Issue: Nearly 12.7 million individuals signed up for coverage in the Affordable Care Act’s (ACA) health insurance marketplaces during the third open enrollment period, and by the end of March there were 11.1 million consumers with active coverage. States that operate their own marketplaces posted a year-to-year enrollment gain of 8.8 percent. To maintain membership and attract new consumers, the state-based marketplaces must sponsor enrollment assistance programs and conduct consumer outreach. These marketplaces relied heavily on such efforts during the third enrollment period, despite declining funding. Goal: To learn which outreach strategies, assistance programs, and other factors marketplace officials viewed as having exerted the greatest influence on enrollment. Methods: Survey of officials representing each of the 17 state-based marketplaces (15 responses). Key findings and conclusions: The cost of coverage and low health insurance literacy pose significant barriers to enrollment for many consumers. Marketplaces sought to overcome them by encouraging consumers to obtain in-person enrollment assistance from ACA-created assistance programs and from insurance brokers, and by partnering with community organizations for outreach activities. Many marketplaces also enhanced their web portals to make them easier to navigate and to give consumers better tools with which to evaluate their coverage options.
By the close of the third open enrollment period for the Affordable Care Act’s (ACA) health insurance marketplaces, approximately 12.7 million individuals had signed up for or been reenrolled in a marketplace health plan.1 This result fits comfortably within the range projected by the U.S. Department of Health and Human Services (HHS), which estimated enrollment of between 11.0 million and 14.1 million.2 Nationwide, plan selections in the third open enrollment season surpassed those in the second by 8.5 percent.3 Year-to-year gains by the states that manage their own marketplaces (8.8 percent) slightly exceeded those experienced by the states that do not (8.3 percent), though these averages mask significant variation among states (Exhibit 1).
The final enrollment tally suggests the marketplaces are on track to meet another HHS target, of 10 million enrollments by the close of 2016.4 (The projection for the end of the calendar year is lower because it reflects attrition; some people who select a plan during open enrollment never take up coverage, while others move from their marketplace plan to other coverage sources as the year unfolds.5) Still, the total is notably less than what some observers had anticipated.6 Researchers have attributed this divergence to the stability of employer-sponsored health insurance (the availability of employer coverage has not declined since the ACA’s enactment, contrary to some expectations); the fact that many people have purchased individual insurance outside of the marketplaces; and ongoing concerns about the cost of coverage, among other factors.7
Studies of marketplace policies and enrollment assistance practices during the first and second open enrollment periods have identified a number of additional factors that likely influenced enrollment. For example, researchers at the Urban Institute found that marketplaces with comparatively strong enrollment during the second open season had highly collaborative outreach and enrollment assistance activities that leveraged the contributions of trusted messengers.8 In marketplaces with lower enrollment, relatively high premiums for those at higher income levels made the problem of coverage affordability more acute. Meanwhile, difficulties with technology platforms and shortages of assistance personnel—the latter in part the result of funding limitations—soured public perceptions and made the enrollment process more burdensome.9
We sought to build on these analyses by examining the actions taken by state-based marketplaces to maximize enrollment and consumer assistance during the most recent open enrollment season. To do so, we asked marketplace officials to complete a confidential questionnaire that sought to identify what assistance and outreach strategies they viewed as most effective and what factors they identified as exerting important influence on sign-ups, positively and negatively. Fifteen of 17 marketplaces responded.10 This brief explores key themes that emerged from those responses.
Personal Connections Forged by ACA Assisters, Community Partners, and Agents and Brokers Drive Enrollment
"We established walk-in centers in high-priority locations. We opened new full-service centers in four communities, three of them in community health centers. These were very successful."
The state-based marketplace respondents were unanimous in suggesting that in-person outreach and enrollment assistance were critical to facilitating sign-ups during the third open enrollment period. One respondent conveyed the group’s experience succinctly: “consumers like to talk to someone person to person. The easier it is for an individual to make a connection and get help, the higher your enrollment and the better the consumer feels.” Marketplaces thus devoted considerable effort to fostering in-person connections—to educate consumers about health insurance and the existence and role of the marketplace, as well as to help those interested in enrolling in coverage navigate the sometimes complex decisions involved in doing so.
