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State-Based Marketplace Outreach Strategies for Boosting Health Plan Enrollment of the Uninsured

People fill out paperwork to enroll in or renew their health care coverage at the Montgomery County Department of Health and Human Services office in Silver Spring, Md., on Nov. 1, 2017.

People fill out paperwork to enroll in or renew their health care coverage at the Montgomery County Department of Health and Human Services office in Silver Spring, Md., on Nov. 1, 2017. Maryland, which had nearly 50 percent more new enrollees this year, was among the states pairing robust, innovative outreach strategies with the American Rescue Plan Act’s continued investment in premium affordability. Photo: Michael Robinson Chavez/Washington Post via Getty Images

People fill out paperwork to enroll in or renew their health care coverage at the Montgomery County Department of Health and Human Services office in Silver Spring, Md., on Nov. 1, 2017. Maryland, which had nearly 50 percent more new enrollees this year, was among the states pairing robust, innovative outreach strategies with the American Rescue Plan Act’s continued investment in premium affordability. Photo: Michael Robinson Chavez/Washington Post via Getty Images

Toplines
  • State-based marketplaces played a key role in leveraging the increased premium subsidies provided by the American Rescue Plan Act, leading to historic take-up of health insurance during last year’s open enrollment period

  • A study of state-based marketplaces’ 2021 outreach strategies shows that key drivers of higher enrollment were advertising plan affordability and undertaking linguistically and culturally appropriate outreach to historically underserved populations

Toplines
  • State-based marketplaces played a key role in leveraging the increased premium subsidies provided by the American Rescue Plan Act, leading to historic take-up of health insurance during last year’s open enrollment period

  • A study of state-based marketplaces’ 2021 outreach strategies shows that key drivers of higher enrollment were advertising plan affordability and undertaking linguistically and culturally appropriate outreach to historically underserved populations

Abstract

  • Issue: The American Rescue Plan Act (ARPA) bolstered the Affordable Care Act’s (ACA) marketplaces as a source of comprehensive coverage, resulting in record enrollment. Because many people qualifying for free or low-cost plans are unaware of their eligibility or face barriers to completing the sign-up process, this historic enrollment required substantial outreach.
  • Goal: To understand outreach strategies state-based marketplaces (SBMs) used to promote health insurance take-up among the uninsured.
  • Methods: Survey of SBMs about advertising and enrollment assistance strategies during the open enrollment period for 2022 coverage.
  • Key Findings: Most SBMs surveyed invested more in outreach during the open enrollment period for 2022 coverage compared to the previous open enrollment period. Nearly all SBMs extended the annual sign-up window into January. Advertising more-affordable plans under the ARPA helped bring in consumers who found coverage unaffordable under the former, less generous subsidy structure. SBMs conducted data-driven outreach and partnered with other entities to target the uninsured and those likely to need coverage, such as unemployment applicants. Culturally and linguistically appropriate outreach encouraged enrollment among underserved groups.
  • Conclusion: Pairing robust, innovative outreach strategies with the Inflation Reduction Act’s continued investment in premium affordability may help protect and build on ARPA-driven coverage gains.

Introduction

The American Rescue Plan Act of 2021 (ARPA) substantially improved the affordability of marketplace plans. By increasing premium subsidies for individuals with lower to moderate incomes and extending subsidy eligibility to people at all income levels, the ARPA’s enactment was the largest expansion of health insurance since enactment of the Affordable Care Act (ACA),1 allowing marketplace enrollment to reach a record high during the most recent open enrollment period (ending in January 2022 in most states).2

Yet a large share of people who could benefit from subsidized marketplace plans are not aware of them.3 Even after the subsidy expansion made marketplace plans more affordable than ever, knowledge of financial assistance remained low among the uninsured.4 Beyond a lack of marketplace awareness, the administrative burdens associated with signing up for coverage can deter enrollment.5 Evidence shows that plan choice overload, complexities in the sign-up process, and confusion over the cost and value of health insurance can reduce take-up of coverage.6 Further, policies that increase the burden of enrolling in marketplace plans midyear are associated with a decrease in midyear sign-ups.7

The marketplaces themselves play a critical role in facilitating take-up of coverage. Marketplace advertising campaigns — particularly government-sponsored ads8 — are linked to increased shopping for and enrollment in marketplace plans, as well as reductions in the uninsured rate.9 Personal assistance when shopping for health insurance (provided, for example, by a marketplace-funded navigator) is associated with higher enrollment rates, especially among people with low incomes.10 By contrast, funding cuts to navigator programs have decreased coverage among underserved communities.11

State-based marketplaces (SBMs) have historically invested in both advertising and consumer assistance, employing innovative strategies to reach the uninsured even when the federal marketplace significantly reduced funding for both marketing and navigators under the Trump administration.12 Notably, states operating SBMs have seen lower uninsured rates than states on the federally facilitated marketplace (FFM),13 and in SBM states a smaller share of individuals who are eligible for subsidized marketplace plans are uninsured (see table).

