States should use their creation of health insurance exchanges required by the 2010 health care law to create prevention programs aimed at promoting long-term savings, expert say, but state officials argue that those "wish lists" might have to wait so states can meet their deadlines.

"To do something different, I sure wish we had an extra year," said Howard "Rocky" King, executive director of Cover Oregon, Oregon's health insurance exchange. "Our first priority is to come up with something that works."

That means states such as Oregon hope to build the foundation of their exchanges first and then add the extras over the next few years.

"States could play a huge, important role in prevention and care coordination," said Ken Thorpe, head of Emory University's health policy department. "But if we're looking at yesterday's benefits, we'll get yesterday's problems. We need to pull costs out of the system."

Otherwise, more people will be covered through the 2010 health care law, also known as the Affordable Care Act, but premiums will continue to go up, Thorpe said.

Rather than focusing purely on making insurance available, states could build evidence-based prevention and lifestyle-change options into the plans. They could insist that their insurers pay teams of hospitals, primary-care physicians, home health care professionals and hospice providers a set price to care for a consumer, rather than pay by the injection, scan or visit.

Without such changes, Thorpe said, health care costs will keep rising.

So far, Thorpe said, California has done the most to promote innovation in its health care exchange.

Health exchanges are state- or federally run websites that allow consumers to choose a health plan, as well as to compare benefits and costs of each plan. Some states will allow all insurers to participate; others have asked insurers to bid to participate; and some states are creating a list of requirements insurers must meet to participate.

Peter Lee, California Health Benefit Exchange's executive director, said that insurance has "been a game of avoiding sick people" to keep insurers' costs low. Now insurers must take everyone, and that means keeping chronically ill people stable and trying to prevent people from becoming sick in the first place.

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