Obstructionism has taken three forms. The first is a refusal by some states to accept federal funds to expand their Medicaid programs. Under the law, the funds cover a hundred per cent of state costs for three years and no less than ninety per cent thereafter. Every calculation shows substantial savings for state budgets and millions more people covered. Nonetheless, twenty-five states are turning down the assistance. The second is a refusal to operate a state health exchange that would provide individuals with insurance options. In effect, conservatives are choosing to make Washington set up the insurance market, and then complaining about a government takeover. The third form of obstructionism is outright sabotage. Conservative groups are campaigning to persuade young people, in particular, that going without insurance is “better for you”—advice that no responsible parent would ever give to a child. Congress has also tied up funding for the Web site, making delays and snags that much more inevitable.

Some states are going further, passing measures to make it difficult for people to enroll. The health-care-reform act enables local health centers and other organizations to provide “navigators” to help those who have difficulties enrolling, because they are ill, or disabled, or simply overwhelmed by the choices. Medicare has a virtually identical program to help senior citizens sort through their coverage options. No one has had a problem with Medicare navigators. But more than a dozen states have passed measures subjecting health-exchange navigators to strict requirements: licensing exams, heavy licensing fees, insurance bonds. Florida has attempted to ban them from county health departments, where large numbers of uninsured people go for care. Tennessee recently adopted an emergency rule declaring that anyone who could be described as an “enrollment assister” must undergo a criminal background check, fingerprinting, and twelve hours of course work. The hurdles would hamper hospital financial counsellors in the state—and, by some interpretations, ordinary good Samaritans—from simply helping someone get insurance.

This kind of obstructionism has been seen before. After the Supreme Court’s ruling in Brown v. Board of Education, in 1954, Virginia shut down schools in Charlottesville, Norfolk, and Warren County rather than accept black children in white schools.