Despite the fact that President Obama’s reelection ensures his landmark health care reform law is here to stay, intransigent Republican governors across the country have been digging in their heels against Obamacare. GOP officials continue to refuse to implement two of the law’s most important provisions — expanding the Medicaid program and setting up state-run health exchange markets — even as deadlines are fast approaching.

But a few Republican leaders are inching toward reform. On Thursday, the U.S. Department of Health and Human Services approved the first four Republican-controlled states to run their own health insurance exchanges, the online marketplaces that will allow Americans to purchase insurance starting in 2014. HHS has given New Mexico, Nevada, Utah, and Idaho the conditional approval to continue working toward setting up their exchanges this year. The Democratic-controlled California, Hawaii, and Vermont also earned HHS approval to move forward.

This brings the list of states working toward health exchanges up to 18. Two additional states, Arkansas and Delaware, will operate partnership exchanges with the federal government.

On the other hand, stubborn Republican governors in states like Florida and Texas have refused to participate in Obamacare, despite the fact that the health exchanges are projected to extend coverage to 25 million Americans by the end of the decade. When the deadline for submitting a state health exchange plan came and went last month, 30 governors decided not to turn one in. States still have until February 15 to choose to follow in Arkansas’ and Delaware’s footsteps and opt for a partnership with the federal government.

And ultimately, the GOP politicians who aren’t putting in any work toward an exchange in order to continue resisting Obamacare are making a purely symbolic statement. The states that refuse to set up their own exchanges simply cede their control to the federal government, which will step in and set up one for them.

Now that President Obama has secured a second term, the implementation of his landmark health reform law continues to march forward — but since stubborn Republican governors across the country see themselves as the last roadblock standing in the way of Obamacare, they’re still doing everything in their power to halt that progress.

Last month, federal officials agreed to give state officials more time to design their health exchange markets in light of Republican leaders’ concerns that they wouldn’t be able to turn in their plans in time. However, as GOP governors continue to resist Obamacare as a purely political statement, Politico reports that they have allowed deadlines to come and go without lifting a finger to do the necessary work to prepare for the impending health care law:

The passive resistance of so many governors could gum up the works if the feds have to handle millions of enrollments, questions from confused customers and greater health plan oversight.

As of Friday — the final deadline for states to declare whether they’ll set up exchanges — more than 30 states had refused to set up the marketplaces, which had been expected to become the source of health coverage for as many as 25 million people by the end of the decade. To some of the law’s most vocal opponents, that’s a pretty good way to keep up the fight against Obamacare.

“The more states that opt out of the state-based exchanges, the harder it will be for the federal government to fully implement Obamacare and the more likely it will be that we can turn back the clock and reframe the health care debate,” Tea Party Patriots wrote to supporters ahead of Friday’s deadline.

Some Republican governors say they’re dragging their feet on reform because they still haven’t had enough time to prepare, or because they need more information from the Obama administration to fully understand what’s expected of them. In the lead up to last week’s deadline, several of the Republican governors who have been particularly resistant to cooperating with Obamacare’s implementation — including Florida Gov. Rick Scott, Louisiana Gov. Bobby Jindal, and Arizona Gov. Jan Brewer – requested a meeting with Obama to talk over the details of the Affordable Care Act’s impact on their states.

But Democratic lawmakers dismiss these concerns as simply a convenient excuse for standing in the way of Obamacare, pointing out that Republican leaders have had plenty of time to complete their homework. “It seems to me it’s just the latest attempt to undo the Affordable Care Act,” Rep. Henry Waxman (D-CA) told the Hill. “Let’s not buy into this next line of attack that the law must be delayed.”

Despite what Obamacare opponents may hope, however, the Republican governors refusing to do the work to prepare for Obamacare in their states won’t actually prevent the health reform law from going into effect. The Obama administration maintains that the health exchanges will be ready in time — even if more of the responsibility for them rests with the federal government rather than with state officials.

The Center for American Progress (CAP) today released a new study highlighting the devastating effect that raising the Medicare eligibility age would have on America’s seniors.

CAP’s study finds that if lawmakers were to raise the eligibility age to 67, as many as 5.4 million 65- and 66-year-olds would have to search for alternative coverage sources — either by postponing retirement, enrolling in an individual plan on one of Obamacare’s statewide insurance exchanges, or qualifying for Medicaid. This dynamic alone will drive up all Americans’ costs by making existing insurance pools older, sicker, and costlier to treat.

