Mathern contends a federally administered health exchange would probably provide the greatest benefit to North Dakotans. However, setting up a regional operation that would include Minnesota, North Dakota and South Dakota is the best long-term strategy because the states are neighbors and the size of the territory would be manageable, he says.
"There are a lot of overhead costs here, many millions of dollars," he said. "Doing it together would save money and make the most sense."
Sixteen states have agreed to set up state-run health insurance marketplaces, while 14 have declined, according to the Henry J. Kaiser Family Foundation, which monitors health care issues nationally. None of the states so far has adopted a regional approach.
The health care law also offers states incentives to expand Medicaid, a state and federal program that provides insurance for poor North Dakotans, to cover anyone younger than 65 who has income less than 138 percent of the federal poverty level. This year, that equals $15,415 for a single person and $31,809 for a family of four.
Dalrymple said the potential state budget effects of a Medicaid expansion are still being analyzed. He expects to ask lawmakers for authority to spend federal money that would finance the expansion, but he wants to avoid a large new state spending obligation, Dalrymple said.
"If the circumstances are right, we wouldn't stand in the way of our people getting more Medicaid benefits in North Dakota," Dalrymple said. "But we have to get comfortable with the idea that this is not just a fool's trap here."
North Dakota now has about 65,000 Medicaid recipients each month. The state's Department of Human Services estimates that the proposed expansion would add another 30,000 people to the Medicaid rolls.
Mathern said the federal government would foot most of the bill for expanding Medicaid benefits to uninsured adults. In other circumstances, the Legislature has been willing to take advantage of federal support, such as providing enough state money to grab the maximum amount of federal aid available for road construction and repairs, he said.
"Up until now, we haven't been willing to do anything," he said. "But there are so many resources available to us if we cooperate that, morally, we can't let that go."