Associated Press

The Affordable Care Act is moving nearer to full implementation daily, but a centerpeice of the law—state-based insurance exchanges—remains up in the air as states wait for answers and guidance.

Under the Obama administration's health care overhaul, states were given until Nov. 16 to choose between creating their own state-based exchanges, partnering with the federal government to run an exchange or doing neither and defaulting to a federally-facilitated exchange. Although the deadline for creating the exchanges was Nov. 16, the administration released a list of "essential health benefits" that must be offered on Nov. 20. On Nov. 15, the deadline for state exchanges decisions was pushed back to Dec. 14.

Additionally, under a new plan released Nov. 30, insurance companies must pay a monthly fee to sell plans through a federally run insurance exchange. The cost of the "user fees" can be passed on to consumers, adding 3.5 percent to premiums for private health plans sold in insurance exchanges operated by the federal government, The New York Times reported. However, states that operate their own exchanges will likely also charge a user fee for participating insurers, according to The Hill.

Alabama
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 696,000

*Figures from the Associated Press

Alabama's Gov. Robert Bentley said that Alabama would not set up a state exchange, and that, in his opinion, the Affordable Care Act is "truly the worst piece of legislation that has ever been passed in my lifetime," al.com reported on Nov. 13.

Bentley, who is a doctor, said the state study commission previously estimated that the state exchange would cost up to $50 million to operate. He also said the state would not expand Medicaid as it currently exists, because of the long-term costs to the state and the nation.

"I will not expand Medicaid as it exists under the current structure because it is broken," Bentley said. "We just can not afford it. The people of America can not afford it."

Alaska
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents:128,000

Alaska's Gov. Sean Parnell said in July that his state would not create a state-run health insurance exchange, and that stance remains unchanged, the Miami Herald reported on Nov. 15.

"Federally mandated programs should be paid for by federal dollars," Parnell said in July. "It doesn't make sense to spend Alaskans' dollars to set up an exchange when so much uncertainty exists about how to implement it and how to gain federal approval."

According to healthinusrance.org, a study by Public Consulting Group estimated that the cost of implementing the exchange in Alaska would be about $6.7 million

Arizona
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 1,306,000

In a letter dated Nov. 28, Arizona Gov. Jan Brewer wrote to Gary Cohen of the Office of Consumer Information and Insurance Oversight to inform him that Arizona did not intend to operate its own health insurance exchange.

"The failure of Center for Consumer Information and Insurance Oversight and Center for Medicare and Medicaid Services to timely issue detailed regulations, written guidance and inform states when required federal services will be made available has made it impossible for Arizona and other states to make informed decisions on proceeding with a state-based exchange," the letter said.

Brewer said the decision was one of the more difficult in her career in public service, The Hill reported. She said she came to the conclusion that the federal government—not Arizona—would maintain oversight and control over "virtually every aspect of our exchange, limiting our ability to meet the unique needs of Arizonans and the Arizona insurance market."

Arkansas
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Decision pending

Uninsured residents: 545,000

In November, Arkansas Gov. Mike Beebe sent a letter to Health and Human Services Secretary Kathleen Sebelius affirming that Arkansas intended to pursue a partnership with the federal government to run its insurance exchange, but a final decision is still pending after the administration extended the deadline for states.

"We've seen the atmosphere start to shift a little bit post-election, and so while our letter is going off to HHS, we are going to follow up and call them and say, 'Hold on to that letter. With the new deadline there is still a chance that it could be amended,'" Beebe spokesman Matt DeCample told the Times Record.

DeCample said Beebe wanted to know if Republican elected on Nov. 6 would be open to a state-run exchange, or if they would be adamantly opposed to it.

California
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 7,471,000

On July 10, 2012, California Gov. Jerry Brown wrote to confirm that, "California remains fully committed to moving forward with a state-based exchange under the Affordable Care Act."

