Re-Election Forces States To Act Soon On Obamacare

States now have only nine days to decide whether to do their own health care exchanges or let the federal government do it for them. Analysts expect there will be a lot of scrambling. Some of the states that are trying to ban the individual mandate going forward have Democratic leadership. Missouri has re-elected its Democratic governor, but has banned him from setting up a state exchange. Robert Siegel talks to Julie Rovner.

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ROBERT SIEGEL, HOST:

While big questions remain about how we'll avert the fiscal cliff, one issue is much more settled today than it was yesterday - the future of the Affordable Care Act, also known as Obamacare. The president's reelection and the Democrats' continued control of the Senate mean that implementation of the law will move forward. And joining us to talk about the next steps is NPR's Julie Rovner.

And first, Julie, what did we learn from this election about the health care law?

JULIE ROVNER, BYLINE: Well, two big things I think. First, it's still kind of hanging by a thread. Last night's national exit polls showed that while health care remains the second most important issue to voters - though it trailed the economy by a mile - voters remained badly divided over the fate of the law. Forty-nine percent said they'd like to see some or all of it repealed, while 44 percent said they'd like to see it expanded or left as is.

The second thing I think that is for better or worse, this law is henceforth going to be known as ObamaCare, which of course started as a slur from its opponents. But now even the president is calling it that. Here he is at his speech in Colorado in September.

PRESIDENT BARACK OBAMA: You know, he calls it ObamaCare and, you know, I like the name. I do care.

(SOUNDBITE OF CHEERING)

SIEGEL: So what happens to ObamaCare now?

ROVNER: Well, when the law passed in 2010, a lot of people complained about how long it would be before the big parts that really expand coverage were to take effect, not until January 2014. Well, now that's just over 13 months away and there is a lot to do, and not all that much time left to do it in.

States have to decide by November 16th - yes, nine days from today - whether or not they're going to implement an insurance market shopping exchange or let the federal government do it for them. And when those exchanges start is also when people have to have - either have insurance or else pay that controversial penalty.

But it's also when insurance companies also have to have to stop discriminating against people with pre-existing conditions. So it's really all the big stuff that people have been waiting for. And thanks to the Supreme Court decision, states also have to decide whether or not they're going to expand their Medicaid programs for individuals earning under about $15,000 a year.

A lot of governors were waiting to see if Mitt Romney got elected and made the law go away. Now they're going to have to actually make that decision.

SIEGEL: Well, voters nationwide may have indirectly voted to retain the law by reelecting President Obama but in some states, voters specifically tried to save no to at least parts of it. I want you to talk about that.

ROVNER: That's right. There were five separate health law-related ballot measures in five separate states. They all passed except that Florida where, of course, it needed 60 percent, but it didn't even get 50. Now, in three of those states - Wyoming, Alabama and Montana - the ballot measures are aimed at - blocking the controversial portion of the law that the Supreme Court upheld, that individual mandate that requires most people to have insurance or pay that penalty.

But because state law can't over ride the federal law, those measures actually don't have very much effect. It's just kind of a talking point.

In Missouri, however, our fifth state, voters passed a measure forbidding the legislature or their newly reelected Democratic governor from creating a state exchange. That presumably will have some effect, particularly since the governor had wanted to use his executive power to do just that. And it should guarantee that the federal government will do it instead.

SIEGEL: Finally, Julie, we just heard about the looming debate around the fiscal cliff. Is ObamaCare, is it on the table? Could the fiscal cliff talks include potential changes or cuts to the health care law?

ROVNER: Well, some people are speculating that it could end up being part of some grand taxing and spending bargain. Remember, the health law makes some pretty significant changes to Medicare and Medicaid. Those are big players in any deficit negotiation package 'cause they're such a big part of the budget. So there's some reason to think that a final budget deal could include some tweaks to the health law, although certainly not a full repeal or even probably a major rewrite.

SIEGEL: Thank you, Julie.

ROVNER: Thank you, Robert.

SIEGEL: That's NPR health policy correspondent Julie Rovner.

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