The report further estimates that while the federal government would save a net $5.7 billion, raising the eligibility age would end up costing states, employers, and Americans an added $11.4 billion in health care spending. Worse still, seniors living in GOP-run states that have very high concentrations of poor, elderly Americans yet have refused to take part in Obamacare’s Medicaid expansion would be hit hardest by the eligibility hike, and as many as 435,000 seniors could end up uninsured by 2021 if lawmakers end up following through on the proposal:

Unfortunately, GOP governors have been digging in their heels against health care reform by refusing to take part in Obamacare’s Medicaid expansion. Just last week, while announcing that South Dakota would not be expanding its Medicaid program, Gov. Dennis Daugaard (R) dismissed the plight of poor, uninsured Americans off-hand, saying, “I want to stress that: these are able-bodied adults. They’re not disabled; we already cover the disabled. They’re not children; we already cover children. These are adults — all of them.” While it is certainly true that these poor Americans — who must make ends meet on less than $12,000 per year — are “adults,” Daugaard’s assurance that they are able-bodied is dubious.

Raising the Medicare eligibility age from 65 to 67 is fundamentally un-serious entitlement “reform.” It’s the kind of proposal that sounds logical — after all, it’s true that Americans are living longer on average — and makes for a quick and easy political pitch. But a brief dive into its mechanics and consequences shows it for what it really is: a shoddy political deal that ends up costing double what it saves by shifting the cost of health care from the federal government onto states, employers, and Americans’ premiums — all while doing absolutely nothing to address the actual roots of America’s skyrocketing health spending.

Under President Obama’s landmark health reform law, states will institute — either on their own or with the help of the federal government — insurance exchanges that will act as virtual marketplaces where Americans can purchase health coverage. Plans on these exchanges must include benefits across ten broad “essential health benefit” categories, including preventative care, maternity care services, and prescription drug coverage. But experts are now saying that states should go beyond the federal standard and designate vision care as an essential health benefit, too.

According to Kaiser Health News, while states mandate vision benefits for children, adults are largely left to fend for themselves, perpetuating a system in which otherwise insured adults decide to forgo vision care rather than pay for crucial treatments out-of-pocket:

[R]esearchers found that more than 40 percent of people in their study lacked vision insurance. They also looked at a subgroup of about 12 percent of people in the study who reporting having glaucoma, macular degeneration, or cataracts — the three leading causes of vision loss in the U.S. About 40 percent of that group also did not have vision insurance. Yet nearly 90 percent of both groups had health insurance.

Dr. Sudha Xirasagar, who oversaw the study, said she was particularly surprised to see such a high number of people without vision insurance, particularly those with serious eye conditions.

“Lack of vision insurance impedes eye care,” Xirasagar said, which “may irrevocably affect vision.”

The researchers also found that people with vision insurance were more likely to have seen an eye doctor within the past year and were less likely to report having difficulty seeing and reading.

“You would think that people who have glaucoma and macular degeneration should be worried about their eyes and should be going and getting [care] regardless of whether they have vision insurance or not. But they don’t, which is a bad thing,” said Xirasagar.

The American Academy of Ophthamology estimates that by age 80, more than half of all Americans have cataracts, accounting for $6.8 billion in annual health spending. And as lawmakers in Washington consider raising the Medicare eligibility age to 67, more and more seniors may have to rely on Obamacare’s insurance exchanges for their care — furthering the case for vision benefits as an essential need.

Health and Human Services (HHS) Secretary Kathleen Sebelius announced on Monday that, for now, states will not be able to receive full federal funding if they choose to implement partial Medicaid expansions. States will need to fully expand the program to be eligible for the matching funds under Obamacare that will offset the cost of the program.

Although the Supreme Court upheld the bulk of the landmark health reform law last summer, Obamacare’s proposed Medicaid expansion was scaled back when the court ruled that states should be able to decide whether or not to expand their programs. Since then, GOP governors have been digging in their heels against reform, refusing to expand their states’ Medicaid pools to extend affordable insurance to millions of low-income Americans. That’s led lawmakers in several GOP-run states, such as Texas and Louisiana, to toy with the idea of partially expanding Medicaid in individual counties as a way of overcoming their governors’ continued obstruction.

But Sebelius has confirmed that pursuing that option will make states ineligible for the matching funds that the federal government will offer to the states that choose to fully expand Medicaid:

[W]e explain how Exchanges and Medicaid administrative costs will be funded and how we will continue exploring opportunities to provide States additional support for the administrative costs of eligibility changes. We clarify in our new guidance that states have the flexibility in Medicaid and the Children’s Health Insurance Program to provide premium assistance for Exchange plans as well as to adopt “bridge plans” that offer coverage through both Medicaid and Exchanges – keeping individuals and families together when they cross the line between Exchanges and Medicaid. And, while the law does not create an option for enhanced match for a partial or phased-in Medicaid expansion to 133 percent of poverty, we will consider waivers at the regular matching rate now and, in 2017 when the 100 percent federal funding for the expansion group is slightly reduced, broad-based State Innovation Waivers.

