HEALTH POLICY CENTER The American Rescue Plan Act’s Marketplace Provisions Early Implementation Experiences and Lessons Learned from Three State-Based Marketplaces Teresa A. Coughlin, Erik Wengle, and Haley Samuels-Jakubos October 2021 Included in the wide-ranging American Rescue Plan Act of 2021 (ARPA) are several provisions that expand the Affordable Care Act’s (ACA’s) premium tax credits (PTCs) for families and individuals who have coverage through the health insurance Marketplaces. These provisions call for one of the most significant changes to the ACA since its passage 11 years ago. Designed to help people affected by the COVID-19 public health emergency (PHE) and to address the affordability of health insurance for people with low and moderate incomes, a long-standing policy problem, 1 the ARPA boosts the amount of the subsidies provided to those already eligible for Marketplace PTCs. For the first time, the ARPA also offers subsidies to people with incomes above 400 percent of the federal poverty level (FPL). Importantly, these ARPA provisions are temporary and last through 2022, unless Congress makes them permanent, as called for in the American Families Plan. That the provisions are temporary underscores the need for quick action on the parts of state-based Marketplaces (SBMs) and the federally facilitated Marketplace (FFM) to ensure people take advantage of this new financial help. If made permanent, the ARPA PTC enhancements are estimated to reduce the number of people uninsured by 4.4 million, to add 5.1 million Marketplace enrollees, and to reduce Marketplace premiums by 15 percent by 2022 (Banthin et al. 2021). To provide some insight into early lessons learned by SBMs implementing the ARPA Marketplace provisions, we interviewed state Marketplace officials, representatives from navigator organizations, and Marketplace health insurers in California, New York, and Washington State. In the interviews, we asked how these states implemented the ARPA Marketplace provisions, how implementation was going, and what future steps they might take. We chose these study states because each has long been a leader among SBMs. Thus, their experiences implementing the ARPA provisions offer lessons that could be helpful to state and federal policymakers as the 2022 open enrollment period approaches and could inform future Marketplace improvements. We conducted semistructured interviews between May and August 2021. To conduct this work, we relied on federal and state documents and reports and other grey literature. Summary of Study Findings State officials in the three study states were eager to take advantage of the ARPA Marketplace provisions. Further, knowing that the enhanced subsidies were available for a short time, states acted quickly to mount robust marketing and consumer outreach campaigns. Sometimes this involved using strategies states had not previously employed, such as coordinating with other state agencies to promote the Marketplace and the enhanced subsidies. We find that how states adjusted their Marketplaces to accommodate the ARPA provisions varied along several dimensions, including in the length of ARPA-related special enrollment periods, implementation schedules, and the extent to which the Marketplace system changes adopted were automated for consumers. In some instances, how study states implemented the ARPA Marketplace provisions aligned with federal action taken on the FFM. Consistent with the FFM, early data released by the study states indicate the ARPA provisions have been promising: Marketplace enrollment is up, the share of enrollees receiving premium subsidies has increased, and consumers are, on average, paying lower premiums. Even while implementing the ARPA provisions, the study states continued to try to improve their Marketplaces and anticipate upcoming needs. As one important example, the study state Marketplaces are partnering with their state Medicaid agencies to prepare for when the PHE ends; now that Marketplace coverage has become more affordable, Marketplace officials think an opportunity exists to enroll people as they are disenrolled from Medicaid. Officials noted that previous take-up of Marketplace insurance by terminating Medicaid enrollees was limited because Marketplace coverage was too costly. Chief among the lessons learned from California’s, New York’s, and Washington’s implementations of the ARPA Marketplace provisions that could be useful to other SBMs and the FFM are the following:  Centering how the ARPA’s new and expanded financial help makes insurance more affordable for more people is essential for ARPA messaging. However, messages need to be customized for different groups. To help overcome long-standing beliefs that health insurance is unaffordable, ARPA messaging could focus on how the enhanced subsidies are new and make health insurance more affordable than ever. For uninsured people, messaging could also highlight the importance of having health insurance during the pandemic. For people insured outside of the Marketplace (hereafter “off-Marketplace” consumers), messages could focus on themes related to saving more with Marketplace coverage. Finally, messaging to current 2 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS Marketplace enrollees could encourage consumers to review their health plan selections to ensure they have picked the best option.  To raise awareness about the ARPA’s enhanced subsidies, marketing and consumer outreach can be conducted via communication strategies including direct mail or print or digital campaigns. Like messaging, strategies should be tailored for different groups. An effective communication strategy reaches people multiple times through different communication channels.  Establishing partnerships with other state agencies (e.g., state unemployment agencies, state health insurance regulators, and state Medicaid agencies) is crucial to helping promote the Marketplace generally and raising awareness among potential enrollees about the availability of new financial help for purchasing coverage.  Engaging Marketplace partners (e.g., health plans, brokers, and navigators) helps with conducting direct outreach and education to current and potential enrollees about the financial assistance the ARPA offers. Major ARPA Marketplace Provisions The ARPA has many provisions, 2 including an increase in the amount of and expanded eligibility for the ACA premium subsidies for people who get health insurance through SBMs or the FFM. In addition, it calls for extra subsidies for people who receive unemployment insurance benefits during 2021. We discuss these in detail below. Enhanced premium tax credits. The ARPA increases the value of PTCs available to Marketplace enrollees by reducing the share of income people are expected to pay toward their premiums (table 1). For example, before the ARPA, people with incomes below 138 percent of FPL in states that have not expanded Medicaid contributed 2.07 percent of their household income to enroll in a benchmark silver plan. Under the ARPA, people with incomes below 150 percent of FPL can select a benchmark silver plan with no premium payment. The law also extends PTCs for the first time to people with incomes over 400 percent of FPL, capping the percentage of income these people contribute toward premiums for a Marketplace plan at 8.5 percent. The ARPA subsidies substantially reduce premium payments for many eligible people. For example, a 64-year-old earning just above 400 percent of FPL would pay $4,394 per year in Marketplace premiums under the ARPA, down from $12,698 per year before the ARPA provisions took effect (Pollitz 2021). As