In a recent letter to President Obama, however, Republican Govs. Bob McDonnell of Virginia and Bobby Jindal of Louisiana (the outgoing and incoming chairmen of the Republican Governors Association) warned of problems. "It is clear that putting in place the new programs you championed will be an enormous strain on state governments and budgets, as well as the federal government," they wrote, adding that the time frame and many provisions in the Affordable Care Act "are simply unworkable."
"States are struggling with many unanswered questions and are not able to make comprehensive far-reaching decisions prudently," the two Republican governors said.
Nevertheless, some states are ahead of the game. On the recommendation of a state health-policy commission back in 2006, Oregon passed legislation establishing an insurance exchange last year. Other states have followed suit, either through legislation or (as in New York) by gubernatorial order.
But as a recent Urban Institute report points out, "many state policy environments remain politically contentious, and progress in exchange development has been slow for some of them as a result." The report warns, "States not achieving significant milestones by now ... are unlikely to be able to establish a state-based exchange by late 2013."