Consumers are getting their first opportunity on Tuesday to buy policies on the exchanges, even as the law remains at the core of congressional budget gridlock that has caused a partial federal government shutdown. The exchanges' funding isn't affected by the shutdown.
A spokesman for Georgia Gov. Nathan Deal dismissed the sweeping law as "a federal issue" and said his boss had no plans to discuss the launch of the exchanges.
State workers in several other GOP-run states were ordered to refer all questions from residents to federal officials. In Oklahoma, state employees were instructed to tell residents they are "not trained or certified to answer questions about the Federal Insurance Marketplace."
South Carolina Gov. Nikki Haley said employees at her state Medicaid agency fielded calls from residents, including some who were frustrated by error messages from online exchanges slowed by heavy traffic. She said the agency would try to help, but she was quick to take a swipe at the law and its federal backers.
"Our job is to get the information out there. The fed's job is to make it work. Unfortunately, it's not working," Haley said. "We're going to continue doing what we can, but this is continuing to be the mess we thought it would be."
With the near-absolute Republican opposition, consumers looking for assistance must turn to non-government agencies, local hospitals and health clinics or other community groups. Many of those entities are using federal grants to pay "navigators" who are trained to help residents understand and use the new marketplace.
Navigators must complete 20 hours of online training offered by the Centers for Medicare and Medicaid Services to be certified. But even those federally paid aides face obstacles.
Florida's health department ordered county health departments to ban navigators from their property. Wisconsin and Indiana charged training fees for the navigators and volunteers.
Texas Gov. Rick Perry ordered that navigators in his state get an additional 40 hours of training, submit to background checks and pass new exams before being certified to help residents. In Tennessee, Gov. Bill Haslam's Commerce Department also imposed background checks on navigators.
The Texas Department of Insurance held a hearing Monday on Perry's directive, which the governor pitched as consumer protection. Democrats said it was a politically motivated move to prevent Texans from taking advantage of the law.
At least four government councils in Texas are no longer participating in the navigator program, according to a local United Way office that got $5.8 million to pay the workers. One attributed the decision to politics.
John Buckner, executive director of the Coastal Bend Council of Governments, said his organization is reliant on state dollars and pointed out that the Legislature dictates its operations. "There's a lot of strong feelings about this program in Austin — the legislative level, in the governor's office," Buckner said. "It seems like with all the issues going on right now, it might be best not to get involved with something that's not being very accepted by the political arena."
The roadblocks haven't squelched demand. Houston resident Priscilla McAfee, 62, plans to use a new exchange policy to replace the Cobra policy that she's used since being laid off last year. She said she's paid between $450 and $500 monthly. Before the exchanges, she found comparable premiums, but for plans that with significant out-of-pocket costs for care. Now, with the tax credits she'll get at her current income, her premiums likely will be cut in half for reasonable coverage.
"I'm thrilled that the United States is finally catching up with some of the other countries in the world that provide health care," she said. "And I'm very grateful for the timing ... at a time that my need is so great."
A handful of states, meanwhile, have quietly made moves to help residents use the exchanges, even as GOP politicians reaffirm their opposition to the overall law.
Like in South Carolina, the state insurance office in Louisiana also has staff willing to answer questions. State government officials in Wisconsin sent letters to about 92,000 people expected to lose Medicaid government insurance at the end of the year, directing them to the exchanges.
And in other states, community groups and insurance companies have tried to step in where state leaders left a vacuum.
Atlanta's Grady Health System, which runs the metro area's safety net hospital and clinics, hosted a fair to explain how the exchanges work.
In Miami's Little Haiti neighborhood, the leader of a local community center planned to spend the day talking on Haitian Creole radio stations to share information, particularly for residents who don't speak English. "This is not a population with a lot of experience buying insurance," said Gepsie Metellus, executive director of the Sant La community center.
The neighborhood is in the heart of Democratic territory in south Florida, but the state government in Tallahassee is ruled by Republican Gov. Rick Scott and GOP supermajorities in the legislature.
Blue Cross/Blue Shield of Oklahoma, which is selling policies in that state exchange, scheduled a public session in Oklahoma City to answer questions. By mid-morning, no consumers had shown up.