2010 to 2014, California’s uninsured rate was cut by more

than half.142 Today the number of Californians without health care coverage is only 11%.143 Riding

this wave, the state is still looking to expand.144 To help publicize the beginning of open enrollment

this fall, Health Care Executive Director Peter Lee is starting a nine-day, 21-city bus tour,

beginning at the State Capitol. The tour is part of a $95 million community outreach campaign

134 2010 Census Interactive Population Search , UNITED STATES CENSUS,

http://www.census.gov/2010census/popmap/ipmtext.php?fl=06 (last visited Nov. 26, 2014 5:40 PM). 135 See id. 136 Shrewry, supra note 131. 137 Id. 138 Lisa Aliferis, Obamacare Explained, KQED NEWS, http://www.kqed.org/news/health/obamacare/obamacare-

guide.jsp (last visited Nov. 26, 2014 5:49 PM). 139 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 140 Covered California, http://www.coveredca.com/, (last visited Nov. 26, 2014 5:54PM). 141 Kristy Farrington, AM Alert: Covered California launches bus tour for second open enrollment , CAPITOL ALERT,

http://www.sacbee.com/news/politics -government/capitol-alert/article3653689.html (last updated Nov. 10, 2014

9:29 AM). 142 Terhune, supra note 31. 143 Id. 144 See Farrington, supra note 141.

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supported by federal funding.145 So, California is an example of how compromise between the

ruling political parties can have greatly positive effects on legislation from the federal government.

C. Mississippi

Mississippi is the epitome of how political polarization stifles progress.146 Mississippi, a

traditional conservative state147 stood to gain from the ACA, with the substantial number of

uninsured residents.148 Mississippi’s conservative politicians even proposed a plan similar to the

ACA in response to the state’s high numbers of uninsured.149 In 2007, Mississippi Republican

Governor Haley Barbour planned a healthcare exchange that would revolutionize the healthcare

scheme in the state.150 The plan would have pattered a plan after Massachusetts health care scheme,

and would have pooled resources from the many in-state small businesses to secure healthcare for

their employees.151 This action was initially seen as a conservative approach for Mississippians by

Mississippians to lessen the state healthcare issues.152The results could not have come sooner, as

Mississippi had one of the worst health care systems in America.153 In 2009, nearly a quarter of

Mississippi residents were uninsured.154 22% of residents lived below the poverty line.155 The

145 Chris Rauber, Covered California predicts Obamacare exchange will enroll 1.7 million in second year,

BAYAREA BIZTALK, http://www.bizjournals.com/sanfrancisco/blog/2014/11/covered-california-obamacare-

17million-enrollees.html (last visited Nov. 7, 2014 6:04 PM). 146 Varney, supra note 31. 147 Voter IQ Project: What happened in Mississippi Republican U.S. Senate Primary should concern a ll traditional

Republican voters, GREENE COUNTRY TEA PARTY,

http://greenecountyteaparty.ohlc.org/2014/08/12/voter-iq-project-what-happened-in-the-mississippi-republican-u-s-

senate-primary-should-concern-all-traditional-republican-voters/ (last visited Nov. 24, 2014 11:00 PM). 148 Varney, supra note 31. 149 Id. 150 Id. 151 Id. 152 Id. 153 Id. 154 Id. 155 Id.

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insured rate was even bleaker for racial minorities.156 One in three African American adults are

uninsured,157 for Native Americans, and Hispanics nearly half were uninsured.158

While, the state was poised for a health care revolution, political polarity was the root cause

of the detrimental effect on the number of insured in Mississippi.159 Despite their own personal

need for healthcare, in 2010, Mississippi citizens elected politicians whose sole platform was to

oppose the ACA and other Washington initiatives.160 It is easy to fault the voters for their own

actions as the ACA could have helped some of the state’s residents, but remember, the ACA passed

without a single vote from a Mississippi congress-person.161 Many in Mississippi felt the federal

government imposed the legislation on the state, so after the passage of the ACA in 2010, plans to

build a revolutionary health care system were scrapped.162 An anti-Washington movement, led by

Mississippi Tea Party co-founder Roy Nicholson, gained popularity in state.163 Nicholson told his

followers,

“We must resist by all means that are right in the eyes of God is not rebellion or insurrection, it is patriotic resistance to invasion. We must resist the Socialist agenda”164

Then in 2011, Phil Bryant, a staunch conservative and follower of Nicholson, won election as

Governor.165 Bryant impeded the previous administrations efforts, hampering the ACA or any state

exchange in Mississippi.166 After contentious meeting with the previous administration regarding

the Mississippi healthcare, Governor Bryant canceled a crucial marketing campaign which would

156 Id at 2. 157 Id. 158 Id. 159 See id; also Varney, supra note 31. 160 Varney, supra note 31 at 5. 161 See Inside Congress, supra note 30; see also Murray, supra note 44. 162 Varney, supra note 31. 163 Id at 5. 164 Id. 165 About Governor Bryant, GOVERNOR PHIL BRYANT , http://www.governorbryant.com/about-governor-bryant/ (last

visited Nov. 24, 2014 11:11 PM). 166 Varney, supra note 31.