California was the first state to pass legislation establishing an exchange, and as of July was moving "full speed" to make the exchange operational, the letter said, and the state is currently developing the infrastructure necessary to operate a new health coverage marketplace "that will support the enrollment of millions of Californians."

Colorado
Associated Press

Exchange option: State exchange

Medicaid option: Decision pending

Uninsured residents: 817,000

Colorado Gov. John Hickenlooper submitted a letter to Gary Cohen of the Center for Consumer Information and Insurance Oversight on Oct.8, 2012, indicating the state's intent to form a state-based exchange.

The letter also broke down Colorado's intentions regarding its reinsurance or risk adjustment programs in the first year of the exchange operations, and its processes and procedures for making eligibility determinations for Advance Premium Tax Credits and Cost-Sharing Reductions.

"We look forward to working collaboratively with (the Center for Consumer Information and Insurance Oversight) to obtain approval for a state-based exchange, ensuring that the Colorado Health Benefit Exchange in operational and ready for business by 2014," the letter concluded

Connecticut
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 391,000

A July 10, 2012 letter from Connecticut's Gov. Dannel P. Malloy said the state was "well along in the process of implementing a state-based exchange," which would work to increase the number of insured residents, promote health, lower costs and eliminate health disparities.

"On behalf of everyone involved in the exchange, we look forward to working with your office to realize the goals of the ACA and to develop an exchange by 2014 that meets the unique market and coverage needs here in Connecticut," the letter concluded.

Delaware
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Expanding

Uninsured residents: 115,000

On Nov. 14, 2012, Gov. Jack Markell of Delaware indicated the state's intention to implement the health insurance exchange through the state partnership option.

"As one of the first states to select the partnership exchange model, Delaware seeks to leverage a shared federal infrastructure, retain management of critical areas most directly impacting Delawareans, and ensure financial viability in light of the size of our population and market," the letter said.

The state partnership exchange model will provide a way to address the needs of Delaware's health care consumers, small businesses, providers and others "in a fiscally responsible manner as we work together to ensure access to quality affordable health care for all Delawareans," Markell's letter concluded.

Florida
Associated Press

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 3,952,000

After Mitt Romney failed to beat President Barack Obama in the November election, Florida Gov. Rick Scott said repealing "Obamacare" is not an option, and his goal is to look at what's good for his citizens, the Tampa Bay Times reported.

In a letter sent to Sebelius in November, Scott requested a meeting to discuss the possibility of creating a health care exchange.

"While I continue to be concerned with the unanswered questions regarding the implementation of (the health care law), I know that we share the same goals when it comes to lowering the costs of health care and addressing the need for better access to quality health care for not only Floridians, but for all Americans," the letter said.

Georgia
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 1,992,000

In a letter sent to Sebelius on Nov. 16, Georgia Gov. Nathan Deal announced the state would not set up a health care exchange, saying he will not commit Georgia taxpayers to a project with so many unknowns and so many unanswered questions.

"We have no interest in spending our tax dollars on an exchange that is state-based in name only," Deal said. "I would support a free market-based approach that could serve as a useful tool for Georgia's small businesses, but federal guidelines forbid that. Instead, restrictions on what the exchanges can and can't offer render meaningless the suggestions that Georgia could tailor an exchange that best fits the unique needs of its population."

Deal said he is concerned by the one-size-fits-all approach and the financial burden the federal mandate imposes on the states.

Hawaii
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 102,000

A July 7, 2012 letter from Gov. Neil Abercrombie of Hawaii to Steve Larsen, Deputy Administrator and Director of the Center for Consumer Information and Insurance Oversight, indicated Abercrombie's intention to begin implementation of a state-based exchange.

The letter breaks down the basic outline of Hawaii's state health exchange, and concludes by saying the state is looking forward to working with the federal government to ensure the exchange's operational readiness for 2014.

Idaho
Associated Press

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 239,000

After the government announced it would give states until Dec. 14 to decide whether or not to create state-based exchanges, Idaho Gov. C.L. Otter announced he would consult legislative leaders and reach a decision by the new deadline.

