Since being enabled by the Affordable Care Act, Consumer Operated and Oriented Plans have felt like dead men walking to the gallows and nearly everyone following health reform has been ready to write their epitaph.

Intended as a replacement for the public option, these new nonprofit plans were modeled on carriers such as Washington's Group Health Cooperative. To jumpstart the CO-OP initiative, the Centers for Medicare & Medicaid Services offered hundreds of millions in startup loans to these largely unknown entities.  Some stumbled early. Vermont rejected its CO-OP's application to sell policies, leading it to close before it ever opened.

But a funny thing might happen: Some crafty maneuvers worthy of the nation's private-sector insurers may give CO-OPs staying power and a number of them are looking at expansion in 2015.

Early enrollment figures for one CO-OP signal that a multi-state approach might be the way to go. One of the few CO-OPs to launch in multiple states, CoOportunity Health, reported enrollment of 35,000 people between Iowa and Nebraska. CoOportunity anticipated 12,000 members in its first year. More importantly, the CO-OP's membership is distributed evenly across different age groups and did not skew older, a common fear for CO-OPs. With a base of 22,000 individuals and 700 employer groups, CoOportunity Health has several more months of open enrollment to build upon those numbers.

At least three CO-OPs are taking a similar approach. For 2015, the Montana Health CO-OP will sell plans in Idaho and Kentucky Health Cooperative is expanding into West Virginia. Minuteman Health, based in Massachusetts, is expanding into New Hampshire.

If those expansions take hold, there's a high probability of further moves into other states to position themselves as true regional players. The Massachusetts and Montana CO-OPs could easily expand to other surrounding states if they find success in 2015 and at some point, even Vermont could get a CO-OP just not the one originally chartered in the state.

There are reports that CO-OPs are also considering reciprocal network agreements, allowing members access to other CO-OP provider networks similar to the BlueCard program. The BlueCard program gives regional BlueCross and Blue Shield plan members a preferred network of physicians virtually anywhere in the country.

A CO-OP network would be smaller many CO-OPs have narrow networks and accountable care partnerships but it could be an important differentiating factor for companies with employees in multiple locations or individuals who want a larger network.

A group effort could improve the CO-OPs long-term prospects. Some CO-OPs will undoubtedly go the way of the Vermont CO-OP. But a broad network, expanded footprints and a unified front could strengthen what was seen as one of the ACA's shakier initiatives.

Follow Bill Melville on Twitter @BillMelvilleHLI

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