Responding to a request from Republican governors, Sebelius last month extended the deadline for submitting a letter of intent and application to operate an exchange to Dec. 14. States falling behind on exchange-building activities can still request help. The deadline to apply to operate an exchange in partnership with the federal government is Feb. 15, 2013.
For the most part, states with Republican governors opted to default to a federal exchange. Just five Republican-led states will run their own exchanges, and two will partner with the federal government.
"The great irony of this whole thing is you have the majority of the Republican governors really allowing the federal takeover of health care when they could choose to have a state exchange," Derksen said.
But will people care whether their state is the face behind the exchange?
"From a consumer perspective, whether you have a state-run exchange or a federal exchange doesn't make a huge difference," said Caroline Pearson, a director at Avalere Health LLC, a Washington, D.C.-based consulting firm. In either case, she noted, people will get coverage.
Where it begins to matter is in the details, Pearson explained. States can customize health plan options to accommodate the particular needs of their residents, she said. And because Medicaid eligibility rules are state-specific, states may be able to do a better job of helping lower income people who apply through the exchange to coordinate coverage with the state Medicaid program, she added.
Avalere Health predicts that roughly two-thirds of the 8.2 million people expected to buy coverage through the exchanges in 2014 will do so through a federally administered or partnership exchange.
"Consumers also need to watch the debate over the fiscal cliff," McArdle cautioned. To offset scheduled tax increases and spending cuts slated to take effect in the new year, Congress could reduce health insurance subsidies under the Affordable Care Act, making health coverage less affordable.
"If the fiscal cliff and deficit reduction negotiations were to result in a reduction in federal subsidies available under the ACA [Affordable Care Act] starting in 2014, that could make coverage in the health insurance exchanges less affordable for some people," he said.
Visit the Henry J. Kaiser Family Foundation's state health facts web page for details on state participation in health insurance exchanges.
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