Schwab_state_based_outreach_boosting_enrollment_uninsured_Table

During the most recent open enrollment period, the ARPA’s subsidy expansion made marketplace coverage more affordable than ever. To learn more about the outreach strategies deployed to ensure consumers took advantage of more generous financial assistance, we surveyed the 21 state-operated ACA marketplaces. Seventeen SBMs responded to our survey.

Key Findings

Outreach strategies of SBMs during this historic enrollment period underscore the importance of adequately funding enrollment assistance and marketing campaigns, providing enough time to enroll in coverage, and using targeted communications as well as broader messaging to reach the uninsured. In addition to investing more in outreach, marketplace survey respondents cited these other actions as effective in encouraging enrollment: extension of the enrollment period, promotion of more-affordable plans, data-driven campaigns, culturally and linguistically appropriate outreach, and coordination with health care providers and other state services.

Most Marketplaces Increased Investments in Advertising and Enrollment Assistance

Following the Trump administration’s significant cuts to the federal marketplace outreach budget, the Biden administration increased funding for FFM marketing and navigator grants.14 Most SBMs in our survey also increased funding for efforts to broadcast the annual enrollment opportunity and help consumers sign up for coverage.

Of the 17 SBMs that responded to our survey, more than half increased their budget for enrollment assisters, who provide one-on-one help to consumers during the sign-up process. A majority of SBM respondents also increased their advertising budget for activities including television, radio, print ads, and other efforts to promote enrollment.15

Several SBMs noted that funding from federal grants supported successful enrollment efforts. This includes modernization grants authorized under the ARPA, which allocated $20 million in funding for SBMs to modernize or update “any system, program, or technology.”16 New York, for example, indicated their modernization grant funded advertising and translations of ARPA-specific messaging, illustrating the importance of federal funding to enrollment efforts even in state-operated marketplaces.

Marketplaces Gave Consumers More Time to Enroll in Coverage

In addition to increasing funding for marketing and enrollment assistance, all SBMs extended the annual open enrollment period beyond 45 days,17 a policy associated with better enrollment outcomes.18 All but one SBM extended the enrollment period into the beginning of the plan year,19 allowing consumers who are automatically renewed into coverage to return to the marketplace after receiving their January bill — which may be higher than they anticipated because of annual premium changes — and enroll in a more-affordable plan.

Respondents that launched new SBMs just before open enrollment credited their extended enrollment window with encouraging coverage take-up. Maine’s new SBM saw a nearly 14 percent increase in new enrollees,20 with many of those consumers signing up during the extended enrollment period. In Oregon, a state operating an SBM that uses the federal marketplace platform HealthCare.gov, consumers shopping for marketplace plans the previous year only had until December 15 to sign up for coverage. In its survey response, the marketplace noted that this year, the Biden administration’s decision to extend the enrollment period on the federal platform until January 15 “contributed significantly” to increased plan selections.21

Affordability Messaging Encouraged Enrollment

Most survey respondents providing information on successful outreach strategies indicated that their messaging around the ARPA’s premium subsidy expansion and more-affordable plan options encouraged enrollment. Colorado, which saw a nearly 21 percent increase in new enrollees compared with the last open enrollment period,22 noted that the savings prompted consumers to “take a second look” after previously determining that they could not afford coverage. Similarly, Vermont, a marketplace that also saw an increase in new enrollees,23 communicated that “if health insurance seemed expensive in the past, it’s time to look again.” Maryland, which had nearly 50 percent more new enrollees this year,24 underscored the success of working with social media influencers to reach consumers who were newly eligible for subsidies under the ARPA and young adults who qualified for additional, state-funded subsidies.

Marketplaces Used Data to Reach the Uninsured

SBM survey respondents also highlighted the use of uninsured data as a successful strategy for enrolling people in need of coverage. Rhode Island, for example, created an on-the-ground “street team” to distribute door hangers, flyers, brochures, and posters in zip codes likely to have uninsured residents based on state-procured data. Washington also identified geographic areas with high uninsured rates and customized advertising based on information about population demographics and preferred media channels. New York targeted outreach toward industries with higher concentrations of uninsured workers and those presumed to be hit hard by the pandemic, including the service industry, small businesses, and self-employed individuals.