"This extension gives us more time to get answers from HHS about what the federal requirements will be," Otter said. "I don't want us buying a pig in a poke, so with this extension I'm hoping we'll get answers to the questions and concerns we're hearing from legislators and the public."

Illinois
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Expanding

Uninsured residents: 1,795,000

In an Oct. 16, 2012, letter to Gary Cohen of the Center for Consumer Information and Insurance Oversight, Illinois Gov. Pat Quinn signaled his state would participate in a state partnership exchange in 2014.

"Access to health care has been a high priority for me throughout my entire career," Quinn wrote. "While we will be working with you over the next year to ensure the people of Illinois have comprehensive and affordable coverage through the exchange, I'm committed to working with the Illinois General Assembly to pass legislation with governance and financing language that will allow us to operate a state-based exchange beginning in 2015."

Indiana
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 856,000

The final decision on Indiana's status falls on the shoulders of Gov.-elect Mike Pence, who said he doesn't want a state-based exchange because he can't justify the estimated $50 million annual cost to his state, The Washington Times reported.

"Without knowing more details on the cost and nature of state-based exchanges, it is possible that our state could be placed in the untenable position of serving as the administrator of a new federal health care bureaucracy over which we have little control," Pence wrote in a Nov. 15 letter. "With the certainty of higher taxes and higher premiums for Hoosiers, along with the uncertainty concerning costs and regulations, I am firmly convinced that refraining from establishing a state-based exchange is the proper course at this time."

Iowa
Associated Press

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 292,000

In a letter sent to Sebelius on Nov. 16, 2012, Iowa Gov. Terry Branstad wrote that Iowa "will continue on its path to creating an Iowa-based exchange that is intended to protect the health of Iowans, ensure the integrity of our health insurance markets and safe-guard our state budget from unnecessary turbulence."

Branstad's letter cites his concerns that an "intrusive" federal exchange would raise costs, and that the health benefit exchanges in the law "do nothing to address the quality of care or make our population healthier."

The state cannot provide HHS with a set of timelines or details about the exchange until the department gives the states clear, binding rules, Branstad said.

"If forced to make a decision with incomplete information, then I have no choice but to default on some level to a federal exchange. That is not my preferred path forward," Branstad wrote. "We have not abandoned our legal responsibility to create an exchange; however, the path towards consensus rests with you and Health and Human Services leadership."

Kansas
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 361,000

At the beginning of November, Gov. Sam Brownback announced the state wouldn't partner with the federal government to set up a health insurance exchange, The Wichita Eagle reported.

"Kansans feel Obamacare is an overreach by Washington and have rejected the state's participation in this federal program," Brownback said in a news release. "My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could cost Kansas taxpayers millions of dollars."

Kentucky
Associated Press

Exchange option: State exchange

Medicaid option: Decision pending

Uninsured residents: 727,000

Gov. Steven Beshear of Kentucky sent a letter to Sebelius in July 2012, indicating his intention to establish a state-run insurance exchange in Kentucky, which would "facilitate the purchase and sale of health insurance for individuals and small businesses, provide one-stop shopping for health consumers to enroll in qualified health plans or other federal and state health care plans, and will provide tax credits and cost-sharing reductions for qualified businesses and individuals."

The state's exchange was being established at the urging of interest groups representing employers, health insurers, insurance agents, health care providers and health care advocates, the letter said.

Louisiana
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 811,000

Louisiana will not be implementing a state health care exchange, Gov. Bobby Jindal told The Huffington Post on Nov. 14, 2012, saying implementing the exchange doesn't make sense.

"When it comes to health care policy going forward, I think the administration has an opportunity," Jindal said. "I think now that he's won reelection, he's got a chance to work with governors."

"The state of Louisiana has repeatedly stated that the law has severe legal problems, is bad policy and is unworkable. Those beliefs remain unchanged," Health and Hospitals Secretary Bruce Greenstein reportedly wrote to Sebelius on Nov. 14.

