The document discusses the history and implementation of the Affordable Care Act (ACA) in the United States. It notes that the ACA passed along party lines with only Democratic support. This caused divergent views of the law between political parties. The summary analyzes how political polarization affected the success of the ACA in different states based on their political leanings before and after the law was enacted. It also proposes reconciling different state experiences to develop workable solutions for states like Nevada.

1. 0
The ACA: Sailing America to Maybe from
the Seas of Yes and No.
Abstract: This paper will analyze the effect political polarization has on legislation from
the federal government, using the Patient Protection Affordable Care Act or (ACA) as an
example. The paper will analyze ACA’s progress from a historical perspective
considering the various political atmospheres of several states across the country
including Nevada. The paper will measure the success of the ACA by the number of
insured persons in each state. Next, the paper will measure the likelihood of the state’s
result based upon that state’s politician’s affiliation with of its source. e.g. Republican or
Democrat. Finally, the paper will reconcile the successes and failures of other states and
propose a workable solution for Nevada and then America as a whole.
By: Reginald S. Thomas

2. 1
The ACA in America: Guiding the ship to
Maybe from the Seas of Yes and No
I. Introduction
The Patient Protection Affordable Care Act1 (ACA) is one of the most divisive topics in
America today.2 The American political system has a substantial influence on this law.3 To casual
onlookers the general rule is liberal Democrats generally support the changes, but conservative
Republicans view the law unfavorably.4 Both sides do have merit. While the ACA as a whole
remains divisive, the majority of the population views many of its major changes favorably.5 This
paper will explore the root cause of this paradoxical dynamic, which is Political Polarization.6
Political Polarization7 caused individuals to favor or disfavor the ACA because of their
identification with a particular political party e.g., Democrat or Republican or ideology e.g., liberal
or conservative. To explore this thesis, this paper will acknowledge the views of both major
political parties. Instead of choosing a side to either justify or invalidate the ACA, this paper will
1 Pub. L. No. 111-148, 124 (2010), amended by Health Care and Reconciliation Act of 2010, Pub. L. No. 111-152,
124 Stat. 1029 (2010) (to be codified primarily in scattered sections of 42 U.S.C.). (*commonly called Obamacare).
[hereinafter ACA]
2 Shane Marks, Ten Most Controversial Topics for 2014,VISUAL.LY,
http://visual.ly/10-most-controversial-topics-2014 (last visited Nov. 22, 2014, 2:52 PM).
3 Inside Story Team, What’s in the legal future for Obamacare as midterm elections come?, AL-JAZEERA AMERICA,
http://america.aljazeera.com/watch/shows/inside-story/articles/2014/7/23/what-is-the-
legalandpoliticalfutureofobamacare.html (last visited Nov. 26, 2014 2:32 PM).
4 Steve Benen, About that ACA ‘repeal’ poll…,MSNBC,
http://www.msnbc.com/rachel-maddow-show/about-aca-repeal-poll (last visited Nov. 22, 2014, 2:46 PM).
5 Infra Ezra Klein, Poll: Republicanshate ‘Obamacare,’ but like most of what it does, THE WASHINGTON POST,
http://www.washingtonpost.com/blogs/wonkblog/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-
what-it-does/ (last visited Nov. 27, 2014 11:21 PM).
6 See Paul DiMaggio, Have American’s Social Attitudes become more polarized? AMERICAN JOURNAL OF
SOCIOLOGY, stating (“The term ‘Political polarization’ refers to cases in which an individual's stance on a given
issue,policy, or person is more likely to be strictly defined by their identification with a particular political party
e.g., Democrat or Republican or ideology e.g., liberal or conservative)(available at
http://www.jstor.org/discover/10.2307/2782461?uid=3739824&uid=2&uid=4&uid=3739256&sid=21105272770593
).
7 Id.

3. 2
measure how examine how divergent stances influence the success of the law despite what the
majority of citizens favor. One of the ACA’s primary goals was to reduce the number of uninsured
citizens by providing affordable healthcare to more Americans.8 Accordingly, this paper will
assess the law’s achievement of that goal by measuring the number of uninsured residents in the
state. To provide some context, first, this paper will recap the cause for reform, then detail the
history of the ACA, and describe the changes the law made to America’s health care system. Next,
the paper assess of how members from the two political parties currently view the changes. Then,
the paper will analyze the different results the ACA has had in traditionally politically divergent
states by considering the following factors: the political history of the state before the ACA, the
extensiveness of the states’ Medicaid program Pre-ACA, and the states’ politician’s response to
the ACA. However, when considering Nevada, the paper will reconcile the successes and failures
of other states to propose a realistic solution to the health care problems in the state. Afterward,
the paper will propose a solution to the problem of Political Polarity in America.
8 Health Care, UNITED STATESSENATOR FOR NEVADA HARRY REID, http://www.reid.senate.gov/healthcare (last
visited Nov. 23, 2014, 5:24 PM).

4. 3
I. American Health Care
Before the ACA, the previous health care system did not reach a large proportion of
Americans.9 To understand the ACA in a nationwide context, you must understand the previous
healthcare scheme in America. People by their nature, periodically get ill and require healthcare
in some form.10 So health care is a necessity, which at some point, nearly all must participate in.11
To aid with the eventual cost of health care there are different schemes.12 America is the only
industrialized nation without universal public healthcare.13 (See Graphic A below)
Compared to other industrialized nations, at the time, America was behind in important metrics
such as number of insured persons and healthcare cost.14 Health care was a substantial cost to some
9 Health Care Facts: Why we need Health Care Reform, OBAMACARE FACTS,
http://obamacarefacts.com/healthcare-facts/ (last visited Nov. 23, 2014, 2:19 PM) [hereinafter Health Care Facts].
10 Evan Horowitz, Everyone gets sick.Should everyone get sick days?,THE BOSTON GLOBE,
http://www.bostonglobe.com/metro/2014/07/31/everyone-gets-sick-should-everyone-get-sick-
days/PgZjuY7v3UQpXHDCFUkTTK/story.html (last visited Nov. 23, 2014PM).
11 Id.
12 Max Fisher, Here’s a map of the countriesthat provide Universal Health Care (America’s still not on it), THE
ATLANTIC,http://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-
universal-health-care-americas-still-not-on-it/259153/ (last visited Nov. 23, 2014, 2:32 PM). [hereinafter Health
Care Around the World].
13 Id.
14 Health Care Facts, supra note 9.

