STATESTATS | February 2014

Mary Winter 2/1/2014


State Health Exchanges in Uncharted Waters

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Health insurance exchanges for all 50 states ramped up in January as the Affordable Care Act continued its rollout. Seventeen states have their own exchanges. The federal government, in varying degrees, runs the exchanges in the remaining states, which have the option to transition to a state exchange after this year. Despite October’s rocky launch of the federal enrollment website,, roughly 2.1 million Americans had signed up for insurance on state or federal websites or by manually completing applications by January 1, the day coverage began.

A goal of the law is to offer affordable health insurance for the 44 million uninsured Americans through these exchanges, also called marketplaces, where individuals can shop for insurance and find out if they’re eligible for federal financial assistance. Small businesses can also buy group health insurance at the exchanges through the Small Business Health Options Program (SHOP). State sites generally have outperformed the federal one; the exchanges in Connecticut, Kentucky, Rhode Island and Washington have done especially well.

Numerous states that accepted federally run exchanges often did so in protest of the law, which policymakers labeled costly, irresponsible, unworkable or a breach of states’ rights. About half also declined federal money to expand Medicaid. 

Who Qualifies for Subsidies?

In most states, people with incomes in these ranges qualify for tax credits to help lower their monthly premiums—or for other financial aid to reduce deductibles or copayments. (Amounts are based on 2013 numbers and are likely to be slightly higher this year.) People who earn less than the lowest amounts may qualify for coverage under state Medicaid.

Health Care Act Basics

Under the law, insurance companies can’t deny someone coverage because of gender or a pre-existing medical condition. When signing up, individuals can choose bronze, silver, gold, or platinum health care plans. Bronze premiums are the lowest, but have the highest copayments; the reverse is true with platinum. Insurance plans on the exchanges must cover, at a minimum:

  • Ambulance services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse services, including counseling
  • Prescription drugs
  • Rehabilitative services and devices
  • Lab services
  • Preventive and wellness services
  • Chronic disease management
  • Pediatric services, including oral and vision care


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