State-Based ACA Exchanges Getting More Attention From the Public

A new Pew Poll released Monday finds higher public awareness of the insurance exchanges in states running their own exchanges than in those with federally-run exchanges. It might be a sign their outreach efforts are working.

President Barack Obama signs the Affordable Care Act on March 23, 2010.
National Journal
Sophie Novack
Sept. 16, 2013, 5:54 p.m.

The aware­ness that health-in­sur­ance ex­changes are avail­able un­der the Af­ford­able Care Act is sig­ni­fic­antly high­er in states with state-run pro­grams than in those that have op­ted to use a fed­er­ally run ex­change, ac­cord­ing to a Pew poll re­leased Monday.

The ACA es­tab­lishes health in­sur­ance ex­changes in each state for in­di­vidu­als and small busi­nesses to com­pare and buy health cov­er­age. States had the op­tion to either cre­ate and run the ex­change them­selves or de­fer the au­thor­ity to the fed­er­al gov­ern­ment. Six­teen states and Wash­ing­ton, D.C., have de­cided to es­tab­lish a state-based ex­change, sev­en are cre­at­ing state-fed­er­al part­ner­ship ex­changes, and 27 have chosen not to cre­ate their own ex­changes and will de­fault to a fed­er­al ex­change in­stead. All the in­sur­ance ex­changes are set to open Oct. 1.

The Pew poll found that 59 per­cent of people who live in states with state-based ex­changes say the ex­changes will be avail­able in their state, while only 44 per­cent of those in states with fed­er­ally run ex­changes say the same. A likely ex­plan­a­tion for the dif­fer­ence is con­fu­sion in states where state-elec­ted of­fi­cials ex­pressly re­fused to im­ple­ment the ex­changes, said Mi­chael Dimock, dir­ect­or of Pew Re­search Cen­ter for the People and the Press.

“There were a lot of head­lines in the states about why not to set up an ex­change, but prob­ably few­er about what the fall­back op­tion would be,” Dimock told Na­tion­al Journ­al Daily. “It’s likely that the ac­tion by state le­gis­latures say­ing no to the ex­changes stuck in people’s minds.”

Con­sumer out­reach and as­sist­ance also dif­fers between state and fed­er­al-based ex­changes. In states with fed­er­ally run ex­changes, con­sumer as­sist­ance will be more lim­ited be­cause these states de­pend on lim­ited fed­er­al fund­ing for Nav­ig­at­or grants and will not have sup­ple­ment­al in-per­son as­sist­ance pro­grams, ac­cord­ing to a Health Af­fairs Health Policy Brief from Ju­ly. State-based ex­changes, on the oth­er hand, have the abil­ity and flex­ib­il­ity to design out­reach and con­sumer as­sist­ance to their par­tic­u­lar pop­u­la­tions.

Cheryl Smith, a seni­or prac­ti­tion­er at De­loitte, said she is not sur­prised by the Pew res­ults for this reas­on. “At the state-level, there is already a small army of people who know how to speak the lan­guage of the com­munity, and who are prob­ably trus­ted in­di­vidu­als,” she told Na­tion­al Journ­al Daily. “States with state-based ex­changes know their busi­ness com­munity, broker com­munity, con­sumer ad­voc­ate com­munity; they’re bet­ter in touch with all these com­munit­ies in a way that’s dif­fi­cult [with fed­er­ally run ex­changes]. The more de­grees of sep­ar­a­tion between the ones who need the pro­gram and the ones ad­min­is­ter­ing the pro­gram, the big­ger gap you have in out­reach.”

State ad cam­paigns have also of­ten ap­pealed to the spe­cif­ic char­ac­ter of the states, from Paul Bunyan ads in Min­nesota to an im­age of the Man­hat­tan sky­line in New York.

HHS plans to run more tar­geted ads dur­ing open en­roll­ment, and will re­lease de­tails in the com­ing weeks. “We know [out­reach] can’t be done by gov­ern­ment alone, and it can’t be done only in Wash­ing­ton,” said a CMS spokes­per­son. “That’s why we’re go­ing straight to the com­munit­ies where the need is greatest, to work with our part­ners on the ground, to reach people right where they are.”

En­roll Amer­ica, a non­profit ded­ic­ated to help­ing un­in­sured Amer­ic­ans en­roll in health cov­er­age un­der the ACA, is mind­ful of this aware­ness gap, and it has de­cided to fo­cus its ef­forts primar­ily on states that have op­ted not to run their own ex­changes, where the law is re­ceiv­ing lim­ited state pro­mo­tion. “We know our biggest chal­lenge at the mo­ment is lack of aware­ness of the mar­ket­places among the un­in­sured,” En­roll Amer­ica Na­tion­al Com­mu­nic­a­tions Dir­ect­or Jes­sica Bar­ba Brown told Na­tion­al Journ­al Daily. “We de­cided to fo­cus our re­sources on states with fed­er­ally fa­cil­it­ated ex­changes that have high con­cen­tra­tions of un­in­sured, to get the most bang for our buck in areas where people most need the in­form­a­tion.” En­roll Amer­ica field staff will be on the ground in ten states, nine of which have fed­er­al run ex­changes, and one — Illinois — which is a part­ner­ship ex­change. The strategy will be a grass­roots ap­proach, fo­cused on one-on-one con­ver­sa­tions.