Culturally and Linguistically Appropriate Outreach Promoted Awareness and Take-Up of Subsidized Coverage

Language barriers are associated with lack of insurance and challenges with the sign-up process.25 SBMs attributed their enrollment successes, in part, to ongoing efforts to mitigate these barriers and help historically underserved populations access coverage. Rhode Island, which noted an increase in enrollees who self-identified as Hispanic, distributed all outreach and communication materials in both English and Spanish (including those for door-to-door outreach and a media campaign) and posted flyers and posters at Spanish-speaking religious congregations. Nevada reported that Spanish-language campaigns outperformed English-language campaigns on almost every paid media platform.

Marketplaces also offered and promoted linguistically appropriate enrollment assistance. The District of Columbia, for example, provided interpreters during a biweekly initiative to give consumers virtual, one-on-one enrollment assistance. Minnesota placed translated advertisements in publications serving Hmong, Somali, and Spanish speakers that emphasized how the marketplace assister network could help consumers in their preferred language.

Culturally appropriate outreach is key to addressing current gaps in knowledge of health insurance eligibility.26 And here, too, SBMs continued their efforts to reach underserved populations. Oregon described the success of video content created for outreach to the state’s Latino/Hispanic population. Nevada also emphasized the importance of authenticity in outreach to Latino/Hispanic consumers, indicating that community partnerships and radio broadcasts contributed to greater outreach impact in these communities. Colorado, which targeted outreach toward LGBTQ, Latino/Hispanic, Black, and rural communities, created representative content and invested in assistance resources to serve these populations.

Coordination with Other State Services and Health Care Providers

SBMs also encouraged enrollment by partnering with other state programs and agencies, as well as health care providers, to reach residents who are more likely to be uninsured. Maine, for example, worked with the state labor department to provide information to consumers applying for unemployment insurance. In Virginia, which saw an almost 18 percent increase in overall plan selections,27 navigators reached new marketplace customers through referrals from social services and health departments.

Respondents also described successful outreach efforts in health care settings, including advertising at pharmacies, health clinics, hospitals, and COVID-19 vaccination and testing sites.

Discussion

Extension of the ARPA’s subsidy enhancements through the Inflation Reduction Act28 — under which an estimated half of nonelderly uninsured people are eligible for either subsidized marketplace plans or employer coverage — will allow marketplaces to sustain and build on recent coverage gains.29 But expanded subsidies have not eliminated the perception that health insurance is too expensive: some uninsured consumers may still be deterred from visiting the marketplaces in the first place, even if they now qualify for free or low-cost plans. Difficulty with the sign-up process also reduces coverage take-up. Consequently, the historic enrollment seen this year likely would not have been possible without robust and innovative advertising campaigns and the availability of enrollment assistance.

Marketplaces are bracing for an influx of new enrollees at the end of the COVID-19 public health emergency (PHE), when Medicaid redeterminations recommence and millions of current Medicaid beneficiaries lose coverage.30 In addition to protecting and extending coverage gains of the ARPA’s subsidy expansion in future open enrollment periods, lessons learned during the marketplaces’ most successful enrollment season provide insight on how to improve take-up among newly marketplace-eligible consumers. Partnerships and data-driven initiatives can help marketplaces identify and reach people who have recently lost or will lose Medicaid. Broadcasting the availability of more-affordable plans may draw more people to marketplaces, including those who previously found coverage out of reach and former Medicaid beneficiaries who are unfamiliar with the marketplace. Enrollment assistance and advertisements reflecting the linguistic and cultural diversity of marketplace-eligible consumers better convey the message that free and low-cost coverage is available. Finally, greater funding for outreach efforts and extended enrollment windows, such as longer special enrollment periods for those losing Medicaid coverage at the end of the PHE, may increase the impact of outreach and improve coverage take-up.

