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The insurance fight proved more difficult than the cancer.

Doctors removed part of Barb Rea's tumorous left kidney in the summer of 2009. She spent the next 18 months battling her insurance company over $40,000 in medical bills.

The company lost her paperwork and incorrectly processed her claims. It claimed her doctors weren't part of the network. Rea would call to discuss a problem, and each time, find herself talking to a different person with a different story.

"They used every trick in the book not to pay," said the 54-year-old Casper resident. "It was just an icky experience. Worse than cancer. It was horrible. It was demeaning. I'm a very smart person. I took very good notes. And I couldn't do it."

Rea and her husband, Tom, are among the roughly 4 percent of Wyoming residents who purchase their own health insurance, rather than relying on the government or an employer for coverage. For people in their situation, choosing a policy can feel a little like grocery shopping in the dark. It's difficult to know exactly what you're buying.

"There is no way to compare apples to apples," Rea said. "There is no way to get a good understanding of the value of a product. We just don't have access to information to know if it is really going to meet our needs."

Wyoming lacks a system for consumers to shop for insurance with the lights on. But that could change in 2014, when the state's first insurance exchange is expected to begin operating.

An exchange is an online marketplace where individuals and small businesses buy insurance. Consumers shop for policies like they do hotels on travel websites like Orbitz, with side-by-side comparisons and customer reviews.

Despite the possible benefits, the success of a Wyoming exchange is hardly certain. Skeptics wonder whether the marketplace could succeed in a rural state with a small population. Designers must also convince a right-leaning Legislature to adopt a program that's most associated with President Barack Obama and federal health reform.

Rea reached a settlement with her company and now volunteers for Project Healthcare, a group promoting consumer-oriented health care in Wyoming. She believes an exchange has the potential to improve the system here. But she's pessimistic lawmakers will establish a program that benefits their constituents.

"All someone in the Legislature has to say is, 'It's going to cost too much,'" she said. "Rather than looking at how citizens can have access to good, affordable health care."

Virtual marketplace

When Congress passed the Affordable Care Act in 2010, it made exchanges a key part of health reform. The law requires Wyoming to open an exchange by the start of 2014. States that don't meet the timeline risk a federal takeover.

Federal health reform remains controversial in Wyoming. But even critics of the reform law see potential in exchanges, said Anne Ladd, chief executive officer of the Wyoming Business Coalition on Health.

Consumers who buy on the exchange will have a better idea of what they're getting. Policies must meet certain minimum benefit standards before they can be sold on the exchange. They're also categorized by the percentage of medical expenses they cover.

Advocates believe an exchange could address the dramatic rise in health care costs through transparency and competition. If patients can shop around, the theory goes, companies will respond with better products.

An exchange would also reduce the number of uninsured people in Wyoming. Between 38,000 and 41,000 people are expected to enroll in the marketplace by 2016, according to one estimate from a state consultant. More than 60 percent will be people who currently go without coverage.

With small-business insurance premiums rising by about 10 percent a year, many owners are finding it increasingly difficult to offer coverage to employees, Ladd said. With an exchange, a business owner could simply set a specific dollar contribution for her workers, and then let employees decide which plan to purchase.

Employees can pay the difference if they prefer a more expensive plan. Leaving those decisions to workers would save business owners time and give employees more choice, said Steve Loftin, president of Casper-based 71 Construction.

"I have to choose one plan for my employees," said Loftin, whose company provides health benefits for 45 employees. "I can't possibly know what each one thinks is the best policy."

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Exchange critics

Health exchanges have their critics, including Regina Meena, who handles policy and legislative affairs for Wyoming Liberty Group, a free-market based think tank in Cheyenne. She believes exchanges are based on a health care model that doesn't work.

Meena predicts exchanges will be ineffective because they don't address Wyoming's small risk pool. State leaders should be looking for ways to decrease government involvement in health care, not the other way around, she said.

"[Exchanges] will not deliver the results," she said. "And the backlash is that all the legislators are going to be held accountable when all the people don't get the results they were promised."

Even people who see the utility of exchanges are skeptical about whether the concept would work in Wyoming. Costs for administering the virtual marketplaces are typically spread over the people who are enrolled. Since Wyoming has such a small population, people who use the exchange might end up paying higher administrative fees than those in surrounding states.

Sen. Bill Landen, R-Casper, is part of a committee reviewing exchange options for the state. He's shares the concerns that Wyoming might be too small for a successful exchange. He also thinks the potential benefits -- lower health care costs and the ability to compare products -- warrant additional study this year.

"It makes it incumbent that we take this slowly," he said. "If we are going to venture into this water, we want to find out how deep this water is."

If the committee concludes Wyoming should create an exchange, it must still convince the Legislature to invest in program that's part of the unpopular health reform law.

The exchange's connection to the Affordable Care Act does present a challenge, Landen acknowledged. But he expects colleagues will give it fair hearing, given the time the committee has spent on the issue.

It's also a debate worth having. Even if the law is repealed, escalating health costs will continue to affect the state's economy.

"Whether we like it or not, regardless of if it comes as a mandate, this conversation is coming up," he said.

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Contact Joshua Wolfson at 307-266-0582 or at josh.wolfson@trib.com. Visit http://trib.com/news/opinion/blogs/wolfjammies to read his blog. Follow him on Twitter @joshwolfson.

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