Charles Dharapak, File, Associated Press
WASHINGTON — Its place assured alongside Medicare and Medicaid, President Barack Obama's health care law is now in a sprint to the finish line, with just 11 months to go before millions of uninsured people can start signing up for coverage.
But there are hurdles in the way.
Republican governors who derided "Obamacare" will now have to decide whether they somehow can join the team. And the administration could stumble under the sheer strain of carrying out the complex legislation, or get tripped up if budget talks with Congress lead to scaling back the plan.
"The clarity brought about by the election is critical," said Andrew Hyman of the nonpartisan Robert Wood Johnson Foundation. "We are still going to be struggling through the politics, and there are important policy hurdles and logistical challenges. But we are on a very positive trajectory." Hyman oversees efforts to help states carry out the law.
In the two years since passage of the Affordable Care Act, the Obama administration has been consumed with planning and playing political defense. Now it must execute.
States must notify Washington a week from Friday whether they will 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, 2013, 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 gives states more leverage but also 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. "I can't imagine walking out the door in the middle of that," she told The Kansas City Star during the Democratic convention. Her office declined to comment.
Republicans will be leading more than half the states, so governors are going to be her main counterparts.
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 be filed in court.
But 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 of their own 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 center-right think tank. "They do not have a uniform position across the board."
GOP governors are pressing Sebelius on whether the administration will approve partial, less costly Medicaid expansions. There has been no ruling yet.
On health insurance exchanges, some governors whose states aren't likely to be completely ready are considering the administration's offer of running the new markets through a partnership.
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