The Affordable Care Act (ACA) expanded affordable health coverage options in the U.S., helping to reduce the number of uninsured individuals. Even so, KFF has found that most people who remain uninsured are nonetheless eligible for coverage and financial assistance through the Marketplace or Medicaid. Many consumers – including most uninsured – have limited awareness of affordable coverage options available to them under the ACA. And the steps people must take to get and keep coverage can sometimes be complex. Accordingly, the ACA required federal and state Marketplaces to establish and invest in consumer assistance to conduct outreach and public education and to help connect people to affordable coverage.

KFF conducted a national, online survey of Marketplace Assister Programs and brokers in 2022. To build the sample for the survey, contact information for Assister Programs and brokers was collected from State Marketplaces (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 Federally Qualified Health Clinics (FQHCs). A total of 3,496 Assister 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 response rate of 2.1%). Additional description of survey methods is included in the Topline accompanying this report.

Our survey asked Assister Program directors and brokers about the help they provided consumers before, during and after the 2022 Open Enrollment Period, reasons people sought help, factors affecting the enrollment process, and other issues. Key findings include:

Assister Programs and brokers report that the need for consumer assistance is high among people they serve. Overwhelmingly, Assister Programs (76%) and brokers (69%) said most or nearly all of the consumers they helped during this ninth ACA Open Enrollment lacked confidence to apply on their own; about two-thirds of Assister Programs (64%) and brokers (66%) said most to nearly all the people they helped had limited understanding of ACA requirements and benefits. Most Assister Programs and brokers (54% each) also said 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 help comparing a large number of plan choices. Some consumers present with complex cases or need language assistance – challenges that Assister Programs say require more resources and technical help than is available from the Marketplace.

Most Assister Programs and brokers said the average time needed to help people newly applying through the Marketplace continued to be between 1 and 2 hours; for consumers returning to renew or change coverage, it was up to 1 hour. This is similar to findings in previous KFF surveys in 2016, 2015, and 2014.

Consumer awareness about Marketplace subsidies and rules is still limited. Nearly all Assister Programs (89%) and brokers (80%) this year also helped consumers last year to sign up for coverage or update subsidies during the 2021 COVID-19 enrollment period. Newly enhanced Marketplace subsidies became effective during the 2021 COVID enrollment period, though our respondents observed that consumer awareness about the enhanced subsidies was low; 71% of Assister Programs and 75% of brokers said most to nearly all consumers they helped during the 2021 COVID enrollment period were unaware of the new, improved subsidies when they first came in for help.

Assister Programs report that some consumers eligible for Medicaid experience delays in getting a final eligibility determination. In 17 states the Marketplace determines Medicaid eligibility, while in the rest, the Marketplace transfers files to Medicaid for a final eligibility determination, which can cause delays. As a result, Assister Programs report the time it takes for consumers to receive an eligibility determination varies widely. Forty-three percent of Programs said eligibility determinations were determined in real time or Medicaid enrollment was automatic, while an equal share of Programs said the process takes longer – 11% said Medicaid determinations were provided in up to 7 days, 21% said determinations took from 8 days to one month, and 11% said it took longer than a month.

Help from Brokers and Assister Programs is similar in many respects but not interchangeable. We also surveyed brokers certified by the Marketplace to sell qualified health plans. The type of help brokers reported providing and people they reported helping resembled that of Assister Programs, though there were important differences, likely reflecting differences in the clients served. In particular, brokers – who rely on commissions – were far less likely to help consumers sign up for Medicaid or CHIP (39% of brokers vs 88% of Assister Programs) and far less likely to conduct outreach activities (27% vs 62% of Assister Programs). Compared to Assisters, Brokers who responded to the survey reported that a smaller share of the consumers they helped were Hispanic, needed language assistance or help with immigration-related problems, or were uninsured.

Brokers rely on private web sites over Marketplace sites. Most brokers (72%) surveyed report using private websites instead of the Marketplace to enroll consumers in QHPs at least some of the time. In most states brokers can use so-called direct enrollment (DE) sites, for example hosted by insurance companies, where consumers can sign up for Marketplace QHPs, though consumers generally are re-directed to the Marketplace site if they also need subsidies. The federal government also promotes use of Enhanced Direct Enrollment (EDE) sites – only available in federal marketplace states – where consumers can apply for both QHPs and marketplace subsidies without ever visiting HealthCare.gov. A majority of brokers in federal marketplace states (55%) said they never initiate QHP applications on HealthCare.gov. When asked why they prefer these alternate enrollment channels, many brokers cited technological features which HealthCare.gov does not offer, such as dashboards that enable them to more easily track client accounts and communicate with clients. Sixty percent of brokers surveyed who use private sites said they would use the Marketplace website more often if offered similar functionality.

Brokers also continue to sell non-ACA-compliant policies. Most brokers (75%) said they also sold non-ACA-compliant policies – such as short-term plans — during Open Enrollment as an alternative or supplement to QHPs, though the volume of these sales was lower compared to QHP sales. For example, most brokers (54%) said they sold more than 50 QHPs during the 2022 Open Enrollment period, while most who also sold non-ACA-compliant policies (67%) said they sold 10 or fewer of these policies.

Most Assister Programs expect to play a role helping consumers through the public health emergency (PHE) unwinding. It is anticipated that the COVID-19 Public Health Emergency may end sometime in 2023, at which point, state Medicaid agencies will resume eligibility redeterminations and will disenroll people who are no longer eligible or who are unable to complete the renewal process even if they remain eligible. As a result, between 5 and 14 million people are estimated to lose Medicaid coverage. Many who lose Medicaid may be eligible to buy subsidized QHPs, if they can navigate that transition. About half of Assister Programs (53%) said they have good working relationships with their state Medicaid agency and nearly 6 in 10 said they have contacted Medicaid to find out how they can help educate consumers about the need to renew their coverage. Half of all Assister Programs reported they are planning outreach activities to educate the public about the PHE unwinding and most (58%) said they will try to re-contact consumers whom they helped apply for Medicaid coverage in the past two years to collect updated contact information.