With less than three years until most aspects of the new health care law start, only 10 states have passed legislation creating new health insurance exchanges.

Some of my darkest predictions about the new health care law are coming true. With businesses again clamoring for corporate tax reduction, the go-to in Pay-Go-obsessed Washington are the affordability subsidies for people who will be using the new health care exchanges.

The insurance companies are off and running and their lobbyists are going to be extremely busy. The gaming of the new system has already begun in state legislators’ and insurance commissioners’ offices, and in regulatory drafting committees far away from scrutiny by the media and the public. Let’s just hope the whole thing is not completely gutted between now and 2014 when the biggest changes to health care begin.

The White House and Democratic leaders have made many promises about health care reform throughout this long and winding process—from guaranteeing affordable, quality care for everyone to pledging tougher regulation of the medical industrial complex that created this broken system in the first place. If the majority party wants to honestly deliver on these promises—not to mention if they want to remain in the majority—then a concerted and immediate effort is required to prove that this week’s legislation is truly the first step toward reform, and not the last.