Greenstein said the health insurance exchanges have unrealistic deadlinee and unclear regulations, and said the health care law will undermine the private health care marketplace and weaken job creation at private businesses.

"The full extent of damage the (health care law) causes to small businesses, the nation's economy and the American health care system will only be revealed in time," he wrote. "The state of Louisiana has no interest in being a party to this failure by implanting a state based exchange."

Maine
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 146,000

While at a Republican Governors Association meeting in Las Vegas on Nov. 15, Maine Gov. Paul LePage said he would not lift "a finger" to implement a state exchange.

"We're not going to get involved," LePage said. "We're going to let Mr. Obama do a federal exchange. It's his bill."

In a Nov. 16, 2012, letter to Sebelius, LePage wrote, "The ACA is full of federal mandates; as such, even a state based health insurance exchange is actually controlled by the federal government. In the end, a state exchange puts the burden onto the states and the expense onto our taxpayers, without giving the state the authority and flexibility we must have to best meet the needs of the people of Maine."

With regulations incomplete two and a half years after the bill passed, the legal status of portions of the bill unresolved and too many unanswered question, Maine "cannot make a prudent ad comprehensive decision in the best interest of our citizens," LePage concluded.

However, state lawmakers are not ruling out the possibility of settings up a state health insurance exchange, The Bangor Daily News reported on Nov. 17.

Maryland
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 734,000

In Oct. 2012, Maryland's Gov. Martin O'Malley sent a letter indicating that the state was making "significant progress" in the establishment of a state-based exchange, and was ready to officially declare its intention to operate that exchange.

The exchange is on track to obtain certification in January 2013 and to launch open enrollment for individuals and businesses by Oct. 1, 2013, the letter said. It estimates the exchange will be fully operational by Jan. 1, 2014.

"We look forward to continuing to work with HHS as we develop Maryland's state-based exchange, and appreciate all of the opportunities available under the Affordable Care Act to expand access, reduce costs and improve the quality of health care for all Marylanders," the letter concluded.

Massachusetts
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 215,000

A July 10, 2012 letter from the office of Gov. Deval Patrick of Massachusetts served as the state's formal declaration of intent to operate a state-based exchange under the Affordable Care Act.

The letter breaks down the state's preparations for establishing its exchange.

Michigan
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Decision pending

Uninsured residents: 1,336,000

A Nov. 16, 2012, news release suggested that Michigan Gov. Rick Snyder has filed with the government for a state partnership exchange, but Snyder has not yet filed a declaration formally choosing Michigan's path.

"Ensuring that Michigan residents have the best available quality health care and customer service has been a priority from day one. I have felt strongly that a Michigan-run MI Health Marketplace could further accomplish this goal," Snyder wrote. "That said, we must be realistic about how feasible implementing this could be under the current federal timeframes. At this point we're moving toward a state partnership exchange."

The state would like more details and clarity from the federal government before choose between a state partnership exchange or a state-based exchange, the release said.

Minnesota
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 453,000

Gov. Mark Dayton wrote to Sebelius on July 10, 2012, reiterating the state's intention to continue the planning and development of a state insurance exchange.

"We will seize the historic opportunities to improve the quality and affordability of health care afforded us by new law, known as the Patient Protection and Affordable Care Act, whose constitutionality has now been affirmed by the U.S. Supreme Court," the letter said.

"The ultimate success of the Patient Protection and Affordable Care Act will depend upon states' willingness to serve their citizens' needs for the best possible health care at the most affordable price," the letter continued. "State leaders who choose to obstruct the implementation of this new law rather than help it realize its fullest potential, clearly establish themselves as part of the problem rather than the solution to providing Americans with affordable health care."

Mississippi
Associated Press

Exchange option: State exchange

Medicaid option: Not expanding

Uninsured residents: 530,000

Mississippi's insurance commissioner said Nov. 14 that the state would create its own state-based insurance exchange despite opposition from Gov. Phil Bryant, The Associated Press reported.