mentioned, these are temporary enhancements available only through 2022, unless Congress acts to extend them. THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 3 TABLE 1 Advanced Premium Tax Credit Schedules under the Affordable Care Act and American Rescue Plan Act, 2021 Range of applicable Income range (% of the federal Range of applicable percentage- percentage-of-income caps poverty level) of-income caps under the ACA under the ARPA <138 2.07 0 138–150 3.10–4.14 0 150–200 4.14–6.52 0–2.0 200–250 6.52–8.33 2.0–4.0 250–300 8.33–9.83 4.0–6.0 300–400 9.83 6.0–8.5 400–500 n/a 8.5 500–600 n/a 8.5 600+ n/a 8.5 Sources: Internal Revenue Service, US Department of Health and Human Services, and the American Rescue Plan Act of 2021, Pub. L. No. 117-2. Notes: ACA = Affordable Care Act. ARPA = American Rescue Plan Act. n/a is not applicable. Three major groups could benefit from these ARPA Marketplace provisions: uninsured people; people with nongroup health insurance purchased directly from an insurer, rather than the ACA Marketplace, known as the off-Marketplace population; and people already enrolled in a Marketplace plan before the ARPA. The estimated ARPA-induced Marketplace enrollment increase is substantial. Nationally, Marketplace enrollment is expected to increase by 30 percent, from 14.9 to 19.5 million, by 2022 (table 2). For the study states, Washington’s enrollment is expected to increase the most (43.4 percent), followed by California (19.6 percent) and New York (15.0 percent). The estimated decline in the number of people uninsured is also considerable, ranging from 11.4 percent in California to 18.0 percent in Washington. Nationwide, the number of people uninsured is expected to drop by 13.6 percent. TABLE 2 Estimated Marketplace Enrollment and Number of Uninsured People in the Study States and the US, with and without the ARPA, 2022 Plan Year Estimated Marketplace Enrollment Estimated Uninsurance Without ARPA With ARPA Without ARPA With ARPA (1,000s of (1,000s of Percent (1,000s of (1,000s of Percent people) people) change people) people) change California 2,145 2,567 19.7 3,682 3,262 -11.4 New York 1,079 1,241 15.0 1,106 944 -14.6 Washington 276 396 43.5 597 489 -18.1 US 14,960 19,574 30.8 30,766 26,579 -13.6 Source: Jessica Banthin, Matthew Buettgens, Michael Simpson, and Robin Wang, “What If the American Rescue Plan Act’s Enhanced Marketplace Subsidies Were Made Permanent? Estimates for 2022” (Washington, DC: Urban Institute, 2021). Notes: ARPA = American Rescue Plan Act. ACA = Affordable Care Act. “Without ARPA” is under the pre-ARPA Affordable Care Act subsidy schedule, and “with ARPA” is under the enhanced subsidies outlined in the ARPA. 4 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS Extra subsidies for unemployed people. Another important ARPA provision is extra subsidies for people who receive unemployment insurance benefits in 2021. Specifically, people who receive unemployment for at least one week in 2021 are eligible for zero-dollar premiums and cost-sharing reductions. Unlike the enhanced subsidies available through 2022, these unemployment subsidies extend through 2021 only. Key Features of the Marketplaces in Three Study States As some of the first states with SBMs, the study states launched their Marketplaces in 2014, the same year the FFM became available. These SBMS, Covered California, NY State of Health, and Healthplanfinder, share many common features but have important differences, largely reflecting the various innovations the states have implemented to improve their Marketplaces (table 3). Some of these programmatic attributes shaped the study states’ experiences with the ARPA. TABLE 3 Key Features of Study State-Based Marketplaces and the Federally Facilitated Marketplace before American Rescue Plan Act Implementation California New York Washington FFM First year of SBM 2014 2014 2014 2014 implementation (plan year) Marketplace enrollment (end of 2021 open 1,625,546 215,889 222,731 8,251,703 enrollment period) Standard open enrollment November 1– November 1– November 1– November 1– period January 31 February 7 January 15 December 15 ACA Medicaid expansion? Yes Yes Yes n/a Standardized plans? Yes Yes No No Community rated? No Yes No No Public option health plan No No Yes No available on Marketplace? Basic health plan? No Yes No No State additional premium Yes No Noa n/a subsidy? Coverage mandate tax Yes No No No penalty? Sources: Open enrollment data for 2021 are from “2021 Marketplace Open Enrollment Period Public Use Files,” Centers for Medicare & Medicaid Services, last modified April 21, 2021. Study states’ open enrollment periods are from Covered California, “Amid a Surge in Enrollment Last Week, Covered California Extends Deadline for Jan. 1 Coverage through Friday,” news release, December 16, 2019; NY State of Health, 2020 Open Enrollment Report (New York: NY State of Health, 2021); and Ryan Blethen, “Open Enrollment for Washington Health Benefit Exchange Begins Friday; Here’s What You Need to Know,” Seattle Times, October 30, 2019. The 2020 open enrollment period for the FFM is from “Key 2020 Open Enrollment Dates,” Healthcare.gov, accessed October 18, 2021. State Medicaid expansion decisions are from “Status of State Action on the Medicaid Expansion THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 5 Decision,” Kaiser Family Foundation, accessed October 18, 2021. Information on standardized plans, community rating, public option health plan availability on the Marketplace, basic health plans, state additional premium subsidies, and coverage mandate tax penalties are from Justin Giovannelli, Kevin Lucia, and Sabrina Corlette, "What Is Your State Doing to Affect Access to Adequate Health Insurance?,” Commonwealth Fund, September 23, 2021. Notes: FFM = federally facilitated Marketplace. SBM = state-based Marketplace. a Washington has created an additional state subsidy program that will take effect in 2023. Shared characteristics include adoption of the ACA Medicaid expansion and longer-than-usual open enrollment periods compared with that of the FFM. Among the innovative features the study states’ Marketplaces have implemented is requiring Marketplace insurers’ participation to create plans and standardize cost-sharing and benefit designs to make it easier for consumers to compare plans (California and New York). In addition, New York has instituted plan community ratings, and Washington offers a Marketplace public option plan. New York is also one of two states (the other being Minnesota) that operates a basic health plan. 3 In contrast, the FFM has not adopted any of these innovations. Finally, California is the only study state that has an individual mandate that imposes a state tax penalty on people lacking health insurance. It was also the only state that provided some Marketplace enrollees with premium subsidies to help address affordability issues before the ARPA; beginning in January 2020, California made available state-financed Marketplace subsidies for people with incomes up to 600 percent of FPL. 4 Under the ARPA, California suspended its state premium subsidies. Study Findings Though each study state took a robust, multifaceted approach to implementing the ARPA Marketplace provisions, the strategies they adopted differed. The states’ implementation plans fell into three broad and interrelated categories:  programmatic designs and ARPA implementation timelines  ARPA messaging  ARPA marketing campaigns and consumer outreach Programmatic Designs and ARPA Implementation Timelines States had to quickly make multiple programmatic and system decisions pertaining to implementing the ARPA