First, a brief explanation of how I visualize the exchange. I see it as having three functions. First is a “sorting chute”, where individuals apply for insurance are screened for Medicaid eligibility. Those who do not meet the criteria for the low-income Medicaid plan then are moved along the insurance path.

Second, it is a marketplace to examine and buy health insurance for individuals and for small employers. The marketplace will present characteristics and costs of insurance policies meeting specified minimum benefit levels and offered by certified health plans. I think of it of a “Travelocity” or “Expedia”, only for health insurance instead of air travel.

Finally, it performs the “back room” functions of integrating various payment streams to pay for the insurance. Money from the individual, his employer or employers, and the federal tax credit for lower income families are blended and then paid to the insurance company.

There may be other tasks, but mostly it appears to be operational. Assessing eligibility, presenting policies for purchase and integrating financing.

The big debate in Idaho is the decision on a federal model of the exchange or a state-run exchange. The cost of construction is not really a big differentiator, with the federal grants available for planning and creation. The differences are in the areas of Idaho jobs, “essential benefits”, and ease of use.

Since almost 75 percent of families in Idaho are below 400 percent of the federal poverty level (and perhaps more of the individual policyholders), there is likely to be little small group or individual market outside of the exchange. And it is difficult for me to see how the small Idaho plans will elbow their way into a federal, national exchange. So if there is no state exchange, I expect significant membership loss in our two Blues, and with membership loss comes job loss. Some estimates are of up to 2,000 jobs.

The whole question of the agent’s role, the navigator’s role, and how they interact with customers is unclear, but I bet that the exchange marketplace will improve the efficiency there as well.

The benefit package is another concern. Here is a link to a previous article on the minimum essential benefits and differences between a state and federal package. My guess is that there will be a significant difference between the two. One small businessman has estimated it as about $1,000 per employee for him.

Finally, anyone who has tried to deal with D.C. rather than Boise, EPA rather than our DEQ, or the central customer service center “back East”, knows that local knowledge is important. Imagine trying to explain Idaho distances to someone in New Jersey!

So I think which exchange is a big deal. But the decision might come down to the politics. There are a number of legislators who believe that if we just say no, “Obamacare” will just go away. Or believe that a U.S. Supreme Court decision on the mandate to carry insurance will also remove the rest of the ACA. Or that a Republican president will make repeal of the ACA happen (I guess they forget about the Senate and filibuster).