One criticism of these programs involves the lack of consensus about the appropriate level of cost sharing. Another is that the evidence base is changing continuously and high-value services may evolve. Finally, the experience of programs such as Medicaid with value-based insurance is minimal. Because Medicaid serves low-income populations, patients may be especially sensitive to small changes in cost sharing. The goal is to balance standardization and innovation to enable patients to compare options while receiving the value intended in the law. A number of states have established their own health insurance exchanges, and the array of choices is broad. Some states, however, have opted to have the federal government step in to establish their exchange. Early evidence indicates that states are balancing a simple shopping experience for insurance with a design that still promotes innovation.

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