We hope states will take advantage of the substantial resources available to help them insure more of their residents. As an independent report highlighted, “Accounting for factors that reduce costs, states as a whole are likely to see net savings from the Medicaid expansion.”

In fact, several independent reports have highlighted the cost-cutting potential of Obamacare’s Medicaid expansion.

Without full federal matching funds for partial expansions, the stakes have been raised for recalcitrant GOP governors and legislatures, who control the state governments of seven out of the ten least-insured cities in America.

Obamacare extends health insurance to tens of millions of Americans, assists the nation’s most vulnerable by outlawing the worst excesses of the private insurance industry, and keeps Medicare solvent for American seniors. And the Wall Street Journal observes that the landmark health law will prove a crucial asset to yet another segment of the American population: those who are are trapped in their current jobs out of fear for losing access to health insurance.

This phenomenon — known in the industry as “job lock” — is an unintended consequence of America’s primarily employer-sponsored health insurance system. Studies have shown that workers who don’t receive insurance through their employers are one and half times more likely to switch jobs than the workers who have employer-sponsored plans. Since insurance coverage can’t be shifted between jobs, some Americans remain in their current positions longer than they would have otherwise because of their fear of losing health coverage, since private insurance might prove unaffordable for them.

This problem is particularly prevalent among older employees in their 50s and 60s, some of whom remain in their jobs simply because they are waiting to qualify for Medicare coverage. Even aside from the fact that this dynamic forces some people to work longer than they might want to, it also creates an inefficient labor market, since workers might not switch over to higher-utility job in order to maintain continuous benefits.

Luckily, Obamacare’s insurance exchanges will allow individuals to purchase coverage on a statewide market, and the law gives consumers tax subsidies with which they can purchase care. Furthermore, small employers might be less likely to forgo hiring due to coverage costs, since Obamacare actually reduces smaller firms’ health care spending.

But proposals to raise the Medicare eligibility age from 65 to 67 would undo some of the progress made by Obamacare in this regard, forcing elderly Americans to work for even longer and exacerbating the “job lock” phenomenon — all while reducing health care spending marginally and shifting costs onto states, employers, and Americans’ health insurance premiums.

A new report from the Commonwealth Foundation finds that Obamacare’s “medical loss ratio” provision — the so-called “80/20 rule” requiring insurers to spend at least 80 percent of every Americans’ premium costs on patient care, rather than on their own profits or overhead — has resulted in a total of $1.5 billion overhead savings and insurance rebates to Americans since its implementation in 2011.

As a press release from the Commonwealth Fund explains, those rebates mostly went to individual policyholders, who are now paying lower premiums since the requirement has forced insurers to reduce their overhead costs and profit margins:

The authors find that in the individual insurance market, improvements were widespread: 39 states saw administrative costs drop, 37 states saw medical loss ratios improve, and 34 states saw reductions in operating profits. Some states stood out for significant improvements. In New Mexico, Missouri, West Virginia, Texas, and South Carolina, medical loss ratios improved 10 percentage points or more, while administrative costs dropped $99 or more per member in Delaware, Ohio, Louisiana, South Carolina, and New York. [...]

The authors note that while insurers in the individual market have a less stringent medical loss ratio requirement—80 percent, as opposed to 85 percent in the large-group market—their traditionally higher overhead costs and lower medical loss ratios mean they have to work harder to reach the new standard. As a result, these insurers lowered both administrative costs and profit margins, therefore reducing growth in premiums.

While small- and large-group plan holders did not enjoy rebates to the same extent as their individual policy-holding counterparts, these larger plan providers still successfully lowered their overhead costs. And the study only addresses savings stemming from current policyholders over the course of the last year. As Obamacare is fully implemented in 2014 and states set up insurance exchanges where Americans may purchase individual coverage, an increasing number of people will benefit from the savings resulting from the 80/20 rule.

The Commonwealth study’s findings confirm earlier predictions about the cost-saving effect that Obamacare’s medical loss ratio provision would have on American consumers.

