A remarkable letter to President Obama from Virginia Governor and Republican Governors Association Chairman Bob McDonnell reveals the extent to which Obamacare’s massive intrusion into 18 percent of the U.S. economy is being executed, on the fly, by bureaucrats in so far over their heads they can’t even see the surface anymore.

The lengthy letter contains a long list of questions that in some cases dive deeply into acronym-filled bureaucratic arcana, but it’s worth scanning just to get an idea of the depth of uncertainty surrounding a law that in just 18 months will intimately affect every health care decision by every family and business in the country, with major impacts not just on their physical but also on their financial health. Here’s just a sample:

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1) Please provide a complete list of regulations that will have to be reviewed, revised and re-opened for public comment prior to implementation as a result of the Supreme Court ruling (e.g., the Medicaid eligibility regulations, exchange regulations related to interface with Medicaid)? What is the schedule for re-issuing these regulations?

2) When will either additional guidance or actual rules be issued on essential health benefits, actuarial value and rating areas?

3) The federal government has already extended deadlines for applying for Level 1 and Level 2 Exchange Establishment funding into 2014. Can we expect extensions of the deadlines for implementation given the uncertainty caused by the Supreme Court ruling and the linkage between Medicaid expansion and exchange eligibility and enrollment functions? In addition, will the deadlines change for states implementing a partnership exchange? Will the deadlines be extended for states implementing a federal exchange?

4) When will the details of the federal partnership options be available? These cannot be considered as an option without details including cost estimates. How will the long term funding of the federally-facilitated healthcare exchanges be sustained?

5) States considering a state-based exchange need to know whether there will be a charge and by how much to use the federal data hub, advance premium tax credit/cost-sharing  reduction service, risk adjustment and transitional reinsurance programs.

There are 12 more sets of questions on health insurance “exchanges,” plus another 13 on Obamacare’s Medicaid expansion. The full letter can be read here. It’s worth at least a quick scan as a stunning expose of the bureaucratic hubris and overreach embodied in this federal law.


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