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The presidential election settled at least one thing: The federal health law survives. But when it comes to implementing the Affordable Care Act, after months of uncertainty, many of the players have been caught unprepared. Late last week the federal government extended the deadline for states to decide what they want to do about health exchanges. Those are the new market places where individuals and small businesses can shop for health insurance.
NPR's Julie Rovner takes a look at what those exchanges are supposed to do, exactly, and what it will take to get them setup.
JULIE ROVNER, BYLINE: So what IS a health exchange? It's really not all that difficult a concept, says Karen Pollitz of the Kaiser Family Foundation.
KAREN POLLITZ: An exchange is a place where you buy health insurance. But it's a lot more understandable and consumer friendly than where you buy it today.
ROVNER: At least that's the hope, says Pollitz.
POLLITZ: They're supposed to have more info available for people that you can understand, not fine print and gobbledygook. They're supposed to have a lot of assistance; people who can help you kind of walk through things; answer your questions; be there in real time.
ROVNER: The exchanges, one for every state, are not only where people will go to choose plans, says Pollitz, who spent some time helping implement the law for the Obama administration. They're also where people will go to see if they qualify for help in affording that care. And lots of people will.
POLLITZ: The Affordable Care Act makes subsidies available based on a sliding scale, depending on how much you earn. And people earning up to four times the federal poverty level - which is about 40, $45,000 for a single person - will be able to get some help paying for their premiums.
ROVNER: The state exchanges will also have to determine who has incomes low enough to qualify for Medicaid, and help them enroll in that program. It sounds like a lot, but there's already a real-world example. Massachusetts passed a law that was in many ways the template for the Federal Affordable Care Act in 2006. It launched, within a year, something called the Massachusetts Health Connector. Here's how its then-director, Jon Kingsdale, described it in 2010.
JOHN KINGSDALE: On the Web, which is where about 85 percent of our applications come in for the unsubsidized insurance, individuals make a purchase decision in 20 to 30 minutes and push a button and they're enrolled.
ROVNER: Kingsdale said what's really made the Massachusetts exchange a success is the high quality and reliability of the plans it offers and the high level of its customer service.
KINGSDALE: That's really the value that we bring. So I think people in Massachusetts trust, when we give our seal of approval to health plans, that those are good values. And we certainly work very hard to make sure we offer the best plans.
ROVNER: But now states that have been on the fence don't have a lot of time left to replicate what Massachusetts has done. Exchanges need to be ready to start signing people and businesses up by next October, for a plan year that begins January 1st, 2014.
And Pollitz says there are a lot of moving parts that must be in place. Exchanges have to certify that health plans offer required benefits, and be able to determine who is and isn't eligible for financial help. And most of all, she says, they have to be able to help people.
POLLITZ: They need to have toll free 800 numbers that you can call. They need to have on the ground navigator and other kinds of consumer assistance programs to help people, you know, hold their hand, help people in languages that they can understand.
ROVNER: So far, nearly 30 states haven't formally said what they'll do. Just over a dozen states have passed legislation to take on this task themselves. Governors in another handful have said they want no part of it. That means federal officials will step in and run the state exchange for them. There is a third option. States can partner with the federal government to run the exchange. And now states can wait until as late as February to decide if they want to do that.
But there's pressure, particularly on Republican governors, to reject any participation in the exchanges. Nicole Kaeding is state policy manager for the conservative group Americans for Prosperity.
NICOLE KAEDING: If you agree with us that this law is not going to work, why would you want to help them in creating it?
ROVNER: Kaeding says there's also a significant cost states could face if they do their own exchanges.
KAEDING: These exchanges are expensive bureaucracies. They're going to cost states an estimated $10 million to $100 million per year and they will be financed through a tax increase on health insurance premiums, a tax increase that will almost surely be passed along to taxpayers.
ROVNER: Friday is still the deadline for states to tell federal officials if they plan to launch their own exchanges. That will send an important signal about the status of the health law. Julie Rovner, NPR News, Washington.