Whether your state has its own health exchange or relies on the troubled Federal exchange, healthcare.gov, depends largely on whether you have a Democrat or Republican as governor.
History is full of ironies.
Most Americans get their medical insurance from their employers. This system is largely a fluke of history. 1930s Depression Era laws limited the ability of American employers to give raises. So when the economy began to boom during and after World War II, employers turned to offering benefits as a way to recruit and retain workers. In other countries, health insurance coverage usually evolved in the post-war, mid-20th century as a government service like the military, police, schools, and fire departments.
For the US, 1965 was a crucial year. It was in this year that Medicaid and Medicare started as programs to help certain groups of uninsured Americans. By 2010 the public health insurance landscape in the US had become a patchwork of programs:
- Medicare for seniors
- Medicaid for low income Americans -mostly seniors and children
- VA (Veterans Administration) for military veterans
- TRICARE for active duty military and their families
- CHIP (Child Health Insurance Program) for low income children
- IHS (Indian Health Service) for Native Americans living on reservations
Ideas for how to cover the big group -the working poor- left out by these programs goes all the way back to the Nixon administration. Ironically, largely Republican think tanks and policy experts created a system of funneling the uninsured into private health insurance programs using subsidies for the poor and individual mandates to require younger, healthier, uninsured people to buy private health insurance. It was this basic program which Republican Governor Mitt Romney installed in Massachusetts. And it is this system of using private health insurers and government subsidies which is the same model making up Obamacare.
Even more irony: More liberal Democrats wanted to simply expand Medicaid to cover the uninsured and have a tax withdrawn from people's checks in the way we pay for Medicare. Some political commentators argue the use of the Romneycare model -plus the adoption of more than a 100 Republican amendments to the ACA- largely was a failed carrot to entice Republican legislators to vote for the ACA. So, while the ACA is largely a Republican idea filled with Republican amendments, the ACA passed with zero Republican votes in 2010.
Thus, it comes as no surprise that most Republican governors have opted to not set up a health exchange for their state and instead let the Federal exchange fill the void.