California, Colorado, and Maryland were among the first states to enact legislation establishing health insurance exchanges called for in the Affordable Care Act. This brief outlines differences that stand out in the states’ initial approaches: the numbers and types of people initially appointed to the boards governing the exchanges; the role of the board relative to the state legislature; how the exchanges interact with existing insurance markets; and the involvement of stakeholders in each state. The decisions made by these states provide information that will be useful for other states implementing their exchanges. Going forward, these states will face a more challenging set of decisions, including how to finance the exchanges, how to make risk-adjusted payments to insurers for people likely to have high medical expenses, and how to avoid gaps in coverage and care for people who may have changes in income.
