After more than three years of legal challenges, political grandstanding, rulemaking and technology building, it's almost show time for the public health benefits exchanges. In a matter of days, Americans will get their first look under the hood of one of the largest new programs ever undertaken by federal and state governments.

If only Click and Clack were narrating this under-the-hood story, we might all be more amused. As it is, most people just seem puzzled.

The Obama administration finally on Sept. 24 ? just a week before open enrollment begins ? revealed details on rates and competition for the 36 federally facilitated exchanges it's managing. Trouble is the rate examples are all for 27-year-olds (not exactly the primary purchasers), and its details on the number of qualified health plans per state are misleading. A total of 22 QHP options are listed for Mississippi, when in fact, only two companies are participating there ? Humana and Centene, and the level of competition is much less than the administration hints.

On a positive note, the Department of Health & Human Services reports that there are an average of eight different insurers participating in each of the 36 federally run exchanges, from a low of 1 (New Hampshire) to a high of 13 (Michigan). It also says roughly one in four issuers is offering health plans in the individual market for the first time in 2014 when exchanges are set to officially open.

Details on the state-run exchanges have been available for weeks, although even with those, it's been almost impossible to compare new rates to pre-exchange rates, to figure out which providers are in or out of networks, and to dig into drug formulary details. That's a complaint by people in the industry.

Put yourself in the shoes of consumers who don?t know the difference between bronze and platinum, subsidies and full price, or narrow and broad provider networks. Throw in formularies, health spending accounts and copays, and the challenge ahead seems large.

Harris Interactive released a poll this week showing that only 9 percent of the public reports that they are extremely or very familiar with the term health insurance exchanges, while another 21 percent are somewhat familiar. In addition, 71 percent of adults believe the exchanges will be difficult to understand.

So in the waning days of the old insurance system, we wrestle with more unanswered questions:

  • How many people will enroll? The party line has been 7 million in 2014 but some estimates are much lower. However, we could also all be surprised and see large numbers of uninsured in places like California, Florida and Texas buy in.
  • Will the young and healthy enroll? What happens if they don?t?
  • What will exchange purchasers buy? If it's the lowest-premium plans, we should all brace for the impacts of a huge out-of-pocket burden for the newly insured.
  • Will the Republicans succeed in de-funding the Affordable Care Act? Probably not, but if they do, the list of questions becomes mind-boggling. No one, not Click or Clack or Conan or Leno could joke us out of that one.

Register for our upcoming webinar, Making the Grade: A Health Exchange Report Card.

Follow Jane DuBose on Twitter @JaneGDuBoseHLI


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