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Many insurance experts and health policy consultants predict only a dozen or so states will be ready to run exchanges on their own — and a few say that projection may be too sunny.

Only a handful of the most militant states are likely to continue all-out resistance to federal health reform if the law is upheld — which ironically would mean the federal government would run their exchanges.

But for most states, the likely scenario is “partnerships” in which states run some parts of these new insurance markets but the feds run many aspects that consumers will experience most directly.

Thirty-four states and Washington, D.C., received exchange planning grants totaling $856 million. Only 14 of them have passed legislation authorizing an exchange, and a couple more are moving ahead under executive orders from the governor. But even some of these states, further along in the planning process, have slowed down while awaiting the Supreme Court ruling on the health law or because the Department of Health and Human Services has been slow to spell out the detailed rules for setting exchange policy.

This partnership approach, which HHS first proposed last summer, is intended to be a transitional step for states that can’t meet the deadline to open their doors in 2014. But now it’s likely to be the default, not the fallback.

This scenario is causing concern at top levels of HHS that exchanges in most states may not meet a key goal of health reform: functioning as a one-stop shop in which people can easily enroll in health insurance whether they pay for it themselves, qualify for subsidized private plans or are eligible for public programs like Medicaid.

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