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.
A recent Manatt white paper, made possible by the generous support from the Robert Wood Johnson foundation, 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 12 FFM states that had not expanded Medicaid as of 2022 had an average uninsured rate of 10.3%. The average rate dropped to 7.0% for the 21 FFM states that had expanded Medicaid. Most significant for this paper on SBMs, the average rate dropped again to 5.8% for the 17 states plus D.C., which had both expanded Medicaid and established an SBM as of 2022.
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. The paper makes recommendations in each of these areas for how the federal government could work with states to ensure that future SBMs are as successful as the 19 current SBMS.
Click here to download a free copy of the full report.