First implemented in 2014 as a cornerstone of the Affordable Care Act (ACA), public exchanges were envisioned as a new health insurance marketplace where millions of uninsured Americans could shop for, compare and purchase affordable, stable health coverage. The new exchanges sought to provide subsidized coverage to Americans who were not eligible for Medicaid.

Since implementation, public exchange coverage has proven to be significantly more costly and less sustainable than envisioned.

  • Medicaid coverage costs 43 percent less than public exchange coverage, which is less affordable for the federal government and consumers.
  • Exchanges have failed to achieve longstanding enrollment expectations of 25 million and cover far fewer people than other coverage platforms.
  • Exchange coverage has declined over the course of each year since ACA implementation, as higher-than-expected costs and other factors have discouraged many healthy individuals from enrolling and staying enrolled.

Medicaid Has Expanded Access to Care by Delivering Affordable, Stable, and Sustainable Coverage

While public exchanges have fallen short of providing consumers with affordable, high-quality, stable coverage options, the ACA’s Medicaid Expansion has succeeded in providing sustainable and effective coverage. Since 2013, more than 16 million additional people have enrolled in Medicaid.

Exchange beneficiaries, as well as the remaining uninsured, would gain the most from being in suitably managed state-based public and private market structures which are more stable, efficient, and effective than exchanges. Transitioning to a simpler, flexible, and more sustainable coverage system can help advance the important goals of providing more affordable coverage options, improving health outcomes, and achieving federal and state budget savings.