Looking ahead to 2017
According to the Wisconsin Office of the Commissioner of Insurance, rate proposals and plan details will not be publicly available in Wisconsin until October 7.
UnitedHealthcare has participated in the Wisconsin exchange in 2015 and 2016. Although they are exiting the individual markets at the end of 2016 in most of the states where they currently offer exchange plans, the Wisconsin OCI indicated that United’s decision – whether to stay in the Wisconsin market or leave at the end of 2016 – won’t be publicly available until October.
Humana exiting individual market
However, we do know that Humana is leaving the individual markets in Wisconsin at the end of 2016, as will be the case in at least a handful of other states. Humana does not participate in the exchange in Wisconsin, so their exit only impacts off-exchange plans. According to Humana’s letter regarding their exit, there will be 6,639 members whose coverage will terminate at the end of the year. Those members will have an opportunity to select coverage from another carrier – on or off-exchange – during open enrollment, which begins on November 1.
Children’s Community Health Plan may join in 2017
Children’s Community Health Plan (CCHP) is an HMO owned by Children’s Hospital of Wisconsin, and they currently offer coverage through Wisconsin’s BadgerCare Medicaid program. In the fall of 2015, CCHP expressed interest in offering plans on the Wisconsin exchange in 2017, and began working through the filing process involved.
By February 2016, their request had been filed with the Office of the Commissioner of Insurance, and was under review. But the Wisconsin Office of the Commissioner of Insurance confirmed by phone in May that CCHP’s application to offer QHPs in the marketplace is being processed by the federal government, not the state. If approved, CCHP will file rates with the Wisconsin Office of the Commissioner of Insurance, but no details will be publicly released until October, as is the case with UnitedHealthcare.
CCHP is hoping to have plans available on the exchange when open enrollment begins in the fall. They are clearly planning to start small, as Bob Duncan, executive vice president of CCHP’s community services, has said that he’ll “be excited if [they] have 1,000 or 2,000 new members in the first year.”
Milwaukee wins White House enrollment challenge
Early in the 2016 open enrollment period, the White House reached out to leaders in 20 metropolitan areas across the country, challenging them to promote outreach to enroll as many residents as possible during open enrollment. HHS and state-based marketplaces looked at total new enrollment in each area, and compared those numebrs with the estimated number of uninsured residents in each area prior to open enrollment.
In February 2016, the White House announced that Milwaukee had won the challenge, with 38,000 newly-enrolled residents during the 2016 open enrollment period. President Obama will visit the city to “celebrate their success in helping ensure Americans have health coverage.”
239k enrolled for 2016
239,034 people enrolled in private plans through the Wisconsin exchange during the 2016 open enrollment period, including new enrollees and renewals. There were 183,682 people with in-force coverage through the exchange in mid-2015, and most of them were likely among the renewals for 2016.
For perspective, 207,349 people enrolled in plans through the Wisconsin exchange during the 2015 open enrollment period, so the 2016 enrollment total is 15 percent higher than the prior year. And in prior years, HHS waited until after open enrollment ended to begin accounting for attrition, whereas the 2016 total had already been reduced to reflect early attrition (unpaid and cancelled enrollments) through February 1.
Open enrollment for 2016 ended on January 31. But people who experience a qualifying event can still enroll in a plan for 2016, as can anyone eligible for Medicaid or CHIP. Native Americans can also enroll in coverage through the exchange year-round.
The penalty for being uninsured is significantly higher in 2016 than it was in 2014 and 2015. Given the sharp increase in the penalty, many residents – particularly those who qualify for premium subsidies – have found that they can fund several months worth of health insurance premiums with the money that would otherwise have been owed as a penalty had they remaining uninsured.
Network Health joins exchange for 2016
Network Health joined the Wisconsin exchange for 2016, offering plans in seven counties: Calumet, Milwaukee, Outagamie, Ozaukee, Racine, Waukesha, and Winnebago. The plans are also available outside the exchange.
Anthem exits exchange for 2016 in some counties
In October 2015, less than a week before open enrollment began for 2016 coverage, Anthem Blue Cross Blue Shield announced that they would pull out of the Wisconsin exchange in three counties: Milwaukee, Racine and Kenosha. In 2012, those three counties had a total population of more than 1.3 million people, out of 5.7 million people state-wide. Anthem also announced that they would significantly reduce the number of available plans in 34 other counties in the state.
