As the healthcare landscape continues to evolve, state-based marketplaces (SBMs) are increasingly proving themselves to be powerful engines of innovation, adaptability, and consumer-centric service. At a recent panel featuring leaders from CITIZ3N, Deloitte, Georgia Access, and former CMS leadership, we explored how SBMs are leading the charge to redefine access and efficiency in public health coverage.
The Shift From Compliance to Capability
Rob Miller, General Manager and SVP at CITIZ3N, opened the discussion by framing the current moment as a transformational one. States are no longer just trying to meet minimum compliance thresholds. Instead, they’re building sophisticated, adaptive systems that align technology, policy, and user needs.
CITIZ3N, leveraging Softheon’s 25-year legacy, is at the forefront of this movement—serving state marketplaces, health plans, and broker networks. By processing over $6 billion in premiums and enabling millions of ACA, Medicaid, and Medicare enrollments annually, the company is demonstrating how integrated solutions can deliver seamless experiences for all stakeholders.
Georgia’s Bold Blueprint: The Uberization of Enrollment
Hari Venkatachalam, Director of Technology at Georgia Access, offered an eye-opening analogy: comparing healthcare enrollment to the restaurant industry’s evolution—from dine-in to takeout to Uber Eats. This “uberization” was Georgia’s Enhanced Direct Enrollment (EDE) strategy in action. Georgia became the first state-based marketplace to fully implement EDE, enabling private partners to offer complete enrollment services without the consumer ever needing to visit the government portal.
Key benefits of this model:
- Increased consumer choice and convenience
- Higher enrollment rates (75%+ through EDE partners)
- Strict standards and oversight to protect consumers
Georgia’s strategy highlights how government systems can embrace private-sector innovation without compromising program integrity.
Innovation in Action: Reinsurance and Income Verification
Georgia didn’t stop at EDE. Through a Section 1332 innovation waiver, the state introduced a reinsurance program that not only reduced risk for insurers but also expanded plan availability in rural counties—transforming coverage access across over 100 counties.
Another standout move was the integration with Georgia’s Department of Labor to replace costly Equifax income verification. The results? A 75% cost reduction and a fivefold increase in verification success rates. It’s a case study in how states can drive innovation, efficiency, and equity by taking ownership of their data ecosystems.
Federal Policy Headwinds—and Opportunities
Randy Pate, former CMS Director, highlighted the shifting sands of federal policy, especially with new rules around program integrity and special enrollment period validations. These changes could flip passive renewals (historically 70% of SBM enrollments) into active renewals—posing massive operational challenges.
Pate argued that state control is a strategic imperative. It allows for:
- Greater resilience against federal volatility
- Direct retention of user fees
- Expanded potential for innovations like reinsurance waivers, state subsidies, and public options
What Makes an SBM Succeed?
Ash D’Souza, Managing Director at Deloitte, emphasized that success isn’t about replicating the federal platform—it’s about building something tailored and effective. He pointed to three foundational pillars:
- User-centric design – Centering the experience around residents’ real needs.
- Data-driven decision-making – Using analytics to uncover gaps and improve coverage retention.
- Interoperability and integration – Connecting state systems for frictionless eligibility and enrollment.
He also spotlighted state subsidies and public option plans as examples of homegrown policy tools that help stabilize and expand markets.
The Path Forward: Technology, Partnership, and Purpose
Across the board, panelists agreed: SBMs must not only adopt modern platforms—they must find partners who innovate with them. Real-time eligibility checks, AI for fraud detection, and cross-agency data sharing are no longer future concepts; they’re becoming table stakes.
The takeaway? States that embrace technology and take ownership of their marketplaces are best positioned to weather federal changes, reduce costs, and serve their populations more effectively.
Debunking the Myths
The session ended with one powerful myth-busting message: You can do this. Building an SBM isn’t an impossible feat. It’s a manageable, scalable opportunity—especially with models to emulate, a decade of lessons learned, and a community of public and private actors ready to help.