5. 4
Americans,15 causing great hardship in many cases.16 To compare, the United States, as a country,
then and currently spends more on healthcare than Japan, Germany, France, China, the U.K., Italy,
Canada, Brazil, Spain, and Australia combined.17 Services that are paid for by compulsory taxes
in other countries, instead, are an individual cost here in the United States.18 That individualized
cost could reach substantial levels,19especially, when families were considered.20 For example, the
average premium in 2009 for a family of four was $20,728.21 This great cost caused many average
Americans to see healthcare as a luxury they could not afford.22 The nation did have Medicaid to
cover low income individuals.23 Generally, low income residents must qualify for state run
Medicaid programs24 and the requirements to qualify for those programs differ from state to state.25
However, vast majority of citizens do not qualify for those programs26 and must either purchase
coverage individually from private insurer27 or obtain insurance through an employer.28 So, to
provide more insurance to the nation’s people, the nation needed an option to bring down the cost
of healthcare for the average American.29
15 Id.
16 Id.
17 Id.
18 Id.
19 Id.
20 Id.
21 Id.
22 Id.
23 Infra Joesph F. Mathews, How Medicaid Works, CARING.COM,
https://www.caring.com/articles/how-does-medicaid-work (last visited Nov. 23, 2014, 5:33 PM).
24 Id.
25 Id.
26 Id. at 3.
27 Health Care Facts, supra note 9.
28 Employer-Provided Health Coverage Informational Reporting Requirements: Questions and Answers, IRS,
http://www.irs.gov/uac/Employer-Provided-Health-Coverage-Informational-Reporting-Requirements:-Questions-
and-Answers (last visited Nov. 23, 2014, 5:24 PM).
29 Id.

6. 5
II. History of the ACA
The ACA aimed to bring down the cost for the average American, but passed with the
support of only one political party.30 To understand subsequent sections analysis on why the
ACA has vastly divergent results across the country,31 you must understand the events leading up
to the passage starting with the election of its principle advocate Barack Obama.32
Barack Obama’s campaign caused a substantial political wave.33 In 2008, regardless of
political affiliation, one must say that times were unprecedented, in America. The country was
stuck fighting two unpopular wars,34 the economy was the worst since the Great Depression,35
and affordable health care was distant to many Americans.36 The Bush administration rightly or
wrongly took most of the blame for these events.37 This caused an anti-Republican sentiment to
sweep across the country.38 To the casual onlooker, Obama was emblematic.39 Obama ran on a
30 Inside Congress, THE NEW YORK TIMES, http://politics.nytimes.com/congress/votes/111/senate/1/396 (last visited
Nov. 23, 2014, 5:57PM).
31 Infra, Sarah Varney, Mississippi, Burned: How the poorest,sickest state got left behind by Obamacare, POLITICO
MAGAZINE,
http://www.politico.com/magazine/story/2014/10/mississippi-burned-obamacare-112181.html#.VG012cmKYn4
(last visited Nov. 24, 2014 11:00 PM) [hereinafter Mississippi Burned]; see contra Chad Terhune, Rate of uninsured
Californiansis halved underObamacare, survey finds, LATIMES,http://www.latimes.com/business/healthcare/la-fi-
health-law-uninsured-california-obamacare-20140709-story.html (last visited Nov. 23, 2014, 3:09 PM) [hereinafter
California Halved].
32 Quin Hilyer, Obamacare’s Hideous History Recounted,SPECTATOR.ORG,
http://spectator.org/articles/35226/obamacares-hideous-history-recounted,(last modified Jul. 3, 2012).
33 Id.
34 Peyton Craighill, Poll: Iraq war still unpopular,divisive on 10th
Anniversary,THE WASHINGTON POST,
http://www.washingtonpost.com/blogs/worldviews/wp/2013/03/17/poll-iraq-war-still-unpopular-divisive-on-10th-
anniversary/, (last modified Mar. 17, 2013).
35 The Great Recession, INVESTOPEDIA,
http://www.investopedia.com/terms/g/great-recession.asp (last visited Nov. 24, 2014, 8:27PM).
36 Health Care Facts, supra note 9.
37 Morgan Whitaker, Bush still getting blame for economic woes, MSNBC
http://www.msnbc.com/politicsnation/poll-economy-bush-obama (last visited Nov. 24, 2014, 8:32 PM).
38 Jim VandeHei, Bush, GOP Congress losing core supporters,THE WASHINGTON POST,
http://www.washingtonpost.com/wp-dyn/content/article/2006/05/10/AR2006051002040.html (last visited Nov. 24,
2014 8:34 PM).
39 See Ben Smith, Why Obama won, POLITICO,
http://www.politico.com/news/stories/1108/15301.html (last visited Nov. 24, 2014, 8:40 PM).

7. 6
campaign of “hope” and “change” to the previous ideals promoted in America.40 This political
movement, along with the anti-Republican sentiment of the time brought a wave of political
change to America.41 After those events, Obama won election by a wide margin42 and his
Democratic party saw substantial wins in both the House and the Senate.43 After the election,
Democrats held a nearly filibuster proof 60 members in the senate and a controlling margin in
the House.44 With this new found political power, Democrats essentially could enact legislation
without any need to compromise with the other side.45 While seemingly beneficial for the
Democrats, these events created a noticeable trend.46 Save Florida, Barack Obama had lost all
traditionally conservative states.47 (See Graphic B below)
40 Aaron Blake, President Obama: A man of many slogans,THE WASHINGTON POST,
http://www.washingtonpost.com/blogs/the-fix/post/president-obama-a-man-of-many-
slogans/2012/07/10/gJQAf8UlaW_blog.html (last visited Nov. 24, 2014, 8:39 PM).
41 Ben Smith, supra note 39.
42 Id.
43 See Kevin Drum, About That FilibusterProof Majority, MOTHER JONES,
http://www.motherjones.com/kevin-drum/2010/09/about-filibuster-proof-majority (last visited Nov. 24, 8:45 PM).
44 Shailagh Murray, House passes health-care reform bill without Republican votes,THE WASHINGTON POST,
http://www.washingtonpost.com/wp-dyn/content/article/2010/03/21/AR2010032100943.html (last modified Mar. 22
2010).
45 See id; see also Drum, supra note 43.
46 Election of 2008, THE AMERICAN PRESIDENCY PROJECT,
http://www.presidency.ucsb.edu/showelection.php?year=2008 (last visited Nov. 24, 2014, 9:01PM).
47 Id.

