President Obama’s re-election has ensured that his signature legislative accomplishment—the Patient Protection and Affordable Care Act—will not be stillborn.  The challenge now is to get it out of the neonatal unit and up and running on its own feet.  There are serious deadlines ahead, the most daunting of which will be creating an “American Health Benefit Exchange” in each state to provide health coverage to essentially all comers not already covered by their employers or other federal programs.  The heavy lifting of creating such exchanges is nominally designated to the states. The first deadline, less than two months away, is January 1, 2013, when states must show that they are making substantial progress toward establishing their exchanges, with the goal of going live on January 1, 2014—the magic date when American health care reform really happens.

Most states will fall far short of these objectives. The exchanges are complex entities that must spell out local care packages conforming to the law, and create and manage a complete panoply of systems to designate and monitor vendors, screen and approve new applicants, police billing and care issues, and much else. As of now, only sixteen states are fully committed and actively working on nuts-and-bolts implementation. Another sixteen have done nothing or are still thinking about what they should do. Eight have declared their non-participation, which is actually helpful, since the feds have the clearance to begin planning for federally run exchanges in those jurisdictions. But the overall progress is worrisome. A shambolic transition that leaves a blotchy map of total failures and partial successes could drag into the 2016 election, and conceivably open the door to resurgence of the lurking Kervorkians of “big government.”

The administration’s solution, which is intelligent, is to offer lagging states the option of partnering with the federal government to get their exchanges live. Three states have already chosen that option. But its attractions come freighted with complications. Certainly, it’s possible for the federal government to set up and run an application and eligibility system, while the state works on its insurance exchange. But imagine, say, issues of data transfers between federal and state systems, and identifying the culprit when system snafus make files of enrollees disappear.

It’s reasonable to expect that partnerships will be a prominent feature of the early exchanges—the default position for most of the states currently lagging, and probably even for some now seemingly in the vanguard.  But that puts a heavy burden on the feds to create one or two very clean and well-defined package of partnership services, including the nature of the interfaces available to state operators, the tasks and deadlines required for partnering states, and all the other gritty details necessary for pulling off multiple partnerships under tight deadlines.

Certainly, some big thinkers should be squirreled away in soundproof rooms developing visions of the brave new world made possible by health care reform. But for the next eighteen months, the overriding priority must be to get the exchanges up and running in a clean and defensible way, as free of scandal and operational mash-ups as reasonable possible—in other words,  just getting the baby out of the crib and into adolescence, however pimply and ungainly that is. The partnerships may be the key leverage point for making that happen and should be at the top of the administration’s attention.

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