"Postelection it's really been 'game on,' " said Kelly Barnes, leader of the health care group at the PricewaterhouseCoopers consulting firm.
Republican presidential candidate Mitt Romney had vowed to begin dismantling "Obamacare" his first day in office. But Romney lost, and instead GOP governors are scrambling to see if they can find an accommodation with the administration after two years of fighting the president's signature law.
"The president won the election ... and New Jersey is going to comply with the Affordable Care Act," Republican Gov. Chris Christie said Friday. Christie said he still has questions about costs and is weighing his decision. Earlier this year he vetoed legislation creating a state exchange, as the new insurance markets are called.
A check by The Associated Press found that 16 states plus Washington, D.C., want to build their own exchanges. Starting Jan. 1, 2014, individuals, families and small businesses will be able to buy private coverage through an exchange in their state, with most consumers getting government assistance to pay premiums.
The exchanges will also help steer low-income, uninsured people into expanded Medicaid programs in many states.
Another seven states have indicated they want to partner with Washington to build their exchanges. Ohio joined this group Friday and West Virginia officials said they're heading in the same direction.
Fifteen mostly Republican-led states say they'll defer to the federal government to build and run their markets. Georgia and Wisconsin formally joined that group Friday. However, New Hampshire, where Democrats won control of the state House in the election, is taking a second look at its decision to default to the feds.
Finally, another 12 undecided states now have until Dec. 14 to determine what role, if any, they'll play.
Obama's election victory guaranteed the survival of his health care law, which is eventually expected to provide coverage to more than 30 million people through the exchanges and expanded Medicaid programs. It was the final hurdle, after the Supreme Court upheld a legal challenge from 26 states. In the aftermath of the election, some Republican state leaders say it's time to accept the law.
"I don't like it; I would not vote for it; I think it needs to be repealed. But it is the law," said Mississippi Insurance Commissioner Mike Chaney, after announcing that his state wants to set up its own exchange. "If you default to the federal government, you forever give the keys to the state's health insurance market to the federal government."
Traditionally, states have regulated the private health insurance market.
But other Republican-led states say they don't have enough information to make a decision at this point and are clamoring for the Obama administration to release major regulations bottled up for months.
"States are struggling with many unanswered questions and are not able to make comprehensive far-reaching decisions prudently," Govs. Bob McDonnell of Virginia and Bobby Jindal of Louisiana wrote Obama earlier this week.
Some of their main concerns are hidden costs of operating the exchanges and the sheer bureaucratic complexity of the new system. The Obama administration has steadfastly maintained it will not postpone the Jan. 1, 2014, launch date for the law's coverage expansion, and it will go ahead in all 50 states. Open enrollment will begin even sooner, Oct. 1, 2013.
Although the public remains divided about the health care law, the idea of states running the new insurance markets is popular, especially with Republicans and political independents. A recent AP poll found that 63 percent of Americans would prefer states to run the exchanges, with 32 percent favoring federal control.
The breakdown among Republicans was 81 percent to 17 percent in favor of state control, while independents lined up 65-28 for states taking the lead. Democrats were almost evenly divided, with a slim majority favoring state control.