Made up of heads of the state's big human services and health-related departments, Gov. Pat Quinn's Health Care Reform Implementation Council crisscrossed the Prarie State over the last eight months, holding four public meetings to hear what Illinoisans had to say about how the state should carry out the changes put forth in the federal health care law. A fifth meeting was held last month to field questions from stakeholders about the council's recommendations. The council issued its recommendations in a dense 48-page report (PDF) last week.

One of the most important issues facing the council was the structure of a state health insurance exchange, which will set up the infrastructure so more than a million uninsured residents will be able to buy subsidized health care starting in 2014. The exchange is a transparent and regulated clearinghouse that will list a variety of competing health insurance plans available to those who currently don't have access to adequate employer insurance. Congress eventually agreed that individual states -- and not the federal government -- would set up their own exchanges by 2014 and would be responsible for operating the marketplace.

The council proposed a "market developer" for the creation of the health benefit exchange. This model, the report says, would mean the exchange, run by the state, would negotiate "with insurers and requires them to compete on price and quality to gain access to the Exchange marketplace." The report adds that such a model "could increase competition, thus reducing the price of premiums or increasing the quality of service or benefits for consumers." The council recommends that the exchange eventually transition to a "market organizer" model, which opens the exchange to "all health insurers that meet minimum federal requirements."

Another interesting recommendation comes in the "dual market" approach pushed by the council, which would maintain the current market in addition to the exchange. (The ACA gives states discretion to fold everyone into the exchange.) Discussing the dual market approach of the exchange with Illinois Statehouse News, the Director of Insurance, Michael McRaith, said, "The consensus from the participants was that a quasi-state agency was an appropriate way forward for the state of Illinois."

But the Center on Budget and Policy Priorities warned (PDF) that such a program could cause adverse selection -- "the separation of healthier and less-healthy people into different insurance arrangements" -- which could "drive up costs not only for consumers and small firms purchasing coverage through the exchanges, but also for the federal government, which must provide premium subsidies to enable low- and moderate-income people to afford coverage in the exchanges."

As a safeguard for the possibility of adverse selection, the council's report says this dual market report will require strong enforcement by the state. The report notes that the Campaign for Better Health Care recommends the same regulations for both the plans in the exchange and those outside it. CBHC also suggests, according to the council, "the same marketing, benefit design and plan-pricing provisions should apply both within and outside the Exchange to deter non-Exchange plans from marketing plans or structuring benefits to attract better risk."

The report is just the first step. Pending federal court cases, which could void the federal health care law appear to be heading to a nasty fight in the Supreme Court. Shortly after winning the midterm elections, Congressional Republicans now in control of the House pushed through a repeal of the bill. And it is, after all, only 2011.