"The whole goal here is to help the consumer in this state have more information and make an intelligent decision about what they are going to buy," Commissioner Mike Chaney said. "If you default to the federal government, you forever give the keys to the state's health insurance market to the federal government."

"At some point the federal government is going to require you to maintain the guidelines they established," Gov. Bryant said. "I do not believe that since the federal government has put over $20 million into this exchange that they're going to say, 'It's yours, Mississippi, and you can manage it.'"

Missouri
Associated Press

Exchange option: Federal exchange

Medicaid option: Expanding

Uninsured residents: 780,000

Missouri Gov. Jay Nixon recently announced the state would not be setting up its own health insurance exchange after voters approved a measure prohibiting the governor or any state agency from setting up an exchange without legislative approval, Kaiser Health News reported on Nov. 13. A bill authorizing a state exchange stalled last year.

"Based on current state law, and the federal deadline, the state-based option isn't on the table for Missouri at this time," Nixon said.

Nixon went on to say that falling back on the federal exchange isn't ideal, and "regulating the insurance market is a power best left in the hands of the states, where we perform those duties more efficiently ad effectively, and provide better service for our consumers."

The Hill reported on Nov. 29 that Nixon will be taking part in the Medicaid expansion.

Montana
Kristin Murphy, Deseret News

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 179,000

According to the Henry J. Kaiser Family Foundation, the federal government will assume full responsibility for running a health insurance exchange in Montana beginning in 2014 unless the state decides to go with a state-based exchange or a state-federal partnership. For a state-based exchange, the state must submit an application and declaration letter to the HHS by Dec. 14. For a partnership exchange, the state must submit a blueprint before Feb. 15, 2013.

Nebraska
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 226,000

According to a Nov. 15 news release, Nebraska Gov. Dave Heineman announced that the state would not participate in a state-run exchange, but would go with the federal exchange.

"Fiscal analysis of budget impacts done by the Department of Insurance and the Department of Health and Human Services calculate the cost of a state insurance exchange for Fiscal Years 2013-2020 at $646 million; while the cost of the federal insurance exchange is $176 million," the news release said. "The cost of a state exchange to Nebraska taxpayers is $470 million more than a federal exchange."

"The reality is that the federal health care law is being totally dictated and totally controlled by the federal government," Heineman said. "On the key issues, there is no real operational difference between a federal exchange and a state exchange. A state exchange is nothing more than the state administering the Affordable Care Act with all of the important and critical decisions made by the federal government."

Nevada
Associated Press

Exchange option: State exchange

Medicaid option: Decision pending

Uninsured residents: 555,000

Nevada Gov. Brian Sandoval signed legislation last year creating Nevada's insurance exchange, and a state board approved a $72 million contract to implement the exchange, The Associated Press reported in August 2012.

Although Sandoval opposed the health care overhaul as a candidate, he said the state exchange was in the state's best interest, and warned that the program will have to become self-sustaining if it is to continue.

New Hampshire
Associated Press

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 136,000

According to the Kaiser Family Foundation, New Hampshire Gov. John Lynch signed a law on June 18, 2012, that would prohibit the state from participating in or enabling a state-based health insurance exchange. With the passage of that law, the federal government is now due to assume responsibility for running the health insurance exchange in New Hampshire beginning in 2014, although the state could still pursue a partnership exchange.

New Jersey
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 1,334,000

As of Nov. 27, New Jersey Gov. Chris Christie was undecided on the state exchanges, saying his state would "comply with the Affordable Care Act," but that he was waiting to receive answers to specific questions before moving forward, The Washington Times reported.

"If they're willing to answer the questions, and I can evaluate how much it's going to cost, then I might be inclined to do a state-run exchange," Christie said. "If they're unwilling to answer the questions for me, then they're going to run it and let them bite it."

On Thursday, Christie signaled his opposition to creating the exchange.

