California has unveiled prices that consumers will pay for a selection of health plans offered through the state under the Affordable Care Act, providing a glimpse into how health care reform may look as it is rolled out across the nation.

Under the federal health care reform law, people who do not get or cannot afford health insurance through their jobs can buy coverage through an exchange, at a group rate negotiated by state regulators.

The cost to a 40-year-old who needs coverage would vary from about $40 to $300 per month for a mid-level plan in California, depending on income. Some young adults, who are less expensive to cover, could pay nothing, depending on how much they earn.

The prices in California, along with those announced in Washington, Vermont and other states, show that premiums under "Obamacare" can be more affordable than had previously been thought. Consumer advocates welcomed the new exchange.

"It's a revolutionary improvement to move from a broken market where people are charged by how sick they are, to a competitive market where people pay what they can afford, based on a percentage of their income, on a sliding scale," said Anthony Wright, executive director of advocacy group Health Access.

"Most consumers buying coverage in the individual market will get financial help and see their premiums go down," he said.

The sweeping federal reform law seeks to extend health insurance to many of the 49 million Americans without it, and alter how care is delivered so as to curb what has been an inexorable rise in healthcare spending.

Republicans who oppose the law had predicted that high premiums would sink Obamacare as the uninsured would not be able to afford coverage even with federal subsidies.

Even the modest rates announced Thursday do not really signal that the program will work, said California Republican Assemblyman Dan Logue.

"This is like a shell game to me," said Logue, co-chair of the assembly health committee, who predicted that taxes would go up to pay for the subsidies, forcing other prices to rise.

"They're not going to tell you that you're going to pay for it in your gas or your food or going to the show," he said.

About a dozen states have set up these exchanges, or large group plans, which are a key element of the giant national health reform effort. Several have already released rates for monthly premiums, and most say the cost will not go up as high as skeptics had feared.

In California, a 40-year-old who makes less than four times the federal poverty level - that is, $95,000 for a family of four or $46,000 for an individual - would pay as little as $40 per month for a mid-level plan in which about 70 percent of medical costs and all preventive care is covered. This excludes additional costs to cover children or a spouse.

The same plan for a person who makes too much to qualify for a subsidy would run about $300 per month on average, the state said. In addition, the total amount consumers would have to pay each year for co-payments and other out of pocket costs would be limited to $6,350 or less, depending on income.

Patients could choose plans that offer lower co-pays if they wished, but would pay higher premiums. In some cases, particularly for low and moderate income workers in their 20s, the premiums are free once a federal subsidy is factored in.

The exchange will also offer what it calls platinum plans, in which co-payments are very low or non-existent. These plans would cost $500 for those who do not qualify for subsidies, but as little as $300 per month for low-wage earners.

The biggest subsidies go to people who make less than 150 percent of the federal poverty level, or about $17,000 for a single person.

Peter V. Lee, a longtime health advocate recruited by the state to help set up and run its program, said costs had been expected to skyrocket because the Affordable Care Act requires health plans to offer more benefits and cover more people than they might otherwise have done.

For example, the plans must cover people with or without pre-existing conditions that would make their care more expensive. The actuarial firm Millman had predicted a 30 percent rise in the cost of monthly premiums for individuals in California under the new exchange.

But Lee said that did not happen. While rates without subsidies may be moderately higher for some consumers next year, most will pay less, he said. The rates announced on Thursday must still be approved by state regulators.

Democratic Congressman Henry Waxman, who backed the health reform act, said the program would protect millions from bankruptcy due to medical costs.

"Californians buying coverage on their own will now have access to the same quality coverage that people get through their employers at the same or lower rates," he said.

California's exchange will offer coverage from 13 insurers; more than 30 had applied to participate.

Among them are some of the biggest names, including Anthem Blue Cross, Blue Shield and Kaiser Permanente. Coverage will also be offered by some companies that had previously limited their activity to the Medicare and Medicaid markets.

Paul Markovich, president of Blue Shield of California, which is offering coverage under the plan, said that to keep prices low, doctors and hospitals had lowered some of their rates. Some insurers also agreed to limit profits, Lee said.

