By Enrique Martinez-Vidal

The third open enrollment period is coming to an end and the lack of drama may signal an opportune time for states to reassess the exchange model they are using. Certainly, eligibility determination and plan enrollment remain critical. But with many of the kinks and transitions worked out, states have an opportunity to pursue additional policy goals like improving customer service, increasing health plan competition, controlling administrative costs, and promoting delivery system transformation.

Different exchange models are more or less suited to the achievement of various goals, as outlined in a new brief written for the Robert Wood Johnson Foundation’s State Health Reform Assistance Network (State Network). As the authors Patrick Holland and Jon Kingsdale state, “Some of the 13 states (including Washington D.C.) that currently bear full responsibility for operation their own SBMs [State-based Marketplaces] may re-evaluate the relative costs and benefits of this model. And some the 11 “in-between” states that share risk and responsibility with the FFM [Federally-facilitated Marketplace] could move to full state control or exit the field altogether.”

It may be more difficult for a state currently using the FFM eligibility determination and enrollment platform to build its own SBM technology infrastructure given that federal funding to do so is no longer available. However, as more commercial firms have developed improved technologies to support exchanges, that option may become more attractive. Another brief written for the State Network explores the feasibility of a state contracting with a single firm to build and operate its marketplace.

Regardless of the technology underlying an exchange, additional health care policy goals beyond robust enrollment may be more attainable under an SBM. For example, because SBMs, for the most part, have an integrated process, Medicaid and Advanced Premium Tax Credit eligibility determination is handled more efficiently through one “front door” and with less likelihood of individuals falling through the enrollment cracks. In addition, it is easier for an SBM to work with its state department of insurance and to be operationally more flexible to actively encourage the participation and retention of health insurers to increase health plan competition than it is for other models that don’t know local markets as well.

While it may seem to be somewhat premature for these moves to be considered, the health care and political landscapes within which exchanges exist are constantly evolving. These briefs present evidence and analysis to help policymakers make considered decisions about how to best structure this important vehicle for getting insurance coverage to those who need it.


Enrique Martinez-Vidal is Vice President for State Policy and Technical Assistance at AcademyHealth. He is also the director of State Coverage Initiatives (SCI), a grant program of the Robert Wood Johnson Foundation, which provides timely, experience- and research-based information and technical assistance to state leaders in order to help them move health care reform forward at the state level. SCI is assisting in the management of the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation, located at the Woodrow Wilson School of Public and International Affairs at Princeton University.

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