8. 7
From this political situation, Democrats from traditionally liberal states48 held the all the political
power in government: the Senate, House, and the Presidency.49
Now, working with only members of their own political party, the three governmental
bodies could pass binding legislation to affect all states, including those who had voted for the
traditionally conservative Republican Party.50 Controversial legislation here could divide the
country along party lines.51 Left leaning legislation favoring a bigger federal government,52 might
disturb those on the right who traditionally adhere to the ideals of bigger business and smaller
government.53 The ACA’s call for bigger government and additional expenses on business made
the law one of the most controversial bills in modern times.54 The Democratic party, for the better
part of 60 years, has attempted to pass universal healthcare.55 Presidents Franklin Roosevelt, Harry
Truman, John Kennedy, Lyndon Johnson, Jimmy Carter, and William Clinton attempted for
decades to pass health care reform in America, all attempts ended in failure because of opposition
from conservatives.56 However, with the new political surge brought by the Obama campaign, the
ACA passed both houses of congress, thus becoming the law of the land.57 Probably, the most
notable thing about the ACA, is that the law passed without a single Republican vote.58 Despite
not voting for the change states such as: Mississippi, Georgia, and Texas would have to adhere or
risk violating federal law.59
48 Id.
49 Id.
50 Id.
51 Id.
52 Democrat vs. Republican,DIFFEN,
http://www.diffen.com/difference/Democrat_vs_Republican (last visited Nov. 24, 2014 8:58PM).
53 See id.
54 See Marks, supra note 2.
55 The history of the US health care reform, FOX NEWS, http://www.foxnews.com/us/2012/06/27/us-health-care-
reform-efforts-through-history/, (last visited Nov. 24, 2014, 9:34 PM). [hereinafter Health Care Reform History]
56 Id.
57 See Inside Congress, supra note 30; see also Murray, supra note 44.
58 See Inside Congress, supra note 30; see also Murray, supra note 44.
59 See Inside Congress, supra note 30.

9. 8
N.F.I.B. v. Sibelius
Almost immediately after the passage, a nationwide lawsuit showed how drastically
polarized the country stood as a whole.60 After the passage of the ACA, twenty-seven states, all
with Republican governors, and the National Federation of Independent Business brought suit in
Federal Court suing the federal government challenging the constitutionality of the Affordable
Care Act.61 The consensus was that the law was going to fail because even at our Supreme Court
were judges whom are termed conservative.62 Those justices appointed by Republican Presidents
held a majority on the Supreme Court.63 Perhaps surprisingly, the Court held the Affordable Care
Act to be constitutional.64 With a 5-4 ruling, usual conservative and Bush appointee, Chief
Justice Roberts sided with the liberal justices.65 This moved shocked many court observers, who
predicted a vote split along purely ideological lines.66 In a winding opinion, Justice Roberts held
that congress had the power to pass the law under the power to tax.67 While the Court struck
down the portion of the ACA requiring states to comply,68 the court held, the federal government
instead could incentivize state government into complying with the law.69 From that day, the
clock began to run on the states to comply or risk losing loss of incentives.70
60 See Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2572, 183 L. Ed. 2d 450 (2012); see also Brandon
Stewart, List of 27 states suing over Obamacare, THE DAILY SIGNAL, http://dailysignal.com/2011/01/17/list-of-
states-suing-over-obamacare/ (last visited Nov. 27, 2014, 11:44 PM).
61 Id.
62 See id.
63 Id.
64 Id.
65 Id.
66 Avik Roy, The inside story on how Roberts changed his Supreme Court Vote on Obamacare, FORBES,
http://www.forbes.com/sites/theapothecary/2012/07/01/the-supreme-courts-john-roberts-changed-his- obamacare-
vote-in-may/ (last visited Nov. 24, 2014 9:49 PM).
67 Nat'l Fed'n of Indep. Bus., 132 S. Ct. 2566, (2012).
68 Nat'l Fed'n of Indep. Bus., 132 S. Ct. 2566, (2012) at 2598.
69 Id.
70 Id.

10. 9
III. ACA Requirements
The ACA’s progressive requirements brought sweeping changes to the American health
care scheme.71 Among other things the ACA: created an individual mandate, an employer, new
insurance regulations, expanded Medicaid, and also incentivized states to create healthcare
exchanges.72 States would have to conform with all of the standards set forth in the ACA or risk
loss of incentives.73
A. Mandates
The most drastic change the ACA made to the United States health care policy is the
individual and employer mandates.74 The individual mandate imposes a duty on every citizen to
obtain health insurance that meets minimum standards set by the federal government.75 Further,
employers with over 50 employees are required to provide insurance to their employee. The
consequences for failure to conform include monetary penalties.76
B. Exchanges
To ease the implementation the ACA’s employer and individual mandates, The ACA
created Health Care Exchanges. Exchanges are websites designed to streamline the process of
businesses providing insurance to individuals. Each Exchange needed to provide information on
all available health insurance options,77 coordinate eligibility determinations for advance able
premium tax credits and cost-sharing subsidies available to individuals with incomes below 400%
of the Federal Poverty Level and Medicaid,78 and provide an analytical tool,79 to provide
71 See id.
72 ACA, supra note 1 at Stat. 163.
73 See Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2598, 183 L. Ed. 2d 450 (2012).
74 ACA, supra note 1.
75 Id.
76 Id.
77 Id.
78 Id at Stat 177.
79 Id.

