In 2009, when Congress passed the health care bill, only one Republican voted in favor. In 2010, using opposition to the new health care law as their rallying cry, Republicans gained 63 seats and control of the U.S. House of Representatives. They also won control of both the legislative and executive branches in 11 additional states, bringing their total to 25.

Last week, on Oct. 1 — the first day of the new federal fiscal year and the launch of the new health care exchanges — the victors of 2009 collided with the victors of 2010. The entire nation felt the impact.

Even when it ends, the government shutdown will have demonstrated the willingness of Republicans to try everything to stop the health care law. Already, well-funded state campaigns are trying to persuade healthy young people not to buy health insurance through the exchanges. If successful, these campaigns will hike premium rates for those who do sign up, spawning dissatisfaction with the new law.

The health care law finances “navigators” to help people sign up, similar to what Medicare has. But red states are hamstringing navigators, often requiring them to pass licensing exams, obtain insurance bonds and pay heavy fees. The more problems people have with the exchanges, the greater their dissatisfaction will be with the new law.

Given this level of intransigence, what is to be done? I believe the country, and the Democratic Party, would be better served if Republican-controlled states were allowed to opt out of the Affordable Care Act, but only if they agreed to three conditions:

• First, opting out requires opting out of all provisions of the law. No individual mandate. No health exchanges. No requirement that insurance companies spend 80 percent of the premium dollar on health care and cover people with preexisting conditions.

• Second, those states that are implementing the health care law will be given great latitude in designing their new health systems. Several states, for example, want to create a single-payer insurance system similar to what Canadian provinces have had for almost 50 years. The existing law allows them to do so only in 2017. They should be allowed to do so in 2014.

• Third, the people of withdrawing states must clearly support the opt out. The legislature must pass a bill. The governor must sign it. And a ballot referendum must be passed.

Some will argue that acceding to the Republican demand would abdicate federal responsibility for the poor and uninsured. But much of the damage to these groups has already been done. Twenty-one of the 25 Republican-controlled states have refused to expand Medicaid coverage, denying insurance to millions of their citizens despite the fact that the federal government would pay 100 percent of the costs (dropping to 90 percent by 2020). The original law mandated expanded Medicaid. Therefore Congress felt no subsidies for buying private insurance for the poor would be needed. The Supreme Court overturned that mandate. The result is that an estimated 8 million Americans who are impoverished and uninsured will be ineligible for federal assistance in Republican-controlled states.

If the Republicans agree to hold referendums, we can expect those 8 million Americans and many others who benefit or will benefit from the health care law to actively participate. And unlike in 2009, when most Americans had no idea what changes Congress was debating, a 2014 debate will be an informed one. Voters in Kansas and Wisconsin will see what is happening next door in Colorado and Minnesota.

Because the referendums will coincide with 2014 election campaigns in which most state legislators and all members of the House of Representatives will be up for re-election, a health care debate will give citizens not only the opportunity to opt out but also the opportunity to truly opt in by changing the composition of their statehouses to put in place governments that support expanded health care.

If states do opt out, the United States will become the world’s biggest social laboratory. Some states will operate under a pre-2009 health structure with large numbers of uninsured and a system dominated by private insurance companies. Others will create systems that provide universal access, likely with a public option.

Some might argue that if states were to opt out the viability of the new health care system will be threatened. But the experience of our neighbors to the north teaches us otherwise. Canada’s health system is managed at the equivalent of our state level. Even the largest Canadian provinces are the size of medium-sized U.S. states. Yet on almost every metric, from coverage to cost to outcomes to customer satisfaction, their health systems score higher than ours.

Allowing red states to “secede” will allow the executive branch to focus on helping those that are trying to implement a complex health care law. Allowing the blue states to create the kind of health system they truly want will allow us all to learn from their innovations. Requiring a vote of the people before a state can opt out will generate intensive discussions in hundreds of communities about what they want in a health system, a discussion informed by the experiences of their neighboring states.

President Obama and the Democratic Party should let the red states go.


David Morris is director of the Public Good Initiative at the Minneapolis- and Washington, D.C.-based Institute for Local Self-Reliance.