The remaining state-based public health insurance exchangesunder the Patient Protection and Affordable CareAct can support themselves, for now.

Andy Slavitt, acting administrator of theCenters for Medicare & Medicaid Services (CMS), gave thatassessment recently during a hearing on the state-based exchanges, but hedeclined to talk about how sustainable the PPACA state-based exchanges will be inthe future.

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"I can't predict who's going to come into the federal exchange,"Slavitt said, referring to state-based exchanges that decide toscrap their own enrollment systems and switch to HealthCare.gov,the exchange enrollment system set up by the U.S. Department ofHealth and Human Services (HHS). "As of today, all of the statesare sustainable."

CMS is a division of the U.S. Department of Health and HumanServices (HHS) and the parent of the Center for Consumer Information and InsuranceOversight (CCIIO), the agency directly responsible foroverseeing the Patient Protection and Affordable Care Act (PPACA)exchange system, including the HealthCare.gov exchanges and thestate-based exchanges.

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The House Energy & Commerce oversight committee organizedthe hearing to look at how CMS is managing the state-based exchangeprogram.

HHS used PPACA grant money to help states set up exchanges, butthe exchanges that went live in January 2014 were not supposed touse the startup grant money to cover operating expenses after Jan.1, 2015.

Slavitt said CMS has an effective program in place to reviewstate-based exchange spending, reject use of HHS grant money forprohibited purposes, and recoup misspent money.

"We control the purse strings," Slavitt said.

Some lawmakers questioned whether CMS has done enough to punishstates with failed efforts to set up exchange enrollment andadministration programs.

Five states had serious information technology problems, Slavittsaid. He said two of those recovered and are still running theirown enrollment systems. Three have shifted to usingHealthCare.gov.

CMS has already recovered money from one of those exchanges, isstarting to recover money from a second, and is closing down andpreparing to recover money from a third, Slavitt said.

Slavitt said most of the state-based exchanges use some kind ofinsurer assessment to pay for exchange operations, and that a fewuse general fund money to pay for exchange operations.

Rep. Susan Brooks, R-Ind., tried to get Slavitt to say how manyexchanges have sustainability problems.

Slavitt told her CMS is talking to all of the state-basedexchanges about sustainability.

"In some cases," he said, "there's a little bit of toughlove."

In the past, CMS had tough conversations with managers of theHawaii exchange that led to that exchange shifting to usingHealthCare.gov, and it had conversations with the Rhode Islandexchange that led to that exchange getting more revenue, Slavittsaid.

"The general rule is, the smaller the state, the greater thecommitment of effort we need to focus on them," Slavitt said.

Rep. Chris Collins, R-N.Y., asked Slavitt about the failure ofHealth Republic Insurance of New York, one of the nonprofit,member-owned Consumer Operated and Oriented Plan (CO-OP) carrierscreated by PPACA.

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"Doctors are calling my office complaining that checks fromHealth Republic are bouncing," Collins said.

Slavitt said CMS and state regulators worked to get theinsurers' enrollees transferred smoothly into replacement coverage,but that questions about provider claim payments should be directedto New York state officials.

When Collins pressed Slavitt for an answer about whetherproviders would be paid, Slavitt said, "The answer is that I'm notgoing to speak for the state."

Brooks, who represents the home district of UnitedHealth GroupInc. (NYSE:UNH), asked what UnitedHealth's plans to withdraw frommost state exchanges means for the exchange program.

Slavitt, who was group executive vice president forUnitedHealth's Optum unit before he went to work for CMS, said theexchange program has hundreds of issuers and thousands ofplans.

"At any given time, there's going to be people entering themarket and some exiting the market," Slavitt said. "Some will havegood strategies and some will have not-so-good strategies. That'sjust how marketplaces work."

PPACA requires members of Congress to get their health coveragethrough the exchange system.

Rep. Michael Burgess, R-Texas, a medical doctor, said hedeclined to use the special group PPACA exchange coverage availableto members of Congress and instead bought bronze coverage throughHealthCare.gov.

The experience was miserable, and the deductible is so high, heviews himself as being functionally uninsured, he said.

He said Congress could improve the PPACA exchange system bypassing a bill he has introduced, H.R. 1196, that would classifyall exchange bronze and exchange silver plans as plans compatiblewith health savings accounts (HSAs), and by increasing the HSAcontribution limit to be the same as the PPACA exchange plandeductible cap.