Implementing Obamacare in a red state--dispatch from North Carolina.

n engl j med 369;26 nejm.org december 26, 2013 2469 because of difficulties with the online marketplaces, and insurers are often receiving inaccurate information from the government about people who do manage to enroll. If such problems persist, they could deter relatively healthy persons from obtaining coverage and prevent the ACA from meeting its enrollment goals. Problems with the federal website will probably recede over time; indeed, its accessibility to consumers is already improving. The greatest long-term challenge to Obamacare remains political rather than technical. Nearly 4 years after enactment of the ACA, the fight over health care reform rages on, a reality underscored by Republican efforts to defund Obamacare during recent congressional debates about raising the debt ceiling and shutting down the federal government. The partisan division over Obamacare extends beyond Washington. The ACA’s contested implementation underscores the critical role that states play in health care reform.1 That role became even more consequential after a June 2012 Supreme Court decision made the ACA’s Medicaid expansion optional for states. States that have embraced Obamacare are expanding Medicaid eligibility, publicizing the law’s new benefits, coordinating outreach and enrollment efforts, and in some cases, operating online health insurance exchanges that are much more successful than the federal website. But what about states whose governments oppose Obamacare? How is health care reform faring in states that refuse to implement major ACA provisions? North Carolina is one such state, and its experiences highlight the unexpectedly difficult path that Obamacare faces in much of the country. Initially, North Carolina was receptive to the ACA. Under Democratic governor Bev Perdue, the state began preparations during 2010–2011 to establish an insurance exchange. The 2010 elections, however, gave Republicans the majority in both houses of the legislature, and though a bill authorizing an exchange cleared the state House, it did not pass in the Senate. In 2012, Perdue announced plans to pursue an exchange in partnership with the federal government. But in the 2012 elections, Republican Pat McCrory won the governorship while Republicans maintained their legislative majorities, Implementing Obamacare in a Red State — Dispatch from North Carolina