Residents in some parts of the U.S. are signing up for health care coverage at a significantly greater rate than others through the new online insurance marketplaces now operating in every state.
The discrepancy may trace back to the political leanings of their elected leaders.
Newly released federal figures show more people are picking private insurance plans or being routed to Medicaid programs in states with Democratic leaders who have fully embraced the federal health care law than in states where Republican elected officials have derisively rejected what they call "Obamacare."
On one side of the political divide are a dozen mostly Democratic leaning states, including California, Minnesota and New York. They have both expanded Medicaid for lower-income adults and started their own health insurance exchanges for people to shop for federally subsidized private insurance.
On the other side are two dozen conservative states, such as Texas, Florida and Missouri. They have both rejected the Medicaid expansion and refused any role in running an online insurance exchange, leaving that entirely to the federal government.
The new federal figures, providing a state-by-state breakdown of enrollment in the new health care program through November, showed that the political differences among leaders over the initiative are turning into differences in participation among the uninsured.
Even though many conservative states have higher levels of poverty and more people without health coverage, fewer of them may receive new insurance, said Dylan Roby, an assistant public health professor at the Center for Health Policy Research at the University of California, Los Angeles.
With the patchwork implementation of the federal health care law, "the gap will exacerbate," Roby said
The U.S. Health and Human Services Department reported this week that 364,682 people had signed up for private coverage through the new health insurance marketplaces as of Nov. 30 and an additional 803,077 had been determined eligible for Medicaid.
But the rate of residents gaining health coverage was more than three times as great in the states embracing the federal health care law than in those whose leaders have resisted it.
In the dozen states embracing the overhaul, more than 50 percent of those who applied for coverage picked an insurance plan or were eligible for Medicaid. That rate was barely 15 percent in the two dozen states that aren't cooperating in the implementation of the federal health care law.
"It's very frustrating," said U.S. Sen. Claire McCaskill, a Missouri Democrat who voted for the federal law only to see it twice rebuffed in a statewide vote and repeatedly rejected by her home state's Republican-led state Legislature.
"The political point has trumped the services that Missourians need," McCaskill said.
In Texas, which has the highest rate of uninsured residents in the U.S., the GOP-controlled state Legislature opted not to create a state-run insurance marketplace and Republican Gov. Rick Perry also declined to expand Medicaid to cover more of the working poor. As of the end of November, just 14,000 Texans had signed up for insurance through the federally run marketplace and fewer than 17,000 of the nearly 245,000 applicants on the exchange had been determined to be eligible for Medicaid.
State Rep. Trey Martinez Fischer, a Democrat from San Antonio who chairs the Mexican American Legislative Caucus, said he nonetheless remains optimistic about the meager numbers.
"To know that there are people who, despite those odds, are still enrolling is encouraging," Fischer said.
In California, which also has a high uninsured rate, more than 107,000 people had picked an insurance plan through the state-run marketplace as of the end of November, and nearly 182,000 others had been determined eligible for Medicaid. That means nearly two-thirds of the 448,133 individuals who applied through the insurance exchange could gain some sort of coverage.
Federal grants in California have helped finance TV and radio commercials, billboards, bus signs and town hall meetings encouraging people to participate in the new health insurance marketplace.
That sort of promotion has been lacking in many of the states that have refused to run their own insurance marketplaces.
In Missouri, where a law forbids the government from implementing an insurance exchange, a coalition supporting the marketplace delayed its promotional campaign because of the technical troubles that marred the launch of the federal website.
"We didn't want to drive people to a frustrating experience," said Thomas McAuliffe, a policy analyst at the nonprofit Missouri Foundation for Health.
Now, advocates for the federal law face a steep challenge to implore people to sign up by Dec. 23, which is the deadline to be covered by health insurance policies that take effect in January.
"When we look at enrollment numbers, we're obviously going to lag behind, because in many parts of the state there's still a sense that Obamacare is not going to help me -- even by the people it's going to help the most," McAuliffe said.
Heather McCabe, an assistant professor of social work at Indiana University-Purdue University Indianapolis, said the low enrollment numbers in many states raise questions about whether people are turned off by the problematic website, don't know they're eligible to use the exchange or have found the policies unaffordable.
"If the answer is that people still don't understand what the exchange is and how to use it, then the answer is we need to do education and help people better access the system," she said. "But if the answer is that the premiums are too high, then we have an issue that's a little more difficult to deal with."