"I will not ask New Jerseyans to commit today to a state-based exchange when the federal government cannot tell us what it will cost, how that cost compares to other options and how much control they will give the states over this option that comes at the cost of our state's taxpayers," Christie said.

New Mexico
Associated Press

Exchange option: State exchange

Medicaid option: Decision pending

Uninsured residents: 506,000

According to a Nov. 14, 2012 Associated Press article, Gov. Susana Martinez's administration is moving forward with New Mexico's state-run exchange, although a fight may be brewing in the legislature.

New Mexico has been working on the exchange plan for some time, Human Services Secretary Sidonie Squier said, and there was never really any wavering on the idea that the state needed its own exchange.

Martinez vetoed an exchange proposal approved by the Democratic-controlled legislature last year, saying it was premature, and Attorney General Gary King is reviewing whether or not the governor can move ahead without legislative involvement.

New York
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 2,780,000

On Nov. 15, 2012, Gov. Andrew Cuomo of New York sent a letter to Gary Cohen of the Center for Consumer Information and Insurance Oversight, confirming the state's intention to establish a state-based health insurance exchange.

"As an early innovator state, New York is actively working to build an easy-to-use, web-based eligibility and enrollment system as envisioned by the ACA," the letter said.

The official confirmation came months after Cuomo issued an executive order to establish a health insurance exchange, saying in April that the exchange would drive down the cost of insurance, The New York Times reported.

North Carolina
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Decision pending

Uninsured residents: 1,583,000

A Nov. 15 Charlotte Observer article reported that outgoing Gov. Bev Perdue had decided on sharing responsibility for setting up a health care exchange between the federal government and the state.

Although Perdue said she would have preferred a state-operated exchange, she chose the shared option so that Gov.-elect Pat McCrory and the legislature can choose between the state-operated or federally operated exchange.

North Dakota
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 74,000

Although North Dakota had examined the possibility of creating a state-based exchange, Gov. Jack Dalrymple announced in Nov. 2012 that the state would go instead with the federal exchange, the Kaiser Family Foundation reported.

Dalrymple expressed doubts that the law's exchanges deadlines can be met, saying that there's more flexibility in applying later to run exchanges once they have already been established, The Associated Press reported.

"There definitely is going to be a lot more information and a lot more that's going to have to unfold here as we go forward," he said.

Ohio
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Decision pending

Uninsured residents: 1,578,000

In a November letter sent to the Obama administration, Ohio Gov. John Kasich said the state would let the federal government run its health insurance exchange, but that the state would retain its right to regulate Ohio's insurance industry, The Plain Dealer reported.

"At this point, based on the information we have, states do not have the flexibility to build and manage exchanges in ways that respond to unique needs of their citizens or markets," Kaisch said in the letter. "Regardless of who runs the exchange, the end product is the same."

Kasich also said the state reserves the right to amend its intentions, and said the federal government hasn’t provided "promised federal guidelines and rules for such issues as essential health benefits, market reforms, multistate insurance plans and more specifics regarding the federal facilitated exchange."

Oklahoma
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 597,000

Gov. Mary Fallin announced on Nov. 19 that Oklahoma would not pursue the creation of a state-based exchange, saying any exchange would be "state-run" in name only and would require Oklahoma resources, staff and tax dollars to implement.

"It does not benefit Oklahoma taxpayers to actively support and fund a new government program that will ultimately be under the control of the federal government, that is opposed by a clear majority of Oklahomans, and that will further the implementation of a law that threatens to erode both the quality of American health care and the fiscal stability of the nation," Fallin wrote.

She also said the state would not participate in the expansion of Medicaid, which she estimated would cost the state up to $475 million between 2012 and 2020, with escalating annual expenses in subsequent years.

Oregon
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 678,000

A July 6, 2012 letter from Gov. John Kitzhaber of Oregon signaled the state's intention to implement a state-run health insurance exchange, citing the state's history in helping its citizens obtain access to health care.

