WASHINGTON - They are central to the Affordable Care Act, and a year ago, the Obama administration anticipated spending about $2 billion in fiscal 2012 and 2013 on grants to states building marketplaces to sell health insurance.
According to budget proposals released Wednesday, the price tag for 2014 will probably be closer to $4.4 billion.
Including grants the administration expects to make in 2014, costs for the state-run exchanges will reach about $5.7 billion. The budget overrun doesn't include money needed to set up federally facilitated exchanges in the 34 states that chose not to cooperate with President Barack Obama's initiative.
"It's a lot more complicated than anybody imagined," Joseph Antos, a health economist at the nonprofit American Enterprise Institute who advises the Congressional Budget Office, said. "To be fair to CBO, this is one of the many areas where they didn't know how big the bread box was, much less what was in it."
When Congress passed the 2010 health care law, lawmakers envisioned most states would build the exchanges, and they were told by their own budget accountants that the startup costs would be about $2 billion.
Initially billed as a Travelocity or Expedia for health insurance, the exchanges will operate more like tax-preparation software, asking customers a series of questions about their income, work and families and drawing on multiple government databases to determine eligibility for insurance programs and subsidies. The exchanges are supposed to open in October to begin enrolling people in plans that start Jan. 1.
Sixteen states and the District of Columbia are building their own exchanges using federal grants. The Obama administration is building all or part of the exchanges in 34 states whose lawmakers didn't want to do the work.
The spending shouldn't be a surprise, said Gary Claxton, a vice president at the nonprofit Kaiser Family Foundation. "It's a major new health program that's going to provide not just insurance but a regulated market with new types of products and financial assistance, with premium tax credits and cost-sharing subsidies to millions of people."