WASHINGTON -- Three years, two elections, and one Supreme Court decision after President Barack Obama signed the Affordable Care Act, its promise of health care for the uninsured may be delayed or undercut in much of the country because of entrenched opposition from many Republican state leaders.
In half the states, mainly led by Democrats, officials are racing deadlines to connect uninsured residents to coverage now only months away. In others it's as if "Obamacare" -- signed Mar. 23, 2010 -- had never passed.
Make no mistake, the federal government will step in and create new insurance markets in the 26 mostly red states declining to run their own. Just like the state-run markets in mostly Democratic-led states, the feds will start signing up customers Oct. 1 for coverage effective Jan. 1. But they need a broad cross-section of people, or else the pool will be stuck with what the government calls the "sick and worried" -- the costliest patients.
Insurance markets, or exchanges, are one prong of Obama's law, providing subsidized private coverage for middle-class households who currently can't get their own. The other major piece is a Medicaid expansion to serve more low-income people. And at least 13 states have already indicated they will not agree to that.
"It could look like two or three different countries," said Robert Blendon, a Harvard School of Public Health professor who studies public opinion on health care. "The political culture of a state is going to play an important role in getting millions of people to voluntarily sign up."
Civic leadership -- from governors, legislators, mayors and business and religious groups -- is shaping up as a huge factor in the launch of Obama's plan, particularly since the penalty for ignoring the law's requirement to get coverage is as low as $95 the first year.
People-to-people contacts will be key, and the potential for patchwork results is real.
"Obviously it's a possibility in terms of there being some real difficulties," said Sen. Bob Casey, D-Pa., whose efforts helped pass the law. Casey also said he believes the Obama administration will be ready to lead in states holding back.
Disparities already are cropping up.
Town Meeting Day -- the first Tuesday in March -- is a storied tradition in Vermont, and this year it provided a platform to educate residents about their options under the health care law. As many as 250,000 may eventually get coverage through Vermont Health Connect, as the state's marketplace is known.
"Even before we were a state, these town meetings existed," said Sean Sheehan, director of education and outreach. "It's a way people come together as a community, and we are counting on those community connections to get the word out." The health care plan was on the agenda at about 100 town meetings, and other local gatherings are taking place.
Texas residents are entitled to the same benefits as Vermonters, but in the state with the highest proportion of its population uninsured, Gov. Rick Perry will not be promoting the federal insurance exchange, a spokeswoman said. Nor does Perry plan to expand Medicaid.