Health-care reform: The 12-month countdown JANUARY 1st 2014 seemed far away when Barack Obama signed his health-care law back in 2010. That is the day when the law's main parts will take effect, including the mandate to buy insurance and the expansion of Medicaid, the health programme for the poor. But recent years have been rather hectic. Republicans hoped to gut "Obamacare" first in court, then by electing a Republican president. But Mr Obama is still in the White House. Obamacare, as even the president now calls it, is still law. And January 1st 2014 is still the date when its main parts must go into effect. The next 12 months will be busy. Even without controversy, implementation would be complex. The law tries to reform a sector that accounts for nearly one-fifth of America's GDP. Its 906 pages invite even more pages of regulation from the Department of Health and Human Services (HHS). But implementation will be much harder than Democrats imagined. Bickering has consumed precious time. HHS has delayed issuing essential regulations. Most important, many state governors remain unco-operative. The big question is how the reality of reform will differ from the Democrats" vision of it. The huge law contains many provisions, but its main goal is to expand health insurance. Beginning in 2014, insurers can no longer refuse coverage to the sick. The cost of insuring them will be paid out of insurance fees from cheap, healthy consumers - the law requires everyone to buy insurance or pay a penalty. The law also sought to extend Medicaid to all those earning up to 138% of the federal poverty level ($15,415 for one adult in 2012). From 2014, those with incomes of 100-400% of the poverty level will qualify for subsidies on new state health exchanges, where individuals can shop for insurance. The law's opponents hoped the Supreme Court would scrap all this. It did not, except one piece. States may choose whether to expand Medicaid. Some measures have already taken effect. HHS has started to reward hospitals for providing good care, rather than lots of it. But some employers are contesting the law's requirement that insurance should cover contraception, and the future of two main provisions, the health exchanges and the Medicaid expansion, is blurry. The exchanges must be ready by October 2013, so consumers can choose insurance beginning in 2014. Some states, most led by Democrats, have prepared diligently. HHS has doled out $1.8 billion to help. Many Republican governors have done nothing. But even enthusiastic states will struggle to meet the deadline. HHS waited until after the election to propose important rules, such as the types of insurance that may be sold. The final regulations are still to come. Republican governors who sat on their hands during the law's first years are now wagging their fingers at HHS for being slow. Many want nothing to do with the exchanges, anyway. "For any state who's running an exchange, it is "state" in name only," scoffed Scott Walker, Wisconsin's governor, in November. Opposition to Obamacare is impeding even some Democratic governors. In Missouri voters passed a ballot measure to prevent their governor from moving forward. Democrats in Washington had hoped that each state would build its own exchange. On December 17th HHS said that only 18 states had applied to do so. Of these, just five are led by Republicans. The remaining states will have exchanges either wholly or partly run by the federal government. HHS is scurrying to prepare. A lawsuit in Oklahoma seeks to scuttle this effort, claiming that a legislative glitch prohibits subsidies on the federal exchanges. But if the suit fails, as seems likely, conservatives will have achieved an odd result: the federal government will have a greater role in health care. Medicaid is an even bigger source of uncertainty. In January state legislatures will meet for the first time since the Supreme Court ruling. They must decide whether to expand Medicaid for 2014. Obamacare promises to pay for 100% of costs from 2014 to 2016, inching down to 90% in 2020 and after. This is a good deal for states, according to scholars at the Urban Institute. An extra 21.3m people would enroll in Medicaid by 2022. The expansion itself would require states to spend an extra $8.2 billion from 2013 to 2022, compared with an $800 billion jump in spending by the federal government. Savings from a drop in uncompensated care might even save some states money. At present the uninsured receive "free" treatment at hospitals, with states picking up part of the bill. But states are still wary. Federal funding is not reliable. Mr Obama's own budget suggested cutting the federal share of Medicaid spending. In the midst of talks over the fiscal cliff, HHS said that idea had been scrapped. But Medicaid cuts may loom in future. All this uncertainty is difficult for state bureaucrats, not to mention hospitals and insurers. During negotiations over reform, hospitals accepted lower payment rates in exchange for the promise of more insured patients. If states don't expand Medicaid, this is a bum deal. Most aggrieved, however, are the patients the law is supposed to benefit. Those with incomes below 100% of the poverty line will not qualify for subsidies on the exchanges. If states do not expand Medicaid, 11.5m poor adults will be left without insurance. The exchanges raise more questions. Will employers stop sponsoring insurance for their workers, leaving them to the exchanges? The insurance lobby says the law's strict requirements will raise prices - for example, a limit on fees for the old will drive up fees for the young. But how expensive will insurance become? HHS says it may delay some requirements, to prevent a spike in prices. But which restrictions would it postpone? And if young consumers pay a penalty, rather than buy insurance, will prices go up for everyone else? By this time next year, at least some of these questions will have answers.