The Obama administration will have to build and operate online health insurance markets for the majority of states – something few expected when the health care reform law was approved in 2010.

Twenty-three states, most led by Republican officials, have declared that they will not set up their own health insurance markets, also known as exchanges, to help individuals and small business find affordable care. Instead, that job will fall to the federal government. The exchanges are a key vehicle under the law to expand health coverage to an estimated 25 million people over the next four years, according to the nonpartisan Congressional Budget Office.

Most experts thought only states with small populations like Montana or Delaware would seek federal help. But the intense dislike that some Republican governors have for the health care law seems to have been a bigger factor than anticipated, leaving Texas and Florida, which together account for nearly 20 percent of the nation’s uninsured, among the states that will let the federal government run the exchanges which begin enrollment in October, with coverage beginning Jan 1. 2014. Florida officials have recently met with Health and Human Services officials, and while no decisions have been made, the fact that a meeting took place between Gov. Rick Scott and HHS Secretary Kathleen Sebelius, raises the intriguing possibility that one of the nation’s most high profile Republican governors (and opponents of the health care law) might actually agree to implement some of the law eventually.

The idea of a health insurance exchange as laid out in President Barack Obama’s signature law seems straightforward: an online marketplace where people will shop for private health insurance, like buying an airline ticket or a hotel room. In order for an insurance company to offer a plan, it will have to meet a set of still-to-be determined essential benefits, giving consumers a way to directly compare what plans offer and what they don’t. But making sure exchanges in every state are ready for business by the law’s deadline of 2014 has been anything but easy given the legal, technical and political questions surrounding them.

Most of the really big changes made by the 2010 health law don’t start until 2014. That includes things like a ban on restricting pre-existing conditions and required insurance coverage for most Americans. But some changes have recently gone into effect. One change that will affect everyone with private health insurance won’t really be noticeable until you renew or apply for new health insurance. It’s called a summary of benefits and coverage and the idea is to help people actually understand what’s in their insurance policies.

After extensive polling and focus groups, it’s clear that most people don’t understand either the coverage or the price of their health care policies. The summary standardizes the format so people will be able to compare benefits and prices in an apples-to-apples comparison and there will also be a glossary of insurance terms available if you ask for it.

How do people take part in an exchange? Enrollment will open in October and end in March, 2014. Consumers will look at health insurance plans on an exchange website, or for those not online, they will be able to obtain details over the phone from a call center. Prescription drug coverage, in-network doctors, co-payments and other details will be spelled out. Consumers will be able to find out from the exchanges whether they qualify for federal subsidies to buy insurance, which will be available to single people and families earning up to 400 percent of the federal poverty level – about $44,000 for a single adult, or $92,000 for a family of four. Those below 138% of the poverty line will be able to sign up for Medicaid coverage in states that elect to expand their Medicaid programs.

So what parts of the health care law have taken effect in 2013? The federal government is sending more money to state Medicaid programs that offer preventative services for free or at little cost. These services include tests for high blood pressure, diabetes and high cholesterol, many cancer screenings including colonoscopies and mammograms, counseling to help people lose weight, quit smoking or reduce alcohol use. In addition, routine vaccinations like flu and pneumonia shots are covered.

Increased Medicaid payments, which started January 1, will mean that doctors that take Medicaid patients will get a pay raise. Payments in every state were brought up to the same level Medicare pays doctors. Some experts say the Medicare rate is too low, but until now, Medicaid paid even less. A recent Kaiser Family Foundation study noted that while it varies from state to state, primary care physicians see an average 73% pay increase.

Another program that began at the start of the year is a national pilot program that will encourage medical providers to coordinate patient care. Rather than have each service billed separately under Medicare, a flat rate would be paid for an episode of care, in effect, bundling services together. Also as of January, affluent seniors face a tax increase for Medicare – those earning in excess of $200,000 (for couples filing jointly, $250,000). This 0.9% tax increase will boost the Medicare trust fund.

A medical device tax also took effect in January, putting a 2.3% tax on the price of medical devices like defibrillators, pacemakers, and artificial joints but it does not include hearing aids or corrective lens. Another tax change people may notice is that up until now, Americans got a tax deduction if all their total medical expenses added up to more than 7.5% of what they earn (minus deductions and exceptions). Those expenses now will have to add up to 10% or more for most tax filers.

The administration has approved the applications for state-run exchanges in 17 states and the District of Columbia. Officials have given approval to state-run insurance exchanges in Utah, California, Hawaii, Idaho, Nevada, New Mexico, Vermont, Colorado, Connecticut, Kentucky, Minnesota, Maryland, Massachusetts, New York, Oregon, Rhode Island, Washington and the District of Columbia. Seven other states have said they want to collaborate with the federal government to set up exchanges (states have until Feb. 15 to sign up for such partnership arrangements). A federal exchange will be available for all states that refuse to take any action.

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Stark has "been part of almost every piece of health legislation that's been enacted, including the Affordable Care Act," Rother says. "And many of the changes and improvements in Medicare trace to him as well."

Congressional Giant, Major Healthcare Advocate, Leaves Capitol Hill

The 113th Congress that began in January was the first one in 40 years to convene without California Rep. Pete Stark, who had a critical hand in many of the big health care laws over that time period. Stark, the San Francisco area lawmaker, was defeated in November by a fellow Democrat under new California voting rules. While he may not be a household name along the lines of former Florida lawmaker Claude Pepper, his impact on the nation’s health care system was a profound one.

So just how influential has Pete Stark been on health policy since he came to Congress in 1973? Very, John Rother, former legislative director of the AARP and now the head of the National Coalition on Health Care, told National Public Radio recently.

Stark has "been part of almost every piece of health legislation that's been enacted, including the Affordable Care Act," Rother says. "And many of the changes and improvements in Medicare trace to him as well."

Among the things that Stark accomplished, was the establishment of COBRA, the 1986 law that allows people to remain on their employer’s health insurance plan after they leave their job, as long as they pay the full premium. Stark also pushed through EMTALA, the Emergency Medical Treatment and Active Labor Act, which requires hospitals that participate in Medicare or Medicaid to see and stabilize anyone who shows up in their emergency rooms, regardless of their insurance status.

The EMTALA law is a much bigger deal than many people realize, fellow California Democratic Rep Henry Waxman told NPR. "Imagine what it would be like in this country if somebody was brought into an emergency room and because they didn't have insurance they were just turned away to bleed to death in the streets," said Waxman, who chaired the House Energy and Commerce Subcommittee on Health for many of the same years Stark chaired the Ways and Means Subcommittee on Health.

Stark was one of the true champions of Medicare in the same way that Pepper was viewed as a champion of Social Security. His advocacy for seniors will be missed in the partisan battles of Congress.

Alan Schlein runs DeadlineOnline.com, an internet training and consulting firm. He is the author of the bestselling “Find It Online” books.

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