With less than a year before state legislation must be in place to implement a critical part of national health care reform, Tennessee and Georgia, along with 18 other states, have not made substantial progress toward meeting federal deadlines, according to reports from several nonpartisan organizations.
In states with conservative leadership, such as Georgia and Tennessee, the deadlines have put state leaders in a Catch-22.
They hope the U.S. Supreme Court will overturn the Affordable Care Act this spring or summer or that the election of a Republican president would pave the way for the repeal or defunding of the law, so they do not want to implement health care exchanges.
"Our goal here remains the same: securing a victory in court," Georgia Gov. Nathan Deal's spokeswoman said Thursday in an emailed statement. Georgia has challenged the law in court.
However, if the law stays in place, states will have missed key deadlines for enacting legislation and receiving federal funding, increasing the likelihood that they will have to cede local control as the federal government steps in to run their exchanges.
Tennessee Sen. Bo Watson insists that will not happen.
No matter what lawmakers may want to see happen with the federal law, Tennessee legislators will not allow the federal government to get involved, Watson, R-Hixson, said Friday.
"The overwhelming consensus among lawmakers is that no one wants to see the federal government step in and set up an exchange," Watson said. "The general sense is how much time and finances do we want to put into the effort, only to have it overturned?"
Under the 2010 federal law, states must put in place health insurance exchanges and have them approved by January 2013, a key component to ensure the federal health care act will be ready to roll out the following year.
Health care exchanges are "one-stop shops" where small businesses or individuals who do not have access to employee health insurance can choose among an array of insurance plans. People can see whether they are eligible for government programs such as Medicaid or state programs, find private insurance plans that best suit their needs or check on eligibility for federal subsidies to buy health insurance.
The exchanges and other changes to health care will provide coverage to about half the people in Tennessee, Georgia and Alabama who are currently uninsured, according to a study by the Urban Institute, a nonpartisan policy research group. Georgians will benefit the most, with more than a million additional people covered under the changes.
Tennessee lawmakers have not introduced any legislation on the exchanges. Legislators in Georgia and Alabama introduced bills in 2011 that failed to pass. A Georgia lawmaker has introduced a bill this year, but there is little chance it will become law.
"It's disappointing that we are just sort hanging back," said Cindy Zeldin, executive director at Georgians for a Healthy Future, a health care advocacy group. "I worry that if we don't move forward on this, then five or 10 years from now we will look across the country and see disparities in access. Those differences will those be exacerbated, largely because of politics."
Several reports released in the last month -- including from The Associated Press, the Center on Budget and Policy Priorities and the Urban Institute -- found a wide disparity among states in applying for federal grants to create the exchanges and passing laws to create insurance exchanges.
Most states have received federal grants for planning the exchanges, with grants available for planning and two stages of establishing the grants.
Tennessee and Alabama applied for and received grants for planning and the first phase of establishment. Georgia has received only planning funding, with the application process deadline for the first phase in June.
States must pass laws to implement the exchange's operation by January 2013 so the Department of Health and Human Services can certify the states to begin operating them.
Public enrollment in the exchanges is set to begin in October 2013.
The uncertainty surrounding the federal law has clouded the process, but it is clear some states are moving ahead much more quickly than others, said David Chandra, senior policy analyst at the Center on Budget and Policy Priorities, a nonpartisan research organization.
"We hope there is at least a minimum standard states have to meet," Chandra said. "It also depends on how interested local leaders are in taking advantage and enhancing their exchanges versus weakening what is required."
There is already technology and planning in place to implement exchanges at the federal level, Zeldin said. The problem with taking that route is that federal funding to implement the exchange is not guaranteed for later than this year.
However, states can come back later and decide they want to put in a state exchange, Chandra said.
"The federal exchange will operate for a year or two as a stopgap measure," he said.
Tennessee has not introduced any bills on the insurance exchange but has done a study on its feasibility.
An Associated Press report in January found the outlook to be unclear in how the state plans to move forward with the process.
"Conservative legislature hostile to health care law," the report states.
Watson said he thinks the individual mandate on the health care law is unconstitutional and should be overturned, but that does not mean he thinks the state should do nothing on exchanges.
Last week, lawmakers discussed the possibility of meeting in a special session later this year after the Supreme Court returns its ruling, Watson said.
The state has done much groundwork for the exchange and has TennCare in place, so it will be able to move quickly once the law is in place, he said.
"Because of our experience with TennCare, Tennessee is a little bit ahead of other states," Watson said.
Others agreed much of the groundwork is in place to implement the exchange once the bill is passed.
"Clearly the facts have shown that they have had many, many meetings in the state, and have made progress on some levels," Chandra said.
Tony Garr, the executive director at Tennessee Health Care Campaign, also provided a strong assessment of Tennessee's status.
"I'd say we are up to speed, sort of in the middle of pack," Garr said. "We continue to move forward on planning initiatives."
Given the alternative -- federal control -- Garr said he is confident political leaders will pass a law so they can have maximum control in implementing the plan.
"I don't know what it will look like, but I fully believe we will have a plan in place before the legislature goes home," he said.
It does not appear Georgia will have a state exchange in place by next year.
Last year, Deal had proposed and supported a bill but received pushback from tea party activists across the state, said Zeldin, with the Georgia health advocacy group.
This year, political will to move forward seems to have evaporated.
The only focus for Georgia is to fight the law in court, said Stephanie Mayfield, Deal's spokeswoman.
"If Obamacare is upheld, the state faces many tough choices as it forces the state to spend money in one area to the exclusion of others, such as education, transportation and public safety," she said in an emailed statement.
Last year, Deal convened a 25-person committee to look at exchanges. The committee recommended the state consider implementing a private health insurance marketplace but did not recommend the state insurance exchange.
Zeldin, who served on the committee, wrote a minority report that contested that opinion.
The state, which has one of the highest uninsured populations in the nation, has too much to lose by not implementing the exchange, Zeldin said.
And the insurance exchanges affect much more than only the uninsured, she pointed out. Businesses look at health care policies when locating to certain states, which means the entire economic outlook for the state can be affected.
"It's about what kind of state we want to be," Zeldin said. "The reality is right now this is a concept -- when you take it out of the conversation of what is before the courts and in the political arena -- that has a history of bipartisan support. It would only benefit the state."