The Affordable Care Act (ACA) Marketplaces have nearly tripled their enrollment in their first decade of operation, from eight million people in 2014 to 21.4 million in 2024. At the national level, the ACA has helped cut the uninsured rate nearly in half through a combination of Medicaid expansion, Marketplace enrollment and other initiatives. However, this national success masks wide variation among the states, from a 2.4% uninsured rate in Massachusetts to a 16.6% uninsured rate in Texas.

This white paper focuses on the role that State-Based Marketplaces (SBMs) have played in helping reduce the uninsured rate in the SBM states and discusses how the 32 states currently using the Federally-Facilitated Marketplace (FFM) could achieve similar coverage gains by establishing an SBM and expanding Medicaid (if not done earlier). The paper relies on insights garnered from interviews with SBM leaders in ten states to explain how SBM states can better target consumer outreach to reach the uninsured, improve coordination between their SBM and state Medicaid agency and enhance affordability by adopting state subsidies and other policy initiatives not possible as an FFM state.

To read the full policy paper, click here.