One of the biggest challenges the White House has in pushing the “American people want to move on” line (besides the election!) is these opting-out Republican governors. There will, of course, be exchanges set up by the Feds for states that opt out, but the Medicaid piece is hugely consequential for the overall working of the law.
I still think all roads lead to the Grand Bargain to stop the nation from going over the Fiscal Cliff, although I keep noticing people disagreeing with that. I just don’t see how you get something grand enough without re-doing the health care entitlements in some way, both because of the sheer dollar figures and because one side (the Republicans) will demand reforms in those programs as the price of doing business.