An article in the Washington Post this week stated that only 13 states and the District of Columbia have formally stated that they intend to set up state-based health insurance exchanges.

What about the other 37 states?

The other states are either behind in their planning, or they have decided not to operate exchanges, the article continued.

The passage of the Affordable Care Act originally intended for all states to create exchange programs. The SCOTUS decision this summer changed that regulation, and now 37 states are either opting to not create exchanges or are not making the exchanges a priority. Why have the states chosen not to set up these exchanges?

Setting up an exchange has proved to be quite complicated. Not only do the states have to set up a marketplace where citizens can compare health insurance programs, but they also must set up call centers and websites to make information accessible from anywhere. These call centers and websites have to be easy to understand, and they have to make all the details of each insurance plan clear to the potential buyer.

States have until November 16 to tell the federal government whether or not they will set up an exchange. The exchanges have to be up and running by October of 2013, though. What a crunched time frame! It seems unlikely that a state will be able to decide to form an exchange and set it up entirely within the space of a year, especially with such limited information coming from the federal government on how the exchanges should be run. Governor Robert Bentley of Alabama agrees: his state has chosen not to set up an exchange because they feel they do not have sufficient information to set it up in a way that would function well.

It seems clear that health insurance exchanges are not sufficient to solve the uninsurance problem. States are choosing not to participate in these exchanges because the exchanges seem inadequate. This is but one example of the limitaitons of the Affordable Care Act: these limitations are appearing more and more often as the ACA continues to be carried out.