Can you save with a health exchange?

Nor will all states choose to run their exchanges through their Department of Insurance, which regulates insurance. "States that perceive their exchange as a purchasing market may feel it needs to be separate from regulation in order to do its job," Gauthier says.

Will exchanges have a physical presence such as a storefront? Probably yes, though not in the traditional sense. "Initially, I think we will see most states use their (insurance) agents and brokers as their partners to help get people into the exchange and purchase coverage," Gauthier says. In which case, you may have already walked into your state's future storefront.

Where do insurance companies fit in?

A major question facing all exchange planners is whether, and to what extent, to limit participation by insurance companies. Some view this as imperative, to simplify the choices for consumers and to drive down policy costs; others say the free market will do both naturally. The federal government is expected to define minimum benefit amounts in the near future.

"What I believe will happen in the end is, you'll have a more simplified product offering, which will save money," says Carroll. "Having government contracting does put downward pressure on the market."

Gauthier says some states may choose a wait-and-see approach.

"In most states, 40-some, these decisions are not yet made," she says. "Some states want any willing plan that is a qualified health plan to participate. Others are designing to limit participation because they believe that will drive quality and efficiency, and we'll figure out the details down the road. California, for example, has legislation that allows them to be selective but doesn't require that they be; it leaves those very important implementation details to the board to determine."

Will you save money?

Once the dust settles, will consumers save money on health insurance?

Conner says yes: "The whole purpose of the exchange is to provide some cost containment. By creating a competitive market with the insurance carriers, we're driving down that cost."

Carroll is optimistic as well. "I believe it will, but it will take time. It's very expensive for insurance companies to be managing too many different products. There are some opportunities to use the exchanges as a way to simplify their offerings," he says.

But Gauthier is cautious.

"It depends on what you mean by saving money. Many Americans who are currently middle class and are struggling to afford health insurance are going to be offered unprecedented levels of subsidies, so from the consumer's perspective, insurance will be more affordable.

"But unless we change the payment system and the way in which care is delivered, the costs are going to be unsustainable and health insurance will not be affordable. I think that the exchanges are a piece of the puzzle, but by no means can the exchanges themselves make insurance more affordable."

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