The provision has become an election year flashpoint between the administration and Republican governors who reject the exchange plan, along with a related expansion of the Medicaid program, as too costly and bureaucratic.
State resistance to exchanges, spearheaded by the governors of Florida, South Carolina, Louisiana, Mississippi and Texas, has been largely overshadowed up to now by the fight over the plan to extend Medicaid coverage to millions of people living near the poverty line.
A larger number of states have done little to establish exchanges because of political uncertainty over the November election, which could set the stage for a repeal of the reform law if voters give Republicans control of the White House and Congress.
"We realize that not all states will be ready to establish these exchanges by 2014, so we are on track to set up the federally facilitated exchange in those states. It is on track to go live," said Mike Hash, the HHS official, who is overseeing the administration's exchange effort.
Speaking at a Capitol Hill conference on health reform, Hash said the administration wants as many states as possible to set up their own exchanges but has begun testing a federal exchange model that can be rolled out "in any number of states".
Thirty-five states have accepted federal grants to plan for a state exchange. But only 13 and the District of Columbia have declared their intention to establish their own marketplaces.
According to the Commonwealth Fund, a private foundation that promotes healthcare system improvements, 24 states have taken no action toward establishing an exchange while eight others have declared that they will not pursue one.
The administration has set a Nov. 16 deadline for states to say whether they intend to set up their own exchanges, create one in partnership with the federal government or let federal officials establish one for their residents.
Some experts believe fewer than 19 will be ready to go with state-run exchanges by the Jan. 1, 2014, deadline for full operation.
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