By Rachel Schwab and Nia Gooding

The Affordable Care Act (ACA) marketplaces were put through their paces last year, with the COVID-19 pandemic and subsequent economic crisis creating greater demand for health insurance options outside of employer coverage. During the Open Enrollment Period (OEP) at the end of 2020, HealthCare.gov had an increase in plan selections over the previous year. Most state-based marketplaces (SBM) also had an increase in plan selections, including two new kids on the SBM block: New Jersey and Pennsylvania. Both states launched new marketplace websites in time for the recent OEP after seven enrollment cycles on the federal website, HealthCare.gov. New Jersey’s marketplace recorded a 9.4 percent increase in plan selections over the last OEP, including a 21.4 percent increase in new enrollees, and Pennsylvania’s marketplace, “Pennie,” had a 1.8 percent increase in plan selections, including a 9.7 percent increase in new enrollees.

In addition to transitioning to an SBM, both states have implemented a number of policies to shore up their individual health insurance markets and bolster enrollment, such as operating a reinsurance program using the ACA’s Section 1332 waivers to reduce premiums, and, in New Jersey’s case, enacting a state-level individual mandate and enhanced premium subsidies. The transition to a state-run enrollment platform provides additional opportunities to grow enrollment, including extending the window to sign up for coverage and investing in outreach and marketing efforts.

New Jersey and Pennsylvania are following Nevada after their recent transition to an SBM; Kentucky, Maine, New Mexico, and Virginia, currently SBMs using the federal platform, are slated to launch their own state platforms soon. These states are doing so because they have identified opportunities for greater autonomy, cost savings, and policy innovation. However, building up the necessary infrastructure and running a marketplace is no small undertaking. Although the process of launching a marketplace has markedly improved since the ACA’s first OEP, launching an SBM still requires considerable investment, both in the purchase of new technology and staff time to oversee the transition. There are also notable trade-offs for states. Today, HealthCare.gov operates relatively smoothly. Consumers and consumer assisters are familiar with the federal eligibility and enrollment platform, and there are few glitches. Switching to a new platform requires transferring the accounts of existing enrollees from the federal government over to the new state system, establishing new pathways for integration – or at a minimum a warm hand-off – with Medicaid, and training assisters in any new processes for determining eligibility for financial assistance and selecting plans, among other critical functions. Small hiccups in the process can have devastating consequences for the consumers who depend on reliable, consistent health insurance coverage. Any state considering making the transition to an SBM has costs and benefits to weigh.

To understand how this transition worked for Pennsylvania and New Jersey residents, and to extract potential lessons for the states transitioning in future years, we sought insight from people on the ground: consumer assisters. Assisters work one-on-one with individuals to guide them through the marketplace enrollment process. They are not the only source of information on the performance of the marketplaces, but they offer a critical perspective on the consumer enrollment experience. We spoke to Navigators and Certified Application Counselors (CACs) who worked in either Pennsylvania or New Jersey during the recent OEP about how the launch of the state marketplace is going for assisters and the consumers they serve.

New State-Based Marketplaces Launch Successfully, but There Are Growing Pains

Assisters See Progress from Transition to State-Based Marketplace

In general, assisters had positive reviews of the new state marketplace operations and websites. In both New Jersey and Pennsylvania, assisters felt that a state-run marketplace, customizable to meet the needs of the state and ultimately to integrate with other state benefit programs, offers the opportunity for meaningful improvements over the federal marketplace. However, the transition was not without some challenges.

One of the most helpful aspects of the new state website was the back-end portal available to assisters. On HealthCare.gov, assisters only had access to the public website, and had to fill out a consumer’s application over the phone. On both of the new state websites, assisters could use their site access to complete applications online, see the consumers they were working with, and track their progress. In Pennsylvania, assisters reported shorter hold times for both the call center and assister hotline, suggesting that the back-end portal may have cut down on call volume. Pennsylvania assisters also noted that a new ticketing system, allowing them to track outstanding issues for consumers, was an improvement from the federal platform, although the tickets lacked detail and a timeframe for resolution. In New Jersey, one assister described the benefits of seeing letters sent by the state to consumers they were helping, noting that this feature was an upgrade over the federal platform, which lacked this function.

Assisters in both states described the public-facing website as easy to navigate. One Pennsylvania organization noted that the majority of the assister community preferred the Pennie website to HealthCare.gov, pointing to features such as the ability to go back through consumer applications without losing information and to change income without having to go all the way through applications. New Jersey assisters reported positive feedback from both assisters and consumers, with one organization noting that assisters found the application to be less “convoluted” than HealthCare.gov.