The policies vary in their provider networks, but Lee said consumers would have access to about 80 percent of doctors in the state, and some of its premier medical centers.

Consumers will be able to begin signing up on October 1 for plans that will go into effect in January. Next month, the California exchange will reveal plans and prices for insurance that small business owners can purchase for their employees.

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Two-thirds of Americans who sign on to buy health insurance using new state marketplaces will actually be getting a federally administered plan, a health consultancy firm projected Thursday.

Only 17 states, plus Washington, D.C, have said they will run their own health insurance exchanges or share responsibility with the federal government.

“These states are expected to enroll 2.8 million individuals out of a total of 8.2 million people nationwide who will buy coverage through exchanges in 2014,” Avaleere said in its report.

The rest have either said they’ll leave it up to the federal government, or are leaning that way.

Friday is the deadline for states to say for sure what they plan to do and just three states – Florida, North Dakota and Indiana – have failed to give an answer so far. But all three have governors who have indicated they won’t be setting up exchanges.

On Wednesday, Pa. Gov. Tom Corbett said his state would leave it up to the federal government.

Republicans who control the House Energy and Commerce Committee’s health subcommittee held a hearing on Thursday to highlight state reluctance to take part in the exchanges, even though they got their deadline extended by a month.

But the Health and Human Services Department said it didn’t matter – people will be able to sign up to buy health insurance on the exchanges as scheduled, in October 2013. Their coverage will start on the first day of 2014 under the 2010 health reform law.

“I am confident that sates and the federal government will be ready in 10 months," Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, which is in charge of the new exchanges, told the hearing.

HHS said earlier this week that six states -- Colorado, Connecticut, Massachusetts, Maryland, Oregon, and Washington – are on track to have their health insurance exchanges approved. California, Hawaii, Vermont, Mississippi, Kentucky, Minnesota, New York and Rhode Island are also on board to run their own, Cohen said. Delaware, Illinois, Iowa and North Carolina want federal-state partnerships.

One of the main goals of the 2010 Affordable Care Act is to get more Americans covered by health insurance. About 15 percent of the population currently goes without, and most experts agree that people without health coverage delay routine medical care until they develop expensive-to-treat conditions. Hospitals and taxpayers often end up footing their bills.

The main way the health care law will get these people covered is on the exchanges. They’re designed to be a kind of online marketplace where people and small businesses can compare different insurance plans available in their states, choose a level of coverage, and find out if they are eligible for federal government subsidies to pay the premiums.

Cohen said HHS is on track to make this as easy as possible. “For example, we are building a website with interactive capabilities and a call center. Consumers will be able to use this to compare qualified health plans, check their eligibility for affordability programs, and enroll in a qualified health plan,” he said at the hearing.

Even if the federal government runs the exchanges, they’ll be subject to state-by-state variation. That’s because state law still determines which insurance companies can sell products within a state’s borders. States also can decide whether to expand Medicaid, the state-federal health insurance plan that now covers mostly the very poor and pregnant women without insurance.

But representatives from several states said the process has been far too confusing and they fear HHS will make an already complicated process even more complex.

“In all my years of public service, I have yet to witness a law so vast with such breathtaking scope, demands on state resources, and lack of federal guidance,” Gary Alexander, Pennsylvania's secretary of public welfare, told the hearing.

“I have hundreds of policy, operational, and technical staffers working to implement this health-care reform law, and yet, we realized early on that we do not have the capacity or the financial resources to address all of the provisions and requirements of this complicated law.”

Bruce Greenstein, Louisiana’s health secretary, echoed this. “We have repeatedly shared our concerns regarding its policy implications, lack of sufficient guidance and unreasonable timelines for implementation,” he said.

Cindy Mann, deputy administrator at the Center for Medicare and Medicaid Services, said HHS had held constant briefings to help guide states. “We are on the phone literally every day with people form the states, helping them, answering their questions,” she told the hearing.

Dr. Joshua Scharfstein, who heads Maryland’s health department, agreed. “We have had a terrific interaction,” he told the hearing, saying he has been “really impressed” with Cohen’s and Mann’s departments.

