"A state can get a health exchange that complies with the ACA in the same way that many businesses buy IT services... [in the form of] software as a service (SaaS).... States just getting started building an exchange right now have already lost federal subsidies to offset startup costs, but an SaaS exchange offers a low monthly operating expense compared to the large capital cost of building a custom state exchange. Rather than a big up-front capital investment in hardware and software, they simply pay to use a shared cloud computing service."