Clipboard: The Affordable Care Act stands. Now what?

If the election had gone the other way, health reporters across the country would have spent the rest of the week—and many to come—reporting on what happens to national health care policy now, with a likely Mitt Romney-led push to repeal at least a large part of the Affordable Care Act.

Instead, we know: The federal health law signed by President Obama in 2010 stands. States have until Nov. 16 to decide whether to create a state-run insurance market or to allow the federal government to do it for them. Those exchanges are expected to come online in 2014, when most Americans will be required to have health insurance and many states will expand their Medicaid programs.

The list of things that must be done between now and the start of 2014 is “pretty massive,” Sarah Kliff of the Washington Post WonkBlog writes. In addition to deciding whether to expand Medicaid to cover people who make up to 133 percent of the federal poverty level—about $30,656 for a family of four in 2012—states must figure out which residents meet that measure, “a huge technical challenge that requires coordination between federal and state computer systems that don’t usually talk to each other,” Kliff reports.

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Among those governors who have not said definitively whether they will create a state exchange is New Jersey’s. Governor Chris Christie was a bulldog on the campaign trail with Mitt Romney but effusive in his praise of President Obama in the past week, following Hurricane Sandy.

As a leading voice in the GOP, it seems his opinion of the Affordable Care Act moving forward will matter.

“I won’t make a decision until I have to,” Christie said last month about whether he will create an exchange, according to the Star-Ledger.

Many of the 30 Republican-led states could hold their ground in opposition.

Fifty-four percent of voters in Missouri went for Romney and Governor Jay Nixon, a Democrat, was re-elected. The state also passed a ballot initiative prohibiting the creation of a state insurance exchange.

Florida voters rejected a ballot question prohibiting laws requiring individuals or businesses to buy insurance, while Alabama, Wyoming, and Montana approved similar measures. Kaiser Health News notes that federal law would take precedence, so the ballot measures have little effect on implementation of the Affordable Care Act.

I asked Josh Archambault, health care policy director for the fiscally conservative Pioneer Institute in Boston, about where opposition to the Affordable Care Act goes from here.

With Republicans leading the House, he expects further efforts to limit funding for implementation of the law or, possibly, to cut federal tax subsidies for insurance coverage for low- and middle-income people. Most states that opposed the law in the case before the Supreme Court this spring retained their Republican leadership, he said, and many will continue their opposition to state exchanges.

“The concern I’ve heard from a lot of folks is that they ultimately don’t believe that they will control their exchange, that federal HHS will have the final say on everything,” he said. “So, from their perspective, that’s not a state-based exchange.”

The fight goes on.

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