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have provided Mississippi residents with general information and coverage options.167 The

exchange then ran largely without publicity for 6 months.168 When it came time to get approval

for federal funds as required by ACA guidelines, Mississippi submitted the previous

administration’s exchange proposal but the federal government denied the proposal, citing

Governor Bryant’s lack of support, making Mississippi the only state to have its exchange

denied.169 Four months later Mississippi’s exchange went dark.170 Disappointingly, as of

December 2013, Mississippi had only a total of 802 signups for health care.171

Furthermore, Mississippi’s politically motivated decisions go much farther.172 Mississipp i

chose not to expand their Medicaid program leaving approximately 138,000 people in the

Medicaid gap.173 Without a healthcare exchange in state these people were left to fend for

themselves.174 The effects of the tumultuous political landscape in Mississippi has already

presented even more drastic effects.175 As a result of the state’s lackluster enrollment numbers and

failed exchange, the state only received 1.1 million dollars from the federal government for their

healthcare system, while a comparably sized less politically tumultuous state, Kentucky, received

252 million dollars.176 If Mississippi does not take realistic steps, the state will continue to have a

high proportion of uninsured.177 Governor Bryant is headed toward reelection in 2015.178 If

conforming to the ACA is not an option, Mississippi must find its own solution.179 Inaction would

167 Id at 3. 168 Id. 169 Id. 170 Id. 171 Id. 172 Id 173 Id. 174 Id. 175 Id at 5. 176 Id. 177 Id. 178 Id. 179 Id.

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hurt the state as it is slated suffer federal subsidy cuts to the tune of $8.7 million in 2015 and 2016,

26 million in 2017; 72.3 million in 2018; 81 million in 2019; and 57.8 million in 2020.180 Roy

Mitchell, the embattled head of the Mississippi Health Advocacy Program put it bluntly: “Ideology

put a man on the moon” and “Ideology can certainly kill health care.”181 Mississippi needs to find

an option that works and fits their state’s needs. So, here we can take that political polarizat ion

itself can cripple legislation.

D. Nevada

Nevada as a swing state is at a crossroads for the ACA. Nevada generally straddles the line

on politics.182 Nevada has one of the most prominent liberal senators in Harry Reid but also has

one of the most popular governors in the country in Republican in Brian Sandoval.183 Unlike, the

successful states Massachusetts and California who did not sue the federal government with the

N.F.I.B., Nevada did join as a party in the suit.184 At the time, the state could not be more polarized

politically regarding the ACA. Harry Reid, as the senate majority leader,185 was one of the bills

key advocates.186 Even now, with the general dislike of the ACA,187 Reid’s website still echoes his

praise for the bill.188 The site reads: “the ACA ensures that all Nevadans have access to quality,

affordable health coverage and touts the laws successes.”189 While on the other side, Republican

180 Id. 181 Id. 182 Brandon Fallon, 5 states likely to become battleground states by 2016 , IVN, http://ivn.us/2014/04/30/states-likely-

to-become-battleground-states-by-2016/ (last visited Nov. 26, 2014 6:12 PM). 183 Sean Sullivan, The most popular governor in the country? You probably haven’t heard of him, THE WASHINGTON

POST , http://www.washingtonpost.com/blogs/the-fix/wp/2014/02/21/the-fixs-10-most-popular-governors/ (last

visited Nov. 26, 2014 6:16 PM). 184 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 185 UNITED STATES SENATOR FOR NEVADA HARRY REID, supra note 8. 186 Warren Richey, New bid to topple Obamacare in court: Did Harry Reid bend the rules?, THE CHRISTIAN

SCIENCE MONITOR, http://www.csmonitor.com/USA/Justice/2014/0508/New-bid-to-topple-Obamacare-in-court-

Did-Harry-Reid-bend-the-rules ( last visited Nov. 25, 2014 6:24 PM). 187 Id. 188 UNITED STATES SENATOR FOR NEVADA HARRY REID, supra note 8. 189 Id.

