Open enrollment for 2018 started this week on the Affordable Care Act’s health insurance marketplaces. Along with its executive actions designed to weaken marketplaces operations, the Trump administration has taken a number of steps over the past year to curb marketplace enrollment, such as making dramatic cuts in funding for enrollment navigators and advertising, scheduling shutdowns of HealthCare.gov during the 2018 enrollment period, and ending the long-standing partnerships between Health and Human Services officials and local enrollment assisters. But while the administration has scaled back efforts to provide health coverage, state-based marketplaces have taken a different approach. We interviewed executives at 15 of the 17 states that operate their own marketplaces.1 All have bolstered efforts to stabilize their markets and maintain or grow enrollment this year, despite the chaotic federal environment.
The Majority of State-Based Marketplaces Have Extended Open Enrollment
While the administration cut the open-enrollment period for the federally facilitated marketplace in half to 45 days, nine of the 12 state-based marketplaces with control over their open-enrollment periods extended them beyond the federal deadline, in most cases into January. (The five state-run marketplaces that use HealthCare.gov for enrollment are not permitted to deviate from the federal government’s default enrollment dates.) Overwhelmingly, states reported that having the flexibility to extend the deadline was critical to fulfilling outreach strategies and giving consumers sufficient time to enroll. Several noted their decision to extend was influenced by the desire to cut through negative federal rhetoric.
In selecting a closing date, many states sought — with some difficulty — to balance the interests of consumers who need more time to decide on a plan with insurers’ requests for a longer coverage period with a full 12 months of premium payments. In the three states that chose not to extend, officials reported that most consumers tend to enroll before the federal December 15 deadline. In one of these states, officials hope that securing a full year of premiums for insurers will help to stabilize those premiums.
States Worked Diligently with Insurers to Ensure Consumer Choice
While the administration seized on headlines of insurer exits, state-based marketplaces worked diligently to maintain insurer participation. Most states allowed insurers to submit two sets of rates to account for uncertainty about the federal cost-sharing reduction payments. In California, marketplace officials even modified insurers’ contracts to allow those who incur 2018 losses as a result of federal policy or enrollment changes to recoup lost funds in subsequent years. New York’s governor issued an executive order preventing any insurer that withdrew from the individual marketplace from offering plans in another state program.
States Modified Marketing and Outreach Strategies to Combat Federal Confusion
This year, state-based marketplaces have either increased their marketing budgets, as in California and Oregon, or modified their strategies to counter misinformation, raise awareness of new deadlines, and remind consumers they are open for business. Most states began advertising earlier, and many shifted away from television marketing to grassroots outreach and media coverage.
Still, many state officials expressed concern that the lack of national advertising could dampen state enrollment. Several said consumers were confused about whether the ACA or marketplaces were intact, and whether there would be affordable options or a range of choices from different insurers.
Looking Forward
While the administration has acted in ways that are likely to reduce enrollment in the marketplaces, state officials have pushed ahead to promote their marketplace’s success. Though it is too early to predict how these efforts will drive enrollment, consumers will likely have better access to coverage as a result of states’ efforts.
1 We interviewed executives of 15 marketplaces, including CEOs, executive directors, and directors of communications. Arkansas and Kentucky did not participate in this research.
