An acrimonious debate over the federal healthcare overhaul is seeping into state capitols, creating fissures among Republicans as the tea party movement reasserts its influence in GOP-controlled areas.
States face decisions about setting up online health insurance marketplaces, and a mid-November deadline for declaring their intentions has sparked conflicts between governors and legislators across the country. In two GOP strongholds, Kansas and Mississippi, elected insurance commissioners are at odds with governors, even though they're all Republicans.
And Kansas Insurance Commissioner Sandy Praeger, well-regarded by fellow state regulators after a decade in office, is a rarity among Republicans nationally, praising the 2010 federal healthcare law for moving the U.S. toward universal access to health coverage. She's kept that stance even as conservatives used discontent with the law to help oust GOP moderates from the Legislature in August primaries.
Praeger wants the state to have a role in running the online insurance marketplace, known as an exchange, and she said she'll have a plan ready. Gov. Sam Brownback, a longtime critic of the healthcare law, plans to wait until after the presidential election to set the state's course and is under pressure from fellow conservatives and tea party activists to avoid any state involvement.
The disagreement with Brownback has political consequences for Praeger, the most prominent of a dwindling number of GOP moderates in state government. Now in the middle of a four-year term, she disclosed in a recent interview that she's all but decided against running again in 2014 and acknowledged she'd have difficulty winning a Republican primary.
"My position is really more apolitical, just trying to be a good insurance regulator," she said. "His is more of a political position, and I understand that."
Brownback's office declined requests from The Associated Press for an interview. It pointed to previous statements that if GOP presidential nominee Mitt Romney defeats Democratic President Barack Obama, who championed the healthcare overhaul, states are likely to get a waiver from many of the federal healthcare law's requirements.
"We're operating in a seat of uncertainty," said state Sen. Mary Pilcher-Cook, a conservative Shawnee Republican who argues any involvement in an exchange would make Kansas a "tool of the federal government."
Exchanges are sometimes described as the health coverage equivalent of websites such as Travelocity. States that aren't setting up their own still can declare by Nov. 16 that they'd like to be partners with the federal government, handling consumer complaints and controlling which companies sell coverage.
Praeger has sent Brownback a recommendation for minimum requirements for policies sold on the exchange, despite his stance.
She's also been a part of the national debate, serving as chairwoman of the National Association of Insurance Commissioners committee on healthcare policy since 2009. She was the group's president in 2008.
According to the Kaiser Family Foundation, 16 states have set up online marketplaces, and three more plan to partner with the federal government.
Seven states have declared that they won't set up exchanges, the foundation says. Six, including Florida and Texas, have Republican governors. In the seventh, New Hampshire, a GOP-dominated legislature set the policy.
In Michigan, GOP Gov. Rick Snyder pushed to set up a state exchange but met resistance from GOP legislators who feared it would hurt them in elections this year. In Missouri, Democratic Gov. Jay Nixon halted work on an exchange amid growing opposition in his state's GOP-controlled legislature, and the state's voters will consider a ballot initiative in November preventing the governor from moving forward on his own.
With insurance commissioners appointed in all but 11 states, they've typically followed their governors. Even in states with elected regulators, the commissioners are from the same political party as the chief executive.
But after Mississippi's statewide elections in 2011, the governorship changed from term-limited Haley Barbour to Phil Bryant. Both are Republicans, but Barbour had pushed to set up a state exchange, while Bryant wants to wait until after the presidential election.
Mississippi Insurance Commissioner Mike Chaney has been sharply criticized by the tea party movement for working on a state exchange. He, in turn, said the tea party members were using "untested legal theories, untested loopholes and fuzzy logic" to try to dissuade him from the work.
The tea party also is a key influence in Kansas, where pressure from the right last year prompted Brownback to reject $31.5 million in federal funds to help build the computer infrastructure necessary for an exchange.
"I'm looking for the state of Kansas to stand up to the federal government and say, 'You've crossed the line and you need to back off,'" said Bob Bowser, an activist from Salina. "We don't want Kansas to adopt any part of Obamacare."
In Kansas, the tea party movement's rise and frustration with the healthcare overhaul boosted Brownback into office in 2010 and gave the GOP its first sweep of all statewide and congressional offices on the ballot since 1964.
In primaries this year, conservatives suggested that GOP moderates who controlled the state Senate were soft in their opposition to the healthcare law. Eight moderate Republican senators lost, all but guaranteeing full conservative control of the Legislature next year.
"The people of Kansas have spoken clearly on this issue in two elections," said Brownback spokeswoman Sherriene Jones-Sontag.
Washington Insurance Commissioner Mike Kreidler, an elected Democrat and the nation's longest serving state insurance regulator, said Praeger is being pragmatic about the federal law.
"You run into this hailstorm," he said. "It gets caught up in this brave new world of making sure Obama doesn't get elected to a second term."