RALEIGH, N.C. — With new online health insurance exchanges set to launch Tuesday, consumers in many Southern and Plains states will have to look harder for information on how the marketplaces work than their counterparts elsewhere.
In Republican-led states that oppose the federal Affordable Care Act, the strategy has ranged from largely ignoring the health overhaul to encouraging residents not to sign up and even making it harder for nonprofit organizations to provide information about the exchanges.
Health care experts worry that ultimately consumers in these states could end up confused about the exchanges, and the overall rollout of the law could be hindered.
"Without the shared planning and the cooperation of the state government, it's much harder for them to be ready to implement this complicated law," said Rachel Grob of the University of Wisconsin-Madison, who has studied differences in how states are implementing segments of the law.
Several of the 14 Northeast, Midwest and Western states running their own insurance exchanges have spent weeks on marketing and advertising campaigns to help residents get ready to buy health insurance. At least $684 million will be spent on publicity explaining what people need to do next and persuading the doubtful to sign up for coverage, according to data compiled by The Associated Press.
By contrast, most states across the South have declined federal grants to advertise the exchanges and ceded the right to run the marketplaces themselves. And early Sunday, the Republican-led U.S. House added to legislation that would avert a partial government shutdown a one-year delay of the creation of the marketplaces. Democrats have said delaying the health care law would sink the bill, and the White House promised a veto.
Governors from the Carolinas to Kansas have decried the exchanges and the rest of the law, which was passed by Congress in 2010 and many argue reaffirmed when voters re-elected President Obama in 2012. The Supreme Court in 2012 upheld the constitutionality of most of the law; a piece of the Medicaid expansion was an exception.
"When it came to Obamacare, we didn't just say 'no,' we said 'never,' " South Carolina Gov. Nikki Haley said last month alongside U.S. Sen. Tim Scott, whom she appointed last December when Jim DeMint resigned. "And we're going to keep on fighting until we get people like Sen. Scott and everybody else in Congress to defund Obamacare."
Others have gone beyond fiery rhetoric.
Missouri's lieutenant governor urged residents to refuse to sign up for federal health insurance, while Kansas legislators and the state's governor enacted a law symbolically declaring that residents can't be forced to buy health insurance.
In Florida, state officials ordered county health departments to bar from their property navigators hired under federal grants to explain the plan's complexities. Broward County commissioners last week ignored that ban and voted to allow navigators and other counselors into county offices, including health departments.
"We've encountered many, many issues with this, and this is a breakthrough for us to be able to go into the libraries, the health departments," said Jerson Dulis, who was trained to help enroll people in the state exchange. He works for Broward Community & Family Health Centers Inc., which received a federal grant to help consumers understand and enroll in health insurance plans.
In places where state officials have declined to disseminate information, the work is left to nonprofit organizations and word-of-mouth among consumers.
North Carolina is among the states that have left the running of its exchange to the federal government. This year, the state refunded what remained of a $74 million federal grant that would have helped consumers and linked computers.
Asa Gregory, 36, of Wilson, works sporadically as a substitute public school teacher and has lacked health insurance for seven years, paying the medical bills after a traffic accident with help from his parents.
"I would like to have health insurance. I think that's a no-brainer," he said.