Congress' failure to pass stabilization money for insurance marketplaces in March has left it up to states to sort out their individual insurance pools. Here's a look at four approaches states might take.
1) Association health plans, or AHPs
The U.S. Labor Department proposed broadening the ability of small employers to pool their employees and negotiate coverage. Insurance commissioners and some state attorneys general caution that AHPs would cause more instability and likely skirt Affordable Care Act mandates.
Major insurers also largely oppose those structural changes. But some carriers, including UnitedHealth Group and Anthem, have asked to grandfather in existing association plans and free them from new regulatory requirements.
A few states are considering ways to check AHPs if they don't comply with the ACA.
2) Farm Bureau model
Iowa lawmakers have combined AHPs with a provision to allow the state's Farm Bureau to give Wellmark Blue Cross and Blue Shield exclusivity on selling plans that don't comply with ACA mandates.
Iowa's individual market has been plagued with segmentation, which critics of AHPs warn could occur in other states. More than half of Iowa's individual health plans don't comply with the ACA because they were grandmothered in.
Tennessee has kept its own Farm Bureau model. About 73,000 residents are enrolled in Farm Bureau individual health plans. For 2018, the Tennessee bureau dropped its ACA-compliant plans, which had seen enrollment climb to more than 15,000 customers, up from 2,400 people in 2016.
3) Medicaid expansion or buy-in
While Arkansas and Kentucky move to stem their Medicaid expansion coverage numbers with strict work requirements, voter-backed ballot initiatives to extend the program are in the works in Idaho, Nebraska and Utah.
Democratic Virginia Gov. Dr. Ralph Northam and GOP Maine Gov. Paul LePage are on opposite sides of gridlock with their legislatures over expansion.
States like Florida, Georgia and North Carolina may reconsider expansion depending on which party wins big in 2018.
Nevada and New Mexico have approved studies to explore a public option for Medicaid. Nevada already gives precedence for Medicaid contracts to its health exchange carriers, but GOP Gov. Brian Sandoval vetoed a buy-in proposal last year saying it hadn't been adequately vetted.
4) State Obamacare
Several states are using the ACA model to shore up their individual markets.
According to the National Conference of State Legislatures, at least 35 states have looked at legislation to trigger a 1332 waiver application process as of February. Even conservative GOP Gov. Scott Walker in Wisconsin has approved a 1332 waiver application for reinsurance.
Idaho's creative dual 1332 and 1115 Medicaid waiver, although dead for now, would have shifted the highest-cost patients to Medicaid and set up a reinsurance pool for the individual market.
Several states are considering legislation to establish a coverage mandate and penalty or are studying how a mandate could work.