There is also the uncertainty of the November election, in which Republican gains could reverse funding or even legal authority for the exchanges.
Perhaps it's no wonder that the details of insurer exchange strategy -- and with them the prospects of millions now lacking coverage -- are still in flux.
Medical providers, local communities, and the public wellness movement
See full coverage
"The management teams all have a positive spin on things, [saying] 'January 1, 2014 is coming. We need to be ready. It's a good volume opportunity,'" said
Thomas Carroll, who follows the industry for investment house Stifel Nicolaus. "No company will come out and say, 'Here are the states where we're going to
operate through an exchange in 2014.'"
Expected to eventually cover more than 20 million Americans, state exchanges are supposed to offer insurance coverage, much of it subsidized, in an online,
easy-to-compare marketplace. But without enthusiastic participation by private insurers, the exchanges won't work.
"For the insurance company, this becomes an opportunity, but it also represents a risk," said Brett Graham, a consultant at Leavitt Partners who advises
insurers on state exchange strategy. "Are there insurance companies saying, 'Whoa, this is coming too fast, we don't have information and we're going to
sit this out'? It may be too early to answer that question."
WellPoint, the country's second-biggest health insurer and the owner of Blue Cross franchises in more than a dozen states, shows every indication of
planning to sell aggressively through exchanges. Like many plans, which have been accustomed to gaining customers through brokers and employers, the
company is trying to sharpen its ability to sell directly to consumers not only through state exchanges but through private exchanges offered by employers.
"You are going to have to market in a more retail environment -- something that this industry hasn't had to do historically," Wayne DeVeydt, WellPoint's
chief financial officer, said at an investor conference last month. "And branding is going to become even more relevant. This year alone WellPoint is
spending almost $50 million in branding for the Blue Cross Blue Shield brand and we would expect those branding dollars would continue."
Carriers are refining smart-phone claims apps, consumer advertising and shopping tools for patients to find better and lower-cost caregivers. Blue Cross
and Blue Shield of North Carolina, in a state where bills to create an exchange failed in this year's legislature, may mimic Florida Blue and other plans
by opening member stores, said Michael Parkerson, the company's vice president of marketing.
Recent decisions by WellPoint and Aetna to buy Medicaid managed care companies are seen as a way not only to profit from the Affordable Care Act's Medicaid
expansion but also to create marketing channels for exchange plans. As members switch between Medicaid and exchanges as their employment and income
fluctuate, the thinking goes, offering plans in both programs will help keep the business.