Paul Fearer and his three colleagues are waiting for the fifth and final appointee to the California Health Benefit Exchange so the board can set policy in motion in preparation for the exchange's start-up in 2014. He joins California Health and Human Services Secretary Diana Dooley, former California HHS Secretary Kim Belshé and former Schwarzenegger administration chief of staff Susan Kennedy on the exchange board.

Fearer indicated that he is particularly focused on improving quality while constraining costs. "Affordability and quality are not in conflict," he said. "The right care at the right time is the most affordable care.".

Fearer earned his stripes at now defunct PacAdvantage, a statewide health insurance purchasing pool for small business, which he chaired for seven years. Fearer said he learned a lot from PacAdvantage -- about what works and what does not." The risk profile of the population being served has to be reasonable to avoid adverse risk selection, a fatal weakness," he said. "Participating plans in PacAdvantage had become the insurers of last resort, making it economically unfeasible to underwrite individuals.

"You also need a competitive offering; efficient, reliable and accurate operations; and customer service addressing underserved communities. That population is most in need of education and information on eligibility and plan choices, which are complicated issues," Fearer said.

Finally, he said the exchange must provide transparent information about plans, providers and coverage options and a robust set of alternatives for individuals so that they can access appropriate care at the right time.

Although the Affordable Care Act sets guidelines for the development of exchanges, Fearer is confident there will be room for tweaking. "The broad range of standards don't preclude innovation," he said. "Over time, operations developed by the exchange will influence the health care delivery system in California."