Affordable Care Act: Federal Health Insurance Exchange

LFDA Editor

In March 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, a federal statute that marks Congress's chief health care reform legislation. Most of the Affordable Care Act (also known as "ObamaCare"), including the controversial individual mandate to purchase health care, was upheld by the U.S. Supreme Court in June 2012.

While there are many aspects of the Affordable Care Act, there are two major provisions that affect state government.  First, each state must run an online health insurance marketplace (also called an "exchange").  Second, each state had to decide whether to expand eligibility for Medicaid.  Click here to see the LFDA issue page on Medicaid expansion.

Online Insurance Exchange in New Hampshire

One of the primary requirements of Affordable Care Act was that every state establish an online health insurance exchange, often described as "one stop shopping" for consumers buying insurance.  Each state had three options to establish the exchange: let the federal government create and operate the exchange, use federal funds to create and operate the exchange on the state level, or partner with the federal government on a limited basis.

HB 1297, passed by the New Hampshire legislature in 2012, forbid the state from using federal funds to create and operate the exchange on the state level.

In February 2013, New Hampshire agreed to partner with the federal government for the online health insurance exchange.  Under the partnership the U.S. Department of Health and Human Service operates the exchange, while New Hampshire government regulates the insurance plans.  New Hampshire is also responsible for consumer assistance for residents navigating the exchange. 

When the federal insurance exchange launched October 1, the website was plagued by problems.  President Obama promised a fix by the end of November 2013.

The exchange was also criticized for only drawing one New Hampshire insurer, Anthem Blue Cross Blue Shield.  Anthem was criticized in turn for offering a narrow network of health care providers.  Anthem says the narrow network lowers costs and ensures quality.  Opponents argue that the narrow network unfairly limits consumer choice.

The state Insurance Department is now studying the network adequacy rules that allowed the Anthem plans to be approved.

Several other insurers, including Harvard Pilgrim Health Care, Minuteman Health, Assurant Health, and Maine Community Health Options, joined the New Hampshire exchange in 2015.


Signed by Governor

Requires health carrier network adequacy rules to include access to providers for persons with substance use disorder. This bill also requires health carriers to notify covered persons of their rights, including the ability to appeal decisions and seek care out-of-network.

Killed in the House

Establishes the federally-facilitated health exchange as the online health insurance exchange for New Hampshire. This also repeals the prohibition against a state-run exchange.

Killed in the House

Prohibits public employers from offering employees any health care plan subject to the excise under the federal Affordable Care Act ("Obamacare"), unless the employee pays the cost arising from such tax. The Department of Administrative Services says that should the terms of the bill take effect while the current collective bargaining agreements are in place, the result will be a violation of those agreements. The federal excise tax is scheduled to take effect in calendar year 2018, and is a tax on "high-end" health plans that may insulate workers from the high cost of care and encourage the overuse of care.

Killed in the House

A resolution urging Anthem Blue Cross Blue Shield to include at least one hospital in each New Hampshire county in its insurance network.

Signed by Governor

Requires the state Insurance Department to hold public hearings before approving any insurance plans to be offered on the online health insurance exchange.

Killed in the Senate

Requires any insurer participating in the online health insurance exchange to include access to a hospital in each county of the state.

Killed in the Senate

Repeals the prohibition on a state-run online health insurance exchange.

Killed in the House

Requires Anthem Blue Cross Blue Shield to allow any health provider into their network for the purpose of participating in the online health insurance exchange.

Killed in the House

Allows insurance companies to sell insurance policies that do not meet state and federal requirements, provided that the state Insurance Commissioner approves the policies.

Signed by Governor

Forbids the state from using federal funds to create and operate an online health insurance exchange on the state level.

Should NH continue to have the federal government run the online health insurance exchange?


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gordona's picture
Gordon Avery
- Salinas

Wed, 08/12/2015 - 11:53am

Affordable Care Act” is nothing of the sort, and more importantly it just affords government permission to deny care.


