Now that the health care reform law has been ruled constitutional, it is imperative that as many states as possible move aggressively to establish a centerpiece of the reform structure: new insurance policy exchanges for people who lack affordable coverage through an employer. Federal subsidies will be available for those with low or moderate incomes.


States that were dawdling or refusing to set up exchanges in expectation that the Supreme Court would strike down the law have little time left to meet tight deadlines. If they fail, the federal government will establish an exchange to serve their residents, who otherwise would have no way to obtain subsidies to reduce the cost of their insurance.


The exchanges will essentially be online marketplaces for private plans that provide a package of essential benefits and consumer protections like guaranteed coverage for pre-existing conditions. They will compete to sell policies to individuals, families and small businesses. Anyone can use the exchanges to gain the benefits of comparative shopping, but most customers are expected to be individuals and families with incomes between 133 percent and 400 percent of the federal poverty level. They will be eligible for federal tax subsidies to make insurance affordable.


Many states are well on the way toward setting up exchanges, a complicated process in which governance procedures must be established, standards must be set for the plans that will compete and new information technologies put in place. The big uncertainty is how many Republican-led states will refuse to set up exchanges either because they adamantly oppose all aspects of the reform law or because they are reluctant to spend any time, effort or money to set up a mechanism that they hope Republicans will repeal after the November elections. That sounds like wishful thinking. States would be foolish to rely on it with deadlines fast approaching.


States must tell the secretary of health and human services by Nov. 16, just 10 days after the election, whether or not they plan to set up their own exchanges. The secretary must then certify by Jan. 1, 2013, whether states are on track to start enrolling people by Oct. 1, 2013, and to actually open for business on Jan. 1, 2014.


The Obama administration, which is eager to see the law implemented effectively, seems willing to accommodate any states that will make a good-faith effort. On Friday, the secretary, Kathleen Sebelius, announced that, in addition to grants already made to 34 states and the District of Columbia to plan their exchanges, she would open up additional financing sources that could be used even after the original start-up deadline. She also pledged to work closely with the states to tailor a federal exchange to meet their needs and a plan for transition to state control.


That sounds like a deal that no responsible elected official should pass up in the quixotic hope that the reform law will somehow go away.