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What’s it like building D.C.’s Obamacare exchange? ‘Organized chaos.’

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition — and read all previous columns here.

When asked to describe what it's like to build an insurance market from scratch, D.C. Health Benefits Exchange Executive Director Mila Kofman settled on two words: "Organized chaos."

Kofman, who joined the exchange in January, can tick off dozens of policy decisions that she and her working groups still need to make, like whether to allow D.C. residents with an employer contribution to shop all health plans—or a select number.

The exchange needs at least a few dozen more staff members. Kofman only moved into her office in mid-March; framed photographs, still unhung, cover a table in her office. The conference room does not yet have light switches, just an array of brightly-colored wires popping out of the wall.

"Every day is a little bit different," said Kofman, who came to the exchange from the Georgetown Health Policy Institute. "But there's always something."

The D.C. Health Benefits Exchange Authority is in a bit of an odd spot. It's may be the smallest Obamacare marketplace set to launch in 2014 (Kofman isn't sure whether her exchange or Vermont's holds the title). That means a more manageable population, but also precludes the District from some of the choices available in bigger states.

It also has access to a wealth of health policy knowledge, with multiple staff and board members implementing the law that they themselves previously helped write. At the same time, the exchange can't lean too heavily on national experts if it wants to reflect local priorities.

"We can lead the nation in terms of implementation," Kofman said. "People are probably paying more attention to us than they otherwise would, because of where we're located."

The D.C. Council established the District of Columbia Health Benefits Exchange Authority in December 2011. Nearly a year later, it received conditional approval from the federal government to launch in 2014, provided that it continued to meet a set of benchmarks.

Already, Kofman has found that the small size of the District's insurance marketplace has limited policy decisions. She does not foresee her exchange only contracting with a select number of insurance companies, meant to give consumers access to only the very best options.

While California will pursue such an approach, Kofman thinks that the nation's capitol doesn't have enough insurance plans for such a limit to be successful.

"In California, they have tons of insurers and can decide on the four or five that they think are best," she said. "Here we don't. There are four insurers in the marketplace. If we make that even smaller, you're looking at one or two plans."

Instead, Kofman sees the exchange as a way to lure in even more insurance plans to sell in the District. She already has verbal commitments from the four plans who already sell here: CareFirst BlueCross BlueShield, Kaiser Permanente, UnitedHealth and Aetna. They do not, however, need to provide an official commitment until next month.

Kofman hopes to woo in some of the plans selling on the Maryland health exchange, noting that the two are right next door to one another—and use very similar technology, some of it built by the same vendors. "I hope that's going to be a feature that's attractive to them," she said. "It'll be very easy because they're essentially looking at the exact same IT infrastructure."

Meanwhile, other policy decisions driven by the small size of the Washington market have proved controversial. Prior to Kofman's arrival, the Health Benefits Exchange board voted to require all individual and small market insurance plans to be sold through their government-regulated portal.

The idea was to increase price competition in the insurance marketplace, by ensuring that all health plans would display their prices in one place.

"Because of the small overall size of this market," Kofman wrote in a report this month, "treating different segments of the market differently is likely to create significant confusion and possibly perpetuate the segmentation of risk as well."

The worry Kofman expressed in that last clause is that, if even a few of the small businesses with really healthy employees buy outside the exchange, then the premiums in the marketplace will all of a sudden become the more expensive option.

Small businesses have, meanwhile, balked at the requirement, arguing that it would limit their options to purchase health insurance. The exchange does not get the last word on this: As Mike DeBonis noted, the final vote goes to the D.C. Council, where members have already voiced some opposition.

Kofman wants that policy to pass, but its only one of many tasks on her agenda in the coming month. In a few weeks, the federal government will do extensive testing of the D.C. exchange to make sure that it can connect to a national data hub, which will have information on who qualifies for subsidies and different public programs.

That's in addition to the calls every two weeks, where federal government and the D.C. exchange touch base on how well implementation is going.

And, of course, there's still the tangle of wires in the conference room that, at some point, needs to get covered with a light switch.

"It's an incredibly busy time," Kofman said. "We're doing everything we can to make sure we are open for business on time. It's an all hands on deck experience."

KLIFF NOTES: Top health policy reads from around the Web. 

Obamacare's 73 percent pay raise for primary care in Medicaid is late. "A huge pay raise promised under the Affordable Care Act for primary care doctors who treat the nation’s poor covered by Medicaid health insurance is nearly three months behind schedule and may take another three months before it kicks in, state Medicaid directors say." Bruce Jaspen in Forbes.

Some small businesses are self-insuring, perhaps to dodge some Obamacare requirements. "As more small employers like NorthBay avoid the health act’s requirements through self-coverage, small-business marketplaces intended to cover millions of Americans could break down and become unaffordable, they say. 'What you’ve got is basically a loophole for the small employer to get out of the ACA requirements,' says Robert Laszewski, a Virginia-based consultant and former insurance executive." Jay Hancock in USA Today.