In February 2023, Ashley Zukoski, an ultrasound technologist who already received health insurance through her employer, discovered she had been enrolled in a different plan sold on the Affordable Care Act (ACA) marketplaces. Without Zukoski’s knowledge or consent, a Florida-based broker had falsified her income and enrolled her in a fully subsidized marketplace plan, such that she never received a premium bill to notify her of the change. When tax season arrived, Zukoski was faced with the threat of paying a steep federal penalty—all because she was improperly enrolled in subsidized coverage that she neither wanted nor authorized.
Zukoski’s experience is not uncommon. During the first eight months of 2024, over 275,000 consumers reported that an agent or broker had made unauthorized changes to their health insurance. Regulators, policymakers, and media outlets have since turned their attention to the growing problem of unauthorized marketplace activity. Now known as “unauthorized plan switching” or “unauthorized enrollments,” these agent- and broker-perpetrated actions have compromised the integrity of the ACA marketplaces.
Unauthorized switches and enrollments have been framed as isolated incidents by bad actors. Yet, as this Comment argues, they reflect a deeper, systemic failure: a narrow and misguided conception of program integrity in the context of health benefit programs. Policymakers have responded to unauthorized switches and enrollments by focusing on conserving federal funding and correcting individual eligibility errors, overlooking the Patient Protection and Affordable Care Act’s broader statutory purpose to promote access and protect consumers. Using the rise of and responses to unauthorized switches and enrollments as a case study, this Comment contends that program integrity must be redefined to center consumer rights and lived experiences in the design, implementation, and administration of marketplace policies.
Traditionally, efforts to protect the integrity of health benefit programs have focused “on paying the right amount” so the right people can get health insurance, while selecting “aggressive actions” to exclude ineligible consumers and limit the misuse of federal dollars. At the same time, it has been assumed that expansions in coverage are a sign of—or are in part a product of—fraud, waste, and abuse. However, building fraud-resistant systems and accessible enrollment pathways are not inherently in tension. In fact, in health benefit programs like the ACA marketplaces, upholding program integrity requires preservation of both its purpose and its security; it demands policies designed to prevent fraud and protect consumers from harm.
Evaluating the ACA marketplaces through a consumer protection lens is therefore critical to delivering on the drafters’ central promise: to connect consumers with quality, affordable coverage while protecting their rights. Broadening this understanding of program integrity can empower regulators to deter fraud without discouraging enrollment, especially among consumers who need marketplace coverage most. A conceptual reframing can also capture the interdependence of consumer protections and program integrity. Ultimately, the more precisely policymakers can define threats to consumer safety, the better positioned they will be to tailor policies to address systemic and structural causes of harm to consumer safety and program integrity. By failing to center consumers in either problem-framing or policy tailoring, however, policymakers risk both eroding consumer protections and undermining program integrity.
Part I provides background on the ACA marketplaces and explains how evolving technology, gaps in regulatory oversight, and policy changes have made certain consumers newly and uniquely vulnerable to unauthorized switches and enrollments. Part II introduces a consumer-centered framework for responding to threats to program integrity and then uses it to critique the recent responses of Presidential Administrations to this unauthorized activity. Finally, Part III explains how a consumer protection lens can influence reform and recommends tailoring solutions to defend the integrity of the ACA.