Exchanges: job no.1.

• Author: Salazar, Martha
• Position: HEALTH REFORM: SPECIAL REPORT - Health insurance exchanges

Health insurance exchanges, often likened to travel websites such as Expedia or Travelocity but for insurance plans, are the most pressing piece of federal health reform state lawmakers will deal with this year.

These insurance marketplaces must be up and running by the start of 2014. By 2020, an estimated 24 million Americans will be using them to shop for health insurance.

Creating them is no easy task. They require complex technology systems, and must operate in concert with state Medicaid programs. In addition, exchanges must be able to help people determine whether or not they qualify for a federal subsidy to make insurance more affordable.

"Exchanges dominated meetings throughout 20l 1, yet the vast majority of state legislatures must deal with the federal establishment mandates this year," says Alabama Representative Greg Wren (R).

"Legislatures continue to wrangle through the policies and politics of exchanges, and constitutional uncertainties loom at every step along the way," he says.

Massachusetts and Utah created insurance exchanges even before federal health reform. As of Jan. 1, 10 additional states have passed legislation to create their own, and many others are still planning or studying options. Louisiana officials chose to let the federal government run their exchange, and a few other states may follow suit.

"The ACA gives states some flexibility to craft the insurance exchanges in ways that make sense to them," says Colorado Senator Betty Boyd (D), who chairs the Senate Health and Human Services...