Obamacare is about unnecessary government intervention and, ultimately, it's all about government control.


Each step forward taken by champions of this socialist program would jerk back two steps from every free American and our God-given rights.


A bloated bureaucracy and weak-kneed politicians sent millions of Americans into financial distress, unseen in history, with this leftist scheme called Obamacare.


The Hippocratic Oath taken by our care providers is one of the oldest, most sacred binding oaths, it has never condoned the taking of innocent life through lack of care, and certainly not via direct action.


The statements above were from Sarah Palin.


Obama went around telling audiences in person and on television that people would realize a $2500. reduction in their healthcare costs. He promised if you liked your policy you could keep it. If you liked your doctor you could keep him. How many saw their policy costs drop? Ours went through the damn roof. Many people who liked their policies were forced to drop them and take the so-called ACA, more money and less benefits, paying more for less.


The trouble is people don’t listen to this socialist when he speaks, he will tell you the truth but it will be intermixed with lies. He, Reid and Pelosi said that Obamacare was not the end-all but just a skip in the rope to Single Payer, womb to the tomb care under the direction and control of the government, full blown socialism. Did anyone say “Death Panels? Oh yes they are here. Doctors are retiring early, some changing careers as they refuse to be ponds in the hands of the government. They refuse to have some government pinhead standing between them and their patients.


Obamacare is exactly what it was meant to be, chaos thrown into a running system, as the hook that would cause the government to have to step in, to bring order to their originated chaos, complete and total control of every man, woman and child under Single Payer.


For the sake of this country and the freedoms we leave to our children this damnable “ACA-Obamacare-SCOTUS Act” must be repealed and thrown in the garbage. Our healthcare in this country was the best in the world, now we are on our way, if not stopped, to being no better then any 3rd. rate socialist state.

Robert Olcott
- Lebanon

Sun, 10/06/2013 - 1:01pm

New Hampshire had a single Health Systems Agency (UHSA-United Health Systems Agency) whose by-laws gave every NH resident over 18 years of age, a vote on the Representatives we had on the five "Sub-Area Councils" and the State-wide Board, as well as committee assignments (Project Review, "Certificate-Of-Need", etc.) which were all mandated under the National Health Planning and Resources Development Act of 1975 (Public Law 93-641) to have Consumer (as opposed to provider) Majorities. "Consumer representative" was well defined: You could not be a consumer representative if you earned more than 10% of your income from a "health related source", were married to a "provider", or were an indirect provider.

Is anyone familiar with why that portion of the old National Health Planning Act was not carried forward into the ACA, when remnants of the old Hill-Burton Act of 1946, which was included in the National Health Planning ...Act of 1975, and a similar provision is made for taxpayer subsidies to "Community Health Centers" as opposed to "Hospitals", in the Affordable Care Act (Obamacare)???  The Supreme Court has ruled that the ACA is a "Tax", yet I don't know who provides my representation in this process.

Lynn Bolles
- Londonderry

Fri, 03/07/2014 - 10:35am

I recently used my Obamacare health plan for the first time in the middle of February.  When I went in for my appointment, the receptionist said because the health plan is so new and they don't know how long it will take them to get reimbursed by the insurance company for my visit, they are requiring a $100 deposit from each patient with the new health plan for EACH visit.  When they received payment from the insurance company, they will return the deposit by mail.  They said this is their office policy.

Is this legal?  I've  never heard of such a thing.  My plan shows that I only have a $5 co payment and I had to hand over $100??  I recently received the EOB showing that the insurance company is paying for the visit, so I should eventually receive my deposit back minus the $5 co pay. 

So....two questions.

Is it legal for them to require $100 from us before we see the doctor??

Can I demand interest on that $100 of mine that they kept for a month?

I'm very angry about this and I'm seriously considering changing my doctor because of this.

Any help?

BrianDunn's picture
Brian Dunn
- Henniker

Tue, 12/16/2014 - 9:25pm

What do Libertarians mean when we talk about a free market economy and how can this be applied to something as well known as Health Insurance?


