With less than three years until most aspects of the new health care law start, only 10 states have passed legislation creating new health insurance exchanges according to a report from the Center for Budget and Policy Priorities (PDF). The Affordable Care Act requires states to set up these exchanges; and if a state fails to create the required exchanges, the federal government will create the exchanges in the state instead.

Some of the states, like Florida, won’t be creating exchanges as part of a partisan stance in opposition to the law in general. In other states, the lack of exchange laws are due to a mixture of politics, policy disagreements about exchange design, and issues about resources.

While many more states will pass laws creating the necessary exchanges before 2014, it is likely that the federal government will be forced to operate exchanges across multiple states that hold a significant percentage of our total population. This is going to be problematic because ACA doesn’t provide HHS any money to run such a large operation.  The fact that the federal government will be forced to run a quasi-national system of exchanges anyway, just reinforces what a terrible policy decision it was to go with state-based exchanges instead of a single national exchange that states could adopt out of.