"Without the shared planning and the cooperation of the state government, it's much harder for them to be ready to implement this complicated law," said Rachel Grob of the University of Wisconsin-Madison, who has studied differences in how states are implementing segments of the law.
Several of the 14 Northeast, Midwest and Western states running their own insurance exchanges have spent weeks on marketing and advertising campaigns to help residents get ready to buy health insurance. At least $684 million will be spent on publicity explaining what people need to do next and persuading the doubtful to sign up for coverage, according to data compiled The Associated Press.
By contrast, most states across the South have declined federal grants to advertise the exchanges and ceded the right to run the marketplaces themselves. And early Sunday, the Republican-led U.S. House added to legislation that would avert a partial government shutdown a one-year delay of the creation of the marketplaces. Democrats have said delaying the healthcare law would sink the bill, and the White House promised a veto.
Governors from the Carolinas to Kansas have decried the exchanges and the rest of the law, which was passed by Congress in 2010 and many argue reaffirmed when voters re-elected President Obama in 2012. The Supreme Court in 2012 upheld the constitutionality of most of the law; a piece of the Medicaid expansion was an exception.
"When it came to Obamacare, we didn't just say 'no,' we said 'never,'" South Carolina Gov. Nikki Haley said last month alongside U.S. Sen. Tim Scott, whom she appointed last December when Jim DeMint resigned. "And we're going to keep on fighting until we get people like Sen. Scott and everybody else in Congress to defund Obamacare."
Others have gone beyond fiery rhetoric.
Missouri's lieutenant governor urged residents to refuse to sign up for federal health insurance, while Kansas legislators and the state's governor enacted a law symbolically declaring that residents can't be forced to buy health insurance.
In Florida, state officials ordered county health departments to bar from their property navigators hired under federal grants to explain the plan's complexities. Broward County commissioners last week ignored that ban and voted to allow navigators and other counselors into county offices, including health departments.
'We've encountered many, many issues with this, and this is a breakthrough for us to be able to go into the libraries, thehealth departments," said Jerson Dulis, who was trained to help enroll people in the state exchange. He works for Broward Community & Family Health Centers Inc., which received a federal grant to provide consumers understand and enroll inhealth insurance plans.
In places where state officials have declined to disseminate information, the work is left to nonprofit organizations and word-of-mouth among consumers.
North Carolina is among the states that have left the running of its exchange to the federal government. This year, the state refunded what remained of a $74 million federal grant that would have helped consumers and linked computers.
Asa Gregory, 36, of Wilson, works sporadically as a substitute public school teacher and has lacked health insurance for seven years, paying the medical bills after a traffic accident with help from his parents.
"I would like to have health insurance. I think that's a no-brainer," he said.
Gregory said he's been checking out the government's information web site at www.healthcare.gov but feels "there's certainly quite a bit for me to learn."
"I'd say, percentagewise, what do I know about what's happening on October 1st? I'd say maybe 40%," he said. "I'm not confident that I know a majority of the information, but it's gathering and I'm looking at it. I'm preparing for the opportunity of the marketplace."
Sherry Graham, 72, said she's hoping insurance company competition will drive down the price she pays for her daughter's individual coverage. Graham said rising premiums force her to squeeze her pension and Social Security checks to pay her daughter's $420 monthly insurance premium because the younger woman works only part-time.
"Every year here I am trying to find another $100 or so to add to the monthly premium to keep her insured," said Graham, of Raleigh. "It's enough to hurt. I have to figure out where to get that money from because I'm not getting a raise, like ever."
In response to confusion over the health overhaul, officials in the Carolinas have grudgingly made moves to lessen disruptions.
North Carolina Gov. Pat McCrory's health agency recently urged county social services departments to discuss the insurance exchanges when people come in seeking food stamps or child care help. The Republican governor's administration also encouraged social services agencies to offer space as available to navigators.
In South Carolina, which also left advertising and running the exchange to the federal government, the state Medicaid agency ramped up its call center to handle 50% more calls as people have questions about the law, deputy director John Supra said.
Others are taking a harder line.
Florida Republicans are vehemently pushing back against implementing parts of the law. The Florida Department of Health recently ordered county health departments across the state to ban navigators from conducting outreach on their property. Florida has one of the highest uninsured rates in the country with an estimated 3.5 million lacking insurance.
Gov. Rick Scott, a vocal opponent of the law, has echoed GOP talking points about privacy concerns, penning a letter last week to top congressional leaders expressing concern about the security of people's personal information as they sign up for health coverage under. Scott's strong opposition has drawn sharp criticism from Democrats.
"It seems that Gov. Scott and his staff spend their days conjuring up new ways to keep Floridians in the dark about healthcare choices coming Oct 1," U.S. Rep. Ted Deutch said at a recent meeting with a handful of navigators.
In Kansas, a 2011 law Republican legislators and Gov. Sam Brownback enacted declared that residents can't be forced to buy health insurance or penalized. The measure was largely a symbolic protest, given supremacy of the federal law.
Missouri bars state employees from helping implement an insurance exchange, leaving it entirely to federal direction. Last week, Lt. Gov. Peter Kinder this week urged Missouri residents to resist the federal law by refusing to sign up for healthinsurance. They could be forced to pay a fine of $95 or more if they don't.
"I don't see any reason to enable the implementation of this law," Kinder said. "I think the whole thing is in the process of collapsing."