provisions. These included whether to establish an ARPA special enrollment period (SEP), when to roll out the various provisions and the extent to which the provisions would be automated, and whether enrollees would be allowed to switch plans or insurers during the SEP. 6 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS TABLE 4 Differences in American Rescue Plan Act Implementation Decisions between Study States and the Federally Facilitated Marketplace California New York Washington FFM End of ARPA SEP 12/31/2021 12/31/2021 8/15/2021 8/15/2021 Timeline of ARPA enhanced subsidies Date available for people with incomes < 400% of FPL 4/1/2021 4/1/2021 4/1/2021 4/1/2021 Date automated 5/1/2021 6/5/2021 5/6/2021 9/1/2021 Date available for people with incomes < 400% of FPL 4/1/2021 4/1/2021 4/1/2021 4/1/2021 Date automated 5/1/2021 6/5/2021 5/6/2021 9/1/2021 Timeline and automation of ARPA unemployment benefit Date unemployment benefit 7/1/2021 First week of Second week 7/1/2021 implemented June 2021 of May 2021 Automated? Yes, when No Yes, when No implemented; implemented eligibility redetermined June 21–26, with a July 1 effective date Plan switching decisions Allow consumers to change plans Yes Yes Yes Yes during SEP? Left up to Left up to Transfer out-of-pocket spending Yes Yes individual individual within insurer? insurers insurers Allow consumers to change Yes Yes Yes Yes carriers during SEP? Sources: Timelines for study states’ enhanced subsidies and automation of the ARPA unemployment benefit are from Peter V. Lee, “Executive Director’s Report,” Covered California board presentation given August 19, 2021; “Health Insurance Changes for Unemployed New Yorkers in 2021,” NY State of Health, accessed October 18, 2021; and Washing Health Benefit Exchange, “Public Health Emergency Special Enrollment and American Rescue Plan Act Implementation,” presentation given August 13, 2021. Timelines for the FFM’s ARPA enhanced subsidies and automation of the employment benefit and the FFM’s plan switching decisions are from “New, Lower Costs on Marketplace Coverage,” Centers for Medicare & Medicaid Services, accessed October 18, 2021; and US Department of Health and Human Services, “2021 Special Enrollment Period Access Extended to August 15 on HealthCare.gov for Marketplace Coverage,” news release, March 23, 2021. Study states’ plan switching decisions are from Covered California, “Covered California Policy and Action Items,” board presentation given March 18, 2021; “Health Insurance Changes for Unemployed New Yorkers in 2021,” NY State of Health; and Joan Altman and Mary McHale, “Part I – American Rescue Plan Act: Exchange Impacts,” presentation given virtually April 12, 2021. Notes: ARPA = American Rescue Plan Act. FFM = federally facilitated Marketplace. SEP = special enrollment period. FPL = federal poverty level. ESTABLISHING AN ARPA SPECIAL ENROLLMENT PERIOD Recognizing that the pandemic has affected millions of people and that access to health care was needed, the US Department of Health and Human Services (HHS), under executive order from President Biden, announced an SEP to allow people to enroll in the FFM from February 15 to May 15, THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 7 2021. 5 HHS later extended the FFM SEP end date to August 15, 2021. New York and California both had had continuously running PHE-related SEPs since 2020. With the passage of the ARPA, both states decided to extend their SEPs through December 2021. One Covered California official explained the state’s reasoning behind keeping the SEP open through 2021: “They knew it was going to be difficult to bring consumers’ attention to the ARPA Marketplace provisions, particularly in the middle of the year, and they wanted consumers to be able to take full advantage of the ARPA subsidies regardless of when they became aware of them.” New York Marketplace officials expressed similar sentiments. Washington adopted a different approach. Though Washington, too, had an SEP during 2020 because of the PHE, the state closed it on January 15, 2021, following the state’s standard open enrollment period (table 3). However, once the FFM opened an SEP for the PHE in February 2021, Washington followed suit. Washington also decided to align with the FFM by closing its SEP on August 15, 2021. Washington officials offered several reasons for closing the state’s ARPA SEP on that date rather than extending it until the end of 2021. First, state officials wanted the SBM to be aligned with the FFM. They also recognized that between the state’s PHE SEP and the ARPA SEP, the state “had been in open enrollment for a long time,” as one official said. Another consideration was to allow Marketplace staff to focus on the process and technical improvements they wanted to introduce for the 2022 open enrollment period, which starts November 1, 2021. THE TIMING AND EXTENT OF AUTOMATION OF THE ARPA PROVISIONS Officials in each study state highlighted the considerable efforts and resources it took to upgrade their systems to accommodate ARPA provisions, especially because each state operates an integrated enrollment system for its public health programs. As one California official observed, it was a “Herculean task to make the changes to the [Covered California] website and make changes to the enrollment system” to maximize the time state residents could take advantage of the enhanced subsidies. At the same time, states were motivated to implement the provisions to help people harmed by the pandemic and, more generally, to help make insurance more affordable. Toward that end, each state implemented the ARPA provisions in different ways using different timelines, which also differed from the FFM’s approach. The FFM launched ARPA provisions in phases, beginning with enhanced subsidies becoming available to new and existing qualified individuals on April 1, 2021. Enhanced subsidies for unemployed individuals, however, were not made available until July 1. In addition, the FFM did not initially automate any of the provisions; instead, it required all current enrollees to log into Healthcare.gov to get the ARPA enhanced savings. 6 However, the FFM began to automatically apply enhanced subsidies for some current Marketplace enrollees in August, and they took effect September 1. 7 Study states used different implementation timelines than the FFM, and they automatically applied the enhanced subsides to eligible enrollees from the start. Washington had the most aggressive approach, rolling out all the new ARPA provisions simultaneously, including the unemployment benefit. Washington officials acknowledged considerable internal debate about how to push out ARPA benefits. Ultimately, they decided it would be too confusing to consumers to say, “You get a benefit now, but you have to come back in August,” as one official said. In April 2021, Washington notified current enrollees 8 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS of the upcoming changes, and by mid-May existing qualifying enrollees’ accounts had been automatically updated with enhanced subsidies for their June premiums. Most enrollees did not need to act to receive these enhanced subsidies, according to officials. 