Anthem enrollees whose plans terminated were able to select a new plan from one of the other carriers for 2016.
Wisconsin exchange carriers
There are 16 carriers that offer individual plans through the Wisconsin health insurance exchange in 2016, although not all carriers offer plans in all areas of the state (the Wisconsin Office of the Commissioner of Insurance has a webpage that shows which plans are available in each county, including off-exchange plans). Wisconsin exchange carriers – and their average rate changes for 2016, if available – are listed below:
- All Savers Insurance Company (UnitedHealthcare) = 20.1% rate increase (15,102 members in 2015)
- Ambetter (Managed Health Services Insurance Corp.) = 9.2% rate decrease
- Anthem Blue Cross Blue Shield (CompCare Health Services) = 9.5% and 9.8% rate increases, depending on plan
- Common Ground Healthcare Cooperative = 18% rate increase (23,629 members in 2015)
- Dean Health Plan = 10.2% decrease for EPO; 3.9% decrease for HMO; 9.7% increase for Prevea360 HMO
- Group Health Cooperative of South Central Wisconsin = 10.9% rate increase (853 members in 2015)
- Gunderson Health Plan Inc. = 8.1% and 8.8% rate increases, depending on plan
- Health Tradition Health Plan = 0.6% rate increase
- Medica Health Plans of Wisconsin = 9.6% rate increase
- MercyCare HMO Inc. = 8.1% rate decrease
- Molina = 1.4% rate increase
- Network Health = new for 2016
- Physicians Plus = 5.1% rate decrease
- Security Health Plan of Wisconsin, Inc. = 13.5% rate increase for Select Plans; 22.7% increase for Classic Plans (20,819 members on Classic plans in 2015)
- Unity Health Insurance = rate increases ranging from 1.7% to 11%
- WPS Health Plan Inc. (Arise) = rate increases ranging from 17.3% to 20.8%
Ambetter (Managed Health Services Ins. Corp.) and All Savers (UnitedHealthcare) were new to the Wisconsin exchange in 2015, and Network Health is new to the exchange in 2016.
Medica is continuing to offer health plans in the individual exchange in Wisconsin, but has exited the SHOP exchange that provides coverage for small businesses. Medica also exited the SHOP exchanges in Minnesota and North Dakota, and noted that the issue was simply a lack of interest from small businesses and brokers.
A week before the start of open enrollment, Healthcare.gov debuted 2016 rates and plans so consumers could begin browsing the available plans. Within the exchange, four carriers have lower average rates for 2016 than they had in 2015. Health Network is new for 2016, and the other 11 carriers had average rate increases that range from less than one percent to almost 21 percent.
According to Citizen Action of Wisconsin, the average premium in Madison is the same in 2016 as it was in 2015. For a 40-year-old who purchases the second-lowest-cost Silver plan (benchmark plan), the premium is $254/month both years (this doesn’t take into account any subsidies). Statewide, however, the average benchmark premium across 19 metropolitan areas in 2016 is $319, which is 4.2 percent higher than it was in 2015 (note that the benchmark plan can be a different plan and carrier from one year to the next – it’s just the second-lowest-cost Silver plan for a given year). Across the entire state, the average benchmark premium is 4.7 percent higher than it was in 2015. For enrollees who are receiving subsidies, the subsidies will be slightly larger in most cases in 2016 to reflect the increased benchmark plan costs.
The average benchmark plan deductible in Madison is lower in 2016 than it was in 2015: $3,400, down from $4,000. But state-wide, the average deductible is more than $1,000 higher in 2016 than it was in 2015.
Common Ground’s (an ACA-created CO-OP) initial rate proposal didn’t show up on Healthcare.gov’s rate review tool, so we can assume it was less than ten percent. But in October, Common Ground Health Cooperative resubmitted a new rate proposal to the Office of the Insurance Commissioner. According to that document, the approved weighted average rate change for Common Ground is 18 percent (this has since been verified on Healthcare.gov’s rate review tool), and impacted 23,629 enrollees in Wisconsin.
All of the weighted average rate changes assumed that people didn’t shop around and switch plans during open enrollment, which obviously wasn’t the case. Ultimately, due to plan changes, the effective average rate increase ended up being lower than the projected weighted averages. When all plan selections had been made during the 2016 open enrollment period, 84 percent of exchange enrollees in Wisconsin qualified for premium subsidies. Their average pre-subsidy rate is $455/month, while their average after-subsidy premium is $125/month.
