President Obama's re-election ensured that his national health care law will be implemented. But now the focus has turned to the difficulties that involves. Health insurance exchanges must be established in all 50 states and the District of Columbia. It is through these exchanges that eligible Americans will be given government subsidies to purchase government-designed insurance plans.
The exchanges are projected to cover 20 million Americans by 2016 and to cost $800 billion over the next decade, according to the Congressional Budget Office. But before that can happen, they must be ready for open enrollment by Oct. 1, 2013, and be fully operational three months after that.
Under the terms of the law, states have the option of setting up their own exchanges, doing so with other states (or the federal government), or simply letting the feds take care of it. As of Friday afternoon, 15 states (most of them with Republican governors) have chosen the last option, citing time constraints and the lack of flexibility within the law. Sixteen other states, plus D.C., have opted to set up their own exchanges; six are doing joint exchanges; and 13 states are undecided. (The Obama administration extended to next month the deadline for states to declare their intentions.)
The governors choosing not to establish state-based exchanges have been criticized by the Left for dallying in the hope that the law would be repealed or struck down in court. But even the localities that decided early on to set up exchanges are struggling with the challenge of doing so under extraordinary time constraints.
In a meeting with The Washington Examiner last week, the head of the D.C. Health Benefit Exchange Authority, Mohammad Akhter, was quite frank. "If you look at the whole implementation of the Affordable Care Act, the time pressure is brutal," he said. "Things have to be done so fast and quick that there is not enough time to go through the whole litany of things that one could."
Akhter emphasized that D.C. has met all federal deadlines and is expected to continue doing so. But he conceded that, as his board makes major decisions about how the exchange will work, members of the board have not had time to explore all options thoroughly, or to consider the ones that might require the passage of new council legislation.
"There's no doubt that if there was better timing this thing could have been done better," he said. "There would have been a lot more consultation, a lot more discussion, a lot more debate. But the reality is this is the way the timing is presented. So, we have to run with what the deadlines are to meet the deadlines."
Such talk reminds us of what people said about the health care law when it passed.
One of the major tasks that the federal government must perform is to compile real time data on all Americans' incomes, so that they can determine their eligibility for federal subsidies. Those data must then be fed into state databases, where they must interact with state government exchange systems. Akhter said that in order for the exchange to function properly, D.C. must set up "the largest data system the District is ever going to have."
Perhaps the federal government has the capacity to set up its end of the system by next October and have it function smoothly. Perhaps it can also create health insurance exchanges for between 15 and 30 individual states that choose not to create them. But forgive us if we are a bit skeptical.