As retailers, services and other businesses shut down in spring because of the COVID-19 outbreak, people across the U.S. abruptly lost their jobs, with 22 million people out of work by mid-April.
Along with losing employment and income, millions also lost their health insurance or ability to pay for it. And though the Affordable Care Act was created to ensure that all Americans could have access to health coverage, some of the unemployed quickly learned that whether they could get coverage depended on where they lived.
In 11 states and the District of Columbia, officials authorized special open enrollment periods so that residents who lost their jobs — or already lacked health insurance and wanted to buy it — could get coverage through state- and district-run insurance exchanges.
But in the 38 states that lacked their own exchanges and instead relied on the federal health marketplace, many uninsured people were left adrift, as the Trump administration refused pleas to reopen enrollment through the federal system.
“This is a missed opportunity to ensure care and save lives,” said APHA Executive Director Georges Benjamin, MD, in an April 2 news release denouncing the Trump decision. “Without health insurance coverage, many people will delay getting the care they need — for COVID-19 and other medical reasons — because of cost. That delay could risk both their health and the health of their communities.”
The ability to reopen enrollment at will is one of many advantages of state-run health insurance exchanges, which are enticing other states to leave the federal marketplace behind.
States operating their own marketplaces are California, Colorado, Connecticut, Maryland, Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont and Washington, along with Washington, D.C. Among the states transitioning to or considering creating their own marketplaces are Maine, New Jersey, New Mexico, Oregon and Pennsylvania.
“States that have transitioned or are considering a transition to a state-based exchange see opportunities that the federal exchange doesn’t always provide, mostly due to the flexibility of running an exchange at the state level,” Rachel Schwab, research associate at the Georgetown University Health Policy Institute, told The Nation’s Health.
Lower costs, better customer service and better data on residents are among the other benefits, Michele Eberle, MBA, executive director of the Maryland Health Connection exchange, told The Nation’s Health. Maryland reopened enrollment from March 15 to June 15.
In the April 2 statement, APHA’s Benjamin app- lauded Maryland, the 10 other states and the district for reopening enrollment.
The health insurance marketplaces are part of the Affordable Care Act, which became law in 2010. The ACA requires each state to offer several comprehensive health insurance plans for residents to choose from. Most states have opted for the federal insurance marketplace.
In recent years, though, technology advancements have made operating a state exchange easier, leading more states to consider a change.
Barriers created by the Trump administration are also pushing states to switch. During the 2018 enrollment period, the administration cut the federal exchange’s consumer outreach budget by 90% and the navigator budget, which provided in-person assistance for enrollment, by 42%, the U.S. Government Accountability Office reported. Repeal of the ACA’s individual mandate, which required people to have insurance or pay a fee and helped financially stabilize the marketplace, took effect in 2019.
In response to those changes, New Jersey announced in March it was transitioning to a state-based exchange for 2021 enrollment.
“Funding sent to Washington to utilize the federal exchange will be better utilized right here in New Jersey, where we can establish policies that create greater stability, access and improved protections for residents,” Marlene Caride, JD, commissioner of New Jersey’s Department of Banking and Insurance, said in a March statement.
A state-based exchange offers greater control over open enrollment periods and allows access to data that can be used to regulate the market and conduct targeted outreach, Caride said. And user fees can fund state exchange operations, consumer assistance, outreach and advertising.
Nevada transitioned to its own exchange this year, Pennsylvania is planning to in 2021 and New Mexico is on pace to make the move in 2022.
In states using the federal exchange, unemployed people who lost their job-based health insurance could sign up for coverage on HealthCare.gov. But people who lost insurance that was not provided through their job — or lacked insurance before the COVID-19 outbreak — do not qualify for special enrollment, unless they experienced a qualifying event, such as marriage or a move. Other options are Medicaid and the Children’s Health Insurance Program, for those who qualify.
For Arizona Gov. Doug Ducey, whose state uses the federal marketplace, that is not sufficient. He asked the Trump administration in March for a special open enrollment during the pandemic emergency.
“Such a move would provide an important option to families in Arizona and across the country who are struggling right now,” Ducey wrote in a March 25 letter to U.S. Health and Human Services Secretary Alex Azar.
On March 31, the White House confirmed that the federal marketplace would not be reopened.
During an interview with The Nation’s Health in April, Lindsay Lang, JD, director of Rhode Island’s state-based marketplace, HealthSource RI, could not name one advantage of the federal exchange over a state exchange.
Rhode Island reopened enrollment from March 15 to April 30. The move posed a financial risk to the system, Lang said. But the state had already softened the risk by introducing an individual mandate and a reinsurance program, which allowed Rhode Island to offer funds to marketplace health insurers to offset medical costs from high-risk customers.
“We wanted to do everything we could as a state to make sure that Rhode Islanders are not hesitating to get tested or have a consultation with a health care provider if they think they need to get tested,” Lang said. “Of course, if they need treatment, we want them to be treated.”
For more information on exchange programs, visit www.commonwealthfund.org.
- Copyright The Nation’s Health, American Public Health Association