While politicians in Washington argue over the Affordable Care Act, its ultimate fate is being decided far from Capitol Hill.
Amid the periodic repeal votes in Congress and activist campaigns on both sides of the debate, states from New York to California are striving to meet an Oct. 1 deadline to implement the heart of the health care law, the online insurance exchanges meant to enroll millions.
The law has already had a major impact on U.S. health care since its passage in 2010. Millions of young adults up to age 26 have received coverage under their parents' policies, seniors are receiving expanded drug coverage, and hospitals are experimenting with incentive programs designed to improve care and cut costs.
Yet its success will rest on how well it delivers on its promise to extend coverage to the 49 million Americans who currently don't have health insurance. With the deadline just four months off, the prognosis is mixed.
"It is going to be a slow start," said Ana Gupte, a Dowling & Partners insurance analyst in Farmington, Conn. "This is not going to be 'Turn this on and everybody's in the exchange tomorrow.' "
Even those states most on target have had to scale back consumer-friendly offerings in their effort to meet the deadline. Others are giving up running their own markets. New Mexico and Idaho last month said they would cede control of parts of their exchanges to the federal government.
States are rushing to solve technical hurdles even as they scrap features deemed too complex to set up by the deadline, said Jon Kingsdale, a Boston-based consultant advising exchanges. That risks making it harder for people to sign up. California, for one, won't directly enroll poor Americans in Medicaid, the joint federal-state health program. New York and 10 other states have put off plans to negotiate lower premiums with insurers.
Some exchanges "are going to barely make it," said Kingsdale, former director of the Massachusetts exchange that became a model for President Barack Obama's overhaul.
Fourteen states and the District of Columbia are building their own exchanges. The other states will become partners with the federal government or leave the job entirely to the Obama administration. By law, the markets must open in October to sell coverage that starts in January.
The idea behind the new system is simple: Offer one-stop shopping and aid, making insurance easy and affordable.
While the goal is simple, the implementation is anything but. States need to set up powerful computer systems that can loop in insurers in real time while sharing data with the Internal Revenue Service, state tax offices, Medicaid and Medicare and other agencies in order to verify customer information. Some states look like they'll be ready. New York hired contractors to prepare its exchange more than a year ago and has 80 staff members dedicated to the effort.
The exchanges are expected to attract about 7 million people next year, rising to 24 million by 2023, the Congressional Budget Office estimates. Yet that number has been reduced from 34 million in 2011, as states opt out of parts of the health overhaul and the Obama administration eases penalties for people who don't buy coverage.
States are also putting off plans that could have squeezed insurer profits, bowing to pressure from the industry and the calendar. Maryland, Washington state and the District of Columbia won't require carriers to standardize deductibles and copays, a step New York and other states are taking to help consumers compare plans.
Some states are also forgoing online tools that would let shoppers filter health plans by provider-network or customer satisfaction scores. For now, the preference is for "bare-bones" approaches, said Heather Howard, program director at the State Health Reform Assistance Network, a Princeton, N.J.-based group advising 11 exchanges.