The Republican party has been fighting against President Obama’s landmark health reform law since it was first introduced, but some GOPers are finally conceding that it may not be in their best interest to resist Obamacare altogether — especially because, as former Senate Majority Leader Bill Frist (R-TN) has pointed out, some important Obamacare provisions actually originated as “Republican ideas.” Frist has urged states to set up health insurance exchanges under Obamacare, since that actually gives state officials more control over their own insurance markets; otherwise, the federal government will simply step in to set up one for them as Obamacare’s implementation marches forward.

But even though GOP officials in deeply conservative states agree with Frist, some intransigent members of the Republican party continue to resist every aspect of Obamacare as a purely political statement. Meet five GOP officials who have been clashing with their fellow Republicans over implementing Obamacare in their states:

Mike Cheney – Mississippi

For the past year, Mississippi’s insurance commissioner has worked under the radar to prepare for a state-level insurance exchange, but his efforts have been thwarted by the rest of his party at every turn. Chaney agreed to cease his work until after the election after mounting pressure from other conservatives. After Obama secured re-election and ensured his health law won’t be repealed, and Chaney informed HHS Secretary Kathleen Sebelius that he plans to oversee the creation of a state-run exchange, Gov. Phil Bryant (R) went to Sebelius to express his objections to Chaney’s decision. According to Chaney — who maintains that implementing Obamacare is “not about politics,” but about following the law — the governor told him that opposing Obamacare is somewhat of a political pact. “He said, ‘We — some of the Republican governors — should not give in to the Obama administration on this, because they will change the rules and control everything. You cannot trust them,” Chaney recounted to Politico.

Gov. Rick Snyder – Michigan

Michigan’s Republican governor wanted to set up a state-run exchange so that his own state officials would have more control over the insurance market. But Republican legislators in his state repeatedly voted to block him from moving forward with plans for implementing an exchange. By the end of August, Snyder conceded he was left with no other options, acknowledging that federal officials would have to step in to set up the exchange since his fellow Republicans prevented him from doing it himself. “He would have preferred a state-based exchange so Michigan can control its own destination instead of the feds being in driver’s seat,” the governor’s spokesperson told the Detroit News.

Sandy Praeger – Kansas

Kansas’ insurance commissioner spent two years working on plans for a state-run health exchange market in her state. But earlier this month, Gov. Sam Brownback (R) announced that Kansas would not be participating in a state exchange, bringing Praeger’s plans to a screeching halt. Praeger told Politico that she doesn’t believe the governor’s position is motivated by a real understanding about what’s best for the state’s insurance marketplace. “I think it’s about politics,” she said. “There’s still a feeling with some conservative governors around the country that somehow not participating will cause this program to fail.”

Don Hughes – Arizona

Arizona’s director of healthcare policy was planning for a state-run exchange before Gov. Jan Brewer (R) announced her intentions for the insurance market in the state. Before the election, Hughes told Reuters that even though Arizona is a very conservative state that remains opposed to Obamacare — it was one of the states that filed a joint lawsuit against the Affordable Care Act — he felt that state officials should still work toward setting up their own exchange. “If we have to have one, I think our preference would be to have a state-based exchange rather than defer to a federal exchange,” he said. Nevertheless, Brewer rejected a state-run exchange earlier this week.

Gov. Bill Haslam – Tennessee

To the dismay of state lawmakers, Tennessee’s Republican governor has been weighing a state-run health exchange. Politico reports that Haslam’s spokesperson explains the governor is carefully weighing all his options to determine what is best for Tennessee, but Republicans in the state have already pledged to block legislation that would work toward setting up an exchange. One Republican representative said he was “flummoxed” by the fact that Haslam might be considering implementing Obamacare — and since Republicans will hold 26 of the 33 seats in the state Senate by next year, they will reject any health exchange plans that Haslam brings to them.

After surviving a Supreme Court challenge and a presidential election, Obamacare is truly here to stay. But the federal government, states, and health care providers now have their work cut out for them as they begin implementing the biggest overhaul of the American health care system since the establishment of Medicare.

One of the biggest challenges will be making sure that Americans have accurate information about their health coverage options so they can successfully enroll in the health plan that’s right for them in 2014. Between states and the federal government instituting health insurance exchanges, expanding Medicaid pools, and issuing insurance subsidies to qualifying Americans, that’s a whole lot of change in a relatively small period of time — and it’s ripe for confusion and misinformation.

Luckily, some health insurers — who were once the most vocal opponents of Obamacare — are accepting health reform’s reality and teaming up with the nonprofit group Enroll America to make sure that the law is enacted properly and that Americans have the right information about which plans and subsidies they qualify for. As Bloomberg reports, the move has as much to do with health insurers’ rational self-interest as it does with the looking out for the American people’s well-being:

Enroll America, a nonprofit created two years ago, has gathered support from the insurers that opposed the law and consumer organizations such as Washington-based Families USA that supported it. The new organization plans a broad-based educational campaign to make uninsured people aware of the health-care law’s benefits and help them sign up, said Ron Pollack, Enroll America’s chairman.