NOTES
  1. Sheryl Gay Stolberg, “Pandemic Relief Bill Fulfills Biden’s Promise to Expand Obamacare, for Two Years,” New York Times, Mar. 8, 2021, updated June 17, 2021; and Karen Pollitz, How the American Rescue Plan Will Improve Affordability of Private Health Coverage (Henry J. Kaiser Family Foundation, Mar. 2021).
  2. Centers for Medicare and Medicaid Services, “Biden–Harris Administration Announces 14.5 Million Americans Signed Up for Affordable Health Care During Historic Open Enrollment Period,” press release, Jan. 27, 2022.
  3. Jennifer M. Haley and Erik Wengle, Many Uninsured Adults Have Not Tried to Enroll in Medicaid or Marketplace Coverage (Urban Institute, Jan. 2021).
  4. Jennifer M. Haley and Erik Wengle, “Uninsured Adults’ Marketplace Knowledge Gaps Persisted in April 2021,” fact sheet, Urban Institute, Sept. 28, 2021.
  5. Congressional Budget Office, Who Went Without Health Insurance in 2019, and Why? (CBO, Sept. 2020).
  6. Katherine Baicker, William J. Congdon, and Sendhil Mullainathan, “Health Insurance Coverage and Take-Up: Lessons from Behavioral Economics,” Milbank Quarterly 90, no. 1 (Mar. 2012): 107–34.
  7. Center for Consumer Information and Insurance Oversight, “Frequently Asked Questions Regarding Verification of Special Enrollment Periods,” Sept. 6, 2016.
  8. Office of the Assistant Secretary for Planning and Evaluation, Reaching the Remaining Uninsured: An Evidence Review on Outreach and Enrollment (U.S. Department of Health and Human Services, Oct. 1, 2021).
  9. For information on the association between advertisements and shopping and enrollment activity, see Sarah E. Gollust et al., “TV Advertising Volumes Were Associated with Insurance Marketplace Shopping and Enrollment in 2014,” Health Affairs 37, no. 6 (June 2018): 956–63. For information on the association between advertisements and coverage, see Pinar Karaca-Mandic et al., “The Volume of TV Advertisements During the ACA’s First Enrollment Period Was Associated with Increased Insurance Coverage,” Health Affairs 36, no. 4 (Apr. 2017): 747–54.
  10. Sara R. Collins, Munira Z. Gunja, and Michelle M. Doty, Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? (Commonwealth Fund, Sept. 2017); and Benjamin D. Sommers et al., “The Impact of State Policies on ACA Applications and Enrollment Among Low-Income Adults in Arkansas, Kentucky, and Texas,” Health Affairs 34, no. 6 (June 2015): 1010–18.
  11. Rebecca Myerson and Honglin Li, “Information Gaps and Health Insurance Enrollment: Evidence from the Affordable Care Act Navigator Programs,” American Journal of Health Economics, forthcoming; prepublication version posted at Social Sciences Research Network, Nov. 11, 2021, last revised Mar. 8, 2022.
  12. For information on historical SBM outreach efforts, see Sabrina Corlette and Rachel Schwab, “States Lean In as the Federal Government Cuts Back on Navigator and Advertising Funding for the ACA’s Sixth Open Enrollment,” To the Point (blog), Commonwealth Fund, Oct. 26, 2018; and Rachel Schwab and Sabrina Corlette, “ACA Marketplace Open Enrollment Numbers Reveal the Impact of State-Level Policy and Operational Choices on Performance,” To the Point (blog), Commonwealth Fund, Apr. 16, 2019. For information on cuts to FFM outreach funding, see Amy Goldstein, “Trump Officials Slash Advertising, Grants to Help Americans Get Affordable Care Act Insurance,” Washington Post, Aug. 31, 2017.
  13. Office of the Assistant Secretary for Planning and Evaluation, State and Local Estimates of the Uninsured Populations in the U.S. Using the Census Bureau’s 2019 American Community Survey (U.S. Department of Health and Human Services, Mar. 2021).
  14. The survey focused on SBM efforts during the recent open enrollment period, but the FFM also made significant efforts to improve outreach during the same period. During this time, the FFM provided more grant funding to navigator organizations and increased investments in marketing, compared with the previous open enrollment period. The FFM also focused outreach and advertisements on communities with lower health care access, worked with cultural marketing experts to develop campaigns in multiple languages and conduct effective outreach to communities of color, and launched a “Champions for Coverage” program to promote enrollment with the help of local organizations across the country. See Centers for Medicare and Medicaid Services, “Marketplace 2022 Open Enrollment Fact Sheet,” Oct. 25, 2021; and Centers for Medicare and Medicaid Services, “Biden–Harris Administration Quadruples the Number of Health Care Navigators Ahead of HealthCare.gov Open Enrollment Period,” press release, Aug. 27, 2021.
  15. Budget increases are defined as an increase in the dollar amount budgeted for the fiscal year that included the recent open enrollment period ending in 2022, as compared to the budget for the fiscal year immediately prior. Assister budgets include funding for one-on-one eligibility and enrollment assisters, which may include funding for enrollment centers and brokers but exclude the marketplace call center and live chat feature. Advertising budgets include funding for activities such as television, radio, print ads, paid media, and other efforts to promote enrollment, excluding funding for assisters. Budgets may include federal grants and federal funding drawn down for Medicaid-related activities.
  16. American Rescue Plan Act of 2021, Pub. L. 117-2, § 2801, 135 Stat. 4, 49 (2021). Every SBM applied for and received federal funding for activities such as consumer outreach, updating marketplace eligibility and enrollment platforms, and improving call center capacity. See Rachel Schwab, “State-Based Marketplaces Eye Health Equity, Expanding Enrollment Under New Federal Grants,” CHIRblog, Georgetown University Center on Health Insurance Reforms, Oct. 12, 2021.