Two dozen states have put in place the makings for federally mandated health insurance exchanges, but Florida isn't one of them.
The state qualified for a $1-million federal grant to plan for an exchange, but Gov. Rick Scott has declined to use the money.
"We won't be utilizing that grant," said Shelisha Coleman, a spokeswoman for the state Agency for Health Care Administration, which would be responsible for developing an exchange, if state leaders ask for one.
So far, though, that request hasn't come.
Last year's Affordable Care Act sets a deadline of 2014 for states to start enrolling their uninsured citizens in health exchanges, where individuals and small businesses can compare costs of private health plans, get questions answered and, ultimately, buy health insurance.
The exchanges are intended to create a central "marketplace" that will let people compare coverage and make health insurance more affordable.
If Florida hasn't created or isn't on the path to creating an exchange by 2013, the federal government will create and run one in the state, according to the health-care reform law.
The exact shape of that federal exchange remains unclear, said Keith Maley, a spokesman for the U.S. Department of Health and Human Services.
"We have been encouraging states to move forward with exchanges," Maley said. "They know their markets best."
The 2013 deadline could be a problem for states that haven't set up exchange by then, the Kaiser Family Foundation study concludes.
Florida could be in that boat. The state is one of several challenging the legality of the Affordable Care Act.
In January, a federal judge in Pensacola ruled that requiring people to buy private health insurance was unconstitutional and that the individual-mandate provision was so entwined in the health-care legislation that the entire law had to be invalidated. But other federal courts have reached different conclusions, and Judge Roger Vinson allowed the law to stand while his ruling was appealed.
Scott has put the brakes on any health insurance exchange while the Affordable Health Care Act faces legal challenges, Coleman said.
Scott, the former CEO of the Columbia/HCA hospital chain, has said he doesn't want to spend state or federal funds on a plan that may be unconstitutional.
The exchange planning grant is among millions in federal funding Scott and state legislators have turned down because of their opposition to the Affordable Care Act.
Among the grants the state has turned down is money aimed at moving long-term care patients into their homes, money for curbing child abuse through in-home counseling and money to educate teenagers about preventing pregnancy. Also rejected was $8.3 million to expand health centers in Osceola County.
So far, 22 states have either created insurance exchanges or put the pieces in place, the Kaiser Family Foundation study found. Two states, Utah and Massachusetts, already have exchanges.
Collectively, those states have tapped $326 million in federal grants to set up the exchanges.
The list of states that have already created exchanges covers the political spectrum – from Alabama to California. Exchanges have been set up as stand-along nonprofits, state-run agencies or quasigovernmental agencies with politically appointed boards.
States that don't have exchanges include 15 – Alaska, Minnesota and Rhode Island among them -- where legislation failed or was vetoed. Another 10, including Florida, have taken no action at all.
In 2009, about 50 million Americans lacked health insurance. Most worked low-wage jobs or for small companies that don't provide private insurance, according to the Kaiser Family Foundation study.
Exchange supporters say the system will give those poor and middle-income people a way to find affordable insurance by bringing insurers together to compete for customers. Those who can't afford premiums would get federal subsidies.
Critics have dismissed exchanges as socialism and a government takeover of the health care system.
Bill Newton, executive director for the Florida Consumer Action Network, said the governor has let politics get in the way of doing what's best for his constituents.
"Gov. Scott has not come up with a way to keep people from getting sick," Newton said. "People need solutions to health care issues. They're saying, 'Give us something real.'"