Democrats on the subcommittee accused Republicans of playing politics and said critics of the health reform law were still trying to undermine it, even though the U.S. Supreme Court ruled it constitutional in June.

“Many of us fear is the purpose of this hearing is to show we can’t move forward,” said California Democrat Henry Waxman. “That’s flat-out wrong. It seems to me it’s just the latest attempt to repeal the Affordable Care Act.”

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States got a last-minute extension late Thursday of a deadline to decide whether they’ll build their own health insurance marketplaces, or let the federal government do it for them.

Republican governors had been complaining about the Nov. 16 deadline to file their formal decision with the Health and Human Services Department, mostly because HHS has not yet told them what a federal exchange would look like.

HHS secretary Kathleen Sebelius gave in at almost the last moment, extending the deadline to Dec. 14.

“While receiving a letter of intent now will help us assist states in finalizing their application, a state may submit both a letter of intent and an application to operate its own exchange by December 14,” Sebelius wrote in a letter to the Republican Governors Association.

It’s the second time in a week that Sebelius let the governors slide. Last Friday, HHS said the states could have nearly a month extra to submit plans of what their exchanges would look like, if they decided to set up their own. She gave them until Feb. 15 to detail plans if they wanted to partner with the federal government to build an exchange.

The 2010 Affordable Care Act aims to get more people covered by health insurance, so they can get medical care when they need it, and so they get care earlier, before easy-to-treat conditions like high blood pressure can cause expensive strokes or heart attacks. One way to do this is by setting up online marketplaces called exchanges to help people to buy insurance.

They’re supposed to provide a side-by-side comparison on price, what’s covered and how much you might have to pay out of pocket for a doctor’s visit. They’ll also be a route for people to get a little extra cash from the federal government to buy insurance; the health care law provides for a generous federal subsidy for many, if not most, buyers.

However, many governors have balked at doing this and most states were procrastinating. Some were gambling that the Supreme Court would strike down the health reform law in June and when it didn’t, they waited to see if Republicans took the White House and Senate in the Nov. 6 election.

Now they will have to decide, but HHS has also taken some time in publishing rules many governors say they need to see before they decide whether to take on the job of running an exchange.

Virginia Gov. Bob McDonnell and Louisiana Gov. Bobby Jindal wrote to President Barack Obama, asking him to extend the Nov. 16 deadline. 

Jindal and McDonnell are among the governors who have said they won’t set up exchanges. Nebraska Gov. Dave Heineman joined the group on Thursday.

"The reality is that the federal health care law is being totally dictated and totally controlled by the federal government," Heineman told a news conference.

South Carolina’s Nikki Haley repeated her decision to opt out of running an exchange Thursday. Other Republicans who have said no include Texas Gov. Rick Perry, Alaska Gov. Sean Parnell and Kansas Gov. Sam Brownback.

But Mississippi has said it will set up an exchange and Florida Gov. Rick Scott, who led one of the major lawsuits trying to overturn the Affordable Care Act, now says he’ll try to do so in his state, also. New Mexico’s Republican Gov. Susana Martinez had been working already to set one up. Heavily Democratic states such as California and Connecticut have already begun work on their exchanges and Colorado says it will, too.

Sebelius said in her letter she would provide more information soon.

“Additional guidance will be released in the coming days and weeks,” she wrote. “We are confident governors will have enough time to decide whether they want to establish an exchange, work in partnership with the federal government or have a federally facilitated exchange in their state.”

The exchanges must, under law, be up and running by January 2014. Open enrollment -- when people get to have a peek at what is on offer and start signing up -- is supposed to start by October of next year.

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Updated at 5:50 p.m. ET, Nov. 9: There’s nothing like a deadline to focus the mind and states have a good one coming up next week – they have to decide if they're going to run their own health insurance marketplaces, called exchanges, or have the federal government do it for them. 

But they got a little break late Friday -- if they do decide to run their own exchanges, they'll have until December 14 to submit their plans to the federal government.

