State-Based ACA Exchanges Getting More Attention From the Public

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.