摘要：Health insurance exchanges are a key component of the Affordable Care Act. Each exchange faces the challenge of minimizing friction with existing policies, coordinating churn between programs, and maximizing take-up. State-run exchanges would likely be better positioned to address these issues than a federally run exchange, yet only one third of states chose this path. Policymakers must ensure that their exchange—whether state or federally run—succeeds. Whether this happens will greatly depend on the political dynamics in each state. ONE OF THE MOST IMPORTANT components of the Patient Protection and Affordable Care Act of 2010 (ACA) 1 is the creation of health insurance exchanges. Exchanges will be online marketplaces through which individuals and small businesses will shop for health insurance. The goal of an exchange is to expand coverage for previously uninsured populations while increasing transparency in the health insurance marketplace by enabling consumers to compare plans in a standardized way. The exchange will also be the mechanism through which qualifying individuals receive subsidies from the federal government to purchase private insurance coverage. It is estimated that 24 million people will receive insurance through an exchange by 2016. 2 Every state will have an exchange, although states have had to decide whether to create the exchange themselves or cede control to the federal government. Public opinion is divided over the ACA as a whole, yet exchanges were not expected to be controversial in their own right. Republicans endorsed organized marketplaces for insurance in the past and even supported state insurance exchanges during the legislative battles over the ACA. 3 A November 2012 Associated Press poll found that 63% of Americans preferred a state-run exchange; 32% favored federal control. Among Republican respondents, 81% preferred state control. 4 However, after 3 years of contentious debates, only 17 states and the District of Columbia chose to create an exchange themselves. Six chose to partner with the federal government, and the remaining 27 states chose to allow the federal government to develop and run their exchange. 5 States can take control of their exchanges at any point in the future. However, a state that inherits a federal structure will have lost the opportunity to make decisions that will dramatically affect both what the exchange strives to accomplish and whether it succeeds. This includes shaping whether the exchange is run inside government or as a nonprofit organization, the role of the exchange in determining what plans can be sold, how the exchange is financed, the role of insurance agents and brokers, and whether interest group representatives sit on the board of directors. The ACA was written with the assumption that states would take the initiative to create their own exchange. The law gives the Department of Health and Human Services authority to fund the creation of state-run exchanges and provide subsidies through state-based exchanges but includes no specific authorization to provide subsidies through a federally run exchange. 1 Neither did the department receive resources to create federally run exchanges. It has had to divert this money from other parts of its budget. Opponents offer several reasons for being cautious about creating a state exchange. For example, state policymakers have complained that federal guidelines have taken too long to develop and that creating an exchange commits them to restrictions of which they are not yet aware. 6 Second, frustration over lack of federal guidance is compounded by a fear of hidden costs. Opponents worry that exchanges will be more expensive than expected and that states will ultimately be burdened by these additional costs. 7 Finally, some argue that states would not have much control anyway and would function as a vendor for the federal government. 8 Although we believe that the benefits of state-run exchanges outweigh these concerns, it may be that there is no single answer to the question of whether a state should have created its own exchange. A state exchange would stand no chance of success if run by leaders who were uncommitted or even belligerent toward the idea. That only 17 states chose to create an exchange should not necessarily be viewed as a failure for the administration of President Barack Obama. This may be the ideal outcome. Every state will have an exchange, and early adopter states will benefit from flexibility and grant money when they design their own exchange. These states will serve as a natural experiment through which the rest of the country can observe the advantages and disadvantages of each model.
