By Donald F. Kettl

        We all know that health “exchanges” are the big innovation of the health insurance reform act. We know they’re supposed to drive down costs, provide citizens with more choice, and ensure that everyone has access to coverage.

            But just what are they? That’s a deceptively difficult question to answer. We don’t have much experience. There are just two health exchanges in operation, staked at opposite ends of the spectrum.

• Massachusetts, where it’s known as the “Connector” https://www.mahealthconnector.org/portal/site/connector/menuitem.a6bd9ea72595da2ea87b5f57c6398041/?fiShown=default) . The Connector is a slick website that offers different packages for different consumers—families, young adults, employees, and employers. Click on the photo that best describes you, and the site walks you through the options for getting health insurance. This exchange guarantees that insurers meet basic government-defined coverage standards. Buyers can pick the plan they like.

• Utah, where the Utah Health Exchange is a market-based e-shopping center for health insurance plans (http://www.exchange.utah.gov/).  This exchange provides extensive information about the companies offering coverage in the state but doesn’t provide any state guarantees of minimum standards.

The big question: what will the federal government require state exchanges to do? These two examples make clear that, left to their own devices, the states will create very different kinds of exchanges. The fundamental dilemma for the federal government is what standards to set for each exchange, and how much flexibility it ought to leave state officials. This is destined to be a huge battleground. If you think the Tea Party debate is intense—wait until you see what’s coming here.

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