The group will reach out to the 43 million uninsured whose participation will help strengthen the funding formula that holds the 2010 Affordable Care Act together. The new customers are expected to help offset added costs for the insurers from new regulations and taxes included in the law.

“Business people in the end have to be pragmatic,” Robert Laszewski, a health insurance industry consultant based in Alexandria, Virginia, said of the companies’ efforts to help the law succeed. “The industry has gotten over it.” [...]

“You want to mimic the success of employer plans, in which everyone is enrolled when they take a job,” said Sara Collins, a vice president at the Commonwealth Fund in New York, in a telephone interview. “It will be essential that everyone comes in to get the coverage that they’re eligible for.”

Since Obamacare ensures that insurers will no longer be able to partake in odious practices like denying Americans coverage based on a pre-existing condition, those firms now have a very real financial stake in making sure that Americans are insured and able to pay for their medical services. Otherwise, insurers run the risk of not having enough healthy Americans participating in their risk pools and helping to mitigate the costs of insuring the sicker Americans that they must now cover. The partnership between Enroll America and health insurance providers is one that will benefit insurance companies and the uninsured alike.

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) released a slew of important new Obamacare rules and regulations today, continuing a widely expected post-election effort to successfully implement President Obama’s landmark health care reform law by 2014.

In a call with reporters, CMS and HHS outlined the new proposed rules, which instruct insurers, providers, and governmental institutions on how they must proceed in implementing Obamacare measures — ranging from a ban on discriminating against Americans with pre-existing medical conditions to public wellness initiatives such as coverage for employees’ gym use. Here are the three most important things you need to know about the new rules:

1) Insurers will be prohibited from discriminating against Americans with pre-existing conditions. Long considered one of the health insurance industry’s most odious practices, refusing to extend coverage to Americans suffering from a pre-existing medical condition will soon be a thing of the past. The first of CMS’s proposed rules mandates that insurance companies will need to base their premium rates solely on an individual’s age, family size, geography, and history of tobacco use — preventing discrimination against Americans for any other reason, such as their gender or their chronic illnesses. The rule will also set strict limits on how much insurers can vary the premiums they charge Americans based on these factors, marking an end to gender rating practices that charged women more than men for the same medical services. This will be a boon to the over 120 million Americans who suffer from a pre-existing condition in one form or another.

2) State exchanges will establish a standard of “essential health benefits” that every plan will be required to cover. Obamacare will require the plans offered under state-wide health insurance exchanges in 2014 to clear federal benchmarks across ten “essential health benefit” categories, including access to maternal care, mental health services, preventative health care, and prescription drug coverage. These assured benefits — which are supposed to reflect the level of coverage offered by a typical employer-sponsored plan — will help correct for spotty coverage that does not actually meet Americans’ medical needs. CMS’s proposed rule requires state exchanges to offer to the same level of coverage as a statewide benchmark health plan of the state’s choosing. If a state’s chosen benchmark plan does not cover all of Obamacare’s required benefit categories — for instance, by not offering mental health services — then the federal government will intervene and supplement that plan so that it does meet the health law’s coverage requirements. The rule also creates standards for prescription drug coverage so that such coverage actually meets Americans’ health care needs and prohibits health plans from designing their benefits in a way that discriminates against certain groups of Americans.

3) Wellness programs will help promote public health and curb health care costs. The last of the three proposed rules is joint guidance from HHS, the Treasury, and the Department of Labor regarding sponsorship of workplace wellness programs. Obamacare encourages preventative health initiatives and a transition from “sick care” to actual “health care” in an effort to both improve Americans’ quality of life and lower national health spending. Under the proposed rule, employers are encouraged to continue both participatory and health-contingent wellness programs — such as subsidizing the cost of employees’ fitness center memberships or enrolling employees in tobacco-cessation programs — in exchange for federal rewards.

These rules will give states more clarity as they move forward in implementing the Affordable Care Act. Although many Obamacare details must still be worked out — particularly regarding the statewide insurance exchanges — the reform law has made enormous strides in the last year that will result in a fairer, more accessible, and more affordable American health care system that is a marked improvement over the pre-Obamacare era. “It’s important to remember what this market looked like back in 2009… We were definitely headed in the wrong direction,” HHS Secretary Kathleen Sebelius said on the conference call.