There were hundreds of people in the room at the opening of America's Health Insurance Plans session on health insurance exchanges this week. It took only about an hour for the elephant to show up.

That happened when someone asked if the millions of dollars and months of time will all go down the tube should U.S. courts rule against the Affordable Care Act's individual mandate and support states that have sued the federal government. The speaker dodged the question, as well she should have, because no one in the room really knew what would happen should the 2010 law start unraveling.

One thing is for sure it would be a big mess. A big part of the U.S. economy has been operating on the assumption that the ACA will survive court challenges because it has no choice but to do so. The federal government has spent more than $300 million just in implementation grants to states that are ahead of the curve on the health benefits exchanges. More than a dozen states have laws in place for exchanges and are starting to build infrastructure to accommodate them.

The ACA requires states to offer benefits exchanges to help individuals and small-business employees to connect to insurance. While the exchanges are set to begin operating in 2014, states must have them in place in 2013.

Word at the AHIP conference in San Francisco this week was that the federal government would be coming out with detailed rules on exchanges within the next two weeks. That will be a relief to state boards and agencies trying to work out details on how the exchanges will work. It will also give direction to health plans trying to decide whether to play in that marketplace.

While every state's approach is looking unique, several speakers in San Francisco stressed that the exchanges will be more than a portal for commercial insurance, but will also connect to Medicaid and other state-sponsored programs. If health plans aren't in the Medicaid markets already, now they may have another reason to do so.

The exchanges promise to be complicated, costly and changeable. And if the courts rule against the Obama administration, changeable may be the one word to sum it all up.

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