11. 10
specification about, marketing, quality, and affordability.80 States that elected to operate their own
state-based exchanges or partnered exchanges were expected to assist the federal government to
determining whether state participants were complying with the mandates.81 States had until
January 1, 2014, to elect whether they would establish a state-based Exchange, partnership with
the federal government, or not establish an exchange at all.82
C. Insurance Regulation
The ACA calls for the states to change some practices by insurers.83 Previously, insurers
could exclude an individual from coverage because of poor health.84 Under the ACA, insurers must
cover all individuals regardless of preexisting conditions.85 Further, the ACA called for monetary
caps for healthcare costs.86 Payments paid like deductibles are also capped annually at $6000
dollars and insurers are forbidden from capping their contribution under a plan.87 Furthermore,
health plans may not rescind health coverage for any reason other than fraud.88 Finally, dependents
are allowed to remain on their parents' health insurance policies until age 26.89
D. Medicaid Expansion
In an effort to provide even more coverage to citizens, the ACA mandates that states expand
their Medicaid programs.90 The ACA incentivized states to expand coverage to people with
incomes up to 133% of the Federal Poverty Level by linking the expansion to the states’ existing
ability to receive federal matching funds toward the state's entire Medicaid program.91 The
80 Id.
81 Id at Stat 182.
82 Id.
83 Id at Stat 131.
84 Id at Stat141.
85 Id.
86 Id.
87 Id.
88 Id.
89 Id at Stat.131.
90 Id at Stat.776
91 Id.

12. 11
expansion of Medicaid eligibility is now essentially optional based on the Supreme Court's
decision.92
IV. Opinion of the Changes
Despite the radical changes, most people on either side actually agree with most of the
law but define their opinion based upon their affiliation with the source.93 While the general rule
is that Democrats favor the law and Republican generally disfavor the law, the law’s provisions
themselves have fans from some unlikely sources.94 While a recent poll says 52% of Americans
disapprove of “Obamacare,”95 and another poll found the majority of Americans both Democrats
and Republicans favored the law’s provisions.96 For example, 80 percent of Republicans favor
creating an insurance pool where small businesses and uninsured have access to insurance
exchanges, 54% of Republicans support requiring companies with more than 50 employees to
provide insurance for their employers, 78% of Republicans support banning insurances
companies from denying coverage for preexisting conditions, and 86% of Republicans support
banning insurance companies from cancelling policies because a person gets ill.97 The
favorability of these provisions is even higher among citizens identifying as Independents.98 In a
separate study, researchers asked people whether they agree with “Obamacare” or the ACA.99
These results often were comical.100 Here’s an excerpt of one of the exchanges:
92 Nat'l Fed'n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, (2012).
93 James Hamblin, Some say they support the Affordable Care Act but not Obamacare, THE ATLANTIC,
http://www.theatlantic.com/health/archive/2013/10/some-americans-say-they-support-the-affordable-care-act-but-
not-obamacare/280165/ (last visited Nov. 28, 2014 12:56PM).
94 Public Approval of Health Care Law, REAL CLEAR POLITICS,
http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html (last visited Nov.
26, 2014 12:00PM).
95 Id.
96 Hamblin, supra note 93.
97 Id.
98 Id.
99 Id.
100 Framing Works Affordable Care Act more popular then “Obamacare”, FSTV,
https://www.youtube.com/watch?v=76Sh-fjrgzU (last visited Nov. 28, 2014 1:04 PM).

13. 12
Q: So you disagree with Obamacare?
A: Yes, I do.
Q: Do you think insurance companies should be able to exclude people with preexisting
conditions?
A: No.
Q: Do you agree that young people should be able to stay on their parents' plans until
they're 26?"
A: They should be able to, yes.
Q: "Do you agree that companies with 50 or more employees should provide healthcare?
A: I do.
Q: And so, by that logic, you would be for the Affordable Care Act?
A: Yes.101
If we take these polls, as true, identifying with or against the source of the ACA has a noticeable
effect on your opinion of the law.102
Progress around the country
If the majority of American’s actually agree with the changes, the true test comes when the
ACA is implemented in the various states. If the provisions are favored by the majority of the
citizens, in isolation of the source, the law should have strong support by the politicians elected to
represent their constituents. The ACA is federal legislation regulating state functions, so the
legislation needs compliance from the state officials to work efficiently.103 Given the divergent
political climates of the states, one probably could guess, this dynamic would lead to equally
divergent results. To analyze the cause of these effects, each section will briefly determine the
political landscape in the state before the ACA, assess the number of uninsured before the ACA,
and the states’ political response to the ACA. Then, determine the law’s success by assessing
enrollment numbers after the ACA .
101 Hamblin, supra note 93.
102 See id.
103 Id.

14. 13
A. Massachusetts
Massachusetts’ usually progressive policies, and existing healthcare infrastructure made
adhering to the ACA fairly easy. In 2006, unhampered by the constitutional restrictions prescribed
to the federal government, Massachusetts, passed An Act Providing Access to Affordable, Quality,
Accountable Health Care, (APQHC), a full 4 years before the ACA..104 The act required: every
individual possess healthcare, created a state run organization to police the program, subsidized
coverage for individuals below the poverty line and created a tax for individuals who could not
prove they possessed healthcare.105 This legislation radically changed the health care landscape
and seemed like a step in the right direction. Both Republicans and Democrats lauded the act as a
bipartisan triumph of 21st century healthcare.106
Even at its worst level, many viewed Massachusetts as the nationwide leader for quality
health care.107 Massachusetts was the first state to pass comprehensive healthcare reform with
mandatory enrollment in 2006.108 The passage of the law came in response to a high number of
uninsured residents.109 In 2006, the number of uninsured residents the state estimated the number
to ranged from 372,000 to 618,000,110 out of the states estimated 6,349,097 population.111 While
that number seemed large, that number accounted for only 5 to 10% of the state’s population.112
104 Chapter 58 of the Acts of 2006, An Act Providing Access to Affordable, Quality Accountable Health Care. 2006
Mass.Act Chp. 58, sec. 47, [hereinafter APQHC]
105 Id.
106 Mike Pridmore, The Real Reason Republicans hate “Obamacare,” DAILY KOS,
http://www.dailykos.com/story/2012/06/29/1104398/-The-Real-Reason-Republicans-hate-Obamacare (last modified
Jun. 29, 2012 10:54 PM).
107 See id.
108 Id.
109 Id.
110 How many uninsured in Massachusetts?, A HEALTHY BLOG,https://www.hcfama.org/pt-br/blog/how-many-
uninsured-massachusetts (last modified Aug.29, 2006, 2014).
111https://www.census.gov/popest/data/historical/2000s/vintage_2006/state.html
112 Population EstimatesVintage 2006:State Tables, UNITED STATESCENSUS BUREAU,
http://quickfacts.census.gov/qfd/states/25000.html (last visited Nov. 26, 2014 11:15 PM).

