The state-based health insurance exchanges are a key component of the Affordable Care Act. Even if the ACA’s individual mandate that people obtain health insurance coverage is declared unconstitutional by the U.S. Supreme Court, it is widely expected that the states and the federal government will continue to implement some form of exchanges. As called for in the ACA, the exchanges will provide a marketplace where individuals can compare and purchase health plans. In addition, they are expected to facilitate various administrative and regulatory tasks to foster competition between insurers, and thereby promote efficiency. While several federal regulations regarding the operations of exchanges have been published, states have significant latitude in an array of exchange design choices. How the states and the Federal government structure the exchanges will play a pivotal role in the success of the ACA’s reforms in terms of access to health insurance and health insurance cost-containment. Exchange-type systems are not new. They are grounded in the concept of managed competition, which was first proposed by Alain Enthoven in the late 1970s. Apart from smaller scale initiatives in the US, such as the Massachusetts Health Connector and the Utah health exchange, several European countries have gathered extensive experience with managed competition since the early 1990s. In the European countries, managed competition takes place at three competitive and regulated markets, i.e. the insurance market, the purchasing market and the provision market. Much of the ACA and subsequent regulations focus on the insurance market, and consequently states have focused on the implementation of insurance competition and setting up the exchanges. This could result in states neglecting some other key conditions for managed competition that are especially important for the long term success of the exchanges. The proposed roundtable will explore some of the key experiences with several European competitive insurance systems that rely on exchanges. Like the US, European countries are responding to slower economic growth and rising costs of health care by trying to encourage greater efficiency in their insurance and healthcare delivery systems. Lessons from the experiences with the European exchanges are not widely known in the US – but they could be extremely valuable to states weighing the effectiveness of design options for their exchanges. The roundtable discussion will be targeted and linked to the challenges faced by the states implementing insurance exchanges in the US. Panelists will be guided by topic rather than country experiences, although they will use examples from several countries and will focus on the implications of the European experiences for US health reform. The Europeans on the panel have done research on the health insurance systems and exchange-like markets in the Netherlands, Germany, Switzerland, and the U.K. At least two of the European panelists will be in the US this fall so travel expenses are not a problem.