“We have to simplify and streamline these systems and processes, change business practices, and do so in a way so it can bring in millions of additional people who are extraordinarily diverse in terms of their cultural, linguistic, educational, economic, and health status,” Belshe explained.

The IT infrastructure will reflect that. It will have to provide a customer-centered enrollment experience that can accommodate the very different needs of various categories of consumers and streamline that end-to-end process for securing and retaining coverage.

The exchange board believes that health reform in California extends beyond coverage. “We really need to be held accountable for how we can achieve better value and lower costs because if we can’t get costs under control then the work we’re doing fundamentally is not sustainable,” Belshe said.

High stakes HIX
The stakes are also very high around health plan participation standards and delivery system improvement strategies. California standards will exceed the federal minimums and the state will be an active purchaser.
“We estimate that we will be purchasing from 7-15 percent of the overall market. So we’ve got some leverage in the marketplace,” Belshe said, including important tools, like selective contracting and the ability to standardize benefits.

In Maryland, Democratic Gov. Martin O’Malley was re-elected in 2010 and has made establishing a health insurance exchange a priority.

Maryland is working on the preparations to link up its eligibility system with the exchange with real-time access and real-time online enrollment. “This is a paradigm shift, and it is very complicated,” said Charles Milligan, Jr. deputy secretary for health care financing in the Maryland Department of Health and Mental Hygiene.

In forging the relationship between Medicaid and the exchange, it’s not simply the eligibility front-end, making sure that people get into the program that’s right for their eligibility, “but we’re also looking to work with the exchange about continuity of care as people move around providers,” Milligan said.

In Maryland, One half of the population in Medicaid will fall out of coverage because of a slight change in earnings and cross over into the exchange in the course of a year. The state is concentrating on alignment at the care level among providers to accommodate that churn, Milligan added.

A patient might be in the middle of chemotherapy, for instance, or pregnant or have a chronic illness and be on eight medications that took a lot of trial and error to get accustomed to, or scheduled surgery.

The exchange will also transform how safety net providers operate. Providers, such as free clinics, federally qualified health centers and community health centers, are unaccustomed to working with insurers, Milligan said. They will take care of the same patients, but now those patients will have an insurance card. The providers must be prepared to get credentials and understand claims and authorization, build competencies in their front office, and establish electronic health records (EHRs).

[Political Malpractice: They all chant 'ACA repeal' but what could a GOP president actually do?]

A lot of covered benefits that have been grant-funded will become part of essential health benefits and these safety net providers may need as part of their strategic business plan to build relationships with commercial carriers because they’re seeing people at 150 percent of poverty.

Golden spike, no guarantee
Getting the IT system ready in time is a major concern for states. The federal government can help facilitate that, however, with final guidance and information on what the federal data services hub is going to look like and when it will be ready, he said.

The federal government is building on existing services and developing a data services hub that collects the federal data to verify eligibility, including IRS tax records, citizenship records from the Homeland Security Department and the Social Security Administration. States will use standards to connect those services with their state eligibility system.

“We’re going to be driving the golden spike in the railroad somewhere along the way,” Milligan said, “and we need the federal government to be there and meet us.”

Whether the federal government will, or will not, be there to help states depends on a number of factors – ranging from the pending Supreme Court ruling, the presidential election come November, and on down to state legislatures, where the real battles are being fought.

For more of our primaries coverage, visit Political Malpractice: Healthcare in the 2012 Election.