15. 14
After, the passage of the APQHC, at one point, that number fell all the way to 3.8%, by far the
lowest in that nation.113
Since the state already had a system similar to the ACA in place, Massachusetts’ response to
the law was favorable. After the ACA passed in 2010, Massachusetts did not join the nationwide
lawsuit, by the N.F.I.B.114 Massachusetts did not need to change much for the ACA.115 The state
already had a healthcare exchange program116 and had one of the lowest uninsured rate in the
country.117 So, the state should have continued to have stellar results. However, the APAQHC
recently failed.118 As of May 2014, Massachusetts scrapped its state run health care exchange.119
The exchange’s failure is attributed to many things including wide reports that the regulations
caused premiums to go up in the state and the prices were too much for the market.120 For example,
the typical family of four’s premium was nearly $13,788, the highest in the country. Further,
people could not sign up for the plans they needed, as many plans were too expensive for
individual’s needs. Massachusetts then enrolled into the federal healthcare exchange.121
While the exchange failed, Massachusetts still has the lowest uninsured rate in the nation.122
The uninsured rate hovers around 3.1% currently.123 It seems the scrapping of the health care
113 Massachusetts, AMERICA’SHEALTH RANKINGS, http://www.americashealthrankings.org/MA (last visited Nov.
24, 2014 11:54 PM).
114 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
115 See APQHC, supra note 104; see also Massachusetts, supra note 113.
116 See, See APQHC, supra note 104.
117 Massachusetts, supra note 113.
118 Jon Kamp, Massachusetts scraps its health insurance exchange,THE WALL STREET JOURNAL,
http://online.wsj.com/articles/SB10001424052702303417104579544350496443052 (last visited Nov. 25, 2014
11:54PM).
119 Id.
120 Michael Tanner, Lessons from the fall of RomneyCare, CATO INSTITUTE,http://www.cato.org/policy-
report/januaryfebruary-2008/lessons-fall-romneycare (last visited Nov. 26, 2014 11:59 PM).
121 Jim Landers, How has the Massachusettshealth insurance law worked out?, DALLASNEWSBUSINESS,
http://www.dallasnews.com/business/headlines/20140503-how-has-the-massachusetts-health-insurance-law-
worked-out.ece (last visited Nov. 28, 2014 9:00 AM) [hereinafter Mass. Health Progress].
122 Id.
123 Id.

16. 15
exchange did not affect the state at all in maintaining their record of providing their citizens with
affordable healthcare. So, we can take from this when the federal legislation from one political
source meets a state with similar policies, that legislation is more likely to succeed.
B. California
Like Massachusetts, California’s liberal politics124 and history of progressive policies
regarding healthcare125 made adhering to the ACA relatively easy. Before the ACA, California
had a 40 year history of providing healthcare to low income uninsured Californians funded by
local and county taxes.126 So, the ACA was not a radical change. In 2010, California had
Republican Governor Schwarzenegger,127 but his tenure is largely seen as very liberal.128
Schwarzenegger ideals confused liberals and conservatives alike because while supported
traditionally conservative causes like smaller government, he also appeared liberal when it came
to social issues such as abortion rights, gun control, and gay marriage.129 The state under his lead,
did not fight the ACA.130
Before the ACA, California had a high rate of uninsured residents.131 In 2009, the rate of
uninsured was 33.3%.132 California has long had the highest number of residents in the nation133
124 Alex Rodgers. These are the most Democratic and Most Republican states,TIME,
http://time.com/3536420/republican-democratic-states/ (last visited Nov. 26, 2014 5:07 PM).
125 Cal. Welf. & Inst.Code § 14005.4 (West)
126 Id.
127The governor’s gallery, ARNOLD SCHWARZENEGGER,http://governors.library.ca.gov/38-schwarzenegger.html
(last visited Nov. 26, 2014 5:10 PM).
128 Mark Sandalow, Schwarzenegger;’sliberal views leave GOP Flummoxed/Actor is pro-choice, pro-gun control
and pro-gay rights, SFGATE, http://www.sfgate.com/politics/article/Schwarzenegger-s-liberal-views-leave-GOP-
2596346.php (last visited Nov. 26, 2014 5:15 PM).
129 Id.
130 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
131 Sandra Shrewry, Close-Up on California:A look at the Medi-Cal Program, THE COMMONWEALTH FUND,
http://www.commonwealthfund.org/publications/commentaries/2005/oct/close-up-on-california--a-look-at-the-
medi-cal-program (last visited Nov. 25, 2014 5:31 PM).
132 Duke Helfand, About 1 in 4 in California lack health insurance study finds, LA TIMES,
http://articles.latimes.com/2010/mar/16/business/la-fi-uninsured16-2010mar16 (last modified Mar. 16, 2010).
133 Id.

17. 16
at an estimated 36 million plus residents.134 In 2009, the uninsured accounted for roughly 8.2
million residents.135 But, all was not bad in California. The state had one of the most substantial
Medicaid programs in the nation. Medi-Cal as it is commonly called did cover a great amount of
the state’s citizens.136 However, many were still left out.137 For example, adults without children
who made more than $15,400, or families of four making more than $32,000 were excluded.138
So, while California was not on the same level as a progressive state like Massachusetts, the state
still had much to work with for the ACA.
California’s willingness to compromise allowed the state’s ACA goals to be realized.
Despite having a member of the opposing party as the state’s governor, California did not join the
initial nationwide lawsuit.139 The state instead embraced the changes the federal law prescribed by
creating a statewide exchange,140 and promoting the new law through an informational marketing
campaign.141 Under the ACA, from 2010 to 2014, California’s uninsured rate was cut by more
than half.142 Today the number of Californians without health care coverage is only 11%.143 Riding
this wave, the state is still looking to expand.144 To help publicize the beginning of open enrollment
this fall, Health Care Executive Director Peter Lee is starting a nine-day, 21-city bus tour,
beginning at the State Capitol. The tour is part of a $95 million community outreach campaign
134 2010 Census Interactive Population Search,UNITED STATESCENSUS,
http://www.census.gov/2010census/popmap/ipmtext.php?fl=06 (last visited Nov. 26, 2014 5:40 PM).
135 See id.
136 Shrewry, supra note 131.
137 Id.
138 Lisa Aliferis, Obamacare Explained,KQED NEWS, http://www.kqed.org/news/health/obamacare/obamacare-
guide.jsp (last visited Nov. 26, 2014 5:49 PM).
139 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
140 Covered California,http://www.coveredca.com/, (last visited Nov. 26, 2014 5:54PM).
141 Kristy Farrington, AM Alert: Covered California launches bus tour for second open enrollment, CAPITOL ALERT,
http://www.sacbee.com/news/politics-government/capitol-alert/article3653689.html (last updated Nov. 10, 2014
9:29 AM).
142 Terhune, supra note 31.
143 Id.
144 See Farrington, supra note 141.

