States have scant precedent to rely on as they shape the twin pillars of President Obama's health care law, an uncertainty that has resulted in what one Iowa official described as 50 discrete "laboratories."
As it stands, 14 states intend to balk at both of the reforms in the law that are set to take effect in 2014, according to the nonpartisan Kaiser Family Foundation, which studies health policy.
Specifically, these states will reject an optional expansion of the Medicaid program within their borders and let the federal government run the virtual marketplace, or "exchange," where eligible residents without employer-based insurance may buy health plans with the help of tax credits. Mississippi may have taken the most tortured approach, after Gov. Phil Bryant quashed an attempt by his own state's insurance commissioner to set up a state-run exchange.
Conversely, the foundation's data shows that 15 states and the District of Columbia have decided to run their exchanges themselves and expand Medicaid, while the remaining states plan to use a mixed approach or have not made up their minds on the Medicaid expansion.
New Jersey and Florida joined the growing ranks of Republican-governed states that will expand Medicaid, meaning just more than half of the nation's population -- roughly 185 million Americans -- live in places that are planning to expand the program to those who earn 138 percent of the federal poverty level, according to a Washington Times analysis of the foundation's data and census estimates.
It will take some time for states to figure out if they have chosen the best way forward under the Affordable Care Act, in view of the long-range goals and politically charged feelings about Mr. Obama's signature domestic achievement, analysts said.
Governors and state lawmakers, they said, may have to adapt on the fly or learn from each other as they forge ahead with health reforms of unprecedented scope.
"There's really nothing quite like this," said Glenn A. Tung, the associate dean for clinical affairs at Brown University.
The buffet of choices under "Obamacare" was both intentional and the result of the Supreme Court's ruling on the law, which allowed states to decline the Medicaid expansion without forfeiting all of their federal funding for the program.
By design, states could choose to run an exchange on their own, let the Department of Health and Human Services run it for them or enter a partnership with the Obama administration. Applications for a partnership had to be submitted by mid-February, effectively locking in the states for months of groundwork on a specific type of exchange. Adding to the complexity, states that opted to run their own exchanges may end up with models that differ widely from each other.
Analysts also said it is difficult to predict if this patchwork of approaches to implementation will disrupt the key goals of Mr. Obama's reforms.
"It depends on who you ask," said Sarah Dash, a project director with the Center on Health Insurance Reforms at Georgetown University.
On one hand, the Obama administration probably did not anticipate that 26 states would defer to a federally run exchange instead of running it themselves, she said. And yet, she added, some people felt a blanket federal exchange would have been a good idea.
Henry J. Aaron, a senior fellow at the Brookings Institution, said it will be hard to discern whether each state has implemented the law to its full potential, and "evidence on what constitutes a good practice will be hedged and subject to controversy."
"There will be glitches and unanticipated problems and, in all likelihood, a very rough few months," he added. "The question will be whether enough jurisdictions can get by these first few months, show that problems can be surmounted, and point the way for other jurisdictions."
Some states are going alone in their pursuit of a winning formula. For instance, Idaho appears to be the only state opting to run its exchange in-house while rejecting an infusion of federal dollars to expand Medicaid -- at least for now.
Although Idaho Gov. C.L. "Butch" Otter is no fan of the president's law, he said state officials must "play the cards we've been dealt" and take control of its exchange. He is employing a wait-and-see approach to expanding Medicaid because he believes the current system is broken, according to his spokesman, Jon Hanian.
"The governor is very aware there are uncertainties in this, but we knew that from the get-go," Mr. Hanian said.
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