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The fight over health care: Still political?

Like it or not, President Obama won a second term, and his health care law is here to stay. The Affordable Care Act was one of the biggest matters of debate during the election, but now that there's no chance of repealing it, state and federal governments have to get to work implementing it.

Yesterday, however, facing Republican complaints, the Obama administration for the second time pushed back a key deadline states face as they begin to build a new health care infrastructure.

State leaders now have one more month to decide whether to build their own health care exchange system -- an online marketplace where consumers can choose from a variety of competing private insurance plans. If they don't want to build their own, states can instead leave it up to the federal government to run their state-based system, or enter into a partnership with the federal government. The exchanges are supposed to be up and running by 2014 and are a core part of the 2010 law -- according to nonpartisan projections, starting in 2016, between 23 million and 25 million people will receive health care coverage through the exchanges.

Ahead of the election, a number of Republican-led states stalled work on the exchanges, in the hopes that a Romney administration would roll back the new requirement. But with little time left to make a decision, GOP leaders are beginning to begrudgingly choose a path forward. As of Friday afternoon, according to a tally by the Associated Press, just 11 states have yet to say whether they'll set up their own or leave it to the feds -- all but one of those states have Republican governors.

These states have found themselves "behind the proverbial eight ball," as Prof. Jay Himmelstein put it, in part because of politics and in part because of legitimate concerns.

"I think there's still a lot of resistance that's been built up and a little bit of embarrassment about not being prepared to follow the law of the land," said Himmelstein, chief health policy strategist at the Center for Health Policy and Research at the University of Massachusetts Medical School. "That being said, the policy track and the IT track [represent] relatively big changes in the economy, and they do take some time to implement."

A number of Republican-led states have defiantly rejected the seemingly small-government option of building their own exchanges, charging the state-based exchanges "are not state-based at all," as South Carolina Gov. Nikki Haley put it.

"Instead, they simply pass along to the state the burdens of a new and cumbersome bureaucracy," she wrote in a letter to Health and Human Services Secretary Kathleen Sebelius. Along with South Carolina, Alabama, Alaska, Georgia, Kansas, Louisiana, Maine, Missouri, New Hampshire, Oklahoma, South Dakota, Texas, Virginia, Wisconsin, and Wyoming are going with the federal option (all of those states except Missouri and New Hampshire have GOP governors).

From a consumer standpoint, at least, it's true that if the exchanges are all functioning as intended, there shouldn't be much of a noticeable difference between the federally-run version and the state-run versions, Claire McAndrew, a senior health policy analyst from the consumer advocacy group Families USA, told Every exchange will have to meet certain standards and follow certain rules -- the HHS, however, hasn't released all of the proposed rules yet.

"States are struggling with many unanswered questions and are not able to make comprehensive far-reaching decisions prudently," the leaders of the Republican Governors Association wrote in a letter to Mr. Obama this week. Republicans argue that those unanswered questions make it harder to estimate the costs of running the exchange. The federal government is covering the costs of establishing the exchanges, but it's up to the states to figure out how to make them self-sufficient once they're up and running.

"Making a decision between the state exchange and federal exchange is a difficult decision without more information," said Tim Jost, a consumer advocate and professor of health law at Washington and Lee University. "In some states with small populations, it probably doesn't make sense to put together an exchange because it's a fairly complex thing."

But while state lawmakers may not have all the details on the exchanges, "they have more than some of them admit," Jost said.

HHS has given enough guidance over the past two years that states like California, New York and Maryland have made significant progress in setting up their exchanges. On top of that, states are free to take very different approaches to managing them.

"Some want to be very active in how they select the [insurance] plans, while others have a more minimalist framework," McAndrew said. California lawmakers, for example, are designing standards for insurers to guarantee that "as a consumer, there's a product available you know you can count on... and you don't have to sift through these slightly different options," she said.

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