For perspective, in 2015, 89 percent of Wisconsin exchange enrollees qualified for subsidies. Their average pre-subsidy premium was $440/month, but their average after-subsidy premium was $125/month – the same as it is in 2016. For people who are receiving subsidies, the subsidies combined with different plan selections during open enrollment have resulted in the same average after-subsidy premium two years in a row.
CO-OP still open
Wisconsin is one of the states that has an ACA-created CO-OP. Common Ground Healthcare Cooperative received federal loans to get up and running, and has been offering health insurance in Wisconsin since the beginning of 2014. Initially, there were 23 CO-OPs offering plans in 25 states. But the Iowa/Nebraska CO-OP failed in early 2015, and 11 more CO-OPs have failed since July 2015 – the majority since the beginning of October due to the 2014 risk corridor shortfall.
Common Ground Healthcare Cooperative lost money in 2014 – as did all but one of the CO-OPs. Their claims exceeded premiums by almost $44 million, and they enrolled more than two and a half times as many people as they had expected in 2014. All carriers that ended up with higher-than-expected claims were supposed to get risk corridor payments to help cushion the losses, but HHS announced in October 2015 that payments would be just 12.6 percent of the amount due. This threw several CO-OPs into financial crises, and Insurance Commissioners across the country have had to make some tough decisions regarding the financial viability of the CO-OPs.
But according to Modern Healthcare’s Bob Herman, the Wisconsin Department of Insurance confirmed in late 2015 that they were not planning to take any action to shut down Common Ground Healthcare CO-OP, and it appeared the carrier will remain financially viable in 2016. In November 2015, Common Ground announced that they were adding Bellin Health System to their Envision Integrated Care Network, which also includes Aurora Health Care. In 2015, there were 23,629 members enrolled in Common Ground Healthcare CO-OP plans.
Drug deductible depends on where you live
In October 2015, Citizen Action of Wisconsin published an eye-opening visual depiction of average prescription drug deductibles across 21 metro areas in Wisconsin. They compared plans available on Healthcare.gov, and the differences from one area to another are dramatic. In Madison, the average prescription drug deductible is just $400. But in Oskosh, it’s $2,547. The other 19 areas fall somewhere in the middle, but more than half the metro areas in the study had average prescription drug deductibles of more than $1,400.
Under the ACA, all health plans must have maximum out-of-pocket limits for essential health benefits that don’t exceed $6,850 for an individual in 2016, and $13,700 for a family. Plans are also required to cover a minimum of 60 percent of average claims expenses in order to qualify as bronze level coverage. But beyond that, carriers have quite a bit of freedom in terms of plan design. So prescription drug deductibles can vary considerably from one plan to another. And although Wisconsin has a robust health insurance market (there are 15 carriers in the exchange), different plans are available from one area to another, with different levels of coverage. The Citize
Bill to increase rate oversight did not pass
In September 2015, Wisconsin State Senator Chris Larson and State Rep. Debra Kolste announced the introduction of new legislation (AB359) that would have required Wisconsin to utilize a robust rate review process, much the same as many other states. Among other things, the legislation would have required the Insurance Commissioner to hold public hearings on proposed rate increases over ten percent, and would also give the Insurance Commissioner the ability to deny rate hikes that aren’t justified by claims costs. Currently, Wisconsin is a “file and use” state, which means that carriers set their own rates, and must simply file them with the state no more than 30 days after implementation.
The legislation notes that “current law prohibits premium rates from being excessive, inadequate, or unfairly discriminatory”, and the state does have an outside actuary that reviews the rates. HHS also reviews proposed rates that include a premium increase of ten percent or more. But Larson and Kolste’s bill would have given the Wisconsin Insurance Commissioner far more regulatory oversight for health insurance premiums. However, it was considered unlikely that the bill would pass in the state’s Republican-dominated legislature; indeed, by mid-April 2016, the legislation was dead.
Wisconsin’s health insurance rates are dramatically higher than neighboring Minnesota. In 2015 the average benchmark (second lowest cost silver) plan costs $373/month (before any subsidies), which is the fourth highest average in the country. In Minnesota, the average benchmark plan cost just $183/month in 2015.