18. 17
supported by federal funding.145 So, California is an example of how compromise between the
ruling political parties can have greatly positive effects on legislation from the federal government.
C. Mississippi
Mississippi is the epitome of how political polarization stifles progress.146 Mississippi, a
traditional conservative state147 stood to gain from the ACA, with the substantial number of
uninsured residents.148 Mississippi’s conservative politicians even proposed a plan similar to the
ACA in response to the state’s high numbers of uninsured.149 In 2007, Mississippi Republican
Governor Haley Barbour planned a healthcare exchange that would revolutionize the healthcare
scheme in the state.150 The plan would have pattered a plan after Massachusetts health care scheme,
and would have pooled resources from the many in-state small businesses to secure healthcare for
their employees.151 This action was initially seen as a conservative approach for Mississippians by
Mississippians to lessen the state healthcare issues.152The results could not have come sooner, as
Mississippi had one of the worst health care systems in America.153 In 2009, nearly a quarter of
Mississippi residents were uninsured.154 22% of residents lived below the poverty line.155 The
145 Chris Rauber, Covered California predicts Obamacare exchange will enroll 1.7 million in second year,
BAYAREA BIZTALK, http://www.bizjournals.com/sanfrancisco/blog/2014/11/covered-california-obamacare-
17million-enrollees.html (last visited Nov. 7, 2014 6:04 PM).
146 Varney, supra note 31.
147 Voter IQ Project: What happened in Mississippi Republican U.S. Senate Primary should concern a ll traditional
Republican voters,GREENE COUNTRY TEA PARTY,
http://greenecountyteaparty.ohlc.org/2014/08/12/voter-iq-project-what-happened-in-the-mississippi-republican-u-s-
senate-primary-should-concern-all-traditional-republican-voters/ (last visited Nov. 24, 2014 11:00 PM).
148 Varney, supra note 31.
149 Id.
150 Id.
151 Id.
152 Id.
153 Id.
154 Id.
155 Id.

19. 18
insured rate was even bleaker for racial minorities.156 One in three African American adults are
uninsured,157 for Native Americans, and Hispanics nearly half were uninsured.158
While, the state was poised for a health care revolution, political polarity was the root cause
of the detrimental effect on the number of insured in Mississippi.159 Despite their own personal
need for healthcare, in 2010, Mississippi citizens elected politicians whose sole platform was to
oppose the ACA and other Washington initiatives.160 It is easy to fault the voters for their own
actions as the ACA could have helped some of the state’s residents, but remember, the ACA passed
without a single vote from a Mississippi congress-person.161 Many in Mississippi felt the federal
government imposed the legislation on the state, so after the passage of the ACA in 2010, plans to
build a revolutionary health care system were scrapped.162 An anti-Washington movement, led by
Mississippi Tea Party co-founder Roy Nicholson, gained popularity in state.163 Nicholson told his
followers,
“We must resist by all means that are right in the eyes of God is not rebellion or
insurrection, it is patriotic resistance to invasion. We must resist the Socialist agenda”164
Then in 2011, Phil Bryant, a staunch conservative and follower of Nicholson, won election as
Governor.165 Bryant impeded the previous administrations efforts, hampering the ACA or any state
exchange in Mississippi.166 After contentious meeting with the previous administration regarding
the Mississippi healthcare, Governor Bryant canceled a crucial marketing campaign which would
156 Id at 2.
157 Id.
158 Id.
159 See id; also Varney, supra note 31.
160 Varney, supra note 31 at 5.
161 See Inside Congress, supra note 30; see also Murray, supra note 44.
162 Varney, supra note 31.
163 Id at 5.
164 Id.
165 About Governor Bryant, GOVERNOR PHIL BRYANT,http://www.governorbryant.com/about-governor-bryant/ (last
visited Nov. 24, 2014 11:11 PM).
166 Varney, supra note 31.

20. 19
have provided Mississippi residents with general information and coverage options.167 The
exchange then ran largely without publicity for 6 months.168 When it came time to get approval
for federal funds as required by ACA guidelines, Mississippi submitted the previous
administration’s exchange proposal but the federal government denied the proposal, citing
Governor Bryant’s lack of support, making Mississippi the only state to have its exchange
denied.169 Four months later Mississippi’s exchange went dark.170 Disappointingly, as of
December 2013, Mississippi had only a total of 802 signups for health care.171
Furthermore, Mississippi’s politically motivated decisions go much farther.172 Mississippi
chose not to expand their Medicaid program leaving approximately 138,000 people in the
Medicaid gap.173 Without a healthcare exchange in state these people were left to fend for
themselves.174 The effects of the tumultuous political landscape in Mississippi has already
presented even more drastic effects.175 As a result of the state’s lackluster enrollment numbers and
failed exchange, the state only received 1.1 million dollars from the federal government for their
healthcare system, while a comparably sized less politically tumultuous state, Kentucky, received
252 million dollars.176 If Mississippi does not take realistic steps, the state will continue to have a
high proportion of uninsured.177 Governor Bryant is headed toward reelection in 2015.178 If
conforming to the ACA is not an option, Mississippi must find its own solution.179 Inaction would
167 Id at 3.
168 Id.
169 Id.
170 Id.
171 Id.
172 Id
173 Id.
174 Id.
175 Id at 5.
176 Id.
177 Id.
178 Id.
179 Id.

