In the realm of health care, the path to better services and improved outcomes often seems obstructed by procedural hurdles and centralized control. However, a shift from the Federally Facilitated Exchange (FFE) to State-Based Exchanges (SBE) presents an opportunity to empower states, foster competition, and drive innovation in health care delivery. This transition isn’t merely about reshuffling administrative structures; it’s a strategic move to harness the dynamism of the private sector while enhancing citizen access to quality health care options. 

One of the most compelling arguments for transitioning to SBEs is the role of competition in driving creativity and innovation. When multiple entities vie for market share, they are compelled to continuously innovate, both in terms of technology and product offerings. When the Affordable Care Act (ACA) exchanges first launched, many states took on custom builds that were not flexible, sustainable, or cost-effective. The need to operate more swiftly and more efficiently drove technology vendors to create a better platform, which paved the way for GetInsured to bring its SaaS platform to life, giving states cost savings, the flexibility to respond to policy and local needs, and a simple way to release new innovative features.  

Competition serves as a potent catalyst for innovation, especially evident in the transition of states from the federally facilitated marketplace to a state-based exchange (SBE). This shift not only fosters innovation within the state’s own administration but also allows for the leveraging of advancements from external entities utilizing the SBE. For instance, if a private company devises an inventive outreach strategy or introduces a cost-effective plan design without compromising coverage, the state can adopt and adapt these innovations. Thus, states embracing SBEs not only innovate internally but also harness the innovative potential of the private sector. This symbiotic relationship aligns well with the pro-business ethos often embraced by red states, amplifying the appeal of private sector involvement in service delivery 

Market-Leading Innovation 

Another great example comes from Nevada, which transitioned to an SBE in the fall of 2019. Since the launch of their SBE, they’ve leveraged technology to not only improve the quality of services but also driven down costs, making health care more accessible to a broader segment of the population. In 2023, Nevada successfully integrated Artificial Intelligence (AI) into their marketplace platform. Working with the GetInsured team, Nevada is the first ACA marketplace to have Center for Medicare & Medicaid Service’s (CMS) approval for the use of AI-based Interactive Virtual Agents to enhance the customer service experience.   

1332 Waivers 

Section 1332 of the ACA allows states to pursue innovation waivers to implement alternative approaches to health care coverage that still meet the law’s coverage and affordability standards. These waivers can be used to design state-specific reforms, such as implementing reinsurance programs to stabilize the insurance market, expanding coverage options, or experimenting with new approaches to enrollment and outreach. While there are several types of active 1332 waivers, the most widely used is for state reinsurance programs. As of plan year 2023, Alaska, Colorado, Delaware, Georgia, Idaho, Maine, Maryland, Minnesota, Montana, New Hampshire, New Jersey, North Dakota, Oregon, Pennsylvania, Rhode Island, Virginia, and Wisconsin all have an individual market reinsurance program. 


One of the most significant advantages of transitioning to a SBE is gaining access to data that was previously restricted to what the federal government provided. This access empowers states to conduct in-depth research and enhance health insurance accessibility for those who need it most, leveraging insights gleaned from the data to drive improvements. 

In Georgia, after the state transitioned to an SBE, extensive research was conducted on the uninsured population to pinpoint their locations and primary barriers to obtaining subsidized health insurance. The findings revealed five distinct personas among Georgians: Single Parents, Black Georgians, Hispanic Georgians, and Young Healthy Georgians. By identifying these personas, Georgia Access could tailor their messaging to each group, effectively communicating the importance and means of acquiring insurance through diverse media channels and tailored messaging strategies. 

To help learn even more about who they were serving, Georgia conducted another study utilizing health plan enrollment and plan data to identify gaps in networks across the state. This analysis yielded intriguing results, highlighting correlations between specific plans and network deficiencies in certain regions. Additionally, it unveiled areas where network inadequacies stemmed from physician shortages rather than a lack of coverage. Armed with this insight, the state gained a deeper understanding of the healthcare landscape, enabling the crafting of targeted policies to address these challenges comprehensively. 

Easy Enrollment 

Realizing that the natural connection between health insurance and tax filing can be leveraged to increase enrollment among the uninsured, some state-based exchanges have implemented “easy enrollment” programs. An easy enrollment program is a system where individuals without health insurance can check a box on their tax return to authorize that relevant information be shared with the state Medicaid office and SBE. This data is then used for an initial assessment to determine if the tax filer and their family might qualify for financial aid for health coverage, such as Medicaid/CHIP or a premium tax credit in the exchange. 

The state Medicaid office or health insurance exchange will contact the tax filer to inform them of the potential coverage and financial assistance they qualify for and assist with enrollment. While Medicaid/CHIP enrollment is open year-round, enrollment for private plans through the exchange is restricted to open enrollment periods or special enrollment periods. States with their own health insurance exchanges that run easy enrollment programs offer special enrollment periods for those who use the program and don’t qualify for Medicaid/CHIP, allowing them to enroll outside the typical annual open enrollment period. To date, Maryland, Colorado, Massachusetts, Pennsylvania, Virginia, New Mexico, New Jersey, Maine, California, Minnesota, and Illinois have launched Easy Enrollment programs.  

The Future is Bright for SBEs 

The transition to SBEs represents a paradigm shift in health care governance—one that prioritizes choice, competition, and collaboration over top-down mandates and centralized control. By embracing this model, states can use the full potential of new technologies to better address local needs in new and creative ways to ensure access to high-quality health insurance and ultimately health care options.