In 2016, Wisconsin has the seventh highest pre-subsidy rates among the 38 states that use Healthcare.gov. Consumer advocates note that Wisconsin’s lax health insurance rate review process is harmful to consumers, as there is little that state regulators can currently do to hold rates in check.
Subsidies, insurance market no longer in danger
Since Wisconsin has a federally-run exchange, the Supreme Court’s decision in King v. Burwell was of critical importance in the state. The plaintiffs argued that the ACA only allowed subsidies to be provided in state-run exchanges, and 34 states – including Wisconsin – have federally-run exchanges (Healthcare.gov) instead. But on June 25, the Court ruled that subsidies are legal in every state, including those that use Healthcare.gov.
At ACAsignups, Charles Gaba estimated that 159,000 people in Wisconsin would have lost their subsidies if the court had ruled that subsidies were only available in state-run exchanges. Coverage would have become unaffordable for them, but also for tens of thousands of other Wisconsin residents who purchase their own health insurance without subsidies.
The American Academy of Actuaries estimates that premiums market-wide would increase by at least 35 percent in states where subsidies are eliminated, and the Urban Institute pegged the potential rate increase at 55 percent. Either way, it would have been catastrophic for the individual insurance market and people who purchase their own coverage.
But fortunately for the residents, medical providers, and insurance carriers in Wisconsin, subsidies were upheld by the Supreme Court, and will continue to be available for current and future enrollees.
Gov. Walker and the King case
In January, ThinkProgress put forth a video from 2013 of Wisconsin Governor Scott Walker saying that there’s “no real substantive difference between a federal exchange or a state exchange…” ACA supporters who wanted the Supreme Court to rule that subsidies are available in every state jumped on Walker’s comments as proof that nobody who was implementing the ACA was aware of the fact that subsidies might be in jeopardy in federally-run exchanges.
Indeed, Walker’s unique solution to Medicaid expansion (details below) indicates that he clearly believed that subsidies would be available in federally-run exchanges, since Wisconsin shifted about 83,000 people from Medicaid to subsidized plans in the exchanges as of 2014 (they are enrollees with incomes between the poverty level and 138 percent of the poverty level, so they are currently eligible for subsidies in the exchange).
But Vox’s Sarah Kliff explained that Walker’s comments didn’t really dismantle the King case, as he was simply talking about who would really be running the show in the exchange, and was pointing out that the state would have to comply with the federal government’s requirements, even if it were technically a state-run exchange.
And to be clear, Walker is no fan of Obamacare. He’s repeatedly called for repeal of the law, and following the Supreme Court’s ruling, Walker said that lawmakers should “redouble their efforts to repeal and replace” the ACA.
2015 enrollment numbers
As of February 22 – after the second open enrollment period had ended – 207,349 people in Wisconsin had finalized their 2015 private plan enrollments through the exchange. Of those enrollees, 90 percent qualified for premium subsidies. More than half of the enrollees (115,755) were renewing plans from 2014, and of those renewals, more than half (66,759) were “active” renewals as opposed to auto-renewals. Of the active renewals, 40,303 switched to a new plan for 2015.
By the end of June, effectuated enrollment in private plans through the Wisconsin exchange stood at 183,682. Attrition is to be expected in the individual health insurance market; some enrollees never pay their initial premiums, while others choose to cancel their plans mid-year. In addition, Healthcare.gov has stepped up enforcement of documentation requirements for immigration and income verification, which has resulted in the termination of some plans and/or premium subsidies.
In addition to the private plan enrollments, another 27,628 exchange enrollees in Wisconsin were eligible for Medicaid or CHIP during the 2015 open enrollment period. Medicaid enrollment continues year-round, but tends to increase during the general open enrollment due to additional outreach and advertising.
Open enrollment for 2015 has ended, and most people can only purchase a new plan at this point (including off-exchange) if they have a qualifying event. However, enrollment is year-round for Native Americans and for enrollees who qualify for Medicaid or CHIP.
Average 2015 rate increase of just 3 percent
In late September, the Wisconsin Office of the Commissioner of Insurance released rate filings for 2015 health plans. The average rate increase in Wisconsin’s individual market (including on and off-exchange plans) is just 3.2 percent for 2015. And two carriers – Medica Health Plans of Wisconsin and Molina Healthcare of Wisconsin – have reduced their premiums by 17 and 11 percent, respectively. Anthem’s rates have increased an average of 9 percent, but that includes exchange plans as well as plans sold outside the exchange.
