o understand what’s happened with the A.C.A. so far, you need to realize that as written (and interpreted by the Supreme Court), the law’s functioning depends a lot on cooperation from state governments. And where states have in fact cooperated, expanding Medicaid, operating their own insurance exchanges, and promoting both enrollment and competition among insurers, it has worked pretty darn well.
Compare, for example, the experience of Kentucky and its neighbor Tennessee. In 2013, before full implementation of the A.C.A., Tennessee had slightly fewer uninsured, 13 percent versus 14 percent. But by 2015 Kentucky, which implemented the law in full, had cut its uninsured rate to just 6 percent, while Tennessee was at 11.
Or consider the problem of counties with only one (or no) insurer, meaning no competition. As one recent study points out, this is almost entirely a red-state problem. In states with G.O.P. governors, 21 percent of the population lives in such counties; in Democratic-governor states, less than 2 percent.
So Obamacare is, though nobody will believe it, a well-thought-out law that works where states want it to work. It could and should be made to work better, but Republicans show no interest in making that happen. Instead, all their ideas involve sawing off one or more legs of that three-legged stool.
