‘Should Texas’ Health Insurance Marketplace be state-run or federally-run?’ is not the right question

A few bills have been filed in the 2023 Texas Legislative Session that would create Texas’ own Affordable Care Act (ACA) Health Insurance Marketplace to replace HealthCare.Gov, the marketplace Texas has used for the last 10 years. 

The initial conversation about these bills seems focused on the question of which level of government  state or federal  should run this crucial function. This narrow focus is misplaced. The Marketplace is a means, not an end. The right question is: what does Texas want to achieve with this change?

The federally-administered Texas Marketplace at HealthCare.Gov is booming. It has more insurers competing to sell coverage than in any other state. It has record enrollment, covering 2.4 million Texans with quality, affordable insurance. It has achieved the highest rate of enrollment growth among states for three years running. In fact, it is working so well that Texas must weigh whether a big disruption to the system  one that also involves some financial risk to the state  is worth it. 

The Marketplace will make countless policy and operational decisions that determine whether millions of eligible Texans can easily enroll in comprehensive and affordable coverage or not. How a state-run marketplace in Texas would perform will depend in large part on the direction and resources provided by the Legislature. The details or the lack of them spelled out in a bill really do matter. 

Is the primary goal to keep what is working well for 2.4 million Texans and build on it, so Texas can further reduce our worst-in-the-nation uninsured rate by connecting more Texans to affordable, comprehensive coverage?  

If that isn’t the primary goal, what is?

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