For a 40 year-old non-smoker, a Commonwealth Fund analysis calculated an average rate increase of 7 percent in the exchange in Wisconsin for 2015, across all metal levels. For people who are enrolled in the benchmark plan (second lowest-cost silver plan) from 2014, The NY Times Upshot found that they could see rate decreases across much of the southern and western portions of Wisconsin, as long as they’re willing to switch to the new benchmark plan for 2015.
There is significant disparity in rate changes from one area of the state to another though. The northeast part of Wisconsin has had the highest rate of health insurance inflation in the state over the last 14 years, although people enrolled in the benchmark plan there should see average rates increases under 6 percent for 2015.
In the Milwaukee area, the benchmark plan is offered by a different carrier in 2015, and so are the lowest-cost silver and bronze plans. People who are on a plan that was auto-renewed on December 15 are still eligible to shop for a new plan anytime until February 15, and Wisconsin is a market where it’s definitely worth shopping around during open enrollment.
New carriers joined the exchange in 2015
The federally-facilitated (ie, through HealthCare.gov) Wisconsin exchange had 13 carriers in 2014, but has 15 for 2015. Two new carriers – UnitedHealthcare and Managed Health Services Insurance Corporation (AmBetter) – joined the exchange for 2015, and their entry is one of the factors that held down rate increases.
Wisconsin was one of only seven states with a federally facilitated marketplace that had at least ten carriers in 2014. But despite the robust competition, Wisconsin’s exchange rates were relatively high in 2014. The average premium for the lowest-cost bronze plan in Wisconsin in 2014 was $287, compared with $249 nationally.
In late October 2013, Citizen Action of Wisconsin created a report highlighting the very different ACA paths taken by Minnesota and Wisconsin, and placed some of the blame for Wisconsin’s high rates on the fact that the state ultimately took a hands-off approach to the exchange and also refused to accept federal funds to expand Medicaid. 2014 rates in Wisconsin are double the rates of neighboring Minnesota. But the rate increase for 2015 – an average of just three percent – is significantly lower than the 5.4 percent national average rate increase.
Despite the small increase for 2015, Citizen Action of Wisconsin released a new report in October that highlighted the ongoing differences between the neighboring states, and the expectation that rates would still be higher in Wisconsin than in Minnesota in 2015.
How many people enrolled in 2014?
The 2014 Obamacare open enrollment period ended in April. 139,815 people had purchased private plans in the Wisconsin exchange by April 19 – nearly a 96 percent increase over the number who had done so by March 1.
In addition to the private plan Obamacare enrollments, Wisconsin’s exchange has also enrolled 97,509 residents in the state’s BadgerCare Medicaid program by the end of June.
According to a Gallup poll, 11.6 percent of Wisconsin’s population lacked health insurance in 2013. The poll found that the rate had dropped to 9.6 percent by the middle of 2014.
Wisconsin Medicaid – a unique approach…
Wisconsin has not expanded Medicaid under the ACA, but has taken a more proactive approach than most non-expansion states in providing coverage for people living in poverty. Wisconsin dropped the existing BadgerCare Medicaid eligibility to 100% of poverty level, which resulted in 72,000 people losing BadgerCare eligibility. Since subsidies for private Obamacare plans purchased in the exchange begin at 100% of poverty level, the residents who lost BadgerCare eligibility were able to purchase heavily subsidized plans in the exchange instead.
However, critics have noted that a lot of those 72,000 people (with incomes just over 100% of poverty) were probably unable to afford a private plan, even with the available cost-sharing and premium subsidies.
As of the beginning of September, the state estimated that 25,800 former BadgerCare members had not yet enrolled in a subsidized plan through the exchange. They initially had until June 30 to do so, but HHS has granted them another special enrollment period – September 4 through November 2 – during which they could apply for a subsidized plan in the federally-facilitated Wisconsin exchange. The Wisconsin Department of Health Services sent letters to the former BadgerCare enrollees who had not yet obtained new coverage, informing them of the special enrollment period.
