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Health Insurance Exchanges and the Affordable Care Act: What To Expect on October 1

You have probably heard the classic definition of the Yiddish word "chutzpah"—it defines the behavior of the youngster on trial for killing both his parents who pleads for mercy because he is an orphan. The current behavior of the Republican party with respect to implementation of the Affordable Care Act (a.k.a. Obamacare) fits that definition pretty well. Republicans are vociferously predicting that implementation of the that law will fail and simultaneously doing all they can to produce that outcome. They seek to stop spending to implement the law. Officials in many states have adopted a stance reminiscent of "massive resistance," the South's futile effort to block implementation of the Supreme Court's decision banning school segregation. A state legislator in South Carolina even proposed that the state give tax credits to help defray any penalties state residents might incur from defying the federal law.

At one level, this effort will fail. Previously authorized spending will continue. The law will be implemented. But it will probably succeed in blocking additional funding that would smooth the roll-out of an admittedly complicated law.

So, what should Americans expect on October 1 when the health insurance exchanges, or marketplaces, open for business and individuals and small businesses try to buy insurance through them? Success or failure?

The not-so-simple answer is: Both! And everything in between.

Seventeen states and the District of Columbia are setting up state-based exchanges. The federal government will manage the exchanges or divide responsibilities with the states in the other thirty-three. But these categories do not begin to capture the range of likely experiences. In several states, elected officials are intimately involved with the health exchanges they created. They are committed to setting up the computer systems and phone banks, and to training the "navigators" and personal assisters who will try to make enrollment unfold as smoothly as possible. They have enlisted business, non-profit organizations, and insurance brokers and agents in a joint effort to make the roll-out a success.

That process can work, as Massachusetts proved when it implemented a law much like the Affordable Care Act. A Republican governor and a Democratic legislature, working with business and labor, showed that close-to-universal health insurance coverage is possible. Sure, there were problems. But rather than exploiting short term problems, rather than wagging fingers and crowing "I told you so," key groups fixed what needed fixing and made the program work.

There is every reason to believe that similar successes will mark the roll-out of the Affordable Care Act in several states. To be sure, even the best efforts will not have eliminated bugs from the computer software used to determine who is eligible to enroll in the health exchanges and to what premium subsidies they are entitled. Not all of those providing information and guiding enrollment will "get it right" every time. As with any large-scale start up, plenty of errors will be made. But with a bit of time and patience and despite the inevitable and often-justified grumbling, things can—and will—be made to work.

But not everywhere. Some state governments oppose implementation or are "slow-walking" measures they need to take to make the new law work. Furthermore, the job is bigger and harder in some states than in others. In Texas, Louisiana, and Florida, none of which have set up state exchanges and in all of which opposition to the Affordable Care Act is widespread, 20 percent or more of the population is uninsured. In contrast, fewer than 10 percent of the populations are uninsured in Hawaii, the District of Columbia, Connecticut, Vermont, and Minnesota, all of which have set up state health exchanges.

I hope I am wrong, but I fully anticipate that in many states, the roll-out of the Affordable Care Act is going to be marked by confusion, error, and legitimate complaining—most of it unnecessary. Some errors and complaints are inevitable when millions flood a new agency, using brand new computer software, staffed by newly- and sometimes inadequately-trained people.

The spirit with which the inevitable problems of implementing a major new law are confronted is critical. With good will, various stake-holders will pitch in, pinpoint the problems, and, with time and patience, the fix them. That is what happened in Massachusetts. It is what will happen in those states, where the governors, legislatures, business, labor, insurers, and consumer groups recognize that they have a shared interest in bringing health insurance to millions of currently uninsured people.

But it is not what will happen in those states where officials who have staked their reputations on predictions of failure remain, defy federal law, and engage in a modern day version of "Massive Resistance." Some newspapers, TV networks, and bloggers, shrill opponents of the Affordable Care Act, will be deeply embarrassed if their constantly repeated predictions of failure prove wrong. So, they can be expected to trumpet each mistake as confirmation of their dire warnings. Observers should keep in mind that when millions of people are applying for coverage, thousands of mistakes are inescapable. They should not lose sight of the fact that many of those mistakes will result from the uncooperative and obstructionist efforts by those who have refused to recognize that the Affordable Care Act is the law of the land and that law-abiding citizens obey the law.