21. 20
hurt the state as it is slated suffer federal subsidy cuts to the tune of $8.7 million in 2015 and 2016,
26 million in 2017; 72.3 million in 2018; 81 million in 2019; and 57.8 million in 2020.180 Roy
Mitchell, the embattled head of the Mississippi Health Advocacy Program put it bluntly: “Ideology
put a man on the moon” and “Ideology can certainly kill health care.”181 Mississippi needs to find
an option that works and fits their state’s needs. So, here we can take that political polarization
itself can cripple legislation.
D. Nevada
Nevada as a swing state is at a crossroads for the ACA. Nevada generally straddles the line
on politics.182 Nevada has one of the most prominent liberal senators in Harry Reid but also has
one of the most popular governors in the country in Republican in Brian Sandoval.183 Unlike, the
successful states Massachusetts and California who did not sue the federal government with the
N.F.I.B., Nevada did join as a party in the suit.184 At the time, the state could not be more polarized
politically regarding the ACA. Harry Reid, as the senate majority leader,185 was one of the bills
key advocates.186 Even now, with the general dislike of the ACA,187 Reid’s website still echoes his
praise for the bill.188 The site reads: “the ACA ensures that all Nevadans have access to quality,
affordable health coverage and touts the laws successes.”189 While on the other side, Republican
180 Id.
181 Id.
182 Brandon Fallon, 5 states likely to become battleground states by 2016,IVN, http://ivn.us/2014/04/30/states-likely-
to-become-battleground-states-by-2016/ (last visited Nov. 26, 2014 6:12 PM).
183 Sean Sullivan, The most populargovernor in the country? You probably haven’t heard of him, THE WASHINGTON
POST, http://www.washingtonpost.com/blogs/the-fix/wp/2014/02/21/the-fixs-10-most-popular-governors/ (last
visited Nov. 26, 2014 6:16 PM).
184 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
185 UNITED STATESSENATOR FOR NEVADA HARRY REID, supra note 8.
186 Warren Richey, New bid to topple Obamacare in court: Did Harry Reid bend the rules?, THE CHRISTIAN
SCIENCE MONITOR,http://www.csmonitor.com/USA/Justice/2014/0508/New-bid-to-topple-Obamacare-in-court-
Did-Harry-Reid-bend-the-rules ( last visited Nov. 25, 2014 6:24 PM).
187 Id.
188 UNITED STATESSENATOR FOR NEVADA HARRY REID, supra note 8.
189 Id.

22. 21
Governor Sandoval joined the in the N.F.I.B. nationwide suit on the behalf of Nevada to invalidate
the law.190 So, one would expect enrollment numbers to suffer as a result of this polarization.191
Before the ACA, Nevada had a substantial number of uninsured residents.192 In 2010,
Nevada had the third highest rate of uninsured in the country at 21.3% behind only Texas and New
Mexico and right ahead of Mississippi.193 In 2010, Nevada had a statewide population of
2,700,551.194 So the number of uninsured comes is estimated at about 575,000.195 Unlike,
California who had a substantial Medicaid program, Nevada’s Medicaid system was very strict.196
For example, non-disabled adults without children could not qualify and adults with children could
only qualify if they also qualified for cash-assistance programs.197 So the state could benefit from
help from the federal government.
Beneficially, unlike Mississippi where the politicians decided to fight the ACA at all cost,
Nevada had a more moderate approach and conformed to the ACA’s mandates.198 After the state
lost NFIB v. Sibelius, Governor Sandoval became the first Republican Governor to fully accept
the ACA. Sandoval said:
190 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
191 See Varney, supra note 31; contra Terhune, supra note 31.
192 David Schwartz, Report finds high number of Nevadans lack health insurance,LAS VEGAS SUN,
http://www.lasvegassun.com/news/2011/oct/24/report-finds-high-numbers-nevadans-lack-health-ins/ (last visited
Nov. 25, 2014 6:44 PM).
193 Jeremy Nighohossian, The state of Health Care spending, NCPA, (available at
http://www.ncpa.org/pdfs/State_of_Health_Care_Spending_2013.pdf)
194 Nevada, UNITED STATESCENSUS, http://quickfacts.census.gov/qfd/states/32000.html, (last visited Nov. 26, 2014
6:51 PM).
195 Id.
196 Jagdeesh Gokhale, The impact of ObamaCare on Nevada’s Medicaid Spending,NEVADA POLICY RESEARCH
INSTITUTE,(available at
http://object.cato.org/sites/cato.org/files/articles/20110510_Impact_of_Obamacare_on_Nevadas_Medicaid_Spendin
g.pdf ).
197 Id.
198 Jeffrey Young, Brian Sandoval,Nevada Governor, is first Republican to back Obamacare Medicaid expansion,
HUFFINGTON POST,http://www.huffingtonpost.com/2012/12/12/brian-sandoval-nevada-medicaid-
expansion_n_2284478.html (last updated Dec. 13, 2013 8:52 PM).

23. 22
"Though I have never liked the Affordable Care Act because of the individual mandate it
places on citizens, the increased burden on businesses and concerns about access to health
care, the law has been upheld by the Supreme Court," Sandoval said in a written statement.
"As such, I am forced to accept it as today’s reality and I have decided to expand Nevada's
Medicaid coverage."199
Upon this decision, the state was presented with two options; enroll into the Federal
Healthcare.gov program or start their own state run exchange to take advantage of federal
incentives.200 Nevada chose the former.201
However, the state’s progress largely remains unseen due to technical difficulties with the
state’s exchange program.202 Nevada contracted with Xerox to create the state exchange Nevada
Health link.203 The website was nearly universally held as a disappointment.204 The exchange’s
launch was delayed many times, and did not become functional until very late into the open
enrollment.205 The website had a scheduled launch date set by the federal government of October
1, 2013.206 However, the website soon experienced crippling setbacks.207 For example, on August
28, 2014, only 22 functions worked on the exchange’s website out of 235.208 Two weeks later, the
prognosis was not any better.209 Experts said the project was at high risk of failure given the quick
deadline.210 Not surprisingly, when the deadline came, the website crashed once, and then again a
199 Id.
200 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.
201 John Sexton, Nevada Health Exchange: A case study in what went wrong, BREITBART,
http://www.breitbart.com/InstaBlog/2013/10/10/Nevada-Health-Exchange-A-Case-Study-in-What-Went-Wrong
(last visited Nov. 26, 2014 7:10 PM.
202 Id.
203 Id.
204 See id.
205 Id.
206 Id.
207 Id.
208 Id.
209 Id.
210 Id.

