Even amid the government shutdown, the new online insurance marketplaces -- known as health insurance exchanges -- were up and running today. There were early reports of computer glitches across several states. Some states, with large numbers of uninsured, are dealing with problems of a different sort.

In the states with largest uninsured populations, the stakes are high for this fall’s insurance exchange enrollment — the difference between the healthcare status-quo and improvements in healthcare access and sustainability.   

Some 5.7 million Texans, almost 25 percent of the population, are estimated to be uninsured, contributing to about $5.5 billion in uncompensated hospital care annually, according to the Texas Hospital Association. But with state leaders declining to expand Medicaid, a number of those uninsured may remain without coverage, caught in an eligibility “donut hole” — too rich for Medicaid but too poor for federal premium assistance, which starts at 133 percent of the federal poverty level under the Affordable Care Act.

Other states with large uninsured populations that are declining to expand Medicaid, like Florida, Georgia, Louisiana, South Carolina and Mississippi, may see similar disparities in access to health insurance for many low-income workers — unless they expand Medicaid, or craft agreements with federal health regulators to extend premium subsidies to residents earning below 133 percent of the federal poverty level.

In some of those states, though, there is still disagreement between government leaders over participating in ACA programs.

In Florida, where 3.5 million residents are uninsured, the deputy health secretary recently told the state’s 60 county health departments that ACA navigators hired by community groups under federal grants should not be permitted on county property. But county health commissioners in Broward County, in greater Fort Lauderdale, and Pinellas County, in greater St. Petersburg, voted to ignore the ban and allow navigators to work in county offices, while community groups, nonprofits and healthcare companies are trying to fill the gap in outreach for the federal insurance marketplace, amid public confusion with health reform.

Meanwhile, the Florida Agency for Healthcare Administration is asking the federal government for $3 billion in grants for the state’s low-income pool, for uncompensated hospital care.

In South Carolina, another state with Republican leaders opposed to Medicaid expansion, almost 500,000 residents are estimated to be eligible for subsidized insurance through the federal exchange, but still almost a quarter of a million residents could be left in the Medicaid-HIX eligibility gap. At the same time, the South Carolina Department of Health and Human Services is implementing a new reform strategy for healthcare delivery based on the Institute of Medicine’s Triple Aim goal.

For instance, as The New York Times highlighted recently, South Carolina Medicaid ended coverage for elective deliveries prior to 39 weeks of gestation, increased reimbursement for physicians offering extended hours during the evening, weekends and holidays, and is certifying primary care walk-in clinics as Medicaid providers at locations like CVS stores.

And for residents in South Carolina and Louisiana who are eligible for insurance premium assistance, the insurance landscape may shift with the new choice of cooperative health plans. The Louisiana Health Cooperative and the South Carolina Consumers’ Choice Health Plan are two of the 24 consumer oriented and operated nonprofit health plans supported by federal loans under the ACA.

[See also: Worries rise on insurance exchanges.]

Co-op plans are looking at attracting individuals, families and small businesses, and in states with federal marketplaces they may eventually be a choice for consumers enrolling under the Medicaid private option — a policy solution Arkansas has found for the Medicaid-HIX “donut hole,” extending insurance subsidies to residents making below 133 percent of the federal poverty level, and one that Pennsylvania’s Governor is also considering. 

In the western part of the country, Arizona, a state with a high uninsured rate (18 percent) will be one to watch. Although state leaders are deferring to the federal HIX, Gov. Jan Brewer partnered with Democratic lawmakers to expand Medicaid eligibility, and the state has a co-op -- Meritus Health Partners. About 300,000 currently uninsured or underinsured Arizonans will be eligible for Medicaid under the expansion bill signed earlier this year.

[See also: Insurance exchanges to spark questions.]

In Nevada, where 22 percent of the state’s population is uninsured, the state is expanding Medicaid and operating its own marketplace, the Silver State Exchange, while a group called Nevadans for Nevadans is operating the federally-supported Nevada Health Co-Op. 

The co-op is selling 109 plans, on the exchange and in the non-exchange market, in bronze, silver, gold, platinum and catastrophic cost-sharing tiers, and like many insurance exchanges in states with diverse populations, is pitching its products equally to English and Spanish speakers.