The NYT reported yesterday that it is likely that only 17 states will operate their own exchanges. As noted in the article by Robert Fear:
The federal government and states face a series of deadlines in the new year. On Jan. 1, Secretary Sebelius must determine whether each state will be able to operate its own exchange in compliance with federal standards. By Feb. 15, states must notify the federal government if they want to help with selected tasks, like consumer assistance and the supervision of health plans, in partnership with the federal government.
On Oct. 1, consumers can begin to enroll in health plans, for coverage starting on Jan. 1, 2014, when most Americans will be required to have insurance.
The remainder have chosen to forego this opportunity. The reasons are multiple but a common theme appears to be the lack of guidance which was forthcoming from the Washington DC bureaucracy. As noted the the NYT piece:
In Tennessee, state officials did a huge amount of planning for a state-run exchange. But Gov. Bill Haslam announced this week that he had decided against the idea because the Obama administration had failed to answer numerous operational questions.
Gov. Chris Christie of New Jersey cited similar concerns in vetoing legislation to establish a state-based exchange last week.
“New guidance continues to trickle out of Washington at an erratic pace,” Mr. Christie said.
I have no particular desire to gloat. Innumerable patients I care for have taken this timetable to heart and are betting on the timely access to insurance which will provide them with affordable coverage independent of pre-existing conditions. I am concerned they have placed their hopes on something many would consider desirable but is not not feasible. Both are required.
When Nancy Pelosi proclaimed that the bill needed to be passed in order to see what what in it, it turns out she was not kidding. At the time the thought was that she was referring to the extensive document already written. However, this aspirational document represented only a shell of what will ultimately be needed. What appeared to be a good and grand idea gets a bit more complicated when the idea is to reconstitute perhaps 20% of the economy and make it micromanaged by federal bureaucrats.
This episode adds new meaning to the term "Intelligent Design". When political officials express skepticism regarding biological evolution and embrace concepts that the universe can and was designed by some intelligent being, they are ridiculed a being ignorant. I agree that those views are ridiculous and should be challenged. Complexity and durable complex systems do not develop as a consequence of top down architects.
Similarly, when human beings try to assume they can take on god like powers they are behaving in an ignorant fashion. I am sure that when HHS took on the task of simply providing guidance to states trying to build exchanges, they quickly found themselves in over their heads. No gods or intelligent design capacity there. I hate to imagine what they have ahead of them when they attempt to build exchanges for the remaining 33 states. These are entities which can evolve over time if the appropriate rules and selection pressures are applied. I have my doubts they can be the product of creation by people and institutions which are made of ordinary people.