24. 23
few days later.211 Because of these difficulties, as of 2014, Nevada decided to entirely scrap the
use of Nevada Health link exchange website and opt for the federally run exchange.212
The decrease in uninsured were nearly equally as dismal as the websites success.213 Experts
forecast that around 118,000 Nevadans should enroll into the states healthcare exchange program
in a 6 month period, a result would have immediately decreased the number of uninsured by nearly
21%.214 However, the true enrollment numbers fell well short of expectations.215 When the records
showed that only 16,000 people had enrolled in the program a tense debate ensued between state
officials and Xerox, the creators of the state exchange.216 Nevada board member Lynn Etkins said
the website created a disaster recovery plan” for Nevada. Many board members attributed the low
enrollment number to Nevada Health Link’s flaws.217 The website missed deadlines218 and was
difficult to navigate for the average user.219 Admittedly, it is hard to say how much polarization
played a roll the success of the ACA in Nevada, but, at least one Xerox executive cites the short
time frame which the company had to create the exchange, after the state’s participation in the
lawsuit, as a primary reason for the failure.220
While the state did have an unreliable exchange, the ACA in Nevada did have some meager
success.221 While not near the 118,000 originally forecast, Nevada still enrolled 38,000 people, a
reduction of the state’s uninsured by nearly 7%.222 The result is less than the favorable compare to
211 Id.
212 Id.
213 Id.
214 Id.
215 Id.
216 Id.
217 Id.
218 Id.
219 Id.
220 Id.
221 Louise Norris, Nevada health insurance exchange,HEALTH CARE INSURANCE ORG,
http://www.healthinsurance.org/nevada-state-health-insurance-exchange/ (last visited Nov. 26, 2014 7:46 PM).
222 Id.

25. 24
the other states of California,223 and Massachusetts,224 but still miles ahead of the poorly
performing state Mississippi.225 The state’s website probably had the most substantial impact on
the enrollment numbers in the state.226
Nevada can solve its health law problems through compromise. Luckily, the state has a
Governor who is more moderate than that his Tea Party contemporaries. Instead of considering
whether we disagree with the other side’s opinion, we should instead look for a common ground
to come up with a plan that works best for the people of our state. Governor Sandoval has already
shown great leadership by steering the state toward a reasonable direction that is with the will of
the people.227 Nevada appears to be off the destructive path of constant obstruction and onto the
path of compromise.228 However, continue to improve, the state needs to be more diligent in their
health care strategy. To succeed there needs to be a substantial statewide campaign telling people
about their options. The state should follow the lead of California and create a statewide marketing
campaign to inform residents of their options.229 The state has already produced commercials to
provide exposure, but the message largely remains unseen to many residents.230So moving
forward, Nevada has to be more active and creative in reaching their citizens and not fall into the
trap of Political Polarity.
223 Terhune, supra note 31.
224 Tanner, supra note 111.
225 Varney, supra note 31.
226 Norris, supra note 221.
227 Id.
228 Id.
229 Id.
230 Nevada Health Link, https://www.youtube.com/channel/UCLgJuz0xWmmMug1oK80qR3w (last visited Nov.
25, 2014 8:40 PM) showing (various videos for the Nevada Health Link exchange).

26. 25
V. Conclusion
There cannot be nationwide progress from the federal government unless there is
compromise. The ACA is an example of how political polarity affects lives in America. Health
care is an issue that effects all people. People have for generations attempted to solve this problem,
but because the unwillingness to compromise, each time ended in failure.231 We must be either,
short sighted or ignorant of the past because we still have not learned from the lessons of the
previous attempts. While the ACA is by no means perfect, there were reasonable way to fix the
legislation that would still conform to the particular needs and desires of the people of each state.
Compromise is the answer to all of these problems. When we lose sight of the other side, we are
no better for it. Goals promoted will almost certainly fail those intended to benefit, when your
political equal perpetually pulls in the opposite direction. Using the ACA as an example we can
see how allowing Political Polarity can cause the exact same legislation that is factually the will
of the people to have paradoxical results, like flourishing in like California,232 yet burning in
Mississippi. 233
Political Polarization influences our everyday life by influencing the way we think. It
would hard to find any reasonable person, in the country, who said health care is not a basic need
for the citizens of a modern country.234 Conversely, it would be relatively easy to find a citizen
that is against the law without a reason, other than opposing its source.235 But the polarity does not
stop with ordinary citizens; the polarity is at every level: from congress,236 to state officials, 237 to
231 FOX NEWS, supra note 55.
232 Terhune, supra note 31.
233 Varney, supra note 31.
234 Fisher, supra note 12.
235 Varney, supra note 31.
236 See Inside Congress, supra note 30; see also Murray, supra note 44.
237 See e.g. Varney, supra note 31.

27. 26
citizens, 238 to even our Supreme Court.239 The problem is within the way we think. As example,
this paper purposely used describing words like left and right, liberal and conservative, Democrat
and Republican because of the ideals these evoke within us. To eliminate the problem of polarity,
it starts on an individual level. We must ask ourselves tough questions. Are these ideas are truly
opposites? Is there another option? Are we simply fighting out of habit? We must do away with
these concepts and analyze issues for ourselves.
In the long term, we need to look into different options. The purpose of democracy is not
for the majority to wield political power over the other side like that of a monarch. Conversely,
the same is true for the minority. It is equally important to work with the majority. The true goal
of democracy is to meet the other side and find a workable solution together. Democracy is finding
a solution to the health care problem that helps those in need that also takes into account the issues
of the other side. Polarity is too taxing on the country. More options can only help the process.
Before, we jump to the black and white conclusions of yes, and no, we should explore solutions in
shades of grey.
238 Id.
239 Nat'l Fed'n of Indep. Bus, 132 S. Ct. 2566, (2012), supra note 60.