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The state re-branded its existing health exchange as Avenue H, after the president’s law evoked connotations of a government-run — instead of consumer-driven — marketplace for insurance, according to state officials.

Idaho, Utah, 15 other states and the District have obtained conditional approval for their in-house exchange. Each of the states sent a letter of intent to HHS officials on the governor’s letterhead, with the top executive’s signature affixed at the bottom.

Philosophical differences

Except, that is, for Mississippi.

The dissension there is more pronounced, or at least more public, than the two Republicans at the center of the dispute might have hoped. By all accounts from statehouse staff, the infighting is not personal. Rather, the two officials are longtime associates who simply reached a philosophical difference on the Democratic president’s signature reforms.

Mr. Chaney said last week that he expects a decision from federal regulators within 10 to 15 days, according to The Associated Press.

Officially, HHS officials have only stated they are neither approving nor denying Mississippi’s application “at this time.”

It is unclear whether the dispute in Mississippi portends additional infighting among the states as exchanges move toward activation in 2014, said Jonathan Gruber, an MIT professor who played a key role in Massachusetts’ health care reforms before he was tapped to assist Mr. Obama’s efforts.

“I haven’t heard of a lot of other within-state tension at this level,” he wrote in an email.

He said the Mississippi situation does, however highlight the “wonderful dichotomy” between those who want to help their state by setting up an exchange and those who are using the situation to “play politics.” In his opinion, the governor has cast himself in the latter role.

Roy Mitchell, executive director of the Mississippi Health Advocacy Program, said the standoff has advocates worried that the governor is trying to thwart the health care law “by any means possible.”

His group recently released a poll that found 51 percent of Mississippi residents have a positive view of a health insurance exchange, based on 1,600 telephone surveys.

“We are very worried about the delay,” Mr. Mitchell said.