This issue brief from the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms examines how states have decided to implement health insurance exchanges under the Patient Protection and Affordable Care Act. States have four options for exchange establishment. States can choose to establish a state-based exchange, default to a federally-facilitated exchange, or conduct certain exchange functions either through a state partnership exchange or a marketplace plan management option.
This issue brief identifies the exchange model chosen in all 50 states and the District of Columbia, and examines how states decided among these options. Seventeen states and the District of Columbia chose to establish state-based exchanges, while 33 states chose to default to federally-facilitated exchanges. Of the 33 states, seven chose to pursue formal state partnership exchanges, and another seven are pursuing a marketplace plan management option. In addition, every state and the District of Columbia took action to evaluate their exchange options, and states considered similar factors including the ability to maintain regulatory control over their insurance markets and tailor solutions to their populations, even while opting for different exchange models. These findings suggest that establishment decisions will continue to evolve as states learn from early successes and challenges and that states may transition between models after 2014.