Implementing the Affordable Care Act's Health Insurance Marketplaces: An Analysis of Enrollment Success by Marketplace Type
AuthorJoiner, Amber J.
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On October 1, 2013, the most visible component of the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA) went live. Health insurance marketplaces provided residents with a place to shop and receive subsidies for insurance plans that contained the essential health benefits required by the ACA. The ACA required each state to establish an exchange, but it also provided flexibility so if a state elected not to (or could not) build its own, the federal government would implement the marketplace. A handful of states chose a hybrid implementation, which used the federal HealthCare.gov website but left certain decisions to the states. In the end, twice as many states chose to use the federal HealthCare.gov website compared to states that created a state-based marketplace and website. This trifurcated approach to implementing the health insurance marketplaces where residents were either served by a federally-facilitated, state-based, or hybrid marketplace, provides a unique situation for comparison and analysis relating to federalism and public policy implementation. This policy analysis examines the implementation of the ACA’s health insurance marketplaces in all 50 states and the District of Columbia. It discusses enrollment success during the first five open enrollment periods across all three marketplace types. Among the federally-facilitated, state-based, or hybrid marketplaces, was one type more successful than the others at enrolling residents in health insurance? What factors may have played a role in success or failure? This study discusses the ACA marketplaces as a case study in federalism and public policy implementation.