It’s a big decision and a big responsibility. One of the main goals of the 2010 health reform law is to get more people covered by health insurance, so they can get medical care when they need it, and so they get care earlier, before easy-to-treat conditions like high blood pressure can cause expensive strokes or heart attacks.

The exchanges – think Travelocity for health insurance – will provide a mechanism for more people to buy insurance. They’re supposed to provide a side-by-side comparison on price, what’s covered and how much you might have to pay out of pocket for a doctor’s visit. They’ll also be a route for people to get a little extra cash from the federal government to buy insurance; the health care law provides for a generous federal subsidy for many, if not most, buyers.

The states had two good excuses this year to procrastinate on exchanges. First of all, there were three major challenges to the law that went all the way to the Supreme Court. Many governors and state legislators were gambling that the Supreme Court would declare the law unconstitutional. It didn’t. Now the Nov. 16 deadline looms.

“This deadline is smoking the states out,” says Dan Mendelson of consultants Avalere Health.

But Health and Human Services Secretary Kathleen Sebelius softened the deadline a bit late on Friday. "The deadline for a Declaration letter for a State-based exchange remains Friday, November 16, 2012," she wrote in a letter to governors. "However, today, in order to continue to provide you with appropriate technical support if you are pursuing a State-based exchange, HHS is extending the deadline for State-based Exchange Blueprint application submissions to Friday, December 14, 2012."

When it ruled in June, the Supreme Court said states could decide whether to offer Medicaid – the state-federal health insurance plan for the low-income – to more people. But the rest of the law stood, including the exchanges requirement. Still, there was another possible way out – the election.

Republicans promised that they’d repeal the entire health reform law if they won in this week’s election. Now that Mitt Romney has lost to President Barack Obama and the Democrats have kept their control of the Senate, any chance of killing the Affordable Care Act is now dead. 

"Obamacare is the law of the land," House Speaker John Boehner said in an interview with ABC News on Thursday.

So far, only 13 states and Washington, D.C. have said they’ll build a health insurance exchange. Eight have said they absolutely will not, and 25 states have been sitting on the fence, says Kelly Barnes, U.S. health industries leader at PricewaterhouseCoopers.

"My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could cost Kansas taxpayers millions of dollars," Kansas Governor Sam Brownback said in a statement Thursday.

Some groups are also urging governors to defy HHS. “States can and do have the power to reject federal attempts to compel their action. Governors should use that power to tell the federal government 'no'," Nicole Kaeding of the group Americans for Prosperity said in a letter sent Friday. “By creating an exchange, states will serve as de-facto administrators of the federal government implementing its rules, regulations, and mandates.”

States that don't set up their exchanges will have to submit to what the federal government does for them.

Avalere predicts 20 states will be ready to run their own exchanges when the bulk of the health reform law takes effect on Jan. 1, 2014. “The consumer will have access to an exchange by 2014,” Mendelson said. “One way or another, this administration has to make sure that everyone who wants to purchase insurance can.”

To make sure that people don't wait until they are sick to buy health insurance, the 2010 health reform law provides for fines on a sliding scale for people who don't buy. And people who want to switch from their employer's insurance can.

States may have been hoping to escape the looming responsibility, but that doesn’t mean they have been doing nothing. “I think there are more contingency plans out there than probably people have declared,” Barnes said.  “A state like California, that has been planning all along, will have a higher level of organization.”

Waiting on the rules
Some Republican governors have done a fair bit of planning, including Bob McDonnell of Virginia and New Jersey’s Chris Christie. But many want the Health and Human Services Department to give them the rules for the exchanges, and to spell out what a federally run exchange would look like.

That would help them choose. Many have also asked if they can do a hybrid, with the state running part and the federal government running part of the exchange.

The federal government hasn’t published those rules. They are currently awaiting approval at the Office of Management and Budget. "We intend to issue further guidance to assist you in the very near future," Sebelius wrote the governors."This administration is committed to providing significant flexibility for building a marketplace that best meets your state's needs," Sebelius added.

“It’s driving the insurance companies crazy to not have any clarity about what they need to be offering in the exchanges,” Mendelson said. “Having said that, when push comes to shove, the insurers want to be offering products in the exchanges. They will rise to the challenge.” After all, the exchanges could mean more than 20 million new customers for insurance companies.

