Like many Republican elected leaders, Mississippi Gov. Phil Bryant is not exactly thrilled about Obamacare's march toward full implementation in 2014.
But while top Republicans continue to slam President Obama and the Supreme Court in Washington for the controversial health care overhaul, Mr. Bryant's primary opposition is sitting nearby, in Jackson.
Mr. Bryant cried foul when his state's insurance commissioner, Mike Chaney, wrote to the U.S. Department of Health and Human Services in November to declare the state's intention to set up a state-run exchange, a necessary step under the Patient Protection and Affordable Care Act that passed into law in 2010 and survived a legal challenge in June on a 5-4 Supreme Court vote.
"It is inevitable that such an exchange will be controlled by the federal government, not by the state," Mr. Bryant wrote to HHS in Washington within two weeks of the state's submission. A month later, Mr. Bryant reiterated in another letter to federal officials that Mr. Chaney's application was not valid and that he, as the governor, had the final say over whether to apply for a state-run exchange.
For now, HHS is putting Mississippi's request on ice while officials in Jackson try to get on the same page.
The clash illustrates the choices facing officials across the country as they come to terms with Mr. Obama's massive law — and the realization that it is not going away anytime soon.
States have three options on the exchanges, considered a crucial building block of Mr. Obama's law. States can run their own virtual marketplace that allows consumers to shop for the best deal on health insurance plans. They can do nothing and let the federal government run such an exchange in their state. Or they can take the middle road and enter a state-federal partnership to set up their insurance exchange.
Half of the states — many of them dominated by Republicans — have refused all cooperation and opted for a federally run exchange, while several have requested a state-federal partnership.
The disconnect in Mississippi underscores the ideological paradox many Republican governors have faced in making peace with the health care law. Just this week, Arizona Gov. Jan Brewer surprised many in her state by announcing she would accept massive new federal subsidies to expand Medicaid coverage under the health care law — even though the Supreme Court ruling allowed the states to decline the federal funds.
On the state-level insurance exchanges, states can resist federal intrusion by running their own state-controlled markets, or they can thumb their nose at Mr. Obama's law by letting his administration run the system by itself and then have to take all the blame if it turns out as badly as many of the law's critics predict it will.
GOP lawmakers and executives grappled with the question, particularly in the 10-day window between GOP nominee Mitt Romney's defeat in the presidential election — sealing off their last realistic hope for an outright repeal — and the initial deadline for states to declare their health-exchange plans. Eventually, Health and Human Services Secretary Kathleen Sebelius granted states a one-month extension to make up their minds.
Neither official involved in Mississippi's turf war is happy with Mr. Obama's law, but Mr. Chaney thinks a state-run exchange would be the best way to tailor the legally mandated program to Mississippi's citizens — instead of handing over control to bureaucrats in the nation's capital.
Republican governors such as C.L. "Butch" Otter of Idaho have expressed similar sentiments in opting for a state-run exchange. In a statement explaining his decision last month, Mr. Otter said the state could be "at the federal government's mercy in how that exchange is designed and run, or take a seat at the table and play the cards we've been dealt."
Another GOP-governed state, Utah, is looking to extend efforts it began on its own, before the word "Obamacare" entered the lexicon.
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.
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.
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