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Overhauling the individual health insurance market — including through the creation of health insurance exchanges — was a key component of the Patient Protection and Affordable Care Act's multidimensional approach to addressing the long-standing problem of the uninsured in the United States. Despite succeeding in enrolling millions of Americans, the exchanges still face several challenges, including poor consumer experience, high operational and development costs, and incomplete market penetration.

In light of these challenges, analysts considered a different model for the exchanges — privately facilitated exchanges — which could address these challenges and deepen the Affordable Care Act's impact. In this model, the government retains control over sovereign exchange functions but allows the private sector to assume responsibility for more-peripheral exchange functions, such as developing and sustaining exchange websites. Although private-sector entities have already undertaken exchange-related functions on a limited basis, privately facilitated exchanges could conceivably relieve the government of its responsibility for front-end website operations and consumer decision-support functions entirely.

A shift to privately facilitated exchanges could improve the consumer experience, increase enrollment, and lower costs for state and federal governments. A move to such a model requires, nonetheless, managing its risks, such as reduced consumer protection, increased consumer confusion, and the possible lack of a viable revenue base for privately facilitated exchanges, especially in less populous states. On net, the benefits are large enough and the risks sufficiently manageable to seriously consider such a shift. This paper provides background information and more detail on this assessment.

The research underlying this paper was sponsored by Aetna, Inc., and conducted in RAND Health Advisory Services, the consulting practice of RAND Health.

This report is part of the RAND Corporation perspective series. RAND perspectives present informed perspective on a timely topic that address the challenges facing the public and private sectors. All RAND perspectives undergo rigorous peer review to ensure high standards for research quality and objectivity.

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