According to a new study by the PwC US Health Research Institute (HRI), the state health insurance exchanges will create a more competitive marketplace worth $60 billion in revenue premiums by 2014 — which will grow to $200 billion by 2019.

Approximately 12 million Americans will purchase health insurance using the exchange market in 2014, reports the Congressional Budget Office (CBO), and that number is expected to grow to 28 million by 2019. Although many design and legal questions are still being determined, many insurers feel the market is simply too large to opt out of the health insurance exchanges.

Those who do participate, however, will face new business risks and stiff competition, said PwC in its report, Change the channel:  Health insurance exchanges expand choice and competition. The survey includes responses from 1,000 consumers and 153 health insurance executives. PwC also conducted interviews with 35 health industry leaders, including those representing state insurance exchanges, health insurers, policy makers, consumer advocacy organizations, and independent quality organizations