The breakdown of states running their own health insurance exchanges versus those using the federally facilitated marketplace will change in due time – but exactly how it will change is still up in the air, said a speaker at Wednesday’s National Health Insurance Exchange Summit, held in Washington, D.C.

For 2014’s open enrollment, 17 states plus the District of Columbia built their own exchanges, 27 defaulted to the federal marketplace and seven are operating partnership marketplaces, according to Alan Weil, executive director of the National Academy for State Health Policy.

That decision mostly came about in early 2011 when state legislatures returned to session and many saw building an exchange as a way of supporting the Affordable Care Act. One cycle of open enrollment is now finished but a series of cycles that include substantive and political issues is yet to come, which will lead to more difficult decisions, Weil said.

Practically, some states do have functioning marketplaces, so there is an understanding that the system can work successfully. Additionally, many see exchanges as a point of leveraging and improving delivery of care.

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Weil said for states that run their own exchange, they are able to impose their own standards and can align care improvement efforts with their exchanges.

“I think over half the states already plan to improve organization of care,” he explained. “If you are serious about that, you are going to realize [that] not controlling plans on the exchange will limit that.” Politically, the cycle will change too. In November, 36 governors will be up for election and a new president will be elected in 2016.

But states must make their exchange decision for 2015 in the very near future. “On one hand, you want to learn from what you did and [analyze] feedback,” Weil said. “But by the time open enrollment closes – your opportunity to adjust for the next year – your window has gotten very short.

“After this year’s cycle, we will see some shifts and [it is] not at all obvious which way the shift will go,” he added. “The map will change, what I don’t know is precisely how.”

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