But an additional 83,000 childless adults with incomes below 100% of poverty level are newly eligible for BadgerCare in 2014. Wisconsin created their own version of Medicaid reform without using the federal funds allocated by the ACA. As a result, the state was able to make its own rules, and people in Wisconsin with household incomes between 100% and 138% of poverty level are expected to purchase subsidized private plans – they are not eligible for Medicaid.
…but not fully expanded Medicaid
Technically, this means Wisconsin has not expanded Medicaid under the ACA (if it did, people with incomes up to 138 percent of poverty would be eligible for Medicaid and the state would receive federal funding for Medicaid expansion). Although Governor Scott Walker has received criticism from consumer advocates, among states that have not expanded Medicaid, Wisconsin is the only one without a coverage gap, since BadgerCare was expanded to cover everyone up to 100% of poverty level (in most states that did not expand Medicaid, eligibility limits are far lower than that).
Nevertheless, 19 Wisconsin counties and the city of Kenosha added referendum questions to their ballots in November, asking citizens to weigh in on Gov. Walker’s decision to not fully expand Medicaid under the ACA. Voters passed all 20 of the ballot initiatives, but they are essentially just a way of communicating resident wishes to lawmakers, as the final decision on expanding Medicaid is up to the Governor and the state’s lawmakers.
Wisconsin’s go-it-alone approach to modified Medicaid expansion could end up being financially challenging, as the state incurred significantly higher Medicaid spending in 2014 and does not have the federal government funding Medicaid expansion as they would do if the state followed the guidelines laid out in the ACA (federal funding in that case would cover 100 percent of newly-eligible enrollees through 2016, and then the state would gradually pay a small portion of the new expenses, capping out at 10 percent by 2020).
Over four years, it’s estimated that the total cost to state and federal taxpayers for Wisconsin’s unique approach to Medicaid will be $2 billion more than it would have been under straight Medicaid expansion as called for in the ACA.
Wisconsin exchange history
Gov. Walker had previously expressed a preference for a state-run exchange rather than a “one size fits all” federally operated exchange. In 2011, Walker used an executive order to create the Office of Free Market Health Care to plan for a Wisconsin exchange. Walker’s plan for a “free-market, consumer driven approach” leaned heavily on an insurance marketplace implemented by former Gov. Jim Doyle. According to one state insurance expert, the only notable change proposed by Walker was to put the exchange online.
However, Walker showed a changed mindset in 2012, returning a $38 million federal grant and closing the Office of Free Market Health Care. In announcing his November 2012 decision to accept a federally operated exchange, Walker said the state would have no real control and much higher financial risk with a state-run exchange.
Legal challenge to the ACA in Wisconsin
The fight against Obamacare is on-going in Wisconsin. US Senator Ron Johnson, a Wisconsin Republican, has brought a lawsuit against the federal government over the issue of congress and congressional staffers receiving subsidies to purchase health insurance through the exchanges.
The federal government believed that the case should be thrown out, as they claim that Johnson has no legal standing since he’s not being harmed by the rule that allows congress and staffers to receive subsidies in the exchange. In September, Johnson began an appeals process with the 7th Circuit Court of Appeals after a lower court sided with the federal government and ruled that he lacked standing to challenge the law.
The oral arguments for the appeal are scheduled for January 21 in Chicago, and Johnson plans to attend the hearing. He and his attorney will be arguing that he does have legal standing to challenge the ruling that allows members of congress and their staffers to receive subsidies in the exchanges.
The whole issue stems from language that Chuck Grassley (R – Iowa) added to the ACA when it was being drafted. His addition requires that congress and congressional staffers lose their employer-sponsored health insurance and switch instead to exchange plans. But those who earn too much to qualify for subsidies would be taking a significant financial hit. They would have gone from having 75 percent of their premiums subsidized (under their government group plan) to paying 100 percent of their own premiums. As such, the Office of Personnel Management intervened and said that congress and staffers could keep their existing subsidies and apply them to the exchange plan premiums. Sen. Johnson is attempting to repeal that ruling.
Wisconsin health insurance exchange links
Wisconsin Office of the Commissioner of Insurance
Assists consumers who have purchased insurance on the individual market or who have insurance through an employer who only does business in Wisconsin.
(800) 236-8517 / email@example.com
State Exchange Profile: Wisconsin
The Henry J. Kaiser Family Foundation overview of Wisconsin’s progress toward creating a state health insurance exchange.