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Please begin with an informative title:

Map of states implementation of health exchanges under Affordable Care Act.
Now that the Affordable Care Act really is the law, the battle ground has moved to the individual states, and the combatants are now all Republicans.
Mississippi Insurance Commissioner Mike Chaney informed HHS Secretary Kathleen Sebelius Nov. 14 that he will oversee the creation of a health insurance exchange despite the objections of Gov. Phil Bryant. On Monday, in a previously unreleased letter, Bryant wrote Sebelius to say he “feels compelled to notify you of my complete disagreement with this move.” [...]

“The governor asked me, ‘What authority do you have to do this?’” Chaney told POLITICO. “And I said, ‘Phil, what authority do you have to stop me?’” [...]

In Kansas, Republican Insurance Commissioner Sandy Praeger — a proponent of creating a health care exchange — devoted two years to an application enabling the state to partner with HHS. On Nov. 8, GOP Gov. Sam Brownback said the state would not create an exchange. [...]

Despite Brownback’s action, Praeger said she intends to press for a state-based or partnership exchange for the remainder of her term, which expires in 2015. [...]

Michigan GOP Gov. Rick Snyder spent months planning a state exchange, which passed the GOP-controlled state Senate but not the state House. On Thursday, a Republican-dominated state House committee killed Snyder’s exchange legislation, leaving the governor unable to impose one. [...]

In Idaho, Republican Gov. Butch Otter supports a state-run exchange — but the GOP-led state Legislature doesn’t. State Rep. Lynn Luker compared state-based exchanges to children’s theater in which the state has the illusion of control but federal overseers are really pulling the strings. [...]

In Tennessee, GOP Gov. Bill Haslam is weighing the idea of creating an exchange while Republicans are pressuring him not to do so. His spokesman, David Smith, said Haslam, “is reviewing the information as it comes and continues to seek answers to a number of unanswered questions.”

In many instances, there are actual, real public servants who want to make government work and see this as an opportunity to help relieve some of the very real burden on states to provide health care coverage. Yes, there are even some Republicans, like Mississippi's Chaney, who want to do their jobs. In Chaney's case, he can. He has broad authority under state law to unilaterally move forward, without interference from the governor or legislature. But he's pretty much in the minority in both terms of commitment to his job and ability to do it.

In some cases, as in Idaho, the governor has some ammunition. Otter convened advisory committees on both the exchanges and Medicaid expansion, and both groups full embraced moving forward because of the savings the state would gain. But Idaho's legislature is kind of crazy, so all bets are off.

But the very real pressures of trying to provide health care affordably to state populations is enough to make this a high-stakes fight. Again. At least this time it's mostly Republican versus Republican.

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Originally posted to Joan McCarter on Fri Nov 30, 2012 at 02:28 PM PST.

Also republished by Daily Kos.

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