In anticipation of the roll out of the Affordable Care Act, President Obama made his now famous comment: June 6, 2009: “If you like the plan you have, you can keep it. If you like the doctor you have, you can keep your doctor, too.” That didn’t happen as planned and in the ensuing years, the Republicans made serious hay out of that failure.

But here is what I think may have caused the misfire. The original plan expected the states to actively participate in the roll out of the ACA. An excited White House assumed an excitement in the various state houses…and really expected each state to build their own market place websites. Of course we know that happened on a very limited basis and those states who did that actually faired better than many of the others.

With state supported market places, there would be an expectation that most if not all of the health insurance companies in each state would participate. That the state insurance commissioners would put some pressure on them to list their offerings on the state sites. If that had happened most every doctor and most every plan available in the US would have been represented. Consumers would have been able to find their plans and their doctors and all would have progressed as planned.

But the fall back position was the federal market place would provide insurance plan offerings in states that could not or would not provide their own markets. Well the majority of states opted out of participation. There is no way that the federal government would be aware of the individual players in all of the local areas…or have much influence on them if they did…and the result is mostly national carriers and a handful of motivated local providers were involved. That limited coverage, it limited providers, it limited the number of plans available.

To me, the reticence on the part of the states to participate inhibited the success of the ACA…and that along with the failure of the individual mandate and the insurance companies raw underestimation of the number of uninsured Americans with major illnesses…is leading to the melt down in the current market place as it stands.

I am not sure how easy this would be fixed if someone decided that the ACA should be patched up…instead of just being replaced with Medicare for all.

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