8 In contrast, California and New York followed the FFM’s approach more closely and implemented ARPA provisions in several steps. According to one New York official, the state’s decision to “bite it [the ARPA provisions] in pieces” was “purely driven by [Marketplace] system complexity.” Further, though they wanted to get benefits out to people as fast as possible, New York also wanted to automate as much as possible. New York launched enhanced ARPA subsidies for current Marketplace enrollees already receiving PTCs first. At the beginning of April, the enhanced subsidies were made available to these enrollees, but enrollees had to actively make changes to their accounts to receive the subsidies. About 20 percent did so, according to New York officials. By June 1, though, the enhanced subsidies were automatically applied to this group. Extending advanced premium tax credits to enrollees with incomes above 400 percent of FPL and to people eligible for the unemployment-related subsidies came later, because these changes involved more system testing and processing, according to New York Marketplace officials. These provisions were both launched the first week of June 2021. Though the advanced premium tax credits for those with incomes above 400 percent of FPL were automated, New York did not automatically apply the unemployment-related subsidies to qualified current enrollees; instead, the state sent notices informing enrollees of the new benefit. California also implemented the ARPA provisions in phases, though its approach was somewhat more automated than New York’s. For current enrollees, enhanced PTCs were available to all income groups starting April 5, 2021, but enrollees had to actively make changes to their accounts to receive them. Then, starting May 1, Covered California automatically applied ARPA subsidies for all eligible current enrollees, including those with incomes over 400 percent of FPL. Eligibility was redetermined for 900,000 households, according to state officials. Like New York, the unemployment-related subsidy was implemented later, but it was automatically applied to qualifying individuals in July 2021. SWITCHING PLANS AND INSURERS DURING THE ARPA SPECIAL ENROLLMENT PERIOD During the ARPA SEP, the FFM allowed Marketplace enrollees to switch health plans within the same insurer, but insurers decided whether enrollees could carry over any 2021 out-of-pocket spending to the new plan (CMS 2021). The FFM also allowed enrollees to change insurers, but any out-of-pocket spending did not transfer to the new insurer. All three study states followed the FFM’s policy and did not allow enrollees to carry over any out- of-pocket spending if they changed insurers. But the states’ approaches to carrying over spending for people who switched plans but stayed with the same insurer varied. Washington followed the FFM, leaving it up to an insurer’s discretion whether consumers could transfer out-of-pocket spending if they switched plans within an insurer. In contrast, New York and California allowed enrollees to change plans within an insurer and to transfer any 2021 out-of-pocket spending to the new plan. THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 9 Developing Consumer Messaging about ARPA Provisions Developing messaging for the ARPA that resonated with different populations was a challenge, which state officials and other stakeholders readily acknowledged. They knew they were up against long- standing consumer behavior and thinking regarding health insurance. For example, some uninsured people feel they cannot afford insurance or do not see the value in having coverage. People with off- Marketplace coverage commonly think they would never qualify for financial assistance purchasing coverage or do not want it. More fundamentally, several interviewees commented that the ACA and the Marketplace have been on shaky policy ground for the past several years, which posed yet another challenge to engaging possibly wary consumers. As one insurer said, “Everything from mandate repeal to the price shock…This market [has been] subject to a much higher degree of fundamental policy change. We’re just coming out of the fourth or fifth case, not knowing if the ACA would survive.” MAJOR ARPA MESSAGING STRATEGIES Affordability was at the heart of each state’s efforts to engage both uninsured people and the off- Marketplace population via messaging about the ARPA provisions. Still, customized messages for target groups were needed. For example, a major obstacle state officials and other interviewees noted was that many uninsured people want insurance but think they cannot afford it. In various ways, states and their partners tried to get the word out that the ARPA brings something new and different to the Marketplace, and that consumers should revisit Marketplace coverage see how cheap it is now. They also let consumers know coverage was available because of new federal pandemic-related relief. Another messaging strategy used for the uninsured population was highlighting the importance of having insurance, particularly during the pandemic. Though affordability was also at the center of messaging for the off-Marketplace group, their messaging had to be tweaked. As one official commented, it does not make sense to communicate “you need insurance” to this group, like it does for uninsured people; instead the message was that people “can save more” if they switch to a Marketplace plan. THE TEMPORARY NATURE OF ARPA SUBSIDIES Almost universally, interviewees did not think the subsidies’ temporary nature was a barrier. Indeed, several interviewees suggested people operate one year at a time when it comes to health insurance. Even so, study states addressed the limited availability of the enhanced subsidies in different ways. On the one hand, California highlighted the subsidies’ impermanence to encourage people to take advantage of the subsidies as quickly as possible. As one official said, “We made brand new ads…explaining that there is $3 billion in the state of California to pay for the subsidy [from the ARPA], and this is your chance!” In contrast, New York and Washington let people know that the subsidies are temporary but, as one official said, “We are not leading with it.” Marketing Campaigns and Consumer Outreach Each study state adopted a robust marketing and consumer outreach campaign to communicate about the ARPA subsidies. Unlike the FFM, which received $50 million in funding to advertise the 2021 ARPA 10 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS SEP, 9 study states used existing Marketplace funds to finance their campaigns; no new state resources were provided. Instead, state officials said they took stock of their operations and moved current resources around to prioritize marketing the new enhanced subsidies. States employed various strategies to conduct their ARPA campaigns and reach consumers, from running TV ads to working with health plans. States also tapped a wide range of agencies to help them reach consumers, including state insurance regulators, state tax boards, and state labor departments. Some of their strategies sought to raise general awareness about ARPA benefits, whereas others were targeted at particular groups (i.e., the uninsured, the off-Marketplace population, and current Marketplace enrollees). RAISING AWARENESS ABOUT THE ARPA SUBSIDIES To raise general awareness about the ARPA, each study state employed paid campaigns that included TV, radio, and print advertising starting in April 2021. They also launched digital campaigns including social searches and streaming videos. Study states also updated their Marketplace websites with information about the ARPA, including a section with frequently asked questions that states modified as provisions were implemented. California and Washington put “quick calculators” on their websites to allow consumers to easily view the benefits of the ARPA subsidies. States also added staff to their Marketplace call centers and expanded the centers’ hours. In different ways, navigators were also brought into to help promote the ARPA. California