One piece of the Affordable Care Act (ACA) that has received little attention is “health care choice compacts” under Section 1333. Section 1333 allows states to enter into agreements under which Marketplace plans following the rules of one state can be sold in other states in the compact. This is a version of what’s often referred to as “selling insurance across state lines.”

While states have made extensive use of other ACA flexibilities, Section 1333 remains nascent. No implementing regulations have been released, and no state has sought to use it.

But now rulemaking appears imminent, and there are indications that the government may adopt an expansive vision for how compacts could be used.

This makes it a good time to consider what Section 1333 can and can’t do. This article explores the scope of authority granted by Section 1333.

In part 1, we discuss the history of the interstate sale of health insurance and the legal issues raised by Section 1333 of the ACA.