To these ends, several marketplaces established physical locations, often retail storefronts located in urban areas, staffed by trained enrollment assisters, marketplace customer support workers, and, sometimes, agents and brokers. Others created partnerships with well-regarded organizations—children’s hospitals and clinics in one state, churches and civic groups in others—and with respected individuals whose long-standing relationships within their communities made them trusted voices for outreach and education.
"I can’t stress enough the importance of agents and brokers. . . . They are a trusted resource throughout the state and they can help educate consumers as well as build a long-term relationship that will help build enrollment stability."
While nearly all respondents noted the efforts of marketplace-certified enrollment assisters in helping to connect consumers—especially hard-to-reach populations—with coverage, most also emphasized the contributions of their state’s agent and broker communities. Several marketplaces described broker-led enrollment centers and advertising support, while one touted a pilot program that enabled authorized agents to receive, at a consumer’s request, a “warm transfer” from the marketplace’s call center so they could assist with enrollment. We did not survey brokers themselves and so cannot shed light on whether they shared this perception of fruitful coordination. Still, the responses suggest that marketplaces are giving increased attention to the services brokers can provide and are doing more to engage them in the enrollment process than what most observers and stakeholders reported in the first two sign-up periods.11
Frequently, marketplaces also leveraged their connections with community leaders and stakeholders to publicize and execute outreach and enrollment events. For example, two marketplaces highlighted their work with faith-based leaders, with whom they partnered to hold events at area churches, mosques, and synagogues, while another reported successful enrollment events jointly staffed by agents and assisters. One marketplace viewed enrollment fairs and outreach events as “pivotal” to its enrollment strategy in the wake of budget cuts that forced the closure of its walk-in center. Still another launched a statewide bus tour to promote enrollment at stops along the way and generate wider media coverage.
States Grapple with Affordability Concerns
"We find that consumers who enroll state the premium tax credits and price were key factors in their decision. Consumers who do not enroll cite the tax credits and affordability as the reason."
Though personal assistance made signing up for coverage an easier task, most marketplaces reported that consumer decisions about whether to enroll and which plan to choose revolved to a large degree around perceptions of health plan cost. As one respondent stated: “affordability and the availability of premium tax credits continue to drive enrollment on the exchange.”
Two states that experienced double-digit increases in premium rates stressed the value of the ACA’s tax credits in insulating eligible consumers from the cost spike. Yet, particularly for those unaware of the subsidies or unclear about what they cover, worries about costs loomed large. And respondents acknowledged that consumers who are not eligible for financial assistance were less interested in enrolling through the marketplace.12
To grapple with the issue of affordability—what one respondent called “the major challenge”—many marketplaces sought to raise awareness of the availability of financial assistance, craft messages explaining how the subsidies work, and convey “a realistic expectation” of premiums. While some states viewed such efforts as successful, others found it a “continual” challenge, made more difficult by what one marketplace argued was confusing coverage of premium rates by the media.
One marketplace, acknowledging the salience of concerns about cost, suggested it had helped its consumers by negotiating with prospective marketplace insurers to limit the size of their rate increases.13 Though only one respondent highlighted this “active purchasing” approach, its mention is notable given that HHS officials have signaled a willingness to pursue a similar strategy for the federal marketplace in future years.14
Improvements in Technology Systems Ease Consumer Frustration
"The marketplace listened to its customers, redesigned the site and dropped the application process for the individual market from 28 screens to 11."
By the third open enrollment period, the state-based marketplaces had moved beyond the early technological failures that plagued their enrollment systems at their launch in 2013. No states encountered prolonged technical issues during the sign-up window and several claimed notable strides in improving the functionality and experience of their online portals. While many respondents said that their websites and back-end technology played a positive role in influencing enrollment, several noted areas for continued improvement.
Among the states that reported a significant positive impact from their technology, three described adding consumer decision-support tools, such as a searchable provider directory and an out-of-pocket cost calculator to facilitate plan comparisons, and two said they had simplified the online application to create faster, easier-to-use services. Still another suggested its systems training program, held prior to open enrollment for agents, brokers, and assisters, was critical to avoiding consumer frustration. The same state also highlighted its capacity to identify unfinished applications, enabling it to issue targeted reminders to consumers to complete the process.
At the same time, several states identified a need for improvements to their platforms. A respondent from one marketplace, which uses the federal platform for eligibility and enrollment, reported that navigation of HealthCare.gov remained a challenge. Another official expressed similar concerns about their state-run platform, wishing for upgrades to the front-end of the marketplace website, which might, in turn, help alleviate “intense volume” at its call center.
