Of the people who purchased health insurance through a public exchange in 2014, 9% more federal exchange participants re-enrolled compared to the state-run marketplaces.

Nearly 8 in 10 (78%) of those in states using the federal marketplace re-enrolled for 2015. That compares with just under 7 in 10 (69%) in states with state-run marketplaces, according to research by health consultancy Avalere Health.

A few factors might explain the difference, including underlying state demographic and economic characteristics that play a role in retention, says Katherine Hempstead, a director at the Robert Wood Johnson Foundation.

“For example, states with higher levels of population mobility will be more likely to have 2014 enrollees migrating to other states,” she says. “Similarly, states where there is more economic activity will be more likely to lose enrollees who get jobs that offer health insurance, or perhaps income increases that place them in off-exchange products. The younger the pool of enrollees, the bigger this impact might be.”

Another big factor is Medicaid expansion, Hempstead adds. States that expanded Medicaid will see movement from qualified health plans. Looking at the states that had the highest retention, they tend to be rural states that did not expand Medicaid, she explains. For example, California shifted about 200,000 exchange enrollees into Medicaid for 2015, Avalere data found.

Caroline Pearson, senior vice president at Avalere, says the why is the “million-dollar question,” but some people may have determined they didn’t receive a good value and decided to go uninsured or may have qualified for employer-sponsored coverage.

Marketing could be another reason, she says. In 2014, the states did a better job than Healthcare.gov on outreach enrollment. In 2015, the federal government “really stepped up their game to raise awareness, but also stay in contact with people who re-enrolled,” she says.

The difference explains some of the discrepancies in 2015 enrollment growth between the federal- and state-run marketplaces. “State-run exchanges lost more ground with enrollment in 2015, making it even harder to achieve annual goals for enrollment growth,” says Elizabeth Carpenter, director at Avalere.


In total, enrollment in the federal exchange increased 61% over 2014 to 8.8 million. By contrast, state-run exchanges increased 12% to 2.8 million. In large federally-run states such as Texas and Florida, enrollment increased 64% and 62%, respectively. In large state-run exchanges, such as California and New York, enrollment increased 1% and 10%, respectively, Avalere notes.

The data does surprise Pearson, since the states did such a good job in 2014 and “we expected them to have another outstanding year in 2015.”

Looking toward the future, Pearson says states are very focused on the fact that enrollment was relatively flat and “they need to figure out how to get the harder to reach” population and maintain current enrollment numbers.

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