Right now, about 48 million Americans are going without health insurance, according to the Census Bureau. That’s more than 15 percent of the population.

About 55 percent of Americans are covered through an employer; 31 percent have a public insurance plan such as Medicare or Medicaid, and 10 percent buy their own health insurance.

23 million likely will get insurance through exchanges
The Congressional Budget Office predicts that 23 million people who don’t have health insurance now will get it on one of the exchanges. More than 18 million of them will qualify for a federal subsidy averaging $6,000 a year per person. People earning up to four times the federal poverty level can get a subsidy: that’s an income of $92,000 a year for a family of four.

But it’s going to be confusing, especially for people who have never had to wrangle with an employer’s open enrollment process before. “If you have had employer-sponsored insurance, at least you are familiar with the terms,” said Barnes. “But there is also a big tranche of buyers who have never had access to insurance before. It’s a less sophisticated consumer.”

Many people will go for bare-bones coverage, Barnes predicts. “Price is going to be the first selector in this round,” she said. “When all else fails, you buy on price.”

Some people who now have employer-covered insurance are doing that anyway. There’s a clear trend for employers to offer less, and to require their employees to pay a bigger share of their health insurance coverage. “It is definitely true that employers are paying for less and less,” Mendelson says.

“They are increasing co-pays and making it expensive for patients to use medical services. But even with those trends, the benefits available in the exchange are likely to be less generous and less robust than what employers offer today.”

Nonetheless, Mendelson says the exchanges will set the standards going forward. “These are going to be solid commercial insurance products offered by leading health insurance companies,” he said. “They are widely seen as the future.”

It will pay, he said, for the companies to make it easy to understand what they’re offering for sale on the exchanges.

Related links:

Boehner: 'Obamacare is the law of the land'

A consumer's guide to health reform, post-election 

Supreme Court ruling leaves poorest Americans at risk

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A quarter of kids live in families struggling with medical bills

Eric Kayne / for NBC News

Brandi DeFrank's son Gabriel, 3 months old, is covered under Medicaid, but the program's coverage for the Texas mom herself ended when she gave birth.

As Mitt Romney and President Barack Obama pack in some last-minute campaigning before Tuesday’s election, polls show voters are split just about down the middle on who they prefer: Romney, who has promised to do everything he can do repeal the 2010 health reform law, and Obama, who says its benefits are just beginning to take hold.

But while the presidential race gets most of the attention, the choices voters make to fill governor’s mansions and state legislatures may have just as big an effect on what kind of health coverage they will have in coming years.

That’s in part because the Affordable Care Act sets it up that way, but even more so because the Supreme Court says it’s up to states to decide whether and how to expand the Medicaid health insurance plan for the poor.

“One thing the voters should be aware of is what are their governors are going to be doing. Will more people have access to Medicaid or access to a state-run exchange?” says John Poelman of healthcare consulting firm Leavitt Partners and a former health policy analyst at the Department of Health and Human Services.

Two states at the two extremes of health care coverage are Texas, with a free-market, bare-bones approach, and Vermont, which is unabashedly going for a European-style, government-supported system.

Brandi DeFrank is one of the 6.3 million people in Texas who lack health insurance. That's a quarter of the state's population and the highest percentage of uninsured people in the country.

Like millions of women across the country, DeFrank, 20, was fully covered under Medicaid, the state-federal health insurance plan for low-income people, while she was pregnant. The birth of her 3-month-old son, Gabriel, was also covered, but after that, her own coverage ended. The baby remains on Medicaid -- all states make some provision for children whose parents lack insurance -- but now DeFrank is on her own and gambling that she won’t get sick.

Under federal law, DeFrank could have been covered under her parents’ health insurance. But when she moved out at 18, her father said she had to learn to be an adult.

“He took me off his insurance,” said DeFrank as she cradled Gabriel in a cheerful playroom at Legacy Community Health Services, a non-profit health clinic in southwest Houston where Gabriel gets care. Her husband, who is working as an intern at a medical clinic, is also not covered, says DeFrank, who is about to begin applying to nursing school.

