Hunt says the core issues that every state has to think through when devising their exchanges include questions on eligibility and insurance market reforms. "But the decisions each state makes are going to reflect their own circumstances. They all have to think about the same questions, but how they answer them is unique to their circumstances," she says.
For example, Utah is taking a free market approach with its exchanges and allowing relatively easy access to the exchange for anyone selling a health plan. "Other states want to provide more information to consumers and take more direction in how they offer products in the market," Hunt says.
Maggie Elehwany, vice president of government affairs and policy with the National Rural Health Association, says it's difficult to say what effect the health insurance exchanges will have in rural areas. "In theory it sounds good, but we don't know yet how it will play out," she says.
"Often if you look at rural areas, there isn't a choice. There are one or two plans. So this has the potential to expand options, which is great in theory. But we are concerned about a lot of the exchanges not doing the outreach to rural areas," she says. "We are intrigued with the co-op concept of different entities coming together to be able to have a plan. Dairy co-ops and wheat co-ops have been found to be effective in rural areas."
Elehwany says the nonpartisan NRHA did not endorse or oppose the ACA, but supported "building blocks" in the law that bolster access to healthcare in rural areas. The challenge now, she says, is to ensure that those building blocks are funded, particularly in critical areas that address provider shortages in rural areas.
"There was a significant expansion of the National Health Service Corps and a big investment in area health education centers which foster a program of growing your own physicians, nurse practitioners, that kind of stuff," she says. "We loved the redistribution of residency slots that targeted rural areas and the 10% bonus for primary care payments. Those were temporary. They may be funded for a short period and the funding will end."