In Georgia, like many other Southern states, opposition to the new federal health-care law runs deep. Yet a conservative committee of experts has, without rancor, outlined a plan to give the state a health insurance exchange, a cornerstone of the legislation enacted last year.

The panel had the blessing of Republican Gov. Nathan Deal, a former congressman who describes himself as the first House member to denounce the health-care law as unconstitutional. Georgia has joined 25 other states in a legal challenge to the legislation that is now on the Supreme Court’s schedule.

But if the law is not overturned by the court or repealed, states will have two choices: to comply with it or wait for the federal government to force it on them.

This reality, and the opportunity to address the dysfunction in state health-care systems, has tempered opposition to the Affordable Care Act, not only in Georgia but also in some other Republican-led states.

In Alabama, Gov. Robert Bentley, a physician, also opted to set up a committee to plan for an exchange and fought his legislature’s decision to scale back Medicaid after enhanced federal funding expired. In Virginia, a task force appointed by Gov. Robert F. McDonnell has completed a review of state health-care policies and produced a set of recommendations designed to implement the law if it is not repealed.

Twenty-six of 29 Republican governors have accepted up to $1 million each in federal grants to design state health insurance exchanges, marketplaces where individuals and businesses can shop for medical coverage. In addition, three of these states — Indiana, Mississippi and Nevada — have received $31 million to implement the plans, according to the most recent federal listing of the exchange grants. Arizona Gov. Jan Brewer has requested $29.8 million for one of these grants despite opposition from her own party.

The exchanges aim to encourage competition among insurers and give consumers access to a variety of insurance options. Under the health-care law, each state must have its exchange in place by Jan. 1, 2014. If not, the federal government will set one up.

The deadline has prompted states to “take a more practical approach,” said Tricia Brooks of the Georgetown University Health Policy Institute, which tracks the progress of the health-care law. Conservatives in many states have been forced to take a sobering look at their health-care delivery systems, “and when they can get away from the politics of all this,” Brooks continued, “they can see that maybe the [new law] isn’t all bad.”

In Georgia, this may be the case. More than 20 percent of the state’s population lacks medical coverage of any kind, ranking Georgia 45th out of 50 states in this category. Only 29 percent of Georgia firms with fewer than 10 employees offer health-care coverage. Many small businesses are so crippled by insurance costs that they say they either cannot hire new employees, are losing the ones they have or are unable to expand because they cannot afford it.

“We’ve got to do something,” said Republican State Rep. Richard H. Smith, the chairman of Georgia’s House Insurance Committee. “An insurance exchange can work whether [the health-care law] survives or not. We still need to give people access to health insurance.”

Deal appointed the Health Insurance Exchange Advisory Committee in June after being forced to pull an exchange bill when tea party conservatives began a protest just as the General Assembly was getting ready to vote on it.

The committee, established by a Deal executive order, includes members from Deal’s cabinet, both parties in the General Assembly, the insurance industry, health-care providers, businesses, consumer groups and the tea party.

On Oct. 27, the committee reached consensus on recommendations it would send to Deal. The Georgia exchange should be a quasi-governmental nonprofit outfit that would operate like the state lottery. It would have a seven-member board of directors, with each director serving up to a three three-year term. There would be separate pools within the exchange for small businesses and for individuals. “Small business” would be defined as one to 50 employees until 2016, when it could rise to 100 employees.

Cindy Zeldin, executive director of Georgians for a Healthy Future, a group that supports the new health-care law, described the recommendations as “more deferential to industry and less mindful of consumers than I would have liked,” but acknowledged that debate and discussion, both on Oct. 27 and at earlier meetings, was unfailingly “cordial and constructive.”

And “everybody listened,” added tea party representative Ed Painter, a photo shop owner from Dalton, Ga. “I like the free market, and the [new law] isn’t free market. On the other hand, I’d do anything to facilitate real health-care reform. It’s a real conundrum for me, and that’s why they put me on the committee. This is hard.”

Deal declined to be interviewed for this article, but Blake Fulenwider, Deal’s health policy adviser, said the governor will receive the committee’s formal report by Dec. 15. If the governor decides “to go forward,” Fulenwider said, “I’m confident we can craft an acceptable project for Georgia.” Fulenwider said Deal and the legislature have not decided whether to draft a health-care exchange bill.

— Kaiser Health News

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.