Funding for Outreach and Assistance Has Declined
Development of the state-based marketplaces was financed largely through federal start-up grants authorized by the ACA.15 These funding opportunities were time-limited, however.16 As implementation has progressed and federal dollars have diminished, the marketplaces have had to tighten their budgets to compete with other state priorities. Two-thirds of respondents indicated that funding for enrollment assistance and outreach/education activities was lower for the third open enrollment period than it had been for the second—most of this group said “much lower”—despite it being “harder to find and reach the remaining eligible uninsured” (Exhibit 2).
Low Health Insurance Literacy Poses a Barrier
Health insurance is complicated, and people face well-documented difficulties understanding how coverage works both when shopping for a plan and, later, when attempting to use it.17 While these challenges are one reason why the state marketplace sought to promote one-on-one help with the enrollment process, nearly half of respondents separately stressed the need to improve consumer understanding of the value and mechanics of health insurance or emphasized their ongoing efforts to do so. Several states saw consumer confusion about premiums, cost-sharing terms, and the ACA’s tax credits as inhibiting enrollment and lamented the spread of misinformation on these topics. Another noted the challenge of ensuring that consumers have accurate information about plan quality and provider networks so they could make informed decisions when choosing plans.
Marketplace enrollment continues to rise; along with other ACA reforms, these coverage gains have helped to reduce the uninsured rate by more than a third over the past two years.18 At the same time, the rate of enrollment growth has not matched initial expectations. There is good reason to view marketplace enrollment levels in the context of broader coverage data: for example, when it comes to risk assessment and plan pricing, insurers must lump together all those who enrolled through the marketplaces with everyone who purchased an ACA-compliant plan outside of them.19 This latter group, while difficult to quantify, may contribute an additional 4 million to the risk pool.20
Yet marketplace enrollment is, without doubt, important in its own right. If the first wave of marketplace enrollees has been relatively sicker and more expensive to treat than those with nongroup coverage prior to the ACA—when insurance companies regularly restricted benefits or denied coverage based on health status—there is some reason to expect that subsequent enrollments, including by people moving from plans that are not compliant with the ACA, could include a greater share of healthy individuals.21 Steady growth of this sort could help blunt future premium increases and promote insurer participation in the marketplaces, ensuring consumers have a range of plans from which to choose.22
Accordingly, there is value in understanding the actions of, and obstacles faced by, marketplaces as they sought to facilitate enrollment during the most recent sign-up period. Our survey of the state-based marketplaces reveals several common strategies and experiences. Most common—in fact, universal—was the value respondents attached to in-person outreach and assistance. Though marketplaces described numerous barriers to enrollment, including consumers’ lack of awareness about their insurance options and financial assistance and the complexities of choosing suitable coverage, they viewed efforts by assisters and other outreach partners to forge personal connections with consumers as crucial to overcoming those barriers.23
Notable too among the responses, if not altogether surprising, was the emphasis given by many marketplaces to technology improvements. These included advances in website functionality and the addition of features to support consumer decision-making. Such efforts, still a work in progress, demonstrate awareness of the need to simplify the enrollment process and provide consumers better tools with which to evaluate their coverage choices and costs. To the extent investment in these areas raises the value proposition of the marketplaces for consumers who are not eligible for subsidies, it also may spur enrollment by a group that so far has largely avoided the marketplaces.
If in-person assistance and technology upgrades were critical, so too was the funding that supported them. Yet most marketplaces reported that budget dollars for outreach and enrollment assistance have declined. Marketplaces have responded to decreased funding by employing strategies that were more targeted, and in some instances more reliant on promotional efforts and social media, than in the past.24 Having less money for enrollment assistance may partially explain marketplaces’ efforts to strengthen partnerships with agents and brokers (though their desire to compensate for perceived shortcomings in broker engagement during prior years likely also drove these initiatives). Should funding continue to diminish, marketplaces may find value in still greater collaboration with these and other stakeholders.
Yet, funding shortages cannot be offset by stronger stakeholder engagement alone. Findings from this survey and others suggest that brokers and assistance personnel tend to serve somewhat different constituencies, with assisters more likely to engage and enroll lower-income and vulnerable populations.25 Given that many of the remaining uninsured fall into these categories, there is danger that further reductions in funding for outreach and enrollment assistance could materially weaken future enrollment growth.26