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Races for Congress get more attention, but another set of elections this fall could make a big difference: your state's insurance commissioner decides how to enforce the federal health care law. Some are being elected this week, and others will be appointed by governors who win. Sarah Varney reports from our member station KQED.

SARAH VARNEY: Fame does not come easy to even the most heroic insurance commissioner. California's current chief forced health plans to scale back double digit rate hikes, and still he's the white knight no one can name.

I'm asking people if they even know who the insurance commissioner is for the state of California.

Unidentified Woman: I have no idea. I have no idea who it is. Who is it?

Unidentified Man: It's not Arnold Schwarzenegger, that's for sure. Might be John something or another? Is that not right?

VARNEY: Steve Poizner. His name is Steve Poizner, and whoever replaces him -and other insurance chiefs around the nation - could change your life.

Ms. SABRINA CORLETTE (Health Policy Researcher, Georgetown University): With the insurance market reforms, it's really going to be important for states to take a proactive role in responding to any problems that come up and making sure plans are really complying with the law.

VARNEY: Sabrina Corlette is a health policy researcher at Georgetown University. She says, under the federal health law, state insurance chiefs will have a long list of new consumer protections to enforce. For example, starting in 2014, health plans can't charge women or sicker people more. They're also helping to write the regulations for their own expanded powers. Congress left it up to an obscure group - the National Association of Insurance Commissioners - to essentially decide critical details, like what health plans can claim as actual medical care versus administration and profit, Corlette says, all of which made these humble regulators very popular with industry lobbyists at their spring meeting.

Ms. CORLETTE: I was stunned to discover that there were about 17 consumer representatives that were focused on health care, compared to over 1000 different insurance industry representatives. Consumer advocates and industry officials say once the rules are written, state regulators will have to crack down on health plans looking to exploit fuzzy rules or weak enforcement. At the same time, if they're too heavy handed, the plans might leave the market. All of which means state insurance chiefs could very well play a key role in whether the federal health overhaul flies or flops.

Laurie Sobel, a senior attorney with the consumer advocacy group Consumers Union, says it matters, then, how the insurance commissioner views the new federal health law.

Ms. LAURIE SOBEL (Attorney): If you have one that really doesn't want to enforce it, then consumers are going to need to fight it every step of the way.

VARNEY: The two candidates vying to become California's chief regulator have starkly different views on how best to protect consumers. Assemblyman Mike Villines is the Republican in the race. He's a skeptic about whether the government can fix a system he admits is broken.

Mr. MIKE VILLINES (Assemblyman, Republican Candidate for California Insurance Commissioner): When you start getting into mandated behavior and you say you have to do these things, when you tell the insurance companies that there's going to be these for sure things in here that you have to do, I think that Californians and I take the nation is not quite ready for that.

VARNEY: His opponent, Democratic Assemblyman Dave Jones, says the federal overhaul will offer critical protections and new choices to consumers.

Mr. DAVE JONES (Assemblyman, Democratic Candidate for California Insurance Commissioner): I plan to use the office, both formally and informally, to take a very assertive role in terms of health insurance reform.

VARNEY: Overseeing the national rule-writing effort is Kansas Insurance Commissioner Sandy Praeger. She's up for re-election - a Republican in a solidly red state and running unopposed. With no challenger, she's instead spending her time worrying about all the details her group must decide.

Ms. SANDY PRAEGER (Kansas Insurance Commissioner): I don't want to get thrown under the bus. We don't want to be blamed if this isn't working. So we've got a huge responsibility to try to get it right.

VARNEY: But many Republican candidates for governor think the law is just wrong. And in some states, those candidates - who could end up appointing new insurance chiefs - want to repeal the federal health overhaul.

For NPR News, I'm Sarah Varney.

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