offered grants to selected navigators to help fund local ARPA ad campaigns, and Washington amended contracts with navigators to allow them to spend their marketing resources outside of the regular open enrollment period to support implementation of the enhanced subsidies. In addition, study states provided partners with webinar trainings about the ARPA, toolkits, informational flyers and posters, and talking points. New York coordinated with state parks to give people ARPA flyers with their parking tags when they entered a park. Insurers, too, launched marketing efforts, including putting ARPA information in plan advertising via social media and direct mail flyers. Some have also called members to tell them about the new subsidies available. Still others have embarked on community-level outreach efforts, such as setting up enrollment and information booths at farmer’s markets, food pantries, and the like. MARKETING AND OUTREACH TO TARGET GROUPS Apart from a general ARPA marketing campaign, states also targeted particular populations to encourage them to take advantage of the enhanced subsidies. Market circumstances partly dictated the extent to which states targeted different groups for outreach. For example, Washington has a fairly limited off-Marketplace group, whereas California has a sizable off-Marketplace population. Uninsured people. States used various strategies to engage uninsured people. One was contacting people who had taken an action on their websites (e.g., requested information, provided an email, or submitted an application without enrolling) and sent information to them about the ARPA, the value of health insurance, and how to find help with enrolling in coverage. States used email, direct mail, and text THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 11 messaging for this effort. In addition, states relied on their navigators to get the word out. Washington sent information about people who did not complete Marketplace enrollment to navigators and had them contact these people with information about the ARPA. Both New York and California launched similar efforts with their navigators. Another important strategy the study states used to reach uninsured people was coordinating with state unemployment offices. In April and June, the New York unemployment office sent emails to more than 5 million people who had received unemployment benefits to make them aware of the new ARPA benefits. California and Washington similarly partnered with their states’ unemployment agencies to provide people receiving unemployment benefits with information about ARPA benefits they might be eligible for. Marketplace officials also said they targeted particular segments of the uninsured population in their campaigns. Washington used social media (e.g., placing ads on TikTok, Spotify, and Hulu) to engage young adults because this group accounts for a big share of the state’s uninsured population. New York pushed hard to reach uninsured people with incomes above 400 percent of FPL by doing outreach to organizations, associations, and other groups that they had not necessarily targeted in the past, including freelancers, restauranteurs, and actor’s guilds. New York also worked with companies like Uber and Lyft to send in-app messages to drivers. California officials noted targeting people in low- income areas, communities of color, and people hardest hit by the pandemic. California also employed strategies that were unique to the state. The first was partnering with its state tax board. As mentioned, California imposes a state tax penalty for people who do not have health insurance (table 3). Covered California worked with the state tax board and sent Marketplace information to tax filers who had paid the penalty. California also obtained lists from all insurers that provided information for consumers who recently terminated their health insurance; this is a new requirement provided through recent state legislation (S.B. 260). In June 2021, Covered California received the first set of lists and started contacting people to see if they may need Marketplace services. The off-Marketplace population. Both Marketplace representatives and insurers highlighted the off- Marketplace group as particularly tough to engage. A central challenge interviewees identified is that many in this group think they will never qualify for financial help in the Marketplace or do not think they need such help. Several interviewees also commented that the timing of the ARPA provisions was difficult for the off-Marketplace group because it is “off season”; that is, the off-Marketplace group has been “trained,” as one insurer put it, to shop for insurance in the fall. Across the board, interviewees were hopeful that more of the off-Marketplace population would move to the Marketplace near the end of the year. That said, a principal strategy states used to reach off-Marketplace individuals was engaging with health plans and encouraging them to notify their members about the ARPA. However, the efforts states dedicated to this strategy varied. In Washington, this was not a big focus because of the limited size of the off-Marketplace population, which the state estimates is only about 30,000 individuals (Altman and McHale 2021). Even so, Washington worked with insurers to get them to let their 12 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS nongroup customers know they may be eligible for the ARPA subsidies in the Marketplace. As one official said, plans have been “surprisingly responsive” to this ask, even though Washington insurers were said to like the off-Marketplace business because such enrollees tend to be more affluent. New York officials estimated 70,000 people with off-Marketplace coverage would transition to the Marketplace because of the ARPA provisions. To help move these people, Marketplace officials asked that health plans notify their off-Marketplace enrollees about the enhanced subsidies. Plans agreed to do so, but, as one state official commented, “We didn’t exactly get the reception [from the health plans] that we’d thought we’d get.” In part, plans’ responses seemed driven by their level of off-Marketplace enrollment. One interviewee commented that the insurer they represent had not been involved much with the ARPA because it did not view the potential gain as worth the additional marketing effort, particularly in the middle of the year. New York Marketplace staff also worked with the state health insurance regulator, the Department of Financial Services, to require health plans to provide information about the ARPA subsidies in their 2022 premium notices to customers. Among the study states, California probably had the most developed approach to engaging health plans to reach the off-Marketplace population. Potential Marketplace enrollment is large in California for this group; the state estimates about 790,000 Californians were enrolled in nongroup health coverage, and 270,000 of them could receive ARPA subsidies (Covered California 2021). The state coordinated with health plans and employed several strategies with the aim of “garnering QHP [qualified health plan] participation to help convert their enrollees…but minimize the risk that the consumer may just go to another plan,” as one Marketplace official said. Toward that end, California launched temporary “microsites” that enable insurer-specific enrollment through the Covered California website in June 2021. 