Conservative organizations have canvassed the country in recent months to try to convince state legislators not to pass bills to create health insurance exchanges.
"Over the last eight to 10 months, we've seen a huge change in course," said Christy Herrera, the American Legislative Exchange Council's health task force director. "Before the deadline, states have the time to carefully deliberate their decision. They shouldn't be pressured."
If states don't create exchanges, ALEC, the Cato Institute and other conservatives argue, the federal government will lack the resources it needs to run the programs needed to implement the 2010 health care law. They say state inaction doesn't really matter, because the federal government will dictate everything anyway.
Exchanges are websites where consumers can compare costs and benefits of all available insurance plans in the state, as well as purchase insurance. If states don't create their own exchanges, their residents can participate in a federal program.
"[Health and Human Services] needs the states more than the states need HHS," Herrera said. Ten states have delayed acting on exchanges because of the groups' influence, according to ALEC.
That's a misguided and costly theory, administration officials and some policy conservatives say. The federal government is already paying for the start-up exchanges, and the law gives the states the flexibility to run their own programs. HHS announced this month that 34 states have accepted grants to pay for exchanges.
"ALEC has definitely had a big impact," said Republican Alabama Rep. Greg Wren, chairman of the National Conference of State Legislatures' federal health care task force. "The last couple of months, you've definitely seen more of a stand-down."
Wren is a member of ALEC, but he wrote a bill that would create Alabama's health exchange.
Wren's bill included provisions that said if the law was struck down by the Supreme Court, amended or repealed, the state's exchange could be abandoned. Alabama's House passed his bill this year.
"It was a defensive move," Wren said. "I still think it's better to have state control."
Alabama Gov. Robert Bentley, a Republican, intervened, saying legislators should wait for the court ruling. The bill was delayed.
States must submit their plans by November — about a week after the presidential election — to meet HHS deadlines for the exchanges to go into effect in January 2014.
Alabama has accepted $9.5 million in planning grants and created an office to implement the exchanges, even though it has delayed Wren's bill. That's not unusual, Wren said.
"At the same time the states appear to be against it, they are implementing parts of it," he said.
The debate, Wren said, is more about politics than policy and has more to do with this year's presidential campaign than states' resistance to exchanges.
States, he said, will definitely control their exchanges, which were designed with help from state insurance commissioners to account for differences in each state's insurance resources. In Alabama, Wren said, Republicans expected an exchange would help even the field in a state with little insurance competition.