Americans are accustomed to watching the federal government waste money. The Alaskan span known as the "bridge to nowhere" - officially, the Gravina Island Bridge -- will cost more than $300 million if it is built, but will be traveled regularly by only 50 people. But the outlay already spent on health insurance exchanges, the centerpiece of President Obama's Patient Protection and Affordable Care Act, beats that bridge by a country mile.medical-money-small

Obama is forking over about $1 billion to states to set up health exchanges, which will be state-run marketplaces where insurance companies sell their health plans to consumers who don't have health coverage through their employers. The concept has merit. But the federal funds spent to pave the way may, like the bridge, go nowhere.

The political landscape has changed since health care reform was passed in 2010 by what was then a Democratic-controlled Congress. Soon the issue will undergo an unprecedented five-and-a-half hour hearing before the U.S. Supreme Court, which could declare the whole act -- or any part -- unconstitutional as early as June. In November, health reform faces another challenge when, as "Portfolio" says, it will be "one of the biggest issues in the presidential campaign."

'Early innovators'

None of this is stopping the Department of Health and Human Services from throwing money at the states with both hands for "early innovator" programs for setting up health insurance exchanges. But many states, especially those with Republican governors, don't want to be early innovators. Some, like Kansas Gov. Sam Brownback and Wisconsin Gov. Scott Walker, are trying to give back the money.

A headcount by the Associated Press shows that significantly less than one-third of the states have signed on, one-third are resisting and the rest are indifferent.

"Most states are taking a wait-and-see approach," reported The New York Times in February. Ohio and New Jersey aren't taking action until the future is clearer, and Arkansas is doing nothing at all. Some states, like Texas, are actively opposed, perhaps because the first $1 billion is only the beginning: Ultimately, someone will have to pay to run these exchanges.

But that doesn't mean these states are turning down free federal money. Quite the opposite. Even the states whose attorneys general will argue against health care reform before the Supreme Court are taking the cash for their programs.

And for the holdouts, Obama has a stick as well as a carrot: A federal exchange will step in and run their state programs if they don't. How much will that cost? No one can say.

Gaining momentum

So why is Obama pushing so hard and fast? Politically, he may be trying to create an atmosphere of inevitability: hoping the ball will roll downhill fast enough that it can't be stopped. With so much of the health care plan already in place, so much money already spent and so many promises made, how can anyone -- court or Congress -- dismantle it?

Obama has chosen his horse and is riding it hard toward an uncertain finish line. He's also racing against the clock. These health insurance exchanges, at least 50 of them, are supposed to be up and running in early 2014, a blink of the eye in terms of the way government runs.

As the Boy Scouts say: "Be prepared." But Washington is not a town for Boy Scouts. And if either the Supreme Court or a reinvigorated Republican Party knock Obama off his horse, wave goodbye to health insurance exchanges, and at least $1 billion of taxpayers' money.