Recent reporting from the U.S. Government Accountability Office (GAO) has renewed attention on fraud risks in health insurance marketplaces. While the GAO’s findings focused on the federally facilitated marketplace, they underscore a broader truth that applies across public programs: program integrity depends as much on system design and enforcement as it does on policy intent.
State-Based Marketplaces (SBMs) powered by GetInsured were not evaluated in the GAO review. However, the report has prompted understandable questions from policymakers and stakeholders about how different marketplace models address similar risks. At a high level, the answer lies in prevention-first design, automation, and continuous oversight.
Designing for Prevention, Not Just Detection
Many of the vulnerabilities highlighted by GAO stem from controls that occur too late in the process—after coverage has already begun, or subsidies have already been paid. By contrast, modern marketplace platforms can be designed to emphasize early validation and consistency checks before coverage is created.
This prevention-oriented approach reduces reliance on downstream reconciliation and minimizes the window in which fraud or improper enrollment can occur. The goal is not to eliminate all risk—no complex public program can—but to ensure risks are identified and addressed as early as possible.
Enforcing Eligibility Through Automation
A key GAO concern was the continuation of coverage without timely verification when eligibility information could not be confirmed. Effective platforms address this risk through automated and enforceable eligibility workflows that are applied consistently across all applicants.
Rather than relying on ad hoc or manual follow-up, automation ensures that:
- Verification requirements are clearly communicated to consumers
- Time-limited resolution periods are enforced
- Outcomes are predictable, transparent, and auditable
- This consistency protects both consumers and public funds, while also supporting administrative fairness.
Strengthening Oversight of Third-Party Activity
Agents and brokers play an important role in helping consumers navigate coverage options, but the GAO report highlighted how insufficient safeguards can allow unauthorized actions or consumer harm.
A strong marketplace model balances access with accountability by embedding:
- Clear authorization requirements
- Traceable actions
- Transparency for consumers when changes are made on their behalf
- These measures help ensure that assistance is legitimate, consensual, and aligned with consumer intent.
Treating Verification as an Ongoing Responsibility
Fraud risk does not end once a consumer is enrolled. Life changes, data updates, and external signals can all affect eligibility over time. Platforms that treat verification as a continuous operational responsibility—rather than a one-time checkpoint—are better positioned to adapt to changing circumstances.
Periodic reviews, monitoring, and corrective workflows help marketplaces respond to issues as they arise, rather than allowing problems to persist undetected.
Aligning With Established Fraud-Risk Frameworks
Perhaps most importantly, sustainable program integrity depends on governance. The GAO has long emphasized the importance of formal fraud-risk management frameworks that include regular assessment, strategy, and evaluation.
Platforms that support this approach enable states to:
- Review trends and outcomes
- Refine controls as risks evolve
- Maintain accountability without sacrificing access
In this model, fraud-risk management is not a static checklist—it is an ongoing practice embedded in both technology and operations.
Moving Forward
The GAO report serves as a reminder that technology choices matter. Marketplace platforms are not neutral vessels; their design decisions shape how effectively policies are enforced and how well consumers are protected.
By prioritizing prevention, automation, transparency, and continuous oversight, State-Based Marketplaces can reduce many of the risks identified in federal programs while maintaining access and consumer trust. As policy, technology, and risk environments evolve, so too must the systems that support them.
Protecting program integrity is not about revealing or replicating any single control. It is about building platforms—and partnerships—that are resilient, adaptable, and designed with integrity at their core.
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