Facing high costs but smaller budgets, states like Hawaii and Rhode Island are struggling to find financially and politically sustainable ways to keep their health exchanges running.

Jeff Kissel’s first task when he took over Hawaii’s health exchange was making sure it worked after a botched first year, but a close second was finding a way to pay for it. The former gas utility CEO is now lobbying his legislature — what he calls “taking a forceful stand for why this business decision works”– to keep the exchange’s lights on.