WASHINGTON (AP) — The election now seems to have cleared the way for the Patient Protection and Affordable Care Act of 2010 (PPACA) to take full effect.
States and federal agencies how have just 11 months to go before millions of uninsured people are supposed to be able to start signing up for coverage.
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 PPACA, 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 U.S. Department of Health and Human Services (HHS) is supposed to 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.
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.
