Timothy Stoltzfus Jost Washington and Lee University School of Law Health Insurance Exchanges and the Affordable Care Act: Eight Difficult Issues

1. Governance How should exchanges be governed? Should they be run by a state agency or a nonprofit entity?

2. Adverse Selection The most significant problem exchanges have grappled with historically has been adverse selection. What should be done to avoid adverse selection against and within exchanges?

3. Self-insured Plans Opening exchanges to large employer plans, and in particular to formerly self-insured employee benefit plans, poses a significant threat to the exchanges. What must be done to make self-insured plans compatible with exchanges?

4. Attracting Employers Exchanges must attract employers as well as individual enrollees if they are to succeed. What can be done to make exchanges attractive to employers?

5. Certifying Plans The ACA requires exchanges to certify health plans that meet certain requirements for participation in the exchange. How should exchanges exercise this regulatory authority?

6. Consumer Information The ACA requires exchanges to make both descriptive and evaluative information available to consumers. How should exchanges fulfill this responsibility?

7. Determining Eligibility Exchanges play a central role in making eligibility determinations for premium tax credits and cost-sharing reduction payments and for the Medicaid and Children’s Health Insurance Programs. How should eligibility determinations work under the Affordable Care Act?

8. Financing Exchanges must find ways to hold down administrative costs and must identify funding sources if they are to succeed. What can exchanges do to reduce administrative costs and attract funding?