The new federal health reform law was born in a fiery battle -- and it remains in one.
No Republican member of Congress voted for the Affordable Care Act that President Obama signed into law in March 2010. More than a year and a half later, conservatives and Republicans remain united in denouncing the act and in pushing the courts to strike it down as unconstitutional.
The shrill political rhetoric conveys a vivid impression of health reform as stalled or facing imminent decapitation.
Conservative activists have been cheered by the slew of constitutional challenges filed by state attorneys general, and by the decisions of Kansas and Oklahoma to return to Washington funding provided to help states implement the law.
Almost unnoticed in the rowdy fracas is the real, general pattern. Many aspects of the law (such as new regulations of insurers and expansion of insurance coverage to children up to 26) are already implemented or in the active planning stage in Washington and in the states, where much of the work is unfolding.
More than three quarters of the states -- red, blue and purple -- have at least taken the first step of introducing legislation to lay the cornerstone of the Affordable Care Act: the health insurance exchanges where individuals and small businesses in each state will be able to shop (often online) among an array of qualified health plans.
In a few states, progressives are turning conservative fears into realities by enacting at the state level what they could not pass in Washington. California quickly signed on to national reform, and Vermont and Oregon are moving toward establishing single-payer and a public option.
But the most surprising development is happening out of the media glare.
A number of Republican state governments around the country are seizing on the significant discretion they have under the Affordable Care Act to design conservative models of reform. Leaders in these states do not equate implementation of the new law with support for President Obama.
A new icon of conservatism -- Wisconsin Gov. Scott Walker -- has established the "Office of Free Market Health Care" to develop plans for implementing the exchange in his state.
Walker's administration accepted $38 million from Washington to take the lead in developing innovative new information technology to simplify the use and operation of the exchange.
Walker's conservative soulmate in Ohio -- Gov. John Kasich -- is also planning to move forward to establish an exchange. He pushes back against conservatives who repudiate the exchange, owing to its partisan paternity.
"I don't operate like, it's theirs, it's not a good idea," he says. "Who cares? Let's get it done."
Indiana's Mitch Daniels. an early favorite for the GOP presidential nomination before withdrawing, issued an executive order to (conditionally) establish an exchange as a nonprofit corporation.
Meanwhile, in Virginia, where the attorney general is spearheading the constitutional challenge to the Affordable Care Act, Republican Gov. Robert McDonnell signed legislation to begin a process to establish an exchange.
Further South, Republican bigwig Haley Barbour is pioneering one of the most striking conservative models of reform by remaking the state's risk pool to serve as a foundation for Mississippi's exchange.
All of these Republican administrations -- and others -- are executing a nifty two-step dance. They denounce the Affordable Care Act to the cheers of activists, while they capitalize on its new funding, new authority and ample discretion to adapt it to their distinctive circumstances and ideas.
This political finesse -- talking down federal reform while pursuing state reform under its auspices -- showcases the trumping of partisanship by pragmatism as state Republican leaders respond to the urgent needs of their businesses and citizens.
Republican Gov. Rick Snyder of Michigan recently called on his GOP-controlled legislature to pass the "Michigan Health Marketplace."
"[E]ven if the ... Exchange was not mandated by the [Affordable Care Act]," Snyder insisted, "I would still be in favor of [it in order to] allow customers and small businesses to make more efficient and better informed decisions about buying health insurance coverage."
Far from being stillborn, health reform is moving ahead in directions that reflect each state's distinctive cultures, policy traditions and markets.
But there is more than pragmatism at work.
Innovative state Republican leaders are preparing for the next battles over national health reform by developing conservative models to compete on cost and quality against the single-payer and public-option systems that state-level progressives are developing to later showcase as models for national reform.
Of course, conservatives hold out hope for reform to be fully repealed, and soon, but that seems less likely.
The court cases that are making their way toward the Supreme Court have been considerably narrowed, and the Supreme Court may decide (as one decision recommended) to duck the case for the time being.
Republican politicians have shifted from their initial position of "repeal" to "repeal and replace," with "replace" only vaguely outlined and in ways that appear to continue the insurance exchange.
Most recently, presidential candidate Mitt Romney proposed to use "waivers" to free states to opt out of the Affordable Care Act, but this will not roll back what is already happening in the states.
It may open the gate for states like Vermont and Oregon to pursue liberal ends more quickly, and may (perversely) set up nonreforming states to subsidize reforming states -- Oklahoma sending tax money to Vermont, for instance.
Here's the question you may be wondering about now: What progress has been made in Minnesota -- a pioneer in medical care as well as in private, nonprofit and government policymaking?
Little, unfortunately. Democratic Gov. Mark Dayton has received federal support to begin planning (as have Republican governors elsewhere), but the GOP Legislature has blocked action -- even on Republican Rep. Steve Gottwalt's proposal to establish an exchange designed to fit Minnesota's circumstances.
Contrary to the warning by Ohio's Gov. Kasich, many Minnesotan Republicans appear to equate any action with political and constitutional abdication.
A lively and important debate over how to implement reform is warranted -- but outright inaction is costly.
It squanders generations of innovation in Minnesota -- including valuable proposals from the administration of former Gov. Tim Pawlenty and from legislators of both parties -- that inspired national and state reforms of provider payment and cost control.
(Pawlenty pushed for paying for outcomes and not just services, as well as for an electronic network for medical records, ideas reflected in the new law.)
All this suggests a new tragic twist to the children's story Little Red Hen. After decades of bipartisan hard work, Minnesota is idly sitting by as other states gorge themselves on our state's labors.
Inaction also misses the opportunity that Michigan's Gov. Snyder is grabbing for his state to control costs, improve quality and expand access. It may also leave Minnesota open to a true "one size fits all" solution.
The federal government may put the state into a federal exchange unless it sees adequate progress by January 2013, which is a nanosecond in the legislative process.
Perhaps most surprising, though, Republican supporters of inaction seem willing to miss an opportunity to pioneer a uniquely Minnesota approach that fits their values.
In the quest for conservative purity, this approach may set back conservatism as they abandon the field of play to the single-payer states and to Republican states that may not be as prepared as Minnesota to develop the strongest alternative.
The direction of health reform is open. The question is whether Minnesota will sit it out on the sidelines.
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Lawrence R. Jacobs is director of the Center for the Study of Politics and Governance at the University of Minnesota's Humphrey Institute of Public Affairs.