Those exchanges are at the heart of state and federal efforts to offer affordable health insurance plans to more than half the estimated
16 million previously uninsured Americans expected to take advantage of the law in its first year. The remainder will receive coverage through expanded state Medicaid programs—at least in those states that choose to accept federal funding for the effort.
The tightening time frame for building the exchanges has brought into sharper focus myriad questions the federal government still hasn't answered and the logistical challenges inherent to such a historic expansion of private insurance coverage.
“Imagine just a million people who have never filled out those kinds of forms before and don't know how to shop and haven't gone through open enrollment once a year for their entire adult lives,” said Jordan Battani, a managing director at Computer Sciences Corp., which is providing consulting services to states on the startup of exchanges. “They're all hitting the water at the same time on Oct. 1 trying to use these systems. It's hard to imagine how this could happen on time.”
Top insurance industry executives agree the states face daunting odds in meeting the ACA's deadlines. The ability of federal and state health insurance exchanges to begin enrolling millions of consumers in nine months “seems challenging,” Stephen Hemsley, CEO of UnitedHealth Group, told stock analysts last week.
The pressure has spawned repeated speculation that various exchange-related regulatory deadlines will be delayed. Last week, rumors swept the country that the Feb. 15 deadline for states to submit partnership exchange applications had been extended. States have the option of forging a partnership with the federal government or neighboring states.
Federal officials moved quickly to quash the rumors. “We've been getting lots of questions about this. … There have been absolutely no changes in policy,” Amanda Cowley, acting director of state health exchanges at HHS, told state health officials in an e-mail.
But misunderstandings abound, especially in states that are moving in opposite directions on exchanges and Medicaid expansion. Last June, the U.S. Supreme Court gave a green light to the exchanges by upholding the law's individual mandate, but gave states the right to opt out of the Medicaid expansion.
For instance, Mississippi Insurance Commissioner Mike Chaney applied to launch a state-run exchange against the wishes of the state's Republican leadership. He told the governor and state legislators that the state-run exchange will be needed to keep the federal government from forcing unwanted growth in the state's Medicaid program.
“A federally facilitated exchange will increase the federal government's involvement in Medicaid eligibility,” he told Modern Healthcare in an e-mail. “And while they cannot expand Medicaid under PPACA, they could use new Medicaid eligibility and enrollment rules to increase current Medicaid rolls.”
A CMS official said the federal government does not have the authority to grow a state's Medicaid rolls against its wishes.
Such types of misunderstandings followed HHS' decision to withhold most details about how they plan to run the federally operated exchange, which will cover every state that does not operate either its own exchange or one in partnership with the federal government. “A lot is riding … on the federal government getting the federal exchange up and running, but I wouldn't bet against the feds on this,” said Heather Howard, director of the State Health Reform Assistance Network, a pro-reform advocacy group. “They have a lot of experience in building systems.”