“I didn’t really think about Medicaid or anything. You’re just thinking about college,” she added. “I saved all my money for books.”

'We're not going to be a part of socializing health care'
Texas governor Rick Perry, a Republican, has said he won’t expand Medicaid to cover people like DeFrank, and the Republican-dominated Texas legislature backed him in turning down $76 billion in federal matching funds that would have helped pay to do it over the first five years.

“We’re just not going to be a part of … socializing health care in the state of Texas,” Perry told reporters in July.

But in Vermont, Gov. Peter Shumlin, a Democrat, and the current legislature are pushing hard for a single-payer system that they say will give them the leverage to lower prices and provide better care for everyone in the state. But they’re not there yet and the election will decide if the state will continue to go in that direction, or whether it will be forced to roll back.

The state’s current continuum of programs asks patients to pay at least a minimum premium if they can. They include Catamount Health, a state plan providing subsidies for some people, along with Blue Cross Blue Shield of Vermont; Vermont Health Access Plan, which provides insurance for people who have gone without for a year or more; Dr. Dynasaur; Medicaid, and pharmacy assistance and premium assistance programs.

On Tuesday, residents will go to the polls to decide whether to keep pushing more, towards government-directed health care plan that covers everyone, paid for by taxes.

That’s what Anna Gebhardt would like to see happen. Even though Vermont offers more coverage options for low-income families than some other states, she and her husband, Oliver, don’t have insurance. Their jobs don’t offer coverage, they can’t afford to buy a private policy and, since Oliver got a raise a few months ago at his job as an audio engineer, they earn too much money to qualify for Medicaid. Their children, Leviah, 6, and Immanuel, 13, are covered under the state’s Dr. Dynasaur program, which offers low-cost coverage for kids, but the family struggles to make the payments for it.

Two weeks ago, Gebhardt, a 33-year-old preschool teacher, was sitting nervously in a Burlington, Vt., emergency room after Leviah fell down at school. When the girl was still crying hours later, her mother took her in. It wasn’t an easy decision. Gebhardt was not entirely sure she was paid up on Anna’s health insurance premium under the Dr. Dynasaur program.

“My fingers were crossed and I was thinking ‘Did I pay the bill last month?’” said Gebhardt. “Two other people had to come over and help make sure we were covered before we could even see a doctor. This gives you a lot of anxiety when you have a child who is crying and in pain,” Gebhardt said. Luckily, she had paid and Leviah was just just fine.

DeFrank and Gebhardt are just the type of people that Democrats want to reach with expanded health care, subsidized by the government if needed. And they’re just the type of people that Republicans say could buy their own insurance if the government would just let the free market take over.

The 2010 Affordable Care Act was designed to transform health care in the United States, which most experts agree currently costs too much and leaves far too many people without health insurance. The Affordable Care Act calls for states to set up insurance exchanges, where people who don’t have health insurance through an employer or through government programs can go and buy a plan -- with government subsidies, if they need them.

It also was meant to provide more care to people who can’t buy insurance by forcing states to expand Medicaid. The hope was to add about 16 million of the poorest people to the rolls -- about half of those who need health insurance. But after a series of challenges to the law, the U.S. Supreme Court ruled in June that the Medicaid expansion requirement went too far. While most of the Affordable Care Act was constitutional, the court ruled, the federal government could not force states to offer Medicaid to more people.

'They can disrupt implementation of the law'
So now two of the biggest provisions of the law -- offering Medicaid to more people and setting up the health exchanges -- are in the hands of state officials.

“They can disrupt implementation of the law. Leadership can either be aggressively moving it forward or impeding it,” Poelman says.

The Obama administration is offering to pay the full cost of expanding Medicaid at first, but lawmakers in states like Texas say they can barely afford Medicaid now, let alone when they’ll have to start kicking in 7 percent for all those extra people in 2019.

