It seems like a simple idea: create new marketplaces, called "exchanges," where consumers can comparison shop for health insurance, sort of like shopping online for a hotel room or airline ticket.

But, like almost everything else connected with the health law, state-based insurance "exchanges" are embroiled in politics. Some Republican governors threatened to refuse to set up exchanges unless they received more flexibility over Medicaid, the state-federal health program for the poor. Lawmakers in other states said they didn’t want to implement any part of the federal health law. Some states, including California, Colorado, Oregon and Maryland, have adopted legislation to establish exchanges. Others are either still discussing such proposals – or are awaiting a governor's signature. Meanwhile, efforts have either died or been rejected in at least a dozen states, including Louisiana, Arizona and Florida. 

Still, some Republican officials are embracing them. And consumer advocates, disease groups and industry lobbyists are jockeying for influence over how the exchanges will be regulated.

If done well, proponents say, exchanges could make it easier to buy health insurance and possibly lead to lower prices because of increased competition. But, if designed poorly, experts warn, healthy people could avoid the exchanges, leaving them to sicker people with rising premiums.

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