When Max Baucus predicted that the implementation of key aspects of the ACA could be a “huge train wreck coming down“, his comments were met with a lot of “see, I told you so!” comments from the right, and some surprise from the left, given how instrumental Baucus was in drafting the legislation. Now Harry Reid has stated that he agrees with Baucus. Reid noted that there is still much work to be done, and that significant 
additional funding is needed in order to make the remaining implementation of the ACA successful. HHS Secretary Kathleen Sebelius pointed out that her requests for additional funding were rejected in a recent short-term funding plan, but she’s optimistic about the ACA implementation, saying “…we are on track to fully implement marketplaces in January 2014 and to be open for open enrollment.”
I would say that the job Sebelius has in front of her is a monumental one, no doubt made harder by the propagation of misinformation and outright lies (there are no death panels!). In addition, a majority of the states opted to either have the federal government run their exchanges (26 states) or partner with the state on a joint exchange (7 states). Only 17 states plus the District of Columbia have taken sole responsibility for running their own health insurance exchanges (Colorado is in this category). So although HHS will likely be able to implement very similar exchanges in the 26 states where they will be fully responsible for running the exchange, making economies of scale work in their favor, the fact remains that they face a significant task: getting exchanges going in more than half the states, often in places where resistance to the ACA is high.
The exchanges are supposed to open for business in October (that’s only six months away), and policy effective dates for plans purchased in the exchanges will begin January 1, 2014. Creating an exchange is not something that can be done in a hurry, and it probably would have been prudent to set an earlier deadline for states to opt in or out of creating their own exchanges (it was in February). But presumably, HHS had been anticipating the responses from most states and were able to plan accordingly in the months leading up to the official opt in/out date.
Less than a year after the ACA was signed into law, Colorado began the – often contentious – process of creating the state’s exchange. They’ve been working on it pretty much constantly ever since. And the result is that Colorado’s health insurance exchange is on track to open on time and provide all of the promised services: small business and individual sales platforms, with an option for employees to select from multiple plan options in the small business exchange. I haven’t seen data from DC and the other 16 states that opted to run their own exchanges, but I would guess that they’re also faring relatively well, compared with the federal exchange (which has said that it won’t be able to offer multiple plan options for employees in the small business exchange until 2015). I imagine that the “train wreck” that Baucus and Reid foresee might very well be the case, but probably not in states that have taken the initiative and time to properly implement their own state-specific exchange.
Time will tell, but my own prediction is that the states that are running their own exchanges will probably have a smoother ACA implementation process than states that opted to hand the whole thing over to the federal government. Not only will those states have exchanges that were 
designed by and for the people who live there (unlike the generic one-size programs that will have to be set up by the federal government), but they’ve also had time on their side. Even back in 2011, when Colorado officials started work on the state’s health insurance exchange, they noted that there was much work to be done and not a lot of time to do it. At this point there’s very little time left – and still much work to be done. Not to mention the fact that Secretary Sebelius hasn’t been given the money needed to properly explain the ACA to a still-skeptical public.
I’m glad that Colorado took the initiative to set up its own exchange, and I think that we’ll probably see better results here and in other states that did the same, when compared with states that washed their hands of the whole matter and let the federal government run their exchanges.
