PPACA 2016: How will exchanges pay their way?

See also: Sebelius defends fed exchange user fee

3. All health insurers in a market could pay fees

One problem with charging exchange issuers a high user fee is that the fee could make the cost of coverage sold through an exchange much higher than the cost of the coverage sold outside the exchange.

When exchange system advocates were promoting the exchange concept, one argument was that distributing coverage through an "Amazon.com for health insurance" would be cheaper than the traditional system.

The board of BeWellNM, New Mexico's health insurance exchange, for example, has talked about funding its exchange with an assessment on all insurers that sell major medical policies, on or off the exchange, and all dental coverage sold through the exchange.

Supporters of that approach say it broadens the potential source of funding for the exchange, decreases the effects on exchange users, and eliminates the possibility that exchange user fees themselves could drive consumers away from the exchange system.

In the District of Columbia, the D.C. Health Benefit Exchange Authority is trying to further expand the base of support for its locally run DC Health Link exchange, by imposing an assessment on insurers that sell all types of health-licensed products in that market, including many products that cannot be sold through the exchange.

The American Council of Life Insurers (ACLI) is fighting that approach in the federal courts, arguing that approach is unfair to insurers shut out of the exchange system.

4. States could use their own tax revenue

Many states have been generous supporters of their exchange programs, and they could continue to support their exchange programs with their tax revenue. Vermont, for example, has been talking about creating a new tax to fund a shift to a single-payer health care system. 

5. They might be able to sell ads

Today, the public exchange programs are major buyers of advertising, but they attract many users themselves. In the past, some exchanges have talked about generating revenue by selling advertising.

See also: New Hampshire uncertain about PPACA outreach money