Friday, November 17, 2023

Where and how do people find plans in the ACA marketplace?

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On October 1, 2013, the day the ACA exchanges first opened for business, President Obama promised that the exchanges would enable shopping for health insurance “the same way you shop for a plane ticket on Kayak or a TV on Amazon.”

The wretched dysfunction at launch of the federal exchange, (and to varying degrees the state exchanges as well), evident that day, immediately made that promise a laugh line. While two months of technical and political hell ensued before was marginally functional, ultimately 7 million people did enroll for 2014 coverage — in line with CMS’s projections — and the image of the insurance shopper sorting through the options on the exchanges took hold. The functioning and messaging on the exchanges improved over time — though the proliferation in recent years of barely-differentiated plans complicated the task of plan selection.

In the ten years since then, I’ve written many posts about the weaknesses and strengths of the exchanges’ functionality and messaging. Do they make it easy to enter a few data points and preview plans and prices (net of subsidy) for the individual viewer? Do they adequately steer those eligible for strong Cost Sharing Reduction to silver plans? In the first cataclysm of the pandemic, did they make Medicaid availability clear? Do their decision support tools (highlighting plans likely to yield the lowest net costs) work well?

All of which might be said to obscure the fact that the unassisted enrollee navigating options via the government-hosted exchanges has become an increasingly rare bird. As insurers have reinvested in the marketplace, brokers selling ACA-compliant plans have proliferated (more than 74,000 were registered in 2023, up from 48,000 in 2019). Since 2021, the Biden administration has replenished the federally funded Navigator enrollment assistance program that the Trump administration had reduced to skeletal form (Navigator funding was cut from $63 million in 2016 to $10 million by 2018, then restored to about $100 million in 2022).

To get a sense of how marketplace enrollees find coverage, it’s worth keeping these points in mind:

  • According to a CMS presentation to brokers, in states in 2023, 71% of active enrollees (new enrollees and active renewers) were assisted by brokers. 74% of new enrollees — 2.2 million out of 3.0 million — were broker-assisted. states accounted for 75% of total enrollment. In total, brokers enrolled 6.8 million of the 9.6 million who actively enrolled. (Of the 2.5 million who were passively re-enrolled, I don’t know how many were broker-assisted, initially, or in plan year 2023.)

  • In states, brokers rely heavily on commercial Direct Enrollment (DE) or Enhanced Direct Enrollment (EDE) platforms, which can process enrollments with subsidies (EDE directly; DE via a redirect to for the subsidy calculation). 81% of active broker-assistance enrollments are via DE or EDE, according to the CMS presentation. In 2023, more than half of enrollments on, excluding auto re-enrollments, were via DE/EDE (5.5 million). By my count of 62 EDE entities, thirteen are web brokers, the rest are insurers. The dominant EDE is HealthSherpa, which just announced that it has already processed 2 million enrollments for 2024. In 2023, HealthSherpa claimed to have accounted for 35% of state enrollments; the company seems on track to exceed that share this year. It’s possible that HeathSherpa processes more marketplace enrollments than any government-run exchange (assuming that other EDEs also have a substantial share of enrollment). To my eye, HealthSherpa is by far the easiest exchange to navigate and the clearest in presenting essential information.

  • In the California exchange, which accounted for 10% of national on-exchange enrollment in 2023, 58% of enrollees were broker-assisted, and another 7% were assisted by nonprofit Certified Enrollment Counselors, Service Center Representatives at the exchange, or other assisters. (See the 2023 Open Enrollment and Renewal Gross Plan Selection Profile, here.)

  • In New York in 2023, according to a presentation by New York State of Health, the state exchange, 76% of enrollees were helped either by brokers or by nonprofit assisters. In Maryland, as of October 2023, 36% of active enrollees (new or plan-changing renewals) self-served; the rest were assisted by brokers, navigators or the state exchange call center. In Colorado in OEP 2023, 62% of enrollments were broker-assisted. In Pennsylvania in OEP 2023, just 44% of enrollments were through brokers [CO and PA added 11/17/23].

  • Back in 2016, a KFF analysis tracked an ecosystem of certified nonprofit enrollment assistance that nationally deployed 34,000 assisters who said they helped 5.3 million people (many of whom likely ended up in Medicaid) in OEP 2016. These included members of the Navigator program, funded by CMS in states (with $63 million in 2016); assisters in Federally Qualified Health Centers, funded with a portion of each FQHC’s federal funding (about $150 million that year); and Certified Application Counselor programs, funded privately or in some cases by states. While Navigator funding was cut to $10 million by the Trump administration by 2018 and refunded by the Biden administration to $98.6 million for OEP 2024, navigators account for only a fraction — albeit an important, often coordinating fraction — of nonprofit, government-certified enrollment assistance (funding for enrollment assistance in FQHCs has always been larger). As far as I know, no one has tracked the development or metamorphosis of this system since KFF in 2016.

  • About 1-2 million unsubsidized enrollees in ACA-compliant plans still enroll off-exchange, which also means off-EDE.

None of this is to suggest that the public faces of and the state exchanges are irrelevant. A substantial minority of enrollees do enroll unassisted. A significant percentage of broker- and navigator- or CAC-assisted enrollees find their broker or assister on the government sites. (A 2019 CMS report boasted that 15% of brokers serving the marketplace participated in the Help on Demand program that the Trump administration, which boosted brokers while all but defunding and denigrating navigators, initiated on The Biden administration has maintained this program, and participation has doubtless expanded considerably.) Brokers and enrollment assisters share screens with clients, in various ways and to varying degrees (though brokers, I imagine, are likelier to share information from EDE platforms). About 10 of the states running their own exchanges offer supplemental state-based subsidies or other state initiatives that can only be accessed via the state exchange, and none of them to date enable processing via EDE. Finally, the exchanges are the final, ultimate authority for complete and accurate listings of all offerings in all markets.

Nonetheless, it’s important to keep in mind that most enrollees in ACA-compliant plans do not navigate the plan selection and enrollment process soup-to-nuts via or the state exchanges. As survey data indicates that most consumers’ understanding of insurance terms and plan features is quite incomplete, it’s good that most enrollees access assistance. As to the quality of that assistance in brokerages large and small — that’s a different inquiry.

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