After months of assuming that the school would burn down before the homework was due, more than half the states in the union are going to be scrambling to create insurance exchanges before a Nov. 16, 2012, deadline to submit a plan.

The Affordable Care Act, upheld by the Supreme Court in National Federation of Independent Business v. Sebelius on June 28, 2012, requires each state to establish a health ¬insurance exchange, basically a website that functions as a one-stop mar¬ketplace for individuals and small businesses to compare and purchase community-rated health insurance.

Individuals with incomes between 100 percent and 400 percent of the poverty level will receive tax credits to help pay for the policy. By 2019, 20 million of the 24 million people that buy insurance on an exchange are expected to receive an average federal subsidy of $6,460 per person, according to Congressional Budget Office estimates. Small businesses can also use the exchanges to purchase plans, or employers can offer employees a voucher to purchase a plan on the exchange.

Exchanges are conceived as a user-friendly interface for low-income and uninsured individuals to maintain consistent insurance coverage if they fluctuate between public programs such as Medicaid and periods of uninsured employment.

Exchanges are inherently neutral politically, simply a mechanism for insurance companies to offer a variety of affordable plans and for consumers to comparison shop the way they do for airline tickets.

However, states, reactions to the exchange mandate in the Affordable Care Act range from the A+ students Utah and Massachusetts, which already have operational exchanges, to truants such as Florida, where Gov. Rick Scott has said he won't implement any element of the law until after the November elections.

As of June 18, 2012, three states had announced they would not create an exchange: Louisiana, Maine, and New Hampshire. Fifteen had established exchanges, 18 were studying options and 14 had taken no significant action, according to the Kaiser Family Foundation.

In states such as Michigan, Georgia and Arkansas, governors and state regulators have accepted, even embraced, the concept, but conservative legislatures blocked implementation while the Supreme Court's decision was in doubt. Michigan, for example, turned down $10 million in federal funding to help establish the exchange, and is not alone in rejecting these substantial inducements to comply with the law.

On the other hand, even before the Supreme Court decision was announced, states such as Maryland and Connecticut had determined to move ahead with exchanges even if the ACA was struck down.

The Massachusetts Connector was launched after the 2006 passage of the state's landmark healthcare reform bill and by 2011 had helped more than 540,000 individuals obtain both subsidized and unsubsidized health insurance. In Massachusetts, premiums for these types of individual and small business policies dropped dramatically after introduction of the Connector, and public support for the program is about 75 percent.

Utah's exchange is a portal that allows employers or individuals to purchase insurance on the web-based exchange. At present, the Utah Health Exchange does not offer subsidized insurance. In June 2012, the Utah Health Exchange had 285 employer groups participating and 6,600 covered lives. Although 140 different products are offered on the exchange, the most popular choices are traditional plans with deductibles in the $500-$750 range. Utah even has a pilot for large employers to use the exchange to shop for health insurance group plans.

So for the recalcitrant states, the bad news is that the school is still standing, the teacher is tapping his foot, and states are now under the gun to finish their work or fail the class. Unless they're counting on the ACA being overturned in the next Congress under a new president, that strategy may not look as attractive as it did last Wednesday.

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