Your kid doesn't come with a manual either:
I've read a lot of studies and research driven papers over the past few months about challenges health exchanges across the country are facing. At the most summary level, these reports generally are rich on data about state-by-state exchange enrollment figures released across the country this past Spring and focus on topics such as preparation for the current open enrollment period and the pros/cons of "active" vs. "passive" exchange approach.* This is good information to consider for relative benchmarking. But just as the circumstance to which every child is born and raised is unique, so is the raising of an Exchange.
Don't discount either one... it's both a Nature and Nurture thing.
Like the double-helix defining our DNA make-up, there are a set of basic building blocks that make up all Exchanges. Again like the double-helix, the organization of these building blocks can seemingly be infinite in complexity. Between the initial penning of the ACA and the uncountable mutations brought on by State legislators, Insurance Regulators, and self-imposed Exchange rules, it's agreed some Exchanges may at first look distinctive from others, but they are really more similar than not. And, important to note, they have all hung on to the instinctive quest to expand coverage availability and seek enrollment. This is the nature part of the beast.
While Exchanges are similar enough in appearance and share an innate drive to seek enrollment, they do have different environments in which they are striving to reach maturity. Because of this, it's easy to see that while they are all very young, we see them developing at different rates.
With tremendous respect to the structures in place that define the genetic make-up of an Exchange and the importance of this never forgotten, I want to share some about one aspect of nurture Exchange development - while Exchange development is still in toddlerhood.
All kids need to be taught the same stuff from scratch.
No matter how many children you may have had a hand in helping raise, you come to see that each one has to learn over time how to become self sufficient. To add, it is only in retrospect you realize how much you have learned over this same time and how no matter how much you know, you will still at times be stumped.
All the above can apply when you help an Exchange take on its work. Organizationally, the Exchange is itself in a new environment for those working to make it the best it can be - Exchange staff. For its staff, it's a new experience where countless decisions need to be made each day on subject matter few, if any of them, have deep experience. Consider it all: Deciphering usually unclear policy and regulations; data transfer protocols with new entities, 2.3 million and counting ways to slice enrollment data, benefit design impact on enrollment risk-mix, potential enrollee decision processes, working to anticipate media/special interest group response (to whatever!), provider and hospital network coverage assessment, and while there are many others - another new area for most all Exchange staff is the establishment of sales channel outreach and marketing disciplines that combine consumer direct, broker, and community organizations.
The progression of juggling all the examples offered above - and more - is hard enough at any start-up looking to gain customers (i.e. for Exchanges, membership during its first open enrollment). Now, think of this start-up doing all this within a government setting. Not easy. Exchange staff as a whole are working to make it all happen. And in working to accomplish all this, they are doing something very interesting: Exchanges are learning much of what it's like to be a health plan.
Maslow was on to something
Rare is the new insurance company launching in this environment (but those trying are seriously applauded!). And for those few working to bring innovation to a significantly changing coverage marketplace, name one who now or in the past has seen an explosion of growth in a manner equivalent to an Exchange? Just when the Exchanges are looking to perform lesson-learned reviews of the last open enrollment, a whole new something is now here: Renewals. How does the Exchange manage added complexity of working to bring the right value to new enrollees while remaining a value to existing enrollees in subsequent open enrollment periods? It's much like being on point for getting multiple kids ready for school every day: You work to build a routine to make it smoother, but they keep finding new ways to make it never quite go very smooth.
However, just as parents somehow manage to get the kids to class so they keep learning, so can and will people help Exchanges evolve. In supporting Exchanges at this juncture be on path to realize their potential, those called on for help who are experienced and knowledgeable in managing price and health services availability for large numbers of people over long periods time have responsibilities. These include providing decisive direction while creating an environment where those progressing along the learning curve are allowed to engage, try, and learn. This transfer of knowledge is key to healthy growth and we must provide this as a basic tenet to Exchanges operating as efficiently as their environment will allow.
All parents have expectations. And the high expectations our country has for the ACA and each and every Exchange (public or private) is for them to become reliable conduits for improved health of us as a population. "Live, Learn, and Pass it on" is a good mantra for anyone having a hand in raising kids. It's no different for raising Exchanges.
( * Actually, all exchanges are - recognized or not - on some continuum of "active".)