President Obama's re-election impacts the domestic policy future of the United States in a number of meaningful ways, but particularly in the arena of health care policy, where the law that bears his name is secure for at least four years. States that have resisted or slowed their implementation of Obamacare now face a number of key decisions  that must be made in very short order. Next week, Republican governors will meet in Las Vegas, Nevada to decide on how to proceed - but already several are making themselves heard on how they will respond to Obama's re-election.
Decision Number One: Exchanges
First, states must decide whether to implement Obamacare exchanges in their state , or cede that responsibility to the federal government. Given that the vast majority of states - more than thirty - have taken little or no steps toward the establishment of an exchange, the general indication from policy staffers with the governors is that a federal exchange will be the preferred option. HHS has extended the window of opportunity for states to decide until February 15 , but many are leaning toward letting the federal government handle the burden.
There are a number of reasons for this. The final word for all decisions within the exchanges, whether created by the states or the federal government, is in Washington. There is very little known thus far about the nature of the federal exchange, and many of the most important regulatory guidance has been left until after the election. But governors may calculate that it would be better not to politically own the process of implementation, particularly given the many pitfalls and organizational challenges involved, if they do not have real authority. The reasoning goes among some policy staffers that it's better to let Washington proceed and avoid blame for failures or rate increases, and not share responsibility in the public eye when little or no power is shared in truth.
Overall, the governors offices I contacted indicated they were unlikely to implement a state-created exchange for these reasons and more. Governors offices which have already announced they are leaning against implementation include several Republicans, such as Florida Gov. Rick Scott , Virginia Gov. Bob McDonnell , Georgia Gov. Nathan Deal , South Carolina Gov. Nikki Haley , Wisconsin Gov. Scott Walker , Kansas Gov. Sam Brownback , and Missouri Gov. Jay Nixon , a Democrat.
Several states also have laws on the books which would conflict with the implementation of an exchange , including Alabama, Arizona, Georgia, Idaho, Indiana, Kansas, Louisiana, Missouri, Montana, Ohio, Oklahoma, Tennessee, Utah, and Virginia. These would likely have to be repealed in order to implement a state exchange.
Decision Two: Medicaid Expansion
Governors will also have to make a decision about whether to accept the Obama administration's push to expand Medicaid. While the Supreme Court gave governors the power to say no to the expansion without losing current dollars, many state legislators are particularly bent on this, as they see the Medicaid expansion as "free" money, at least in the short term. The long term ramifications of Medicaid expansion, however, will almost certainly lead to higher paymen