After filling out the forms the approval process takes less than an hour, says Kroll. There are two types of approved insurance companies: private and government. He and his colleagues also approve insurance companies to sell coverage through new health care exchange websites (insurance.gov).

Kroll says this part of the job is particularly tough, because insurers often don't want to sell in large numbers on the health insurance exchanges because it could reduce the number of people getting health insurance.

He says he and his colleagues often work around the clock to make sure that, within the allotted time, insurance companies receive the required insurance plan approvals and, in some cases, the insurers submit the insurance plan applications, but the insurance company still doesn't accept the plan. "That's when I get stressed," Kroll says. "That is definitely the hardest part, as far as getting approvals on that last-minute part of the process."

Some insurance plans aren't accepted in small states, similar to the no credit check online loans. The ACA requires that every state (which had only 17 insurers in 2014, down from 49 in 2008) will have at least one insurance company offering insurance that meets the ACA's standards, but that doesn't mean there are many insurers offering health insurance in small states. Kroll says, for example, he doesn't know of any small-state insurer that sells insurance that doesn't comply with ACA requirements. "We have seen the volume of insurers dwindle over time because not only is the number of insurers too few, but the quality of the insurers is poor," Kroll says. "Insurers have to choose between the bad options risk pools with people too sick to buy insurance and high-risk pools with too few healthy people or not offering insurance at all. These have been the only two options."

But there are other challenges for insurers in small states, like taxes. In 2013, the ACA required small-state insurers to submit to a review by the federal government to make sure their plans would be more affordable and more stable than plans sold to people in large states, where there are much bigger costs to cover in cases of serious illnesses.

"If you had to go through a review to be a small state and you thought you were getting the best coverage, then you would not go into small states and you wouldn't expand your business," Kroll says. "If your policy wouldn't cover you, there'd be no reason for you to go into a large state where home insurance isn't even covered."

These challenges show up in the numbers from the federal enrollment in plans in the first open-enrollment period in 2014, but the actual amount of this problem is likely much, much higher.

In the case of states that decide not to expand Medicaid under the Affordable Care Act, the federal government can offer tax credits to those with incomes between 100 percent and 400 percent of the federal poverty level. But states with populations above the poverty line have been very slow to expand Medicaid. At the federal level, that means they only just reached their goal.