This report from The Commonwealth Fund examines the key design decisions that states seeking to establish state-based health insurance exchanges under the Patient Protection and Affordable Care Act are implementing by October 1, 2013.  This report examines key design decisions made by the 17 states and the District of Columbia that chose to establish a state-based exchange.  The analysis finds that states made significant progress in structuring their exchanges, with states varying in their design decisions.

Among the key design decisions implemented by the state-based exchanges were:

  • States structured exchanges to reflect their unique needs and capabilities
  • States adopted formal and informal mechanisms to foster a competitive marketplace
  • States limited or standardized plans and emphasized quality in consumer choices
  • States designed their Small Business Health Options Program (SHOP) to minimize market disruption and improve employee choices
  • States promoted consumer assistance through navigators, in-person assisters, and agents and brokers

Many states expect to exceed some federal requirements—to collect and display quality data, for instance—for 2014.  These findings suggest that states capitalized on the flexibility provided by the Affordable Care Act to tailor their exchanges to their unique needs and made decisions with an eye towards outcomes, such as enrollment, consumer experience, and sustainability.  These findings also suggest that states’ initial decisions will inform future exchange implementation and that states will adjust their decisions while continuing to adopt innovative approaches to accomplish policy goals. The report was written by the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms.

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