The continuing saga around the deadline delay for states to decide whether they'll establish their own health insurance exchanges doesn't change the final upshot: All states are anticipated to have an online insurance marketplace, one way or another.
The delays may also make a federal/state partnership model for the exchange more palatable and a way out for unprepared states, at least in the initial years, according to an expert on state healthcare issues.
Health and Human Services Secretary Kathleen Sebelius in November extended the deadline to Dec. 14 for states to not only submit their blueprints for a state-based health insurance exchange but to decide whether they would establish the exchange on their own or seek federal help.
In announcing the delay, Sebelius said HHS is "committed to providing states with the flexibility, resources, and time they need to deliver the benefits of the healthcare law to the American people."
Some states were revisiting their decision in light of President Barack Obama's reelection, said Patrick Howard, who leads Deloitte Consulting's state healthcare practice.
"The reality of the situation is that to get something like this decided is a collaborative process - the departments of insurance and health and human services, perhaps members of the governor's office all have to be on board - to make that final decision of which way you are going to go," he said, adding that the HHS secretary may have decided to give the states more time to complete that thought process inside their organizations.
Some states had held hard and fast to not making any plans, "but a number were doing, as well they should, contingency planning on both alternatives," Howard said. The most critical deadline is Oct 1, 2013, when state exchanges must be ready to start enrolling individuals. The exchanges become operational Jan. 1, 2014.
"You're marching toward a pretty tight timeline. I think a number of states will look at their own preparedness, and realistically ask, can we get all things done that we need to get done by Oct. 1, 2013," Howard said. If they have been doing contingency planning, it's possible that they can get there.
"If they haven't been doing things in the background and are starting from square one, the odds of them actually making an October implementation are relatively slim," he said.
What may become a more attractive option is the federal partnership model.
"I think more states will embrace that federal partnership model perhaps for a year and then transition to a state-based exchange, giving them a little more time to think through their business processes and technology," Howard said.
Some states can enable an exchange through an executive order, while others need legislative authority for setting up the organization to administer the program. Some state legislatures won't be meeting again until early 2014.
"That gets you to more states looking at the federal partnership model and eventual transition if they can get enabling legislation. I think that makes sense for them," Howard said. "We've all been waiting with bated breath to look at what the results of this determination are," he said, adding that it will be "a key landmark what they are going to say in those blueprints."
In general, the recent election did not significantly change the grip that Republicans have on state legislatures, meaning that state roles in implementing features of the health reform law will still face challenges. Many states, for example, require enabling legislation for health insurance exchanges.
After the election, 26 state legislatures remain in GOP hands, while Democrats gained four for a total of 19, and four state legislatures are divided, according to Tim Storey, senior legislative fellow, National Conference of State Legislatures. It's also a factor at the governors' level, where only 11 states have divided governments.
"States have really coalesced around one party or another," Storey said.
The Republican wave in the 2010 elections framed where they were headed in the 2012 elections. The GOP gained 740 seats in state legislatures in 2010, Storey said. Of the 7,383 state legislators in the country, 80 percent or 6,034 seats were in play in the 2012 election.
"And Republicans still have a majority of all legislative seats after the 2012 election, with 53 percent Republican, the highest majority since the 1940s, and Democrats have 47 percent," Storey said.
One aspect of that recent turnover will affect state roles in health reform and health IT, on which the ACA depends, and that is a lack of experience on the job.
"Nearly one half of all legislators will have two years or less in this job in legislature," Storey said. "It will take a big education effort for you to push health IT on their agenda."