This blog was originally posted on the Georgetown Center on Health Insurance Reforms’ CHIRBlog.

As COVID-19 cases climb, social distancing – the best tool we have to bring the virus to heel – has wrought an unprecedented loss of jobs, income, and health coverage. Over the coming months, the uninsured rate is expected to skyrocket. In the midst of the public health and financial crises spurred by the novel coronavirus, the Affordable Care Act (ACA) offers crucial safety nets: Medicaid expansion and health insurance marketplaces where consumers can access comprehensive coverage as well as financial assistance for premiums and cost sharing.

The ACA’s marketplaces were designed for those who do not have access to coverage through an employer or public insurance program, offering health insurance that covers essential health services, including pre-existing conditions. While many of the newly unemployed will be able to report income low enough to qualify for Medicaid (up to 138 percent of the federal poverty line in states that expanded the program under the ACA), the marketplaces offer a comprehensive coverage option to people who don’t qualify for Medicaid, including financial help for those earning up to 400 percent of the federal poverty line.

But not all marketplaces are alike, and that creates disparities for some consumers based on where they live. Currently, twelve states and the District of Columbia operate their own marketplace and enrollment platform (state-based marketplaces, or SBMs), while 32 state marketplaces are entirely operated by the federal government (the federally facilitated marketplace, or the FFM). An additional six states manage key marketplace functions but rely on the federal enrollment platform, HealthCare.gov. The administration that operates HealthCare.gov has repeatedly tried to roll back the ACA, slashed funding for marketplace outreach and assistance, and continues to promote the sale of non-ACA-compliant products.

Although these and other efforts to undermine the ACA have led to market turmoil, the states that run their own marketplaces have used their greater autonomy to generate better enrollment outcomes than the FFM. Now, during the COVID-19 crisis, the ability to call the shots for their marketplaces gives SBM states a significant advantage in helping consumers obtain comprehensive, affordable health insurance. Here are some opportunities for the SBMs that do not exist for FFM states:

Special Enrollment Opportunities for the Uninsured and Those Losing Income 

Typically, consumers can only enroll in marketplace coverage during an annual open enrollment period, unless they experience a life change such as losing health insurance, getting married, having a baby, or moving. Many of the estimated 17 million people who have recently lost their jobs also lost their job-based insurance; these individuals will have a 60-day window in which to sign up for Marketplace coverage. However, millions who lost their jobs may not have had an offer of coverage from their employer (indeed, less than 30 percent of small businesses offer health insurance to their employees). These individuals would not, absent another life change, automatically qualify for a special enrollment opportunity.

In response to the COVID-19 pandemic, twelve of the thirteen states (including the District of Columbia) that run their own health insurance marketplace are allowing the uninsured to sign up for marketplace plans through a special enrollment period. Early evidence suggests that many thousands will take advantage of the new enrollment opportunity; many who apply for coverage are likely to find themselves eligible for free or low-cost coverage through Medicaid and subsidized marketplace coverage.

The SBMs should also consider implementing a special enrollment period for consumers who have been enrolled in an off-marketplace individual policy but lose income and become newly eligible for marketplace subsidies. This is an existing special enrollment opportunity created through federal rulemaking last year, but many SBMs (and the FFM) have yet to implement it. As consumers experiencing job loss or reduced income find themselves unable to afford the premiums for an off-marketplace health plan, making this special enrollment opportunity available is more critical than ever.

The SBMs can also work to reduce the numerous bureaucratic barriers to signing up for coverage, allowing individuals to self-attest to changes in income and eligibility rather than requiring the submission of extensive verification paperwork.

On the other hand, the 38 states that rely on HealthCare.gov are stuck; President Donald Trump decided not to reopen HealthCare.gov to allow the uninsured to sign up for health insurance and access financial assistance, despite numerous calls from state leaders to do so. The Trump administration instead plans to tap a hospital relief fund to cover the cost of treating uninsured COVID-19 patients.

Robust Outreach Efforts

Announcing a special enrollment opportunity is just the first step; people need to know it is available. The SBMs are responsible for outreach and marketing efforts that help individuals and families learn about their insurance options and ultimately access coverage. Research has shown that advertising marketplace coverage is associated with better enrollment outcomes, and in recent years, the SBMs have invested more in marketing efforts than their federal counterpart. The SBMs also have access to data about consumer enrollment behavior that helps them understand key characteristics of the uninsured, allowing for more targeted and effective marketing.

In response to the COVID-19 pandemic, some SBMs are spending hundreds of thousands of dollars on an outreach campaign to advertise enrollment opportunities. Authority over marketplace budgets allows these states to redirect funding in order to respond quickly to the growing public health emergency. State marketplace authorities can also update their customizable websites to promote enrollment opportunities and other resources for consumers. Through data-driven, well-funded outreach efforts, the SBMs can reach the most vulnerable consumers who are in need of coverage.

The SBMs can also more effectively coordinate with other state agencies. State enrollment platforms can integrate Medicaid eligibility determinations better than the federal platform. SBMs can also work with the state unemployment agency to connect to people who have recently lost their jobs.

Unfortunately, states that rely on the federal government for outreach are restricted by limited resources, limited data on who is enrolling or attempting to enroll in marketplace plans, and a lack of control over the website consumers visit to find out about coverage options.

Consumer Assistance Networks and Call Centers

In addition to being able to budget for, design, and conduct robust outreach campaigns, the SBMs control a critical feature of marketplace accessibility: consumer assistance networks. The ACA’s Navigator program provides one-on-one assistance to help consumers understand their coverage options. Navigators are a particularly important resource for underserved, vulnerable populations. The SBMs award grants to organizations that provide consumer assistance, set parameters for Navigator activities, and connect consumers to the appropriate entities when they need help. In the current crisis, these organizations can also play a critical role supporting navigators’ transition to remote, instead of in-person, sessions with consumers.

The crucial need for access to health care during the COVID-19 pandemic, paired with the jump in people losing access to job-based coverage has prompted a widespread need for consumer assistance. At the same time, many individuals currently enrolled in marketplace coverage will need to report changes that could increase the amount of financial assistance they receive. Furthermore, the availability of Navigators and other credible, certified enrollment assisters is particularly important as new insurance scams are popping up across the country. While the Trump administration has cut funding for the Navigator program in states on the FFM, SBMs have continued to invest in their programs. State marketplace authorities can leverage their increased access to enrollment metrics and information about the uninsured to direct funding to organizations that serve populations in need. And as social distancing restrictions related to COVID-19 have mandated that millions of people stay home, SBMs have the flexibility to ensure that consumer assistance remains accessible to consumers online and over the phone.

States that run their own marketplaces also operate their own call centers, where consumers can contact the marketplace directly. During the COVID-19 pandemic, these centers are experiencing high call volume, while social distancing is requiring a change in the way they operate. Here again, SBMs can redirect resources, enhance training, and ensure call centers have the capacity to accurately and efficiently serve consumers. States with their own online enrollment platform can also update their website to highlight answers to frequently asked questions, thereby alleviating some of the pressure on the call centers.

Looking Forward

States have taken the lead in responding to the COVID-19 pandemic, including in efforts to improve consumers’ access to health coverage and services. While the federal government has been reticent to use the ACA’s critical safety net, states can’t – and shouldn’t have to – go it alone. There are numerous actions the Trump administration can take, either on their own or prompted by Congress, to ensure that access to health insurance isn’t dependent on what state you live in. In the meantime, the SBMs, which are growing in number, will continue to lead the way.