10 Consumers can also access an insurer’s cobranded Covered California microsite via a link on the insurer’s website. For off-Marketplace consumers who switch to a Marketplace plan within the same insurer, insurers must transfer any out-of-pocket spending accrued to the new plan. Apart from engaging insurers, California and New York also reached out to insurance brokers to help re-enroll off-Marketplace consumers. The New York Department of Financial Services, the state’s insurance regulator, sent out 130,000 emails to health insurance brokers about the availability of the enhanced subsidies under the ARPA. Covered California encouraged (though did not require) insurers to offer incentive bonuses to agents for moving off-Marketplace enrollees to Marketplace coverage. California officials said some insurers are doing this. One plan representative we spoke with said their plan established a bonus program for the ARPA that pays top brokers $100 per individual transferred. Marketplace enrollees. As discussed above, the study states automated many of the ARPA provisions for current Marketplace enrollees, so marketing and outreach to this group was more limited. Even so, some people needed to take an action to take up benefits. For example, people who did not report their income or people who had experienced changes (e.g., began receiving unemployment benefits) but had not reported them needed to notify the Marketplace to receive the benefits. To reach these enrollees, each study state conducted an email or direct mail campaign to tell current enrollees about the ARPA, see if it applies to them, and encourage them to report any changes that may affect their eligibility. As THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 13 one state official put it, “We’re constantly trying to make sure that they [current enrollees] are at the most advantageous position.” Another part of this outreach effort was educating all enrollees to consider getting more comprehensive coverage, especially for those with incomes below 250 percent of FPL. In addition, states engaged partners to contact current enrollees about the ARPA. New York sent lists to facilitated enrollers of their clients who could potentially benefit from enhanced subsidies. (Unique to New York, facilitated enrollers are health plan employees certified by the state to enroll people in health insurance, including Marketplace products. Marketplace officials said facilitated enrollers account for the bulk of Marketplace enrollment, about 60 to 70 percent.) California and Washington launched similar efforts with their navigator networks. Early Effects of the ARPA Marketplace Provisions in Study States Consistent with reports from the FFM, early data from the study states suggest the response to the ARPA Marketplace provisions has been strong. Since implementing the ARPA provisions in mid-August 2021, 11 the number of new plan selections made in California’s Marketplace, though lower than that in the FFM, was 2.6 times higher than during the same period in 2019 (257,350 versus 97,430). The increase in new plan selections was comparable in Washington’s Marketplace. TABLE 5 Changes in Plan Selections, Premiums, and the Share of People Receiving Subsidies in the Study States and Federally Facilitated Marketplace, 2019 and 2021 California New York Washington FFM Plan selections during 2019 comparison perioda 97,430 n/a 10,763 383,026 Plan selections during 2021 comparison perioda 257,350 47,116 28,027 1,541,591 Percent change, 2019–21b 164.1 n/a 160.4 302.5 Percent reduction in average monthly premium under ARPA APTCs (%)b 49 48 47 50 Average 2021 Marketplace premium before ARPA APTCs ($)b 571 656 505 590 Average monthly premium savings due to ARPA APTCs ($) 90 155 86 67 Share with subsidies, 2019 (%) 80.3 58.0 65.0 88.0 Share with subsidies, 2021 (%) 86.3 64.0 78.0 93.0 Percentage-point change in people receiving subsidies, 2019–21b 6.0 6.0 13.0 5.0 Sources: Plan selections in California and the share of California residents with subsidies in 2019 and 2021 are from Peter V. Lee, “Executive Director’s Report,” Covered California board presentation given August 19, 2021. Plan selections in New York and in the FFM for the 2021 SEP were calculated using US Department of Health and Human Services, 2021 Final Marketplace Special Enrollment Period Report (Washington, DC: US Department of Health and Human Services, 2021); and US Department of Health and Human Services, 2021 Marketplace Special Enrollment Period Report 1 (Washington, DC: US Department of Health and Human Services, 2021). Washington’s 2019 and 2021 SEP plan selections are from Washington Health Benefit Exchange, “Public Health Emergency Special Enrollment and American Rescue Plan Act Implementation,” presentation given August 13, 2021. The share of New York residents with subsidies in 2019 is from NY State of Health, 2019 Open Enrollment Report (New York: NY State of 14 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS Health, 2019); the authors calculated the share of New Yorkers with subsidies in 2021 using NY State of Health, “Health Insurance Coverage Update September 2021” (New York: NY State of Health, 2021). The shares of Washington residents with subsidies in 2019 and 2021 are from Washington Health Benefit Exchange, Health Coverage Enrollment Report Spring 2019 (Olympia, WA: Washington Health Benefit Exchange, 2019); and Washington Health Benefit Exchange, “Public Health Emergency Special Enrollment and American Rescue Plan Act Implementation.” Shares of people with FFM coverage receiving subsidies in 2019 and 2021 are from Centers for Medicare & Medicaid Services, Health Insurance Exchanges 2019 Open Enrollment Report (Baltimore: Centers for Medicare & Medicaid Services, 2019); and US Department of Health and Human Services, 2021 Final Marketplace Special Enrollment Period Report. Notes: ARPA = American Rescue Plan Act. FFM = federally facilitated Marketplace. SEP = special enrollment period. APTCs = advanced premium tax credits. n/a = not available. a For each state the 2021 comparison periods are after the passage of the ARPA. Importantly, they are not a perfect comparison with the 2019 comparison periods: The 2019 comparison periods were true SEPs, meaning a person had to have a qualifying life event to enroll in Marketplace coverage. In contrast, the 2021 comparison periods have functioned like open enrollment, meaning people did not need to have a qualifying life event to enroll in coverage. The goal of the comparison is to assess the effect of the ARPA enhanced subsidies on enrollment by comparing 2021 enrollment with a similar period in the recent past (2019) when the enhanced subsidies were not available. Finally, the dates used to calculate the percent change between the 2019 and 2021 comparisons periods were bound by what the states have reported and are not the same. The 2019 and 2021 comparison periods are as follows: April 10–October 10 for California, February 15 to August 15 for New York, May 6–August 15 for Washington, and May 6–August 15 for the FFM. Data were not available for the 2019 comparison period for New York. b Data in these rows are authors’ calculations. With the launch of the ARPA provisions, average monthly premiums decreased by almost half in each study state, consistent with the FFM experience. However, the average premium savings were higher in the study states than in the FFM and varied, ranging from a high of $155 per month in New York to a low of $86 in Washington. This variation in savings owes to the variation in state premiums, which reflect some contextual factors (e.g., underlying state demographic differences, such as age and income), Marketplace program characteristics, and other influences. For example, the higher average premium savings in New York reflect the state’s higher average monthly premium ($656) due to