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2014 Perhaps Too Soon for State-Based Exchange Management

When the Affordable Care Act passed, many on the left were exercised by its long implementation time. The fact that most of the benefits of the law didn’t come until 2014 seemed to drain it of its political utility. Many made the point that Medicare came into being less than a year after passage.

But that was a different time, with a working government. The Wall Street Journal reports today that we’ll be lucky to make the 2014 date for all the exchanges to get set up.

As governor of Kansas, Kathleen Sebelius once hopped on a plane to Washington to plead with federal officials for health funding.

Now the tables have turned. Ms. Sebelius, the secretary of health and human services, is trying to appease cash-strapped governors who will have big sway over the success of the health overhaul passed in March […]

Early this month, Ms. Sebelius’s office plans to host governors’ staff from across the country to begin tackling the most ambitious part of the legislation, which calls for setting up state-based exchanges where some 30 million Americans are expected to buy coverage.

State officials say they are struggling to meet the law’s deadline for getting the exchanges running by 2014. Strapped budgets have left states without the staff to handle basics such as writing grants to apply for implementation funding, officials say.

You can account for much of the difference right there. Medicare was a federal mandate and basically involved signing seniors up to the program. Because of compromises, this law enacts 50 separate state-based insurance exchanges, and coming in the middle of a crisis in state budgets, the states have varying degrees of manpower and capacity to devote to that project. So a federally enacted law relies on the states to pull it off. Which is why Sebelius is doing all this hand-holding.

The solution would have been a standard, national exchange, where everyone could access a set of insurers, and the federal bureaucracy could manage the affordability credits. But that would have hurt Ben Nelson’s fee-fees, so here we are.

States also need expanded Medicaid funding to keep up with the mandates for eligibility written into the law. But Congress has refused to pass that thus far. They’ll have another go at it today, with a Medicaid/edujobs bill getting a cloture vote in the Senate. But Nelson and his cronies are the gatekeepers for that one, too.

Some positives, like health professionals attempting to provide quality care for less, have come out of the Affordable Care Act. The exchanges, however, have the potential to really crush the success of the effort, and that’s in the hands of the states, many of which lave chief executives who are actively hostile to the whole concept.

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David Dayen

David Dayen

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