A deep dive into the world of brokers & agents in the ACA marketplace

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Over at the Wiley Online Library, Aleka Gurel, Director of Government Affairs at HealthSherpa, has published an excellent, in-the-weeds analysis of the history & impact of private insurance brokers & agents on ACA marketplace (on exchange) enrollment.

Here's an excerpt (note that this website is actually among the data sources she cites):

On October 1, 2013, President Barack Obama stood in the Rose Garden and announced that Healthcare.gov was “open for business.” Americans who needed health insurance could visit the site to “compare and purchase affordable health insurance plans, side-by-side, the same way you shop for a plane ticket on Kayak […] same way you shop for a TV on Amazon. You just go on and you start looking, and here are all the options” (Remarks by the President on the Affordable Care Act, 2013). President Obama's words evoked a vision of straightforward plan selection and enrollment driven by the consumer, with benefits and costs clearly articulated and easy to compare between plans.

A decade later, relatively few enrollees across Healthcare.gov and State Based Marketplaces (SBMs) have an entirely solo shopping and enrollment experience that matches the President's description.1 In 2016, the first year that data was available, insurance brokers enrolled 43% of all Healthcare.gov enrollees; (Centers for Medicare & Medicaid Services, 2018) by the record-breaking 2024 Open Enrollment Period, 78% of active enrollments were facilitated by brokers (Grant, 2024).

Despite this, little attention has been paid to the role of brokers in the recent affordable care act (ACA) Marketplace growth, with credit instead being attributed to expansions in financial assistance, the 2023 unwinding of the Medicaid continuous coverage requirements, and increased funding of Navigator assistance programs (Ortaliza et al., 2024). Likewise, prior research has focused mainly on evaluating the enrollment impacts of assister programs (Myerson & Li, 2022), paid advertising (Karaca-Mandic et al., 2017), and direct outreach campaigns by SBMs (Ericson et al., 2023; Myerson et al., 2022).

This may be in part because data on brokers' involvement in the Marketplace is difficult to access; the Centers for Medicare and Medicare Services publish only limited data on broker participation, and SBMs vary widely in their provision of enrollment data, including data related to broker enrollment. Other data that might prove useful in such analyses, such as the amount of commission paid to brokers by different insurance companies, is generally nonpublic.

This paper leverages internal data from HealthSherpa, a broker enrollment platform for ACA plans that supported 52% of active enrollments during the 2024 OEP, to supplement existing public data sources and provide insight into the role of brokers in ACA outreach and enrollment. I show that brokers have always played a substantial role in connecting consumers to ACA coverage, and that improved access to enrollment technology may have helped brokers working in Healthcare.gov states make a greater contribution to enrollment growth compared to brokers in SBMs.

Gurel makes a lot of interesting & important points, some of which I already knew and some which are new to me. I strongly advise reading the whole thing.