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Governor Sandoval joined the in the N.F.I.B. nationwide suit on the behalf of Nevada to invalidate

the law.190 So, one would expect enrollment numbers to suffer as a result of this polarization.191

Before the ACA, Nevada had a substantial number of uninsured residents.192 In 2010,

Nevada had the third highest rate of uninsured in the country at 21.3% behind only Texas and New

Mexico and right ahead of Mississippi.193 In 2010, Nevada had a statewide population of

2,700,551.194 So the number of uninsured comes is estimated at about 575,000.195 Unlike,

California who had a substantial Medicaid program, Nevada’s Medicaid system was very strict. 196

For example, non-disabled adults without children could not qualify and adults with children could

only qualify if they also qualified for cash-assistance programs.197 So the state could benefit from

help from the federal government.

Beneficially, unlike Mississippi where the politicians decided to fight the ACA at all cost,

Nevada had a more moderate approach and conformed to the ACA’s mandates.198 After the state

lost NFIB v. Sibelius, Governor Sandoval became the first Republican Governor to fully accept

the ACA. Sandoval said:

190 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 191 See Varney, supra note 31; contra Terhune, supra note 31. 192 David Schwartz, Report finds high number of Nevadans lack health insurance, LAS VEGAS SUN,

http://www.lasvegassun.com/news/2011/oct/24/report-finds-high-numbers-nevadans-lack-health-ins/ (last visited

Nov. 25, 2014 6:44 PM). 193 Jeremy Nighohossian, The state of Health Care spending, NCPA, (available at

http://www.ncpa.org/pdfs/State_of_Health_Care_Spending_2013.pdf) 194 Nevada, UNITED STATES CENSUS, http://quickfacts.census.gov/qfd/states/32000.html, (last visited Nov. 26, 2014

6:51 PM). 195 Id. 196 Jagdeesh Gokhale, The impact of ObamaCare on Nevada’s Medicaid Spending , NEVADA POLICY RESEARCH

INSTITUTE, (available at

http://object.cato.org/sites/cato.org/files/articles/20110510_Impact_of_Obamacare_on_Nevadas_Medicaid_Spendin

g.pdf ). 197 Id.

198 Jeffrey Young, Brian Sandoval, Nevada Governor, is first Republican to back Obamacare Medicaid expansion,

HUFFINGTON POST , http://www.huffingtonpost.com/2012/12/12/brian-sandoval-nevada-medicaid-

expansion_n_2284478.html (last updated Dec. 13, 2013 8:52 PM).

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"Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health

care, the law has been upheld by the Supreme Court," Sandoval said in a written statement. "As such, I am forced to accept it as today’s reality and I have decided to expand Nevada's

Medicaid coverage."199

Upon this decision, the state was presented with two options; enroll into the Federal

Healthcare.gov program or start their own state run exchange to take advantage of federal

incentives.200 Nevada chose the former.201

However, the state’s progress largely remains unseen due to technical difficulties with the

state’s exchange program.202 Nevada contracted with Xerox to create the state exchange Nevada

Health link.203 The website was nearly universally held as a disappointment.204 The exchange’s

launch was delayed many times, and did not become functional until very late into the open

enrollment.205 The website had a scheduled launch date set by the federal government of October

1, 2013.206 However, the website soon experienced crippling setbacks.207 For example, on August

28, 2014, only 22 functions worked on the exchange’s website out of 235.208 Two weeks later, the

prognosis was not any better.209 Experts said the project was at high risk of failure given the quick

deadline.210 Not surprisingly, when the deadline came, the website crashed once, and then again a

199 Id. 200 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60. 201 John Sexton, Nevada Health Exchange: A case study in what went wrong, BREITBART ,

http://www.breitbart.com/InstaBlog/2013/10/10/Nevada-Health-Exchange-A-Case-Study-in-What-Went-Wrong

(last visited Nov. 26, 2014 7:10 PM. 202 Id. 203 Id. 204 See id. 205 Id. 206 Id. 207 Id. 208 Id. 209 Id. 210 Id.

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few days later.211 Because of these difficulties, as of 2014, Nevada decided to entirely scrap the

use of Nevada Health link exchange website and opt for the federally run exchange.212

The decrease in uninsured were nearly equally as dismal as the websites success.213 Experts

forecast that around 118,000 Nevadans should enroll into the states healthcare exchange program

in a 6 month period, a result would have immediately decreased the number of uninsured by nearly

21%.214 However, the true enrollment numbers fell well short of expectations.215 When the records

showed that only 16,000 people had enrolled in the program a tense debate ensued between state

officials and Xerox, the creators of the state exchange.216 Nevada board member Lynn Etkins said

the website created a disaster recovery plan” for Nevada. Many board members attributed the low

enrollment number to Nevada Health Link’s flaws.217 The website missed deadlines218 and was

difficult to navigate for the average user.219 Admittedly, it is hard to say how much polarization

played a roll the success of the ACA in Nevada, but, at least one Xerox executive cites the short

time frame which the company had to create the exchange, after the state’s participation in the

lawsuit, as a primary reason for the failure.220

While the state did have an unreliable exchange, the ACA in Nevada did have some meager

success.221 While not near the 118,000 originally forecast, Nevada still enrolled 38,000 people, a

reduction of the state’s uninsured by nearly 7%.222 The result is less than the favorable compare to