its use of community rating (table 3). Finally, the share of Marketplace enrollees who receive subsidies to help pay their premiums has increased relative to 2019 since the ARPA provisions took effect. State officials also reported observing other changes since the ARPA provisions’ implementation, including changes in enrollee plan selections. Washington officials reported that since it launched the ARPA provisions in August 2021, 82 percent of Marketplace enrollees who switched plans changed from a bronze plan (data not shown; Washington Health Benefit Exchange 2021). Similarly, New York reported that the share of enrollees choosing silver plans has increased while the share in bronze plans has declined since the ARPA subsidies became available (NY State of Health 2021b). More broadly, California officials reported that the enrollment increase brought about by the ARPA has contributed to the state’s ability to negotiate a low rate change with health plans for 2022. Further, Covered California will expand the regions in which current Marketplace insurers operate and add a new insurer in 2022, which will help increase competition and consumer choice, according to state officials. 12 In contrast, the number of insurers approved to participate in Washington’s Marketplace declined by one for 2022, and the state approved an average 4.17 percent rate increase for Marketplace plans in the coming year, despite rate decreases of more than 3 percent in the past two consecutive years. 13 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 15 Lessons Learned The study states’ early experiences implementing the ARPA Marketplace provisions offer the following lessons that can be useful for other SBMs and the FFM as the 2022 open enrollment period approaches and for informing future Marketplace efforts:  Modifying Marketplace systems and programmatic features can help state officials effectively and efficiently implement the new ARPA provisions. To the extent possible, policymakers can make Marketplace system upgrades that, after notifying enrollees in advance, will automatically apply enhanced subsidies so consumers do not need to act to receive them. This is a comparatively low-cost strategy that makes enhanced subsidies available quickly without requiring consumer action. Though modifications to premiums and cost-sharing reductions have to be implemented every open enrollment period, the ARPA experience has illustrated the importance of being able to make system and program changes midyear.  Policymakers should also consider lengthening the ARPA SEP. Doing this will allow consumers to take full advantage of the financial help the ARPA offers.  It is important that ARPA messaging emphasize how the new and expanded financial help makes insurance more affordable for more people. However, different groups require different messages. To help overcome long-standing beliefs that health insurance is unaffordable, ARPA messaging can underscore that enhanced subsidies are new and make health insurance more affordable than ever and can encourage consumers to revisit Marketplace coverage. For uninsured people, messaging can also highlight the importance of having health insurance during the pandemic. For off-Marketplace consumers, central messages can focus on saving more with the enhanced Marketplace subsidies. Finally, messaging to current Marketplace enrollees can encourage such enrollees to review their health plan selections to ensure they have picked the best option.  To raise awareness about the ARPA enhanced subsidies, marketing and consumer outreach can be conducted via communication strategies ranging from direct mail to print and digital campaigns. Like messaging, however, it is integral that communication and outreach strategies be tailored for different groups (e.g., placing ads on social media platforms to reach young adults but relying on radio ads and billboards in rural areas where people tend to be older and to drive more). An effective communication strategy should also reach people multiple times using different communication channels.  Establishing partnerships with other state agencies (e.g., state unemployment agencies, state health insurance regulators, and state Medicaid agencies) is essential to promoting the Marketplace generally and raising potential enrollees’ awareness about the availability of enhanced subsidies. Working with state agencies allows the Marketplace to reach new populations who could be greatly helped by the ARPA provisions. These alliances will become especially important when the PHE ends. 16 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS  Engaging Marketplace partners (e.g., health plans, brokers, and navigators) is integral for conducting direct outreach and education to current and potential enrollees about the financial help the ARPA offers. These entities can be important messengers providing hands-on help with enrolling in Marketplace coverage or switching to a different plan that offers better benefits at a lower price. Marketplace partners can be engaged in several ways, including urging plans to allow consumers to switch plans and transfer any accrued out-of-pocket spending or encouraging plans to offer incentives to brokers. Finally, allowing carrier-specific shopping experiences in the Marketplace could help promote the ARPA provisions among plans and brokers. Going Forward Even while implementing the ARPA provisions, the study states continued to look for ways to improve their Marketplaces and anticipate upcoming needs. Regarding the latter, study state Marketplaces are partnering with their state Medicaid agencies to prepare for when the PHE ends. Now that Marketplace coverage has become more affordable, Marketplace officials think an opportunity exists to enroll people in the Marketplace as they are disenrolled from Medicaid; officials noted that the take-up of Marketplace insurance by terminating Medicaid enrollees was previously limited because such coverage was too costly. Indeed, California is working on operationalizing autoenrollment, through which people no longer eligible for Medicaid will automatically move to Covered California. This was included in recent legislation (S.B. 260), and expected implementation is June 2022. In addition, Washington passed a state subsidy in spring of 2021 that is slated to be implemented at the end of 2022, just as ARPA subsidies terminate if Congress does not make them permanent. One Washington official acknowledged, however, that the state subsidy would not be “nearly the same kind of money” available through the ARPA, and it would need to be targeted to people with very low incomes. Across the board, stakeholders hoped the ARPA enhancements will be made permanent, which is called for in the August version of the federal budget reconciliation package (JEC Democrats 2021). Apart from helping with affordability, many interviewees felt making the subsidies permanent would help stabilize the Marketplaces, which could help raise consumers’, brokers’, and insurers’ confidence in and reliance on the Marketplaces for coverage. Making enhanced subsidies permanent would also allow states to shift their attention to implementing other improvements to their Marketplaces, such as reducing out-of-pocket costs beyond premiums or extending open enrollment periods (Levitis 2021). Moving forward, many important issues pertaining to the Marketplaces need monitoring, including the impact of the end of the ARPA unemployment-related enhanced subsidies in December and what happens when the PHE ends. THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 17 Notes 1 Centers for Medicare & Medicaid Services, “2021 Special Enrollment Period for Marketplace Coverage Starts on HealthCare.gov Monday, February 15,” news release, February 12, 2021, https://www.cms.gov/newsroom/press-releases/2021-special-enrollment-period-Marketplace-coverage- starts-healthcaregov-monday-february-15. 