Two more states are about to jump ship onto their own ACA marketplaces
By 2028 over half the U.S. population will enroll via a state-based exchange
The main reason for pushing for 51 separate websites in the first place was mainly just an attempt to win over a few conservative "states rights" votes in Congress from Republicans and some conservative Democrats. There were some practical advantages to doing it this way as well (potential innovations from trying things different ways, plus a few states like Vermont and Massachusetts wanted to offer additional financial assistance beyond the normal tax credits/cost sharing provisions, and Hawaii already has an existing state law which is actually better than some of the provisions included via the federal exchange)...but on the whole, the sheer economy of scale advantages of one federal site make the downsides seem pretty small in comparison for most states.
Ironically, it turned out to be a good thing that there were over a dozen state-run websites last year, because many of them helped mitigate the worst of the damage during the early, ugly days of HealthCare.Gov (as you may recall, only about 25,000 people enrolled via HC.gov in October 2013, vs. over 75,000 across the state-run exchanges). However, it's almost 2 years later now, and HC.gov is operating pretty damned smoothly these days (yes, I know, the billing "back end" is still being worked on, but it's magnitudes ahead of where it was on 10/1/13).
In this section, I was arguing that consolidating every state's ACA platform onto HealthCare.Gov would make more sense from an efficiency and simplicity standpoint.
However, I also noted that there are other benefits to state-based exchanges such as keeping money within the state (as opposed to ~2-3% of ACA premiums going to the federal government), allowing for more granular enrollment data (as opposed to relying purely on whatever HC.gov data CMS is willing to share), and perhaps the biggest one: A state-based exchange allows states to offer their own supplemental premium/CSR subsidies (which can't be done on the federal exchange for technical/logistical reasons), which took on additional importance this year.
I therefore then went on to make the opposite argument, noting that with the politics of the King vs. Burwell case having been settled, states might actually be more likely to strike out on their own platform instead:
It's even conceivable that a few years from now, after 1) The ACA has become even more firmly entrenched nationally; 2) the software/technology for running a state exchange has become even more streamlined, simplified, faster, easier to use, cheaper, etc etc; and 3) (hopefully) some changed attitudes/changed administration officials (ahem), a few states on HC.gov now may even decide to go ahead and move onto their own "full" exchange/website after all...completely of their own volition.
I realize that sounds pretty crazy now (since there'd be no financial incentive to do so), but anything's possible...and with King out of the way, at least that's a viable option now.
Skip ahead a few years, and lo & behold:
Nevada wants out of federal health exchange
Nevada's Silver State Health Insurance Exchange took the first step on Thursday to getting out of the federal healthcare.gov system and build its own exchange.
The Legislative Interim Finance Committee granted SSHIX $1 million from its own reserves to put together an RFP and find a private provider.
NM will operate its own exchange platform starting with the 2021 plan year
New Mexico has a unique exchange; the state runs the small business portion, and while the individual exchange is also technically state-run, Healthcare.gov is used to enroll people in individual insurance (ie, a federally-supported state-based marketplace). But the exchange is planning to establish its own enrollment platform that will be in use by the fall of 2020.
New Jersey Gov. Phil Murphy signed into law a bill establishing a state-based health care marketplace.
Murphy signed the legislation on Friday in a private ceremony.
Under current law, New Jersey uses a federal exchange, or marketplace, letting people shop for and enroll in coverage under the Affordable Care Act.
The new law establishes the state's own exchange. Murphy, a Democrat, said the law also gives the state more control over open enrollment as well as giving the state access to data that it can use to regulate the market. He says it was necessary to protect against Trump administration ``sabotage'' of the law also known as Obamacare.
Lawmakers estimate participation in Medicaid under the Affordable Care Act increased by 36 percent or nearly 500,000 people over nearly four years.
Pennsylvania is poised to roll out its own online health insurance exchange to take the place of the one run by the federal government for the state's residents since 2014, saying it can save money for hundreds of thousands of policy-buyers.
