A look at budding innovation in state-based ACA marketplaces

With their recent stability, the Affordable Care Act marketplaces are well-positioned for innovation—but there's still room to take what's working nationwide, according to a new report.

As of 2023, 20 states operate a state-based marketplace and 30 rely on Healthcare.gov for sign-ups. Some state-based exchanges use the federal website for enrollment. State-based programs that use their own website have greater flexibility to roll out enrollment campaigns or programs to make signing up easier, for example, according to a new policy brief from the Commonwealth Fund.

Five state-based marketplaces, for instance, use that ability to establish "easy enrollment" programs. In these initiatives, residents can note on their tax forms if they are uninsured and interested in gaining coverage. The state can then use that data to point them to the appropriate coverage type, whether that's the exchanges or Medicaid.

In addition, four state-based exchanges have established auto-enrollment programs, which make the consumer experience simpler and more convenient.

The federal marketplace has also established programs that aim to make it easier for people to gain coverage. The feds have offered special enrollment periods designed to help people with lower incomes secure insurance. These were later adopted by 16 state-based exchanges, according to the report.

Both states and the federal exchanges are taking a closer look at health equity, too, the report noted. Five state-based exchanges have rolled out equity-based design requirements for plans, which seek to address conditions with key disparities, such as diabetes, maternal health asthma and hypertension.

A growing number of state-based marketplaces are requiring payers to secure accreditation from the National Committee for Quality Assurance to assess how well they're advancing health equity.

Similarly, the federal marketplace will require participating insurers to make a "good faith effort" to collect and submit data on race and ethnicity.

However, while there are hotbeds of innovation in both the state-based and federal exchanges, it's rare that these changes spread across the map, according to the analysis.

"Both the FFM and SBMs have established innovative policies later adopted by some, but not all marketplaces, including the federal low-income special enrollment period and standard plan requirements," the researchers wrote. "Nationwide adoption of these policies, as well as other proactive efforts to bolster and expand access to this crucial source of coverage, could lead to more consistently consumer-friendly marketplaces in every state."