The Washington Post

Concern growing over deadlines for health- care exchanges

With many states unwilling or unable to get insurance exchanges operational by the health-care law’s deadline of Jan. 1, 2014, pressure is growing on the federal government to do the job for them.

But health-care experts are starting to ask whether the fallback federal exchange called for in the 2010 law will be operational by the deadline in states that will not have their exchanges ready.

“It will be an enormous uphill battle to get this thing launched on time,” said Robert Laszewski, a consultant and former insurance executive who is watching the effort closely. “They have a Herculean task, even if everyone was cooperating.”

The federal exchange — like the state models — would be a one-stop Web site where individuals and small businesses could compare insurance policy offerings on price, coverage and quality.

The exchanges also will assist applicants in determining whether they are eligible for Medicaid or for federal subsidies or tax credits to help offset premiums. Thus, the exchanges will need to incorporate state and federal data on income, employment and residency. Enrollment through the state and federal exchanges is scheduled to begin in the fall of 2013.

It’s hard to know how far along the federal government is because the Obama administration has “been very reluctant to provide any updates on progress,” said Dan Schuyler, a director at the consulting firm Leavitt Partners in Salt Lake City, which is advising states on the exchanges.

The Department of Health and Human Services did not respond to requests for comment.

Those designing a federal exchange face enormous technical, political and financial challenges.

Technically, data from a host of federal agencies need to be collected into one system, which then must be linked with computer systems in 50 states and the District of Columbia.

Matt Salo, executive director of the National Association of State Medicaid Directors, said computer systems in some states are old and may need substantial upgrading. There is some doubt, he said, about whether there is enough “physical capacity in the IT systems world” to get it all done in time.

“Our members have been having conversations with the vendors since the law was passed, and they are coming to the gradual conclusions that no, they don’t have the capacity to do this everywhere in the time frame,” Salo said.

Political threats also abound. No one knows whether the Supreme Court will invalidate part or all of the law next year; it is not clear how much funding will be available to launch and operate the federal exchange; and the outcome of the presidential and congressional elections could delay or derail the entire process.

Although federal officials are saying very little about their progress, they have signed contracts worth more than $150 million with several private contractors who are working on creating the federal exchange. Last month, Oregon’s top insurance regulator, Teresa Miller, was hired by HHS to oversee development of health-insurance exchanges.

The administration is taking a three-pronged approach, said Schuyler, who formerly was director of technology at the Utah Health Exchange.

Step-by-step approach

First, a Federal Data Services Hub is being built to pull together information across agencies, such as the Internal Revenue Service and Social Security. States will be able to plug in to that data hub if they run their own exchanges. HHS has signed a five-year contract worth about $69 million with Maryland-based Quality Software Services to set up the hub.

The second prong is to beef up the site to include more information on health insurers and the health law. Although the site has some information on insurers sorted by Zip code, more is coming.

And finally, the federal government has signed a $94 million contract with Northern Virginia-based CGI Federal to build the federal exchange. The firm also is helping with the site. A company spokeswoman referred questions to the government.

Despite the contracts, many significant questions remain unsettled about the operation of the exchanges, whether the marketplaces are managed by the states or by the federal government.

Benefit ‘rules’ needed

Still unspecified, for example, are the final rules for “essential benefits” that the federal government will require insurers to offer in all policies sold on the exchanges. Details on what the federal exchange will look like are still lacking.

Also not clear are the standards — and the work required — for states to upgrade their computer systems to link with the federal data hub. States will be assessed in January 2013 to determine whether they will be ready by that fall.

It is possible to set up exchanges fairly fast, said John McDonough, one of the principal authors of the Massachusetts law that created a similar site. In that state, the exchange was running within about six months of the law’s enactment, he said.

“Massachusetts had a head start because it had already done a modernization of its data system, so it’s not completely analogous,” said McDonough, director of the Center for Public Health Leadership at the Harvard School of Public Health, “but it doesn’t take as much time to get an exchange up as a lot imagine.”

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