The Commonwealth Fund released a report examining the challenges that states and federal government will face in implementing the health insurance exchanges required by the Affordable Care Act. The report identifies 8 particularly difficult issues and makes suggestions for how those issues should be dealt with.

From the executive summary: 

The state-level health insurance exchanges to be created under the Affordable Care Act (ACA) are expected to play a major role in the purchase and sale of health insurance when they become fully operational in 2014. This report focuses on eight of the most difficult issues that the states and the federal government face in implementing the exchanges: governance of the exchanges; avoidance of adverse selection; making self-funded plans compatible with exchanges; making exchanges attractive to employers; exchanges' use of their regulatory authority; determining the information that exchanges must make available to consumers and employers; the exchanges' role in making eligibility determinations for premium tax credits and cost-sharing reduction payments and their relationship with public insurance programs; and reducing administrative costs. The report also examines how the ACA handles those issues, and makes concrete recommendations as to how those issues should be addressed.

Full Report: Health Insurance Exchanges and the Affordable Care Act: Eight Difficult Issues (PDF | 473 KB)