2 Other important ARPA insurance provisions not addressed in this brief include subsidies for COBRA payments and 2020 premium tax credit reconciliation relief. 3 A basic health plan is an option under the ACA that allows states to establish a program in which people with incomes between 138 and 200 percent of FPL enroll in health plans with low to no premiums and very limited cost sharing. Nearly 800,000 New Yorkers were enrolled in the state’s basic health plan as of February 2020; see New York State of Health (2021a). 4 As discussed later, in 2021 Washington adopted a state subsidy slated to be implemented in 2023. 5 CMS, “2021 Special Enrollment Period for Marketplace Coverage Starts on HealthCare.gov Monday, February 15,” news release. 6 Importantly, consumers who do not act will receive the enhanced premium tax credits when they file their 2021 federal tax returns. 7 “New, Lower Costs on Marketplace Coverage,” Healthcare.gov, accessed October 15, 2021, https://www.healthcare.gov/more-savings/. 8 However, those who had not previously reported their incomes or had not reported that they received unemployment in 2021 had to act to receive the enhanced subsidies. Likewise, people who did not take the maximum amount of premium tax credits in advance or had not given permission to the Marketplace to update their accounts had to update their accounts to receive subsidies. 9 Centers for Medicare & Medicaid Services, “HHS Secretary Becerra Announces Reduced Costs and Expanded Access Available for Marketplace Health Coverage under the American Rescue Plan,” news release, April 1, 2021, https://www.cms.gov/newsroom/press-releases/hhs-secretary-becerra-announces-reduced-costs-and- expanded-access-available-Marketplace-health. 10 Though microsites were designed for the off-Marketplace group, other potential and current enrollees can use them. In addition, the microsites allow users to shop for all Marketplace insurers. 11 Dates for plans’ special enrollment periods vary somewhat because of data availability and differences in when states implemented ARPA changes. 12 Covered California, “Covered California Announces 2022 Plans: Full Year of American Rescue Plan Benefits, More Consumer Choice and Low Rate Change,” news release, July 28, 2021, https://www.coveredca.com/newsroom/news-releases/2021/07/28/covered-california-announces-2022- plans-full-year-of-american-rescue-plan-benefits-more-consumer-choice-and-low-rate-change/. 13 Washington State Office of the Insurance Commissioner, “Average 4.17% Rate Change Approved for 2022 Exchange Health Insurance Market,” news release, September 20, 2021, https://www.insurance.wa.gov/news/average-417-rate-change-approved-2022-exchange-health-insurance- market; and Washington State Office of the Insurance Commissioner, “Kreidler Approves Average Rate Decrease of 3.2 Percent for Washington’s 2021 Exchange Health Insurers,” September 4, 2020, https://www.insurance.wa.gov/news/kreidler-approves-average-rate-decrease-32-washingtons-2021- exchange-health-insurers. 18 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS References Altman, Joan, and Mary McHale. 2021. “Part III – American Rescue Plan Act: Call To Action.” Presentation given virtually May 3. Banthin, Jessica, Matthew Buettgens, Michael Simpson, and Robin Wang. 2021. “What If the American Rescue Plan’s Enhanced Marketplace Subsidies Were Made Permanent? Estimates for 2022.” Washington, DC: Urban Institute. CMS (Centers for Medicare & Medicaid Services). 2021. “American Rescue Plan and the Marketplace.” Baltimore: Centers for Medicare & Medicaid Services. Covered California. 2021. “Covered California Policy and Action Items.” Board meeting presentation given April 8. JEC Democrats (Joint Economic Committee Democrats). 2021. “Health Insurance Tax Subsidies in the Build Back Better Act Will Provide Affordable Health Insurance for Millions of Americans.” Washington, DC: Joint Economic Committee Democrats. Lee, Peter V. 2021. “Executive Director’s Report.” Covered California board meeting presentation given August 19. Levitis, Jason. 2021. “The American Rescue Plan’s Premium Tax Credit Expansion—State Policy Considerations.” Princeton, NJ: State Health and Value Strategies. NY State of Health. 2021a. “At a Glance: 2020 Open Enrollment Report.” New York: NY State of Health. ———. 2021b. “Health Insurance Coverage Update September 2021.” New York: NY State of Health. Pollitz, Karen. 2021. “How the American Rescue Plan Will Improve Affordability of Private Health Coverage.” San Francisco: Kaiser Family Foundation. Washington Health Benefit Exchange. 2021. “Public Health Emergency Special Enrollment and American Rescue Plan Act Implementation.” Presentation given virtually August 31. About the Authors Teresa A. Coughlin is a senior fellow in the Health Policy Center at the Urban Institute and a recognized expert on the Medicaid program and the health care safety net. In her current work, Coughlin is examining the financial impact of the pandemic on hospitals, examining costs and sources of funding for uncompensated health care for the uninsured, and leading Urban’s team on the Centers for Medicare and Medicaid Services–sponsored national evaluation of the State Innovation Models Initiative. During her more than 30-year career in health policy, Coughlin has published on a wide range of topics, including Medicaid, managed care, dual eligibles, state health policy, the health care safety net, Medicaid hospital finance arrangements, and geographic variation in Medicaid spending. Erik Wengle is a research analyst in the Health Policy Center. His research is focused primarily on the implementation of the Affordable Care Act and the future outlook of the Health Insurance Marketplaces. Wengle graduated from the University of Maryland in 2013 with a BS in environmental science and policy. Haley Samuel-Jakubos is a former research analyst in the Health Policy Center. Her research spans across a range of topics, including health care payment and delivery system reform at the federal and state levels, health information technology, and access to care. Before joining Urban, Samuel-Jakubos interned with the Senate Committee on Health, Education, Labor, and Pensions and assisted with THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS 19 tracking various health policy issues. She graduated with distinction from the University of North Carolina at Chapel Hill with a BSPH in health policy and management. Acknowledgments This brief was funded by the Bernard and Anne Spitzer Charitable Trust. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at urban.org/fundingprinciples. The authors thank the individuals who participated in the interviews for this project. We very much appreciate them giving us their time and insights. We also thank Jessica Banthin, Linda J. Blumberg, Genevieve M. Kenney, and Stephen Zuckerman for their input and guidance throughout the study. Finally, we thank Rachel Kenney for her editing and Luis Hassan Gallardo for his assistance in this work. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness and 500 L’Enfant Plaza SW enhance the well-being of people and places. Washington, DC 20024 Copyright © October 2021. Urban Institute. Permission is granted for reproduction www.urban.org of this file, with attribution to the Urban Institute. 20 THE AMERICAN RESCUE PLAN ACT’S MARKETPLACE PROVISIONS