Only 15 U.S. states plan to operate health insurance exchanges under President Barack Obama's reform law, leaving Washington with the daunting prospect of creating and operating the new online marketplaces in at least two-thirds of the country.
On the eve of a federal deadline for states to say whether they will run their own exchanges, 11 other states have informed the administration that it should plan to be heavily involved in setting up private health insurance markets within their borders, said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, on Thursday.
Experts say the number of states planning to operate their own exchanges could reach 18 and the District of Columbia by the time the deadline expires on Friday. But the administration would still be left to set up exchanges in at least 30 states, a challenge that is raising questions about how successfully U.S. officials can implement a key provision of the healthcare reform law known to advocates and opponents alike as "Obamacare".
"All exchanges will be open for enrollment in October 2013," Cohen, who is overseeing implementation of the exchanges, said in written testimony to a health oversight panel in the U.S. House of Representatives.
States that don't run their own exchanges would opt for one of two alternatives: a federally facilitated exchange that requires minimal state participation, and a federal partnership exchange in which states help by performing certain duties.
States have until Feb. 15 to say whether they intend to seek a federal partnership exchange. Four have done so already, Cohen said.
The Patient Protection and Affordable Care Act, which Obama signed into law more than 2 1/2 years ago, is expected to extend health coverage to more than 30 million uninsured Americans after it comes fully into force on Jan. 1, 2014.
About half of those newly insured would purchase private coverage from online exchanges at federally subsidized rates.
Ultimately, the number of people expected to find coverage through exchanges is expected to reach 26 million, according to the nonpartisan Congressional Budget Office.
The remainder would be covered by expanding the Medicaid program for the poor to cover all adults earning up to 133 percent of the federal poverty level, or about $15,000 for individuals and $30,600 for a family of four.
To provide exchange coverage in multiple states, the administration will have to erect an information technology system capable of processing marketplace operations in a manner customized to meet the needs of healthcare consumers in different states.
Experts say the biggest challenge will likely be providing adequate customer service to handle enrollment and fielding a technology system capable of interfacing seamlessly with the system of each state government.
Cohen told the House Energy and Commerce Subcommittee on Health that the administration is building a website with interactive capabilities and a call center and has begun testing a data services hub designed to determine eligibility.