Obama or Romney: How 2012 Elections Will Impact Exchanges

If Obama is re-elected, Cowart says, HIX will continue as a policy, regardless of who controls the Senate. But if Republicans control the Congress and try to repeal or replace PPACA, then the president would very likely veto the attempt.

If HIX go forward, then most healthcare executives will need much more education on the details, Cowart says. Selecting a rate for the exchanges is a complicated process. First the governor of each state must determine what the essential health plan benefits will be. Then the payers have to organize their networks around those benefits, and then both the commissioner of insurance in each state and the HIX have to oversee the adequacy of that network and the premium pricing to buy that plan.

"What's not in [the law] is oversight on what a plan pays a provider. So it's certainly plausible, in regulations that aren't written yet, for there to be some oversight as to what [rate] is 'reasonable,'" he says."And many governors won't make a decision on how to proceed with exchanges until after the election."

If rates prevail at Medicaid levels or below, then 57% of healthcare executives in the ReviveHealth/Catalyst survey feel the impact on the bottom line would lead them to make substantial cuts to operating costs or do something drastic such as "merge, cut service lines, or close units." Nearly a quarter of respondents say they would decline to participate, while other responses included assertions that they "would go out of business" or "go bankrupt."

That's a grim possibility for some hospitals and health systems Regardless of the election outcome, Cowart says, "On November 7, we're all going to have to have a very adult conversation about exchanges and Medicaid expansion."