The Affordable Care Act is the law of the land – even House Speaker John Boehner affirmed that point in an interview with Diane Sawyer on ABC Nightly News. The countdown clock on implementation is ticking and there are no more time outs left.  States need to move full speed ahead to beat the clock and bring home the full benefits of health reform for their residents by 2014.

Here are the most important steps they should take right now:

• Extend Medicaid coverage to more low-income people. The Supreme Court left this decision in the hands of states and, so far, a majority of them have not yet decided whether or not they will move forward on this cost-effective option.  Medicaid is the most cost-effective way to connect people with coverage. Covering parents is the single best way to make sure kids are covered and get the health care they need.  The federal government has made states a generous offer and states should move promptly to accept the offer. States need to be ready to welcome new Medicaid enrollees in 2014, so the sooner they decide the sooner they can ensure eligibility systems and outreach in place to serve their residents.

• Determine who will run the exchange – the state, the federal government or a combination of the two.  States have until November 16^th to indicate whether or not they are going to run a state-based exchange, partner with the federal government, or let the federal government completely run the exchange.  States will have to tell federal regulators that they plan to go ahead by November 16, but they will have until Dec. 14 to submit plans for state-based, online markets, according to a letter sent to governors today from Health and Human Services Secretary Kathleen Sebelius. Those who want to partner with the federal government to set up the markets have until Feb. 15. As my colleague Sabrina Corlette at Georgetown University’s Center on Health Insurance Reforms pointed out, states need to act quickly as open enrollment for the health insurance exchanges is scheduled to start on October 1, 2013, less than 11 months from now.  Insurers need time to develop their products, price them, and have them reviewed and approved by state departments of insurance. And exchanges need time to build their systems and test them.

There are many more steps that need to be taken by state and federal policymakers to make the Affordable Care Act a reality for all Americans.   Successfully getting through these two important steps would be a good start.