"Oregon's exchange came to fruition through Senate Bill 99, which passed the Oregon legislature with strong bipartisan support in June 2011," the letter said. "The mission of the Oregon Health Insurance Exchange is improving the health of all Oregonians by providing health coverage options, increasing access to information, and fostering quality and value in the health care system."

Pennsylvania
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 1,319,000

Pennsylvania Gov. Tom Corbett said Dec. 12 that his state would not be setting up a health care exchange — for now. Corbett cited inadequate answers to questions about cost and other issues, The Associated Press reported.

"Health care reform is too important to be achieved through haphazard planning," Corbett said. "Pennsylvania taxpayers and businesses deserve more. They deserve informed decision making and a strong plan that responsibly uses taxpayer dollars."

Rhode Island
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 122,000

Gov. Lincoln Chafee's July 5, 2012 letter to Sebelius said that the state would be establishing a state-based exchange consistent with the Affordable Care Act.

According to the letter, the state's exchange advisory board has been meeting regularly, and the exchange will help "provide Rhode Island families and small businesses with access to more affordable, high quality health insurance coverage."

South Carolina
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 754,000

In November, Gov. Nikki Haley confirmed the state wouldn't set up a state-run health exchange.

"Under the PPACA, the federal government is required to establish exchanges and gave individual states the choice to participate. Yet, as we worked through the process of analyzing the options available to South Carolina, it became abundantly clear that state 'participation' was in name only," Haley wrote in a letter to Sebelius. "The law's state-based exchange programs are not state-based at all. Instead, they simply pass along to the state the burdens of a new and cumbersome bureaucracy."

Uncertainty on regulations and implementation due to a lack of information from the federal government comes at a time when the country can hardly afford it, the letter concluded.

South Dakota
Associated Press

Exchange option: Federal exchange

Medicaid option: Unlikely in 2014

Uninsured residents: 108,000

Gov. Dennis Daugaard announced at the end of September that South Dakota would not operate a state health insurance exchange, but would maintain control of insurance regulation.

"After extensive research and analysis, it has become very apparent that operating our own exchange will simply not work for South Dakota," Daugaard said.

According to a news release from the governor, the cost analysis indicated that the annual operating costs of a state exchange would range from $6.3 million to $7.7 million.

"The federal law requires exchanges to be self-sustaining by 2015, which means we would either have to charge a fee to South Dakota citizens using the exchange, or increase taxes, neither of which I am willing to do," Daugaard said.

Tennessee
Associated Press

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 982,000

According to a Monday report from Nashville Public Radio, Tennessee Gov. Bill Haslam said he is listening to all sides before making a decision on whether or not the state will run a health insurance exchange.

A Nov. 11 timesfreepress.com story indicated that Haslam is "probably" leaning toward creating a state-run exchange, but that GOP lawmakers would likely resist such a move.

"As someone who has always said closer-to-home government is the better, like I said, that's probably why I lean toward doing it," Haslam said at the time. "That being said, we don't have all the answers, so we haven't made a final decision."

Texas
Associated Press

Exchange option: Federal exchange

Medicaid option: Not expanding

Uninsured residents: 6,654,000

In July 2012, Gov. Rick Perry wrote to Sebelius, saying he opposed the expansion of Medicaid and the creation of a state insurance exchange, calling them "brazen intrusions into the sovereignty of our state." A Nov. 15 letter indicated his feelings toward both were unchanged.

"This is a federally-mandated exchange with rules dictated by Washington," Perry wrote in his Nov. letter. "It would not be fiscally responsible to put hard-working Texans on the financial hook for an unknown amount of money to operate a system under rules that have not even been written."

A Dec. 1 New York Times article indicated that Texas Democrats are optimistic the 2013 legislative session can lead to a deal to bring in billions in additional federal dollars for Medicaid. The Kaiser Family Foundation estimated Medicaid expansion as laid out in the Affordable Care Act would cost Texas $5.6 billion from 2013 to 2022.