This frustrates Garnet Coleman, a Democrat in the Texas legislature who represents much of Houston’s poor downtown. Coleman says not only would expanding Medicaid save money in the long run, by getting people treated earlier, it would create much-needed jobs. “Health care is a growth sector,” Coleman says. It will create “beaucoup jobs -- good jobs, as your mama would say.” Jobs that people can get with two-year degrees. “This is just a boost in the arm to the state of Texas,” he says.

Coleman is delighted that Perry and the legislature are balking on setting up an exchange for Texas and looks forward to seeing what the federal government will do instead. The 2010 health reform law says that if states don’t set up their own exchanges by 2014, HHS will do it for them.

Different paths to the same goal
It’s not that Democrats want health care and Republicans don’t. Both sides agree in principle that it’s better for everyone to have health insurance of some kind.  It’s cheaper to treat disease or injuries early, and best to prevent disease in the first place. People are more likely to get vaccinated and to take medications such as blood pressure drugs if they’re seeing a doctor regularly.

The Obama administration says the way to get there is with subsidies and government oversight, with a healthy marketplace allowing private health insurers to offer more to those who can pay -- and strict regulation to make sure insurance companies don’t cherry-pick the healthiest customers or dump patients just when they need insurance the most.

Republicans argue that freeing up the marketplace would do that more efficiently. They say that government regulations make it impossible for insurers and health care providers to compete enough to bring costs down.

“No one says it’s better to leave people out,” says Joel Ario, former director of health insurance exchanges at HHS, who is now at law and consulting firm Manatt Phelps & Phillips. “It is just a question of what we can afford or not afford.” It’s also a question of who can best make those decisions – states or the federal government.

“With exchanges, the question is whether the federal government should have a heavy hand in making them work,” Ario added.

In Texas, polls suggest the Republicans will dominate. This likely means Texas will continue to offer a bare minimum of health care and will let the federal government set up its health exchanges.

“There are states referred to as ‘Hell, no states’,” said David Smith, an analyst at Leavitt, the healthcare consulting firm. “A lot of those states don’t necessarily have governors who are up for election.” In those states, voters have to decide whether to help governors by electing members of the same party to the state house.

In Vermont, Shumlin’s Republican opponent, Randy Brock, says single-payer health care is too expensive. Vermont’s legislature will take up the question of how to pay for it in January, with options including a capital gains tax or a tax on employers.

Where other states stand
Republican governors like Iowa’s Terry Branstad, Arizona's Jan Brewer, Sam Brownback of Kansas, Louisiana’s Bobby Jindal, Nebraska’s Dave Heineman, Nikki Haley of South Carolina and Scott Walker of Wisconsin say they have no intention of expanding Medicaid. Florida’s Rick Scott says he won’t expand Medicaid even though his state has the second-highest rate of uninsured adults, after Texas.

Leavitt’s team predicts the majority of state governors -- at least 30 -- will be Republican after the election. Eleven states will be electing governors, and eight of them have Democrats in office now.

States that are safe for Democrats include Maryland, where Gov. Martin O'Malley was one of the first governors to move on health reform. Oregon governor John Kitzhaber also makes health reform a central policy.

Next door in Washington state, health care is playing a big role in making the race tight, with Democrat Jay Inslee, an eight-term congressman from Seattle, battling the Republican state attorney general Rob McKenna. Inslee supported the health law in Congress; McKenna isn’t against expansion but he thinks Medicaid patients should share some of the costs. 

In Indiana’s race, Republican congressman Mike Pence has said he wouldn’t set up a state insurance exchange. His Democratic opponent John Gregg hasn’t endorsed the health reform law, either, but has met with current governor Mitch Daniels about how Indiana should move forward on building a health insurance exchange.

Alabama, Florida, Montana and Wyoming have ballot measures asking residents whether they want to block the mandate requiring people to get health insurance. Missouri voters are being asked to decide whether to allow the governor to establish health insurance exchanges.

While they wait to see what happens, Gebhardt and her husband, Oliver, are gambling that they won’t get sick and need medical care.

“We are constantly at the whim of decisions being made by people who don’t depend on those services and don’t realize how their decisions affect people,” Gebhardt said. “We are constantly in limbo. We could create a system where efficiency works for the people and for the budget. That is where Vermont can lead the way.”

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