The Republican-controlled Legislature gave final approval Friday to legislation authorizing the move, after Gov. Tom Wolf had pressed for the bill's passage this month in the hope that its savings measures can take partial effect in 2020 and full effect in 2021.
Wolf plans to sign the bill Tuesday, his office said.
Tailoring coverage education and enrollment efforts to Maine:
Following up on her commitment to pursue a State-based Marketplace, this third approach will move Maine towards a State-based Marketplace, allowing Maine to capture funding currently going to Washington, D.C. and use those dollars to promote enrollment and customize outreach to fit Maine’s needs. It also can improve the consumer experience by extending the annual open enrollment period so people have more time to sign up for coverage.
Kentucky governor relaunches kynect with expanded mission
A state-run web portal that signed up hundreds of thousands of people for health coverage before its dismantling was relaunched Monday by Kentucky's governor, who gave it an expanded mission to guide people seeking help from an array of assistance programs.
Retaining its original kynect name, the portal will allow Kentuckians to request health coverage and other support, including job training; foster care and assistance for food; child care, elder care and substance abuse recovery. Military veterans can seek assistance on the site.
Georgia State-Based Exchange Blueprint Letter
The State of Georgia is in a unique position relative to other states that previously transitioned off the Federally-facilitated Exchange (FFE), as much of the work to transition occurred prior to submitting the State-based Exchange Blueprint Application (Blueprint).
On Tuesday, February 14, 2023, Georgia Insurance and Safety Fire Commissioner John F. King submitted a letter to the Centers for Medicare and Medicaid Services ("CMS") offering additional context regarding the State's operational and technical readiness to transition to a State-based Exchange (SBE).
Illinois will take a big step forward by creating a state-based health insurance marketplace and instituting a rate review process to protect people from insurance rate hikes.
House Bill 579 could help Illinois become the 19th state to create a state-based health benefits exchange. Sponsors said this would allow Illinois to expand healthcare access by identifying uninsured communities, having effective outreach for residents, and helping people enroll in plans best suited for them.
Virginia is slated to become the nation’s 19th state-based exchange now that CMS has given officials the greenlight to fully transition away from healthcare.gov starting Nov. 1 for the 2024 plan year. Meanwhile, the State Corporation Commission (SCC), which administers the exchange, has suspended the state’s reinsurance program that had lowered premiums by about 20% for 2023, so individual plan rates are set to increase by an average 28.4%, according to a presentation made during an Aug. 9 hearing on the 2024 rates.
(The order that the states passed their respective legislation differed from the order in which they actually launched their exchanges: Virginia launched theirs in November 2023, Georgia in November 2024 and Illinois in November 2025.)
As of today, 21 states (w/DC) operate their own state-based ACA exchange platform, including CA, CO, CT, DC, GA, ID, IL, ,KY, ME, MD, MA, MN, NV, NJ, NM, NY, PA, RI, VT, VA & WA. This is up from 15 states back during the first Open Enrollment Period in 2013-2014.
Since then, a few states have actually bounced back & forth between the federal exchange at HealthCare.Gov and their own platform:
- Hawaii had a state-based exchange (SBE) for the first two years of Open Enrollment before being forced into shutting down and moving back to federal exchange control due to both serious technical and management problems.
- Nevada had an SBE for the first year, had to scrap it & move back to HC.gov after major technical problems, then re-launched a new SBE in 2019.
- Kentucky had an SBE which operated smoothly for several years until Republican Governor Matt Bevin shut it down for no particular reason...only for his successor, Democratic Governor Andy Beshear re-launched a new version of it four years later.
- Both Idaho and New Mexico were hosted by the federal exchange for the first few years of the ACA before splitting off from it onto their own SBEs, but these were already in the works from Day 1; they just took a couple extra years to put into place.
