President Barack Obama’s re-election means his overhaul of the U.S. health-care system, opposed by most Republicans, will move ahead in all 50 states, with or without the cooperation of their governors.

State officials who held off implementing some aspects of the 2010 Patient Protection and Affordable Care Act now face pressure to make decisions almost immediately. They have eight days to advise the federal government how they plan to manage state-run exchanges created by the law to provide medical coverage to the uninsured or face a virtual U.S. takeover of their insurance markets.

With Republican candidate Mitt Romney promising to repeal the law, all but 13 governors had taken a wait-and-see approach. Now those that “thumbed their nose” at the president must quickly reassess, said Mississippi Insurance Commissioner Mike Chaney, a Republican who said he will submit a plan for his state’s exchange by the Nov. 16 deadline.

“The message to governors is the verdict is now in,” said Ron Pollack, executive director of Families USA, a consumer advocacy group that backs the law. “The Affordable Care Act is moving forward. Either they help cooperate with its implementation, or people in their state could be left out in the cold.”

In addition to playing catchup with Obama, states also would need to keep pace with hospitals and insurance companies. Hospital chains such as HCA Holdings Inc. and insurers including UnitedHealth Group Inc., the biggest private provider of health benefits, have spent millions on technology, marketing and plan development to prepare for the new business.

“Our priority for the organization is to get the organization ready to both comply with and play in target markets from an exchange standpoint,” David Cordani, chief executive officer of Bloomfield, Conn.-based Cigna Corp., told analysts on a conference call last Thursday. “But we’re keenly focused on the amount of moving parts that exist within the regulatory environment and within the state and federal environment over the next two to three quarters.”

Thirty-four states have accepted at least two grants from the federal government to start planning an exchange, according to the U.S. Department of Health and Human Services. That puts about 20 states in a position to build an exchange or partner with the federal government on one, in addition to the 13, plus the District of Columbia, that have already said they’ll run their own.

The rest “have either explicitly said ‘no’ or have taken so few steps that you can’t really see them shifting quickly enough to play an active role,” said Alan Weil, executive director of the National Academy for State Health Policy, which assists states implementing the health law, in an interview.

Arkansas has moved ahead with plans to create a statefederal partnership with its exchange, set to begin enrolling up to 326,000 people in October 2013. The state has accepted three federal grants totaling $27.5 million, said Cynthia Crone, the exchange’s planning manager.Exchange officials expect Gov. Mike Beebe will officially notify the federal government by Nov. 16 that it will pursue a partnership exchange, she said,

Governors who don’t meet the Obama administration’s deadline will see the federal government set up exchanges in their states that will decide which insurers can sell plans to their residents. The federal exchange also will control enrollment of low-income people into state Medicaid programs.

“We still haven’t seen proposed regulations in a couple of critical areas,” said Alissa Fox, senior vice president for lobbying and policy development at the Blue Cross and Blue Shield Association in Washington, a trade group for 38 state Blue Cross and Blue Shield insurance companies.

“What the states have to do and what the plans have to do, in designing and having products ready to market, a huge undertaking has to happen,” she said.

Obama’s victory over Romney removes most of the remaining uncertainty about the health-care law that lingered since the law largely survived a challenge before the Supreme Court in June. Obama will enjoy a Senate that’s still controlled by his Democratic Party, meaning any legislative attack on the law passed by the Republicanled House will die in the other chamber, as it has for the past two years.

With the threat of repeal gone, Obama may be more willing to grant states greater flexibility, or even delay some of the law’s provisions to ensure it can be implemented successfully, said Paul Keckley, executive director of Deloitte LLP’s Center for Health Solutions research group in Washington.

The administration may consider giving governors more time to set up exchanges, Keckley said. Or it may be willing to accept a more lenient definition of exchanges to get their systems up and running. In the end, Keckley expects few states to cede the new insurance markets to the federal government.

“The federal government doesn’t want to run the exchange,” Keckley said in a telephone interview. “The federally run exchange was always meantas a backstop. To set up and run that federal exchange, they would have to go through the usual appropriations process in Congress. That’s a whole new battle, and I don’t think anyone in the administration is interested in that.”

The health law isn’t entirely clear of potential changes. Obama and Congress face a combination of tax increases, spending cuts and a federal debt limit that will require negotiated legislation.

Information for this article was contributed by Drew Armstrong and Stephanie Armour of Bloomberg News and by Charlie Frago of the Arkansas Democrat-Gazette.

Front Section, Pages 2 on 11/08/2012