From Google News

• By
• LAURA MECKLER
• And
• LOUISE RADNOFSKY

Health-insurance companies spent more than $80 million trying to defeat President Barack Obama's health-care plan. Having failed, they have spent the years since trying to kill a string of provisions they don't like.

And yet, it is those same insurance companies that are working harder than just about anyone to try to make the law succeed.

It is one of the paradoxes of the sweeping health-care law: Fierce critics can also act as supporters who are key to whether the law will work. With Mr. Obama's struggles in selling the law, their efforts have become even more critical to its success.

In political debate, the law is seen in black and white. But for those on the front lines of American health care, positions are less clear-cut, because the law does a lot of different things, all at the same time.

It requires insurance companies to cover people even if they are already sick. But it also generates new business for insurers by requiring most Americans to have coverage. It tries to control the rising cost of care with a string of experiments. But it also raises taxes on health-care companies.

Health insurers are lobbying Congress to repeal the new taxes they face. At the same time, they are carrying out campaigns to sign people up through new insurance marketplaces, which are mostly set to open on Tuesday despite technology troubles at both the federal and state level.

Divided passions also are found at the U.S. Conference of Catholic Bishops. At one end of a long corridor, near a "Respect Life" poster, sits the office of Richard Doerflinger, who leads the Catholics' antiabortion lobbying.

In 2010, he nearly brought down the entire health bill in a dispute over whether subsidies to help low-income Americans buy insurance amounted to government-funded abortion. He is now helping dozens of Catholic organizations suing to overturn a requirement that most employers cover contraception.

At the other end of the hall in the ornate headquarters of the bishops sits Kathy Saile, who is working to persuade states to expand Medicaid, the health program for low-income Americans. Outside her office hangs a portrait of Msgr. John Ryan, known for his liberal social activism during the early 20th century.

Ms. Saile said there is no incongruity between her work and that of Mr. Doerflinger. "You come at it from different perspectives, but we all have the same priority, which is the sacredness of the human person," she said.

In July, the Catholic Conference of Ohio issued an action alert for Catholics to call state representatives to urge them to back Medicaid expansion. The same month, a similar alert asked Catholics to contact their members of Congress to support legislation stripping contraception and abortion-coverage provisions from the law.

Catholic hospitals are also helping spread word about new marketplaces where Americans who don't currently have access to insurance can sign up for coverage.

"I think Catholics have sometimes misunderstood the bishops' position on the law," said Father Patrick Delahanty, executive director of the Catholic Conference of Kentucky. "The law needs to be fixed, not be repealed."

Most of the calls to repeal the law have come from Republican politicians. But the law puts Republican governors in a tight spot because it allows states to expand their Medicaid programs with federal funds covering almost all of the cost. Most GOP governors say the expansion of Medicaid, a federal-state program for the poor, is unaffordable, while others say they don't want to pass up the federal money if it helps get more people covered.

Ten GOP governors, many of them critical of the law overall, are supporting Medicaid expansions or alternate versions to achieve the same goal. In August, Michigan Gov. Rick Snyder, a strong critic of the president, pushed an expansion bill through the state Senate in a close vote.

North Dakota Gov. Jack Dalrymple has called the health law "wrong for North Dakota." But this year, he backed an expansion of Medicaid for his state. "In the end, it comes down to, are you going to allow your people to have additional Medicaid money that comes at no cost to us, or aren't you? We're thinking, yes, we should," he told the Grand Forks Herald in January.

His administration awarded a $595,000 contract to a consultant to devise messages for state employees and others to use when promoting the law. The messages, released this month, include: "Medicaid expansion is a smart investment," and "North Dakotans now have more choices for affordable health care."

Health-insurance companies may have the strongest love-hate relationship with the health law. They like the requirement that most Americans carry insurance or pay a tax penalty—that is new business for them. And they like subsidies to help people afford premiums. But they have rebelled against regulations guiding what coverage must include, and have campaigned against new taxes and cuts in payments to private Medicare insurers that help pay for the new subsidies.

The result has been a steady stream of criticism—and an intense effort to sign people up for the new exchanges.

It is particularly important to insurers that young, healthy people enroll in order to balance out more costly, sicker customers they will soon be required to cover.

Blue Cross Blue Shield is working with Walgreen Co. to educate consumers through a website and information at 8,000 stores across the country. Highmark Inc., a Pittsburgh insurer, is sending tractor trailers to college campuses. And WellPoint Inc. has teamed with Univision Communications Inc. to inform Hispanics through television ads and some 70 town-hall meetings.

Karen Ignagni, president of trade group America's Health Insurance Plans, said insurers want Congress to improve the law, but they also must make sure that the new system succeeds. "This is what our members do," she said. "They sell insurance."

Write to Laura Meckler at laura.meckler@wsj.com and Louise Radnofsky at louise.radnofsky@wsj.com