An early indicator of whether the implementation will be choppy could come Nov. 16, when states must declare whether they intend to manage their exchanges on their own, cede full control to the federal government or enter into some form of federal-state partnership.
The exchanges are supposed to make it easier and more transparent for small businesses and millions of individuals who are not covered through employers to shop for health insurance. Many of these individuals will be eligible for federal subsidies to buy private coverage.
So far, only 13 states and the District of Columbia have officially said they will set up exchanges. Republican governors in about a dozen states have held off giving their answer for months — first in anticipation of the Supreme Court’s ruling, and then, after the court upheld the law, in the hope that Mitt Romney would win the presidential election and make good on his promise to repeal it.
Robert Laszewski, a health-care consultant and former insurance executive who opposes the law, predicts that most of these leaders will now choose to take command of their states’ exchanges. But while some — including the governors of Virginia, Nebraska and New Mexico — hedged their bets by quietly laying the groundwork to run an exchange, those that have made virtually no preparations could find it hard to make up for lost time.
Meanwhile, many health-care experts predict that even states that have always planned to run their exchanges — for instance, New York and Kentucky — might not be ready by Oct. 1, 2013 — the date by which the exchanges must start enrolling people.
As a result, at least for the first year or two, the federal government could be in full or partial charge of exchanges in as many as three dozen states.
“I think it’s safe to say that we are likely to see quite a number of federal partnerships,” said Jennifer Tolbert,who has been tracking state progress for the nonpartisan Kaiser Family Foundation.
Is the federal government up to the job?
“That’s the $64,000 question,” Laszewski said. “The Obama administration has said emphatically that they will be ready, but so far they’ve produced no information about how they’re going to do it.”
Also looming over the law are the negotiations Obama will soon undertake with Republicans over how to pull back from the “fiscal cliff” — nearly $500 billion in automatic tax hikes and spending cuts set to take effect next month.