The state-centered infrastructure – for both consumers and assisters – had several advantages. In New Jersey, assisters applauded the state’s tailored technology, as well as the benefits of state-centered support with knowledge of New Jersey issues and other coverage programs. They also observed improved communication between the state platform and New Jersey’s Medicaid program, which facilitated shorter wait times for consumers. Pennsylvania assisters appreciated the marketplace’s efforts to integrate them into decision-making, noting that assisters are well represented on Pennie’s board of directors, and that early discussions among assisters, the marketplace, and the state’s Medicaid agency helped to pave a smooth pathway between state coverage programs. New Jersey, unlike Pennsylvania, does not have a governing board, and outside of the state budget process, there is little publicly available information about marketplace operations and decision-making due in part to their governance structure. New Jersey’s insurance department, where the marketplace is housed, held meetings with assisters during the OEP, including bi-weekly meetings with state-funded Navigators to provide program updates and technical assistance. Although assisters in New Jersey pointed to frequent meetings and useful training sessions, they also indicated a need for more dialogue with state officials and greater collaboration across assister groups. However, assisters expressed optimism about the potential for coordinating efforts across organizations to improve outreach efforts and initiatives such as social marketing.

The transition also increased funding for assisters, after the Trump administration significantly reduced grants to Navigators. While some reported that their funding has been below levels from the federal marketplace’s early years, they noted an increase since the state took over marketplace operations. New Jersey, for example, expanded their Navigator program from one organization funded at $400,000 in only one region of the state under the federal government, to 16 Navigators with total funding of $3.5 million that resulted in consumer assistance provided in every county in the state.  However, all agreed that, in light of new COVID-19 special enrollment periods (SEP) available in both states, additional funding could be used to strengthen outreach and assistance efforts.

Assisters Recommend Additional Call Center Training and Capacity, Website Improvements

Despite the success and potential of the new state enrollment systems, assisters identified a number of issues that impeded or slowed their efforts to enroll consumers. Assisters in both states reported a lack of adequate training among call center representatives, which sometimes rendered them an unreliable source of help. In Pennsylvania, assisters noted that they often received different answers from different people. In New Jersey, assisters found it challenging to get help for more complex cases, particularly when immigration status affected consumer applications. While some assisters reported state call center wait times to be shorter compared to the federal call center, assisters in both states did report long wait times—up to an hour in some cases.

Regarding the website interfaces, while many assisters preferred the new state platform, assisters in both states found room for improvement. According to one assister organization we spoke to in New Jersey, while the new state application was seen as less complicated than the federal marketplace’s application, some assisters found it to be oversimplified, particularly for income determinations. In Pennsylvania, assisters reported the need to improve clarity and sufficiency of the Pennie website’s information, such as the frequently asked questions and answers available to consumers and assisters.

Even with the ability to more closely collaborate with state Medicaid offices as an SBM, there are still challenges associated with communicating with those consumers who have their accounts transferred between the marketplace and Medicaid to ensure a smoother process. Assisters in Pennsylvania identified difficulties with account transfers as well as confusing messages to consumers regarding Medicaid eligibility. Accessibility was also an issue; in particular, Pennsylvania assisters noted that it would be helpful to fully translate both the website and applications for Spanish-speaking consumers, and described getting reports of long waits for language phone lines. And while plan search tools got positive reviews from assisters in both states, in Pennsylvania, assisters described issues with the plan comparison tool papering over nuances in cost-sharing structures, and noted that unlike on HealthCare.gov, Pennie’s provider search tool did not allow for searching by dental providers.

Takeaways

Overall, New Jersey and Pennsylvania’s SBMs had successful debuts in the midst of a global pandemic. With the help of assisters, both states were able to launch their platforms with few missteps, and were even able to increase enrollment. Assisters identified several improvements to the enrollment process after the SBM transitions, including enhancements to marketplace technology, support systems, funding streams, and outreach efforts.

However, despite these successes, both of the new systems have room for improvement. States contemplating or in the process of transitioning to SBMs should take note of the potential benefits that come with operating their own marketplace platforms, and keep in mind potential obstacles that they will need to prepare for. In Pennsylvania, assisters credited early conversations with Pennie and the state Medicaid agency with a smooth transition. New Jersey assisters hope for greater communication between their organizations and the marketplace, and collaboration between assister groups. Further, assisters in both states cited the need to provide adequate funding during the ongoing SEPs as well as sufficient support through capacity building and robust training.

Finally, states who decide to run their own marketplace should expect it will take time to get it right – as one assister pointed out, “you’re building the airplane as you fly it.”