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CHARLESTON, W.Va. -- In the past year, Jeremiah Samples has worked a lot of 12-hour days.

He comes in early to work at the West Virginia Insurance Commission. At night, after his 1-year-old son goes to sleep, he often goes back to work.

"My son's smile melts any stress away," he said. "He reminds me of what this is all about."

The 28-year-old Kanawha County native is overseeing the creation of West Virginia's health insurance exchange. He and his co-workers have three years, but they're still racing the clock.

After Jan. 1, 2014, at least a quarter-million West Virginians will be eligible to sign up for subsidized or free health insurance under the federal health-care reform law.

"2014 is tomorrow," Samples said, rubbing his eyes. "There's so much to do between now and then."

"This is not a large state, and there are approximately 260,000 West Virginians without insurance," he said, "so what we're doing here will affect the lives of people you know."

Under health reform, each state creates its own exchange. They are likely to be quite different, Samples said. The Utah exchange relies heavily on the free market, while the Vermont legislature has voted for a single-payer system.

If a state decides to have no exchange, its citizens go into a national exchange created by the federal government.

Samples has his eye on the clock. By Jan. 1, 2014, all Americans must have health insurance, and all exchanges must be up and running, so people can log on to compare policies and prices.

People will be able to buy policies through the exchanges. Small businesses will be able to pool their numbers for more buying power.

"We want to work out technical bugs in advance," Samples said. "There's going to be mass confusion out there in January 2014, and I don't want to compound it by having tech glitches in the exchange."

When people sign on, they will see policies offered by private companies like Mountain State Blue Cross/Blue Shield and other familiar names, he said.

The Insurance Commission will have reviewed all policies on the exchange to make sure they cover basic primary and hospital care prescribed by federal law. No scams will be listed, he said.

Since insurance companies no longer can refuse to cover people who have pre-existing conditions or cut off customers who get sick, he said, those policies also will be more reliable.

Starting in 2014, individuals who earn up to $46,000 will qualify for subsidized policies that cost less than before. So will families of four who make up to $93,000 in 2014 dollars, according to the Kaiser Family Foundation.

An estimated 125,000 West Virginians will get subsidies, according to the best available estimates, Samples said. The higher the income, the lower the subsidy.

"Most subsidies go to working uninsured people," people who make too much to qualify for Medicaid, but too little to buy good insurance, he said. "They may work in fast food. Maybe they have a job where the employer does not offer coverage. Or they're self-employed.

"They might not be sick or have a chronic ailment right now, but things happen, and health bills can bankrupt you."

The law pays for the subsidies by specified taxes so as not to add to the deficit. A subsidy averages, nationwide, about $6,000 per year.

In 2014, another estimated 150,000 West Virginians who make less than $15,000 will be eligible for Medicaid coverage that costs them nothing.

What about people who already have insurance or get no subsidy? They will save, too, in a less obvious way, Samples said. Their premiums and medical bills are driven up by millions of dollars in unpaid medical bills and emergency room costs that get shifted each year onto paying patients.

With universal insurance, that cycle stops.

Large employers like the chemical companies, that have self-insured plans can keep them, he said. They will be grandfathered.

For people who don't use computers, the Insurance Commission will create an 800 number and arrange for local "navigators" who sit down with people one-on-one and help them navigate the new exchange. There will be paper applications.

"Lots to do before all this can happen," Samples said.

What does Samples want to tell West Virginians at this point? "Three things.

"First, don't panic. There's a lot of misinformation out there. People need to educate themselves, sift through all the information and misinformation."

Second: "This is the start of a long process. It's a marathon, not a sprint."

Third: "The public has to be involved in the creation of the exchange, to make this a success. So we're going to make this a transparent process."

To hear from the public, the Insurance Commission is sponsoring six forums statewide and setting up four advisory committees. (See schedule, this page.)

The next step: State lawmakers must give the official green light if West Virginia is to have its own exchange. Otherwise, West Virginians become part of a national exchange.

States must tell the feds their plans by 2013. If West Virginia has its own exchange, many questions must be answered. For instance:

| Should we combine small business and individuals into one big pool for more negotiating power?

| Which insurance companies will participate? "We have had detailed discussions with many," Samples said.

| What kind of staff and experts will be needed to review and approve premium increase requests, as the health reform law requires.

| How can the state avoid the scenario in which healthy people pay the penalty and only sick people sign up? "That would poison the pool," Samples said.

| How will insurance policies be reviewed, described and categorized?

| Precisely how many people qualify for subsidies?

| Does West Virginia have a large enough pool of customers to make an exchange viable? "We're going to run economic models on that question."

| What if the state requires all insurance to be sold through the exchange? "We're bringing in actuaries to answer questions like that."

| What if a lot of people pay the penalty and stay out while they're healthy, then sign up as soon as they get sick? A strict enrollment period policy can help, Samples said.

| How will massive data be transmitted between Washington and the states?

West Virginia could also combine forces with other states to make a bigger pool. "We've talked about that with several states," Samples said, "but we are a small state with a lot of chronic disease, and right now, most states are still trying to figure out what their exchange will look like. We're going to have to wait to answer that one."

Samples will not answer policy questions, he says. "The exchange board answers those," he said. "I'm the facilitator, the organizer of information."

Who will be on the exchange board? Will insurance companies be represented? Consumers? Brokers? Lawmakers will answer that question.

The Legislature must also decide whether the exchange will be run by the Insurance Commission or be an independent board like the Public Employees Insurance Agency board.

Samples knows that various members of Congress have vowed to repeal the health-reform law. He knows 20 states have sued to stop the mandate that everyone have insurance. "Our job is to make this work as well for West Virginians as it can," he said. "Till somebody tells us the law is different, we'll keep trying to do that."

West Virginia applied for federal money to create an exchange at a time when the national health-reform law was in doubt, he notes. "People thought it was a good idea" to give people a place to review approved insurance.

West Virginia was already working on its exchange when the national law passed, "so we were ahead of the curve." They had brought in national technical experts and consulted with states that have exchanges.

Several other states have asked West Virginia for help in the past year, he said. "We're seen as a leader in this," he said. "We recently helped Arkansas with some technical matters."

In October, his boss, Insurance Commissioner Jane Cline -- also president of the National Association of Insurance Commissioners -- told the Gazette-Mail that the Governor's Office had not let the commission hire enough staff members to create the exchange.

They have now received permission to hire three more analysts. "Once we get them on board, we'll be humming along," Samples said.

The workdays will stay long, he said. "But it's temporary, and this is a very exciting time to work in health care. I wasn't around when Social Security or Medicare were passed, but this affects as many people."

On a dry-erase board in his office, he has written his overall goals. "They remind me of the big picture when I get lost in the details," he said.

In red letters, he wrote: "Better organize West Virginia health insurance market ... facilitate access to health care for working uninsured . . . drive system efficiency and cost containment . . . provide portal to all health-care services in West Virginia"

At the bottom, in big blue letters, he wrote: DO NO HARM.

"That sums it up," he said.

Reach Kate Long at 304-348-1798 or katel...@wvgazette.com.