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WASHINGTON » The long slog has turned into a sprint. President Barack Obama’s health care law survived the Supreme Court and the election; now the uninsured can sign up for coverage in about 11 months.
Even the government’s top-ranking Republican, House Speaker John Boehner of Ohio, said Thursday that "Obamacare is the law of the land." But not all hurdles have been cleared.
Republican governors who opposed the law have to decide whether it’s better for their states to now help carry it out. The administration could stumble carrying out the complex legislation, or get tripped up if budget talks with Congress lead to scaling back the plan.
"We are out of the political gamesmanship and into the reality," said Sandy Praeger, Kansas’ Republican insurance commissioner. Next week, states have to say whether they’re committed to building the framework for delivering health insurance to millions.
"We are still going to be struggling through the politics, and there are important policy hurdles and logistical challenges," said Andrew Hyman of the nonpartisan Robert Wood Johnson Foundation, which is helping states carry out the law. "But we are on a very positive trajectory."
Instead of being dismantled by a Republican president and Congress, Obama’s law is now on track to take its place alongside Medicare and Medicaid. The action starts right away.
A week from today, states must notify Washington whether they’ll be setting up new health insurance markets, called exchanges, in which millions of households and small businesses will shop for private coverage. The Health and Human Services Department will run the exchanges in states that aren’t ready or willing.
Open enrollment for exchange plans is scheduled to start Oct. 1, and coverage will be effective Jan. 1, 2014.
In all, more than 30 million uninsured people are expected to gain coverage under the law. About half will get private insurance through the exchanges, with most receiving government help to pay premiums.
The rest, mainly low-income adults without children at home, will be covered through an expansion of Medicaid. While the federal government will pay virtually all the additional Medicaid costs, the Supreme Court gave states the leeway to opt out of the expansion. That adds to the uncertainty over how the law will be carried out.
A steadying force within the administration is likely to be HHS Secretary Kathleen Sebelius. The former Kansas governor has said she wants to stay until the law is fully enacted.
Governors will be the main counterparts to Sebelius, and Republicans are leading more than half the states.
Some, like Rick Perry of Texas and Rick Scott of Florida, have drawn a line against helping carry out Obama’s law. In other states, voters have endorsed a hard stance. Missouri voters passed a ballot measure Tuesday that would prohibit establishment of a health insurance exchange unless the Legislature approves. State-level challenges to the federal law will continue to percolate.
Other GOP governors have been on the fence, awaiting the outcome of the election. All eyes will be on pragmatists like Chris Christie of New Jersey and Bob McDonnell of Virginia, whose states have done considerable planning to set up exchanges.
"Republican governors are at the center of the health care universe right now," said Michael Ramlet, health policy director at the American Action Forum, a conservative think tank. "They do not have a uniform position."
A check by The Associated Press found 17 states and the District of Columbia on track to setting up their own exchanges, while 10 have decided not to do so. The federal government could end up running the show in half or more of the states. Hawaii is among the states farthest along toward a plan.
A recent AP poll found that 63 percent of Americans want states to run the exchanges, with 32 percent favoring federal control.
As far as Medicaid, 11 states including Hawaii have indicated they will expand their programs.
