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The presidential election is over.

The Affordable Care Act, what critics derisively call “Obamacare,” is the law of the land.

And, after 100 years of failed attempts to create universal health insurance, the country is haltingly headed toward a historic reform of the health care system to cover 32 million uninsured Americans, starting in 2014.

But now comes the hard part: making it work.

A centerpiece of the health care reform law is the health insurance exchange, online marketplaces for health insurance in each state, much like Expedia or Orbitz for travel.

The idea is that small businesses and individuals without affordable employer-provided insurance will use the exchanges to compare and buy private health plans, and determine if they are eligible for Medicaid or subsidies from the federal government to buy a health plan.

At least, that’s the plan.

Enrollment is set to begin in less than a year, on Oct. 1, 2013, for policies that go into effect Jan. 1, 2014. Yet many states waited to prepare until after the election for an initiative that has to rank as one of the most complicated ever undertaken by government.

It’s anticipated that New York will enroll about 1 million people over three years – out of 2.7 million uninsured in the state. But even states that got an early start, such as New York, face a daunting list of challenges.

“We have needed every minute of time,” said Danielle Holahan, director of policy and planning for the New York Health Benefit Exchange.

One example in the difficult path to implementation: The online exchanges must offer easy and accurate transactions that involve multiple parties, including commercial health plans, state Medicaid programs, employers, insurance brokers, and organizations with local offices that will be established to offer guidance to consumers.

Can the websites in each state be made robust enough technologically – and on schedule – to accomplish this?

Another example: There are about 15,000 health insurance policies sold in New York State alone, varying mainly in co-payments and deductibles.

Can the plans be pared down to a more manageable number and be accompanied with information about the quality of the insurers so that consumers can make informed decisions based on more than price?

Key questions about how the exchanges will operate remain unanswered, Holahan acknowledges, in some cases because states are awaiting guidance from the federal government.

But New York is meeting deadlines, she said.

“Health reform is an amazing achievement. It’s what many of us have been fighting for for many years,” said Elisabeth R. Benjamin, vice president of the Community Service Society.

“But we’re building on the existing insurance system, and that makes things complex,” she said. “Getting this started is bound to have a lot of problems.”

Benjamin, whose New York City group researches and advocates for health reform, said New York officials have been “very responsive” to what’s proven to be a very difficult job.

Among other developments in recent months, New York selected the state’s largest small-group plan, Oxford EPO, as the benchmark plan with the “essential benefits” that insurers in the exchange must provide. The state also outlined additional coverage areas that insurers must offer to meet the requirements of the health reform law.

They include pediatric dental and vision coverage equal to the benefits offered through New York’s Children’s Health Insurance Program, habilitative services in parity with rehabilitative services, mental health and substance abuse parity, and annual and lifetime dollar limits.

The state in September also filed hundreds of pages of documents with the federal government in a required “blueprint” report, identifying its progress in certain areas, such as information technology and recommendations on policies to remove incentives for insurance companies to seek only the healthiest enrollees.

Earlier this month, as a Nov. 16 deadline loomed, the Obama administration at the request of Republican governors announced it would give states more time to decide whether to build online health insurance markets or have the federal government run one for them. States that want to manage their own exchanges have until Dec. 14 to submit blueprints, and states that want to run exchanges in partnership with the federal government have until Feb. 15. Otherwise, the federal government plans to run the state’s exchange.

So far, 17 states have committed to running an exchange, according to health care consultant Avalere Health.

It’s not clear yet which health plans will be in the exchanges and exactly how much they will charge in premiums because the exchanges are not yet up and running. But insurers are preparing to compete.

Like others tracking the development of the exchanges, they have concerns over many issues, such as the information consumers will have in order to make choices.

“If one insurer sells an identical plan at a lower price than others but has a record of denying claims, consumers should be able to know that. Otherwise, you won’t know what you’re really paying for,” said Dr. Michael Cropp, chief executive officer of Independent Health.

He said the exchanges should incorporate access to quality measures that include an insurer’s record on coverage denials and complaints, in addition to rankings on medical care, such as how well they do on screening for cancer and monitoring diabetes.

State officials say they intend to do this, but information on complaints and denials will only be available for insurers that have been doing business in New York and not new companies that enter the market to compete in the exchange.

“I’m concerned that the public will have to accept a less-than-adequate system to move the ball down the road,” Cropp said.

Likewise, consumer advocates warn that the exchanges must devise an appeals system to resolve disputes quickly and effectively.

New York officials realize the potential for problems if as many disputes as possible aren’t addressed before they worsen into official appeals, Holahan said.

“We’re working on the mechanics of that,” she said.

Questions also remain over the affordability of the health plans in the exchange and measures to prevent some insurance companies from getting stuck with the sickest and costliest patients.

The health reform law requires states to establish risk adjustment measures that transfer money from insurers with relatively healthy enrollees to those with relatively unhealthy and expensive enrollees. Some insurers aren’t satisfied yet with the proposed measures.

“The models so far are inadequate to prevent some insurers from skimming the healthier population with an inferior product that may have standard benefits but has a track record of denying coverage,” said Cropp.

Without adequate risk-adjustment measures, insurers will be inclined to price their products higher to offset the uncertainty of whether they will bring in the revenue needed to cover the cost of the individuals who enroll through the exchange, according to Jared Gross, vice president for health care economics at BlueCross BlueShield of Western New York.

“We need to know more about how risk will be assigned and payments made,” he said.

Insurers also oppose one of the funding mechanisms of the health reform law, saying it will lead to higher premium prices.

Beginning in 2014, the law will assess a new sales tax on health insurers based on the total amount of premium dollars they collect. Insurers warn that the cost will be passed on to consumers, making policies less affordable for individuals and employers.

“We estimate the tax will add $400 to a family plan once it fully kicks in in 2016,” said Don Ingalls, vice president for state and federal relations at the Blues.

email: hdavis@buffnews.com