The Affordable Care Act (ACA) has expanded affordable health coverage options in the United States, helping to reduce the number of uninsured people. Even so, KFF has found that most people who are still uninsured are still eligible for coverage and financial assistance through Marketplace or Medicaid. Many consumers – including most uninsured – have limited knowledge of the affordable coverage options available to them under the ACA. And the steps people need to take to get and keep coverage can sometimes be complex. As a result, the ACA has directed federal and state markets to establish and invest in consumer assistance to conduct public awareness and education activities and to help connect people to affordable coverage.
KFF conducted an online national survey of support programs and market brokers in 2022. To constitute the sample for the survey, contact details of support programs and brokers were collected from the markets of (SBM), the Center on Medicare and Medicaid Services (CMS) which administers the Federal Marketplace (FFM), and the Health Resources and Services Administration (HRSA) which oversees enrollment assistance by qualified federal health clinics ( FQHC). A total of 3,496 support programs were invited by email to participate in the survey, and 258 programs responded and were included (for a response rate of 7.4%). We also contacted 68,705 brokers certified to sell Marketplace coverage and 1,424 responded and were included (for a 2.1% response rate). A further description of survey methods is included in the Topline accompanying this report.
Our survey asked support program managers and brokers about the help they provided to consumers before, during and after the 2022 open enrollment period, why people asked for help, factors affecting the registration process and other issues. Key findings include:
Assistance programs and brokers report that the need for consumer assistance is high among the people they serve. Overwhelmingly, support programs (76%) and brokers (69%) said that most or almost all of the consumers they helped during this ninth ACA Open Enrollment lacked confidence to apply on their own; About two-thirds of support programs (64%) and brokers (66%) said almost everyone they help had a limited understanding of ACA requirements and benefits. Most assistance programs and brokers (54% each) also said that the majority of consumers they helped had difficulty understanding basic health insurance terms and concepts. Consumers also needed help answering questions about their household income and composition, and comparing a large number of plan choices. Some consumers have complex cases or need language support – challenges that support programs say require more resources and technical assistance than is available in the marketplace.
Most support programs and brokers said the average time to help new applicants through the marketplace continued to be between 1 and 2 hours; for consumers returning to renew or change their coverage, it was up to 1 hour. This is similar to the results of previous KFF surveys in 2016, 2015 and 2014.
Consumer awareness of subsidies and market rules is still limited. Almost all assistance programs (89%) and brokers (80%) this year also helped consumers last year to purchase coverage or update subsidies during the COVID-19 enrollment period 2021. The newly enhanced Marketplace grants went into effect during the COVID 2021 enrollment period, although our respondents observed that consumer awareness of the enhanced grants was low; 71% of assistance programs and 75% of brokers said nearly all of the consumers they helped during the 2021 COVID enrollment period were unaware of the new and improved subsidies when they applied for help for the first time.
Assistance programs report that some Medicaid-eligible consumers are experiencing delays in getting a final eligibility decision. In 17 states, the Marketplace determines Medicaid eligibility, while in the others, the Marketplace transfers files to Medicaid for a final eligibility determination, which may cause delays. As a result, assistance programs report that the time it takes for consumers to receive an eligibility determination varies widely. Forty-three percent of programs said eligibility determinations were made in real time or Medicaid enrollment was automatic, while an equal share of programs said the process took longer – 11% said Medicaid determinations were provided up to 7 days, 21% said determinations took 8 days to a month, and 11% said it took more than a month.
Help from brokers and support programs are similar in many ways, but not interchangeable. We also interviewed brokers certified by the Marketplace to sell qualified health plans. The type of help brokers reported providing and the people they reported helping were similar to assistance programs, although there were important differences, likely reflecting differences in the clients served. In particular, brokers—which rely on commissions—were much less likely to help consumers enroll in Medicaid or CHIP (39% of brokers vs. 88% of assistance programs) and much less likely to conduct outreach activities (27% vs. 62% of assistance programs). Compared to assistants, brokers who responded to the survey indicated that a smaller proportion of the consumers they helped were Hispanic, needed language assistance or help with immigration issues. , or were uninsured.
Brokers rely on private websites rather than Marketplace sites. Most brokers (72%) surveyed say they use private websites instead of the marketplace to enroll consumers in QHPs at least occasionally. In most states, brokers can use so-called direct registration (DE) sites, for example hosted by insurance companies, where consumers can register for the QHP Marketplace, although consumers are usually redirected to the Marketplace site if they also need grants. The federal government is also encouraging the use of Enhanced Direct Enrollment (EDE) sites — only available in federal market states — where consumers can apply for both QHPs and market grants without ever visiting HealthCare.gov. A majority of brokers in federal market states (55%) said they never initiate QHP applications on HealthCare.gov. When asked why they preferred these alternative enrollment channels, many brokers cited technology features that HealthCare.gov does not offer, such as dashboards that allow them to more easily track client accounts and to communicate with customers. Sixty percent of surveyed brokers who use private sites said they would use the Marketplace website more often if it offered similar functionality.
Brokers also continue to sell non-ACA compliant policies. Most brokers (75%) said they also sell non-ACA compliant policies – such as short-term plans – during open listing as an alternative or supplement to QHPs, although the volume of these sales is lower than that of QHP sales. For example, most brokers (54%) reported selling more than 50 QHPs during the 2022 open listing period, while most of those who also sold non-ACA compliant policies ( 67%) said they sold 10 or fewer of these policies.
Most assistance programs expect to play a role in helping consumers through the public health emergency (PHE). It is anticipated that the COVID-19 public health emergency may end in 2023, at which time state Medicaid agencies will resume new eligibility determinations and de-enroll individuals who are no longer eligible or are not able to complete the renewal process even if they remain eligible. As a result, it is estimated that between 5 and 14 million people will lose their Medicaid coverage. Many who lose Medicaid may be eligible to purchase subsidized QHPs, if they can navigate this transition. About half of assistance programs (53%) said they have a good working relationship with their national Medicaid agency, and nearly 6 in 10 said they have contacted Medicaid to find out how they can help educate consumers about the need for renew their coverage. Half of all assistance programs said they planned outreach activities to educate the public about how PHE is going and most (58%) said they would try to re-contact consumers they have helped apply for Medicaid coverage in the past two years to collect updated contacts. information.