Taken together, these trends highlight the ground-level challenges that health care poses to states. A year after Congress passed the biggest revisions to the health-care system since the 1960s, states are grappling with their own versions of the fiscal and ideological battles that still are roiling Washington.
States that have moved gingerly so far on health exchanges have not necessarily rejected the idea outright. Only one, Louisiana, has told the federal government it does not intend to build an insurance marketplace for its residents. In states that refuse, the law allows the federal government to step in.
An exchange must be available in each state by 2014. The idea is to help a slice of the public for whom insurance traditionally has been especially expensive: Americans who buy coverage on their own or as part of small companies. The exchanges are supposed to make it easier for them to compare health plans while creating pools of customers large enough to slow rising prices.
States have a deadline of January 2013 to prove to federal health officials that they are on a path to be ready.
The furthest along are seven states that have adopted laws establishing their exchanges. California did so last year, followed this year by Colorado, Hawaii, Maryland, Vermont, Washington and West Virginia. Two others, Virginia and North Dakota, passed laws expressing their intent to form an exchange, without spelling out details of how it should be run. Both states have Republican governors who oppose the federal law but maintain it would be worse to entrust an exchange to the federal government.
Seven other states, including some with GOP leadership, have not passed any relevant legislation but have accepted federal grants to prepare key components of the exchanges, including systems to determine which residents are eligible.
Elsewhere in the country, there has been less progress. Nearly a dozen legislatures have defeated or allowed to expire bills that would have created an exchange, according to analyses by the National Conference of State Legislatures and the Center on Budget and Policy Priorities. At least 13 other states have not even considered such proposals.
In many such cases, lawmakers oppose the federal law. But in Kentucky, where Democrats control the governor’s office and the House of Representatives, Rep. Tom Burch (D), who heads the Health and Welfare Committee, said his party was simply waiting for the Obama administration to issue regulations spelling out federal requirements in more detail. “So much of this stuff is still speculation,” he said.