WASHINGTON -- Here's a reality check for President Barack Obama's health overhaul: Three out of four uninsured Americans live in states that have yet to figure out how to deliver on its promise of affordable medical care.
This is the year that will make or break the health care law. States were supposed to be partners in carrying out the biggest safety net expansion since Medicare and Medicaid, and the White House claims they're making steady progress.
But an analysis by The Associated Press shows that states are moving in fits and starts. Combined with new insurance coverage estimates from the nonpartisan Urban Institute, it reveals a patchwork nation.
Such uneven progress could have real consequences.
If it continues, it will mean disparities and delays from state to state in carrying out an immense expansion of health insurance scheduled in the law for 2014. That could happen even if the Supreme Court upholds Obama's law, called the Patient Protection and Affordable Care Act.
"There will be something there, but if it doesn't mesh with the state's culture and if the state is not really supporting it, that certainly won't help it succeed," said Urban Institute senior researcher Matthew Buettgens.
The 13 states that have adopted a plan are home to only 1 in 4 of the uninsured. An additional 17 states are making headway, but it's not clear all will succeed. The 20 states lagging behind account for the biggest share of the uninsured, 42 percent.
Among the lagging states are four with arguably the most to gain. Texas, Florida, Georgia and Ohio together would add more than 7 million people to the insurance rolls, according to Urban Institute estimates, reducing the annual burden of charity care by $10.7 billion.
"It's not that we want something for free, but we want something we can afford," said Vicki McCuistion of Driftwood, Texas, who works two part-time jobs and is uninsured. With the nation's highest uninsured rate, her state has made little progress.
The Obama administration says McCuistion and others in the same predicament have nothing to fear. "The fact of states moving at different rates does not create disparities for a particular state's uninsured population," said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight at the federal Department of Health and Human Services.
That's because the law says that if a state isn't ready, the federal government will step in. Larsen insists the government will be ready, but it's not as easy as handing out insurance cards.
Someone has to set up health insurance exchanges, new one-stop supermarkets with online and landline capabilities for those who buy coverage individually.
A secure infrastructure must be created to verify income, legal residency and other personal information, and smooth enrollment in private insurance plans or Medicaid.
Yet in states where Republican repudiation of the health care law has blocked exchanges, there's little incentive to advance before the Supreme Court rules. South Carolina is among numerous states that have sued to stop the law from taking effect. The Supreme Court decision is expected this summer.