A conversation with the Shriver Center’s Stephani Becker about the importance of a state-run health exchange

This past spring, Gov. J.B. Pritzker appointed Stephani Becker to the Illinois Health Benefits Exchange Advisory Committee. Becker is associate director of health care justice at the Shriver Center on Poverty Law. Along with other committee members, she advises the Illinois marketplace director on how to set up the state’s health care exchange, also known as the state marketplace. Open enrollment begins in fall 2025. 

Nearly 20 states run their own marketplaces. Last year, Illinois voted to create its own insurance exchange to give the state more authority to regulate health coverage and assist people who need insurance. The Shriver Center supported these efforts because we believe everyone deserves health care, regardless of income, race, and immigration status.  

Becker recently spoke about the significance of the exchange and our continued efforts to expand health care to everyone in Illinois.

How did health care exchanges start?

When the Affordable Care Act (ACA), or Obamacare, was passed in 2010, it created two new ways for people to get coverage. One was through the expansion of Medicaid, a federal program administered by states for people with low income. The second was through the creation of a federal health exchange, which is a fancy word for an online store available to those who don’t qualify for Medicaid, Medicare, or job-based coverage.

To make plans more affordable, the federal government subsidizes private insurance plans for individuals and families with lower income, who lack employer-based coverage but whose income is too high to qualify for Medicaid. The ACA also gives states the ability to create their own marketplaces.

What are the advantages of a state-based exchange?

Since 2010, the Shriver Center has fought for a state-based exchange for several reasons. For one, it allows for improved, targeted outreach to the uninsured. In the federal marketplace, the Centers for Medicare & Medicaid Services collects data about who is and isn’t insured but doesn’t share information with state insurance departments. With this data, we can identify specific zip codes with uninsured residents and fine-tune our efforts to encourage enrollment either in Medicaid or private insurance through the marketplace.

The state exchange gives us more authority to customize the system. Although the federal marketplace offers plans for some immigrants, the Illinois exchange can provide subsidies and expand access to undocumented immigrants, as one example. Flexibility is another factor. States can make enrollment periods longer or even open special enrollment periods in the wake of a natural disaster or a climate event.

What can the marketplace do to reduce health inequities?

Many uninsured people assume they can’t afford health care when that’s often not the case. Our challenge is to correct these common misconceptions through culturally competent enrollment assisters. With more data about who’s uninsured in marginalized communities, we can train navigators from similar backgrounds to help people find affordable, quality care. The state recently announced a $6.5 million grant that organizations can apply for to help build out the navigator program. The money will target people with disabilities, low income, and an acute risk of homelessness, among other hard-to-reach groups.

The price of health insurance affects everyone, but especially people with low income. Tools like rate review, which enable regulators to reject unreasonable price hikes to premiums, will help control costs. We hope that, with these changes, Illinois will see improvements to health equity.

How will having a state-run marketplace affect Medicaid?

State control allows the two systems to talk to one another. There’s a lot of bouncing around between Medicaid and the marketplace, due to fluctuations in income and other factors. For example, when someone loses their job with health insurance, they might qualify for Medicaid. That same person could subsequently find a job that doesn’t offer insurance, but their income disqualifies them from Medicaid. In that case, a marketplace plan would be the right fit.

In instances like these, many people give up and go without health care. That’s where state control of the health system — both Medicaid and the marketplace — really helps. With a robust network of navigators, we have a far better chance of preventing people from falling through the cracks. Being uninsured puts you at serious risk of accruing debilitating medical debt. It also produces poor health outcomes, as people stop taking prescribed medications and seeing their doctors and start putting off needed medical procedures.

How many people in Illinois are enrolled in Obamacare?

Currently, enrollment is at over 390,000. That’s the highest number yet and a 16 percent jump from last year. We know that’s partly attributed to enhanced premium tax credits (PTC) available through the American Rescue Plan Act. Zero-dollar premium plans are now available to people with annual income below $22,000 and the average enrollee in 2024 saved an estimated $700 due to PTC enhancements. More people also joined the marketplace when COVID-era protections ended and millions lost their Medicaid coverage.

We’re expecting to see another enrollment boost because the federal government has given DACA youth, otherwise known as Dreamers, access to the marketplace beginning in November. While many Dreamers have insurance through their employers, we anticipate thousands will purchase insurance on the marketplace. Illinois has close to 30,000 Dreamers.

Tell us more about the Illinois Health Benefits Exchange Advisory Committee.

I’m one of two consumer advocates appointed to represent people looking for high-quality, low-cost health care. The other committee members represent insurance companies, hospitals, navigators, brokers and physicians. I’m honored to bring a health justice perspective to the committee and use my position to fight for everyday people who are falling through the cracks of our system.

What are some of the top achievements in health justice from this last legislative session?

A few major wins from the last legislative session will affect all private insurance plans. The Birth Equity Bill requires companies to cover maternal services provided by midwives, doulas, and lactation consultants and expand pregnancy services, including labor, abortion, and miscarriage. The bill was crafted to address poor maternal health outcomes for Black women, who are more than three times as likely to die from pregnancy than white women. The inequities are due to several factors including how health care providers treat black women vs. white women. The health system is like all our other systems — it operates in a way that disadvantages people of color.

The General Assembly also approved the Healthcare Protection Act, sweeping legislation that bans short-term “junk” plans and “step therapy,” a process requiring people to try cheaper medicine before insurers cover drugs prescribed by their doctors. Other protections include the end of prior authorization for inpatient mental health care and new requirements for insurers to improve the accuracy of their in-network provider lists. Another victory that’s gotten a lot of attention is the governor’s medical debt relief program. In the first year alone, it will erase $1 billion in medical debt for more than 300,000 Illinoisans.