     The philosophy behind the free market system is easy to understand. The free market system simply believes that the the private sector (i.e. private citizens and businesses) can run any program or commodity better than the Federal Government.

     When we break down health care we must realize a few important details first. First, we have a customer; a person whom is in need of the commodity of health care. Secondly we have the commodity itself; doctors or hospitals. Under the free market system these are the only two parties present in the exchange. It is simple supply and demand; there is a need for a product and there is the person who provides the product to the customer.

     Now we must observe the current market system and how it operates. We still observe a costumer in need of a product and business/commodity which provides the product. The difference comes in that the current system adds a third party to the mix. This third party is represented by the health care insurance companies or now the federal government. The insurance companies and federal government act as a bridge or 'middle man' between the consumer and the provider. In a free market system a patient would simply go to his doctor for care and pay a doctor for the service provided. In the current system the consumer must pay an insurance company to connect to the services of the doctor whom then performs the service and then is compensated by the insurance company.

     The free market system argues that the third party is an unnecessary part of the natural business cycle and must be removed. The free market system argues that because there is an unnecessary third party involved, this increases the cost to the customer. It is very easy to explain how/why this occurs. We must realize that insurance companies are businesses within themselves. Insurance companies are actually very large and quite profitable businesses. Running a business naturally incurs great expenses. We must consider rent for insurance buildings/headquarters, electricity costs, overhead, marketing, employees, employee benefits,pensions, retirements etc. THE MONEY FOR ALL OF THESE EXPENSES IS BUILT INTO AND PAID FOR WITHIN THE PREMIUMS OF THE CUSTOMERS OF THAT INSURANCE COMPANY. So as a customer, rather than simply paying for a doctor to examine you like you would in the free market system, you are now also paying in part for the insurance company and their employees who process your information and interact with the doctor. Basically as a customer you are paying money to both the doctor and the insurance company/government rather than just the doctor them self. By eliminating the third party involved in the exchange of goods, the cost to the consumer for the good naturally decreases. It is as fundamentally simple as this.

     I believe spending less money for a commodity is something everyone in the United States would vote for and support. Unfortunately this concept is not explained often or at all and most people do not have an understanding of what Libertarians mean when we speak about the a free market economy and why this is a fundamentally better system than the one we currently operate. I also think this is a message everyone could get behind if they understood the mechanics involved.

     Critics of this system argue: How can we be sure it would remain fair? How would a free market economy regulate itself without federal regulations in place to control it? The answer is competition. A free market economy rewards the best product or product value at the best price. Furthermore, the more competition that exists for any product the more the price of that product is driven down by the market. A simple example of this can be found in common power tools. You walk into a Home Depot to buy a drill and are presented with brands like Dewalt, Makita, Milwaukee, Black and Decker, Craftsmen, Ryobi, etc. Lets say I buy Dewalt, although it one of the most expensive brands, I buy this because I view it as the best quality product at the most reasonable price. How is this an example of how the free market self regulates itself? When competition for a similar product exists prices drop and set themselves. Because Craftsmen and Ryobi offer a drill at much lower prices, this actually regulates the prices of the more expensive brands such as Dewalt or Milwaukee. If Dewalt got greedy and ignored the prices of their competitors by charging an exorbitant amount of money above their competiros they would most likely lose more sales and their business would suffer. In this way the prices of the bottom of the market set and control the prices at the top of the market. The more competition that exists within the market the more it benefits the consumers within the market. If we rid ourselves of all the federal regulations on all commodities this is the prosperity we could expect in all commodities in a free market economy.


Brian Dunn

Libertarian Party 2016

E Plurbis Unum, ensuring liberty for the future of New Hampshire

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Issue Status

Three insurers will offer plans through the New Hampshire health insurance exchange this year: Anthem, Harvard Pilgrim and Ambetter. 

However, Minuteman health won't be offering plans, and those currently subscribed will have to find different coverage in 2018. 


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