The N.C. Senate is slated to vote as early as this evening on a measure that would reject both expansion of the state Medicaid program and creation of a state-run health insurance exchange. As senators prepare for their debate, they might be interested in former Health and Human Services deputy secretary Tevi Troy‘s article on exchanges in the latest Commentary magazine.

Troy reminds us that “[m]ost conservative health-care experts have no theoretical problem with the concept of an exchange, nor do liberals. …”

The Obama exchanges are of a different order entirely, however. They will not merely be advisory; they will be policymaking bodies and enforcement mechanisms. They are designed to take control of the way heath-care access is granted at the state level — the cost, the shape of the coverage, and who is getting how much care. According to the text of the Affordable Care Act, the state-based exchanges must determine who has access to the exchanges; restrict the number of plans that can participate; set up a tiered system of insurance plans; regulate the practices of participating insurance plans; establish call centers and certain types of forms for consumers to use; and monitor the way companies market plans to consumers in a variety of ways. And since the 2,700-page statute is not detailed enough, the administration is expanding upon these requirements through the drafting of ongoing regulations — 13,000 pages of them so far, and counting.

The Obama exchanges have a Big Brother quality to them. They were created to keep track of the Department of Health and Human Services-approved levels of essential benefits, who receives subsidies and of what size, and who gets insurance and who does not. The annual operating costs of running the Obama-envisioned exchanges are still unknown; most estimates are in the $30 million range per state, but some go as high as $100 million. Oregon is hiring 150 people for its call center alone.