211 Id. 212 Id. 213 Id. 214 Id. 215 Id. 216 Id. 217 Id. 218 Id. 219 Id. 220 Id. 221 Louise Norris, Nevada health insurance exchange, HEALTH CARE INSURANCE ORG,

http://www.healthinsurance.org/nevada-state-health-insurance-exchange/ (last visited Nov. 26, 2014 7:46 PM). 222 Id.

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the other states of California,223 and Massachusetts,224 but still miles ahead of the poorly

performing state Mississippi.225 The state’s website probably had the most substantial impact on

the enrollment numbers in the state.226

Nevada can solve its health law problems through compromise. Luckily, the state has a

Governor who is more moderate than that his Tea Party contemporaries. Instead of considering

whether we disagree with the other side’s opinion, we should instead look for a common ground

to come up with a plan that works best for the people of our state. Governor Sandoval has already

shown great leadership by steering the state toward a reasonable direction that is with the will of

the people.227 Nevada appears to be off the destructive path of constant obstruction and onto the

path of compromise.228 However, continue to improve, the state needs to be more diligent in their

health care strategy. To succeed there needs to be a substantial statewide campaign telling people

about their options. The state should follow the lead of California and create a statewide marketing

campaign to inform residents of their options.229 The state has already produced commercials to

provide exposure, but the message largely remains unseen to many residents.230So moving

forward, Nevada has to be more active and creative in reaching their citizens and not fall into the

trap of Political Polarity.

223 Terhune, supra note 31. 224 Tanner, supra note 111. 225 Varney, supra note 31. 226 Norris, supra note 221. 227 Id. 228 Id. 229 Id. 230 Nevada Health Link, https://www.youtube.com/channel/UCLgJuz0xWmmMug1oK80qR3w (last visited Nov.

25, 2014 8:40 PM) showing (various videos for the Nevada Health Link exchange).

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V. Conclusion

There cannot be nationwide progress from the federal government unless there is

compromise. The ACA is an example of how political polarity affects lives in America. Health

care is an issue that effects all people. People have for generations attempted to solve this problem,

but because the unwillingness to compromise, each time ended in failure.231 We must be either,

short sighted or ignorant of the past because we still have not learned from the lessons of the

previous attempts. While the ACA is by no means perfect, there were reasonable way to fix the

legislation that would still conform to the particular needs and desires of the people of each state.

Compromise is the answer to all of these problems. When we lose sight of the other side, we are

no better for it. Goals promoted will almost certainly fail those intended to benefit, when your

political equal perpetually pulls in the opposite direction. Using the ACA as an example we can

see how allowing Political Polarity can cause the exact same legislation that is factually the will

of the people to have paradoxical results, like flourishing in like California,232 yet burning in

Mississippi. 233

Political Polarization influences our everyday life by influencing the way we think. It

would hard to find any reasonable person, in the country, who said health care is not a basic need

for the citizens of a modern country.234 Conversely, it would be relatively easy to find a citizen

that is against the law without a reason, other than opposing its source.235 But the polarity does not

stop with ordinary citizens; the polarity is at every level: from congress,236 to state officials, 237 to

231 FOX NEWS, supra note 55. 232 Terhune, supra note 31. 233 Varney, supra note 31. 234 Fisher, supra note 12. 235 Varney, supra note 31. 236 See Inside Congress, supra note 30; see also Murray, supra note 44. 237 See e.g. Varney, supra note 31.

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citizens, 238 to even our Supreme Court.239 The problem is within the way we think. As example,

this paper purposely used describing words like left and right, liberal and conservative, Democrat

and Republican because of the ideals these evoke within us. To eliminate the problem of polarity,

it starts on an individual level. We must ask ourselves tough questions. Are these ideas are truly

opposites? Is there another option? Are we simply fighting out of habit? We must do away with

these concepts and analyze issues for ourselves.

In the long term, we need to look into different options. The purpose of democracy is not

for the majority to wield political power over the other side like that of a monarch. Conversely,

the same is true for the minority. It is equally important to work with the majority. The true goal

of democracy is to meet the other side and find a workable solution together. Democracy is finding

a solution to the health care problem that helps those in need that also takes into account the issues

of the other side. Polarity is too taxing on the country. More options can only help the process.

Before, we jump to the black and white conclusions of yes, and no, we should explore solutions in

shades of grey.

238 Id. 239 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.