If you want to understand how the intersection of ideology, intergovernmental relations, and a complex health care system have in so many places stymied the Affordable Care Act, do not let the sun set on you tonight without reading the piece on Mississippi by Kaiser Health News’ Sarah Varney, published by Politico Magazine.

Varney’s story is in every respect a tragedy. Mississippi was actually well-positioned to implement Obamacare thanks to a decision by former Republican Gov. Haley Barbour to set up a state-based insurance purchasing exchange (before ACA was enacted) on the advice of the Heritage Foundation. And Lord knows Mississippi needed every element of Obamacare, given the horrific health needs of its population and an existing Medicaid program that was among the most restrictive in the country (in no small part thanks to Barbour).

But then the Supreme Court made ACA’s Medicaid expansion optional, and Barbour’s successor, the Tea Party champion Phil Bryant, decided not only to reject the expansion but to kill the existing state purchasing exchange before it could become a vehicle for Obamacare. And so the state that most needed health reform was caught very flatfooted when the ACA fully arrived, with its initially screwed-up federal exchange and its cuts in non-ACA funding for hospitals serving the poor. For a good while it looked like insurance would not be available at all in big parts of the state, and even when an insurer stepped up to cover all counties, it did so with the assurance of no competition in many.

But underlying the whole fiasco was the rejection of the Medicaid expansion, as Varney explains:

The state’s low standard of living means many people earn less than the federal poverty limit but too much for Medicaid; under the health law, they can’t buy insurance on the exchange, leaving 138,000 Mississippians who fall into what has come to be known as the Medicaid gap…. The Medicaid gap also fueled a negative feedback loop about the law. As [ACA Navigator Minnie] Wilkinson describes it, people felt deceived: “They were under the impression that the less money you made, you get insurance for free.” It killed momentum even for those who could have bought heavily subsidized coverage on the exchange. Word spread quickly: This Obamacare is a waste of time, and Obama was to blame.

The quote that really sums up the whole piece, and the highly unfortunate reliance of the Obama administration for ACA implementation on states whose leaders have been devoted to sabotaging health reform, is from Roy Mitchell, executive director of the Mississippi Health Advocacy Program: “We work hard at being last.”

Read Varney’s account, and remember it next time you hear someone rhapsodize about the glories of “devolution” or “federalism” in health care policy. It’s a killer.

Ed Kilgore

Ed Kilgore is a political columnist for New York and managing editor at the Democratic Strategist website. He was a contributing writer at the Washington Monthly from January 2012 until November 2015, and was the principal contributor to the Political Animal blog.