Whether and How Obamacare Is Implemented is Largely Up to States

They could monkeywrench the whole thing, we hope

After running a gauntlet of legal and political opposition, the Affordable Care Act is poised to bring the United States closer than it has ever been to universal health insurance. But just how close it gets will be up to individual states.

To reach its goal of covering 30 million low-income Americans in 2014, the Obama administration wants states to take two crucial steps: create an online health insurance exchange where people can sign up for coverage; and expand state Medicaid programs to cover 17 million more low-income adults. Each state will have an exchange whether it wants one or not, because the federal government will create them in states that fail to do it on their own. But the administration is asking states to take the initiative.

Republican governors, who have almost uniformly refused to build exchanges, are also rejecting the idea of extending their Medicaid programs for the poor to include able-bodied adults. Breaking ranks are GOP governors in Arizona, Nevada, New Mexico and North Dakota who have agreed to the expansion; and officials in Idaho, Mississippi, Nevada, New Mexico and Utah who have said Yes to running state insurance exchanges.