Good news alert: Web search for health insurance has been cleaned up

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ACA marketplace enrollment surged by 21% in 2022, from 12.0 million as of the end of the Open Enrollment Period for 2021 to 14.5 million in OEP 2022.  The primary cause was plainly the massive boosts to premium subsidies provided by the American Rescue Plan in March 2021 (witness the enrollment surge in the emergency Special Enrollment Period in effect when the boosted subsidies came into effect). Ramped-up federally funded enrollment assistance and advertising may also have helped.

A less visible marketing measure may also have been a factor: the online search environment has been cleaned up.  Search today on Google for "health insurance" or "Obamacare" and HealthCare.gov, the federal exchange that serves 33 states, will top the search results. Search for "health insurance Nevada" and Nevada Health Link, the state-run ACA exchange, will be on top. The same is true for all of the 17 states (and D.C.) that run their own exchanges. There are some slight variations on Yahoo and Bing, but results there are also generally reliable. 

Only to be expected?  Maybe -- but for years, until mid-2021, online search for health insurance was a bear trap, baited with ads and websites that often steered people toward lightly regulated, unsubsidized ACA-noncompliant plans, or toward a single insurer or incomplete menu of ACA-compliant offerings. The Trump administration turbo-charged the noncompliant market by extending the allowable term for "short-term, limited duration" (STLD) plans to a full year, with up to two years' renewal. Online "lead generators" promising cheap health insurance, and often steering respondents to brokers selling STLD and other noncompliant (and unsubsidized) plans (e.g., fixed indemnity plans), proliferated.

I don't have means to show what Google search results for terms like those cited above would have yielded in the Trump era (or before). I do, however, have a preserved search from last December on Yahoo (captured when Yahoo somehow interposed itself as the default search engine on my browser).  Here are the results for "Covered California" -- the name of California's state-based exchange:

The first result, Healthplans.com, collects information similar to that gathered in the "preview plans and prices" tools used by Covered California and all the ACA exchanges. But it won't work unless you provide a name, address and phone number. And a small-print, legally required disclaimer at bottom warns:

Yahoo has since cleaned up its act: if you search "Covered California" now you'll get Covered California on top. Google results were clean at the time of this screen capture (last December) -- I checked after I discovered that my default browser had been switched.

What changed? In response to a query, CMS sent the statement below outlining measures they take and have taken to quell misleading ads and search results. What's left unclear is the timeline: how and when did the search environment improve?

CMS maintains relationships with representatives from Google, Yahoo, and BING and CMS has had direct conversations on this topic. Each search engine has published policies on health care advertising as well as policies on misrepresentation. Misrepresentation is when an ad tries to look like a different organization, such as a broker trying to look like HealthCare.gov. When CMS sees an ad we think is misrepresenting HealthCare.gov, we share it immediately with the search engines. CMS will continue to monitor and work with our search partners to ensure that consumers are connected to reliable and accurate search results.

This policing grew much more effective some months in advance of Open Enrollment for 2022, which began on November 1, 2021.  The change may have something to do with the search engines' "published policies" alluded to by CMS above. On that front, George Kalogeropoulos, CEO of the commercial online web broker HealthSherpa, has a tale to tell. 

HealthSherpa is the marketplace's second largest enrollment vehicle by volume, accounting for a third of HealthCare.gov's 2022 enrollment.  It is the dominant player in a federal program called Enhanced Direct Enrollment, through which CMS allows commercial brokers and insurers to process applications, including subsidies, in HealthCare.gov states via a dedicated channel on HealthCare.gov. HealthSherpa is used by thousands of brokers as well as the general public.

As a catalyst for one significant change in the search environment for health insurance, Kalogeropoulos points to a policy update that Google issued in May 2020. The upshot:

Google will no longer allow ads for documents and/or services that can be obtained directly from a government or a delegated provider. This includes offers of assistance to obtain these products or services. A delegated provider is defined as a company that has been officially entrusted or assigned by the original provider (the Government) to provide certain products or services on their behalf.

While health insurance brokers are "delegated providers" of government services, and subject to regulation* as to how they present their services and products they sell online, lead generators are not -- and they dominated search engine results for health insurance and related terms. Google, however, did not immediately recognize ACA marketplace insurance as a government service.  Health insurance is conspicuously absent from the admittedly "non-exhaustive" list of services excluded from advertising, which includes those helping people obtain 

passports and other forms of national ID; proof of permanent residency; proof of immigration status/registration; driving licenses; travel documents like visas and Electronic Travel Authorizations (ETAs); social security cards; hunting or fishing licenses; gun licenses or registration; and documents or information derived from official registries like birth certificates, marriage certificates, and military records.

HealthSherpa approached Google with a memo arguing that health insurance should be included in the exclusion (HealthSherpa is itself a licensed web broker and therefore a "delegated provider"). Two meetings, in which representatives from CMS and the state-based marketplaces participated and argued this case, took place in 2020. Google convened a third meeting in April 2021 to announce an update to its health insurance policy. That update, published in June 2021, states:

On June 2, 2021, Google will update the Healthcare and medicines policy to require certification for health insurance advertising in the United States. Government advertisers are exempt from the certification process. 

In the United States, advertisers will need to be certified by G2** as a provider of health insurance before they can advertise on Google.

A parallel policy for web search was implemented shortly afterward. Yahoo and Bing appear to have followed suit.

Health insurance ads are a major revenue source for Google and the other search engines, and this change of regulation and practice likely cost them significantly. 

State-based exchanges also fight solo battles against efforts to hijack searches for their services and ramped up those battles in the pandemic years. Audrey Gasteier, chief of policy and strategy at the Massachusetts Health Connector, said in an email that in August 2020, the exchange's compliance department started filing complaints with Google, based on Google’s policy regarding trademark use in paid ads, to remove the ads on Google that inappropriately used Health Connector trademarks. For several months, the Connector submitted around 20 ads per complaint.  The effort has significantly reduced the number of ads on Google that purport to be the MA Health Connector, according to Gasteier, and they have been able to drastically reduce the complaint barrage.

The direction online searches take may have a significant impact. In November 2021 alone (the first month of Open Enrollment for 2022), searches centered on "Obamacare" and "ACA" alone numbered around 500,000, according to HealthSherpa, pointing toward more than a million such searches during the Open Enrollment season. And searches including those terms are far from representing the whole universe of searches for health insurance plans.

Efforts by CMS and the state-based exchanges to curb online disinformation and diversion in health insurance marketing did not begin or end with the initiative of 2020. At present, search results below the topline usually include individual insurers and often include the pre-ACA web broker eHealth, which currently shows ACA marketplace plans without a whisper that subsidies are available to most prospective enrollees. But if you search for health insurance under almost any rubric at present, the government-run exchanges*** are hard to miss. 

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* See 45CFR155.220(c)(3)(i))

** A "G2 provider of health insurance" is licensed and registered to provide ACA plans in all jurisdictions where they do business.

***  Health insurance searches also often yield other government sites, included geo-targeted state Medicaid services, clustered at the top.

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