- And finally, there's Oregon, which, like Nevada, originally had their own SBE but saw it fail spectacularly out of the gate, as immortalized in this fun John Oliver bit at the time:
Like Nevada and Hawaii, Oregon was forced by massive technical glitches to scrap their SBE and move home to the mothership...but, like Nevada did in 2019, over a decade later, the Beaver State is taking another crack at it this fall:
Senate Bill 972 (2023) requires OHA to transition the Marketplace from a state-based marketplace using the federal platform (SBM-FP) to a state-based marketplace in time for open enrollment for plan year 2027. Specifically, OHA is required to procure and administer both an information technology platform and call center, to replace the federal platform and call center, and provide electronic access to the health insurance exchange in this state by November 1, 2026.
How this change will better serve communities harmed by inequities
- Access to data and evidence to tailor outreach and be more intentional about efforts to enroll disproportionately uninsured people, including people of color and rural residents.
- Collection of data, particularly on race and ethnicity, is widely recognized as fundamental to understanding enrollment disparities.
- Additional and more reliable data will allow Oregon to refine its outreach and communication strategies, both overall and in real time to reach targeted communities.
- Immigrants and non-native English speakers may be more likely to enroll if additional translation and interpretation services are available to help them complete the application or to communicate effectively with navigators, agents and brokers, or the call center
But it's not just Oregon: Check out what's happening to another "O" state across the country:
Oklahoma Insurance Department Announces Transition to Health Insurance State-Based Exchange
OKLAHOMA CITY— The Oklahoma Insurance Department (OID) today announced that Oklahoma will transition from the federally facilitated HealthCare.gov platform to a State-based Exchange (SBE) for the 2028 Open Enrollment Period.
This transition, authorized by Oklahoma House Bill 1512, will enable Oklahoma to retain and reinvest revenue currently being sent to the federal government, enhance consumer experience, and spur local market growth. In addition to the transition, OID is planning to pursue a Section 1332 State Innovation Waiver to further strengthen affordability and market stability.
“By operating our own health insurance Exchange, Oklahoma can make decisions locally, reduce reliance on Washington, and empower Oklahomans to have access to affordable coverage options tailored to their needs,” said Insurance Commissioner Glen Mulready. “Our goal is to encourage competition, make health insurance more affordable, and make sure the dollars Oklahomans already pay are used to build a better health insurance Exchange here at home.”
The Exchange will sit within OID and Deputy Commissioner for External Affairs, Ashley Scott, will serve as the Director. She has helped launch several successful programs in the department and has become a trusted regulator across the country and in Oklahoma with her experience with health insurance.
“I appreciate Commissioner Mulready trusting me with this opportunity and look forward to this new challenge,” said Scott. “We are taking back control of our individual market and will better serve Oklahomans across the state with this effort.”
Key changes and benefits for Oklahoma consumers include:
- Local Control: Oklahoma will manage health coverage decisions, so policies reflect the needs of Oklahomans.
- Enhancing Consumer Experience: Oklahomans will have access to Oklahoma-based customer service, streamlined enrollment options, and a secure Exchange strengthened by partnerships with trusted local agents and web brokers.
- Keeping Oklahomans’ Dollars in Oklahoma: Oklahoma will take back millions of dollars each year that currently go to the federal government, keeping those resources in Oklahoma to support improvements that better serve Oklahomans.
- Improving Affordability and Stability: Oklahoma will create a state reinsurance program starting in the 2028 coverage year, supporting market competition and slowing cost increases.
Consumers will continue to use HealthCare.gov to enroll in health plans for 2026 and 2027 coverage. Beginning in November 2027, consumers will be able to shop for and enroll in plans for the 2028 coverage year through Oklahoma’s State-based Exchange.
OID will work closely with issuers, agents, and community partners to provide a smooth transition and will continue to coordinate with the Centers for Medicare and Medicaid Services (CMS) to meet regulatory milestones.
So there you have it: Oregon will move to an SBE this fall and Oklahoma will follow it a year later. At that point there will be 23 out of 51 states (including DC) operating their own exchanges...representing over 50% of the total U.S. population.
Stay tuned...
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