Utah
Laura Seitz, Deseret News

Exchange option: Decision pending

Medicaid option: Decision pending

Uninsured residents: 424,000

The Deseret News reported on Dec. 11 that Gov. Gary Herbert sent a three-page letter to President Obama touting Utah's Avenue H and asking for departmental approval of several requests to waive "restrictive" federal rules.

State officials have until Friday, Dec. 14, to inform the federal government of its plan regarding a federal insurance exchange expansion to include Medicaid, Wendy Leonard reported.

Vermont
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 61,000

A July 2012 letter from Vermont indicated the state was "actively pursing the establishment of a state-based exchange," which would "serve all Vermonters, offering comprehensive, consumer-oriented support for Medicaid eligible individuals, subsidized individuals, individuals purchasing without any subsidy, small employers, and, eventually employees of large employers."

The state-based exchange will be operational Jan. 1, 2014, the letter said.

Virginia
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 1,023,000

Virginia Gov. Bob McDonnell announced prior to the federal government's Nov. 16 deadline that the state would default to a federal health insurance exchange, while signaling the state could possibly change course at a later date.

After the government pushed back the deadline to Dec. 14, Democrats in Virginia urged the governor to call a special session to discuss how the state would address the overhaul. McDonnell previously said a special session was unnecessary.

The Associated Press reported on Nov. 20 that McDonnell is opposed to expanding the state's Medicaid program.

Washington
Associated Press

Exchange option: State exchange

Medicaid option: Expanding

Uninsured residents: 812,000

In July 2012, Mike Hash of the Center for Consumer Information and Insurance Oversight received a letter from Washington Gov. Christine O. Gregoire chronicling the state's work toward setting up Washington's state exchange.

"In 2011, I signed bipartisan legislation directing the establishment of Washington's Exchange," the letter said. "Set up as a quasi-governmental entity, the exchange is governed by an eleven-member board that has met regularly since its formation last December and is fully vested in the success of the exchange and in meeting the demanding timelines of the (Affordable Care Act)."

West Virginia
Associated Press

Exchange option: Federal-state partnership

Medicaid option: Decision pending

Uninsured residents: 266,000

A Nov. 18 Associated Press article indicated that West Virginia officials expect to partner with the federal government to operate a state run insurance exchange.

Officials believe that between 37,000 and 60,000 people would participate in the exchange, which would affect the state's ability to run the exchange by itself due to the cost.

A Nov. 14 Charleston Gazette article suggested Gov. Earl Ray would not establish a state-run health insurance exchange, but said that he has not announced his final decision.

Wisconsin
Associated Press

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 562,000

In a Nov. 16 letter, Gov. Scott Walker of Wisconsin said his state would not build a state-based health insurance exchange, deferring instead to the federal government's exchange.

"In Wisconsin, we have been successful in providing health insurance coverage to over 90 percent of state residents without the creation of an exchange and absent federal regulation," Walker wrote. "With more guidance and greater state flexibility, our competitive market system would have ensured health insurance coverage to the most vulnerable Wisconsinites without federalization of our market."

The state's Department of Health Services estimated the costs of running the exchange would have been between $45 and $60 million, the Milwaukee Journal Sentinel reported.

Wyoming
Kristin Murphy, Deseret News

Exchange option: Federal exchange

Medicaid option: Decision pending

Uninsured residents: 84,000

According to a Nov. 14 Wyoming Tribune Eagle article, the state will not implement a state-run insurance exchange, but will keep an eye on the federally run exchange's implementation and act accordingly.

"The question we are going to want to answer is if we want to continue to let (the federal government) run it, partner the state with the feds and have the state take part of the responsibility, or run away from the feds as fast as we can and find other states to partner with," Rep. Elaine Harvey said.

"The question is to what degree do we want to preserve the regulation of our own markets within our state borders," Elizabeth Hoy, Gov. Matt Mead's health care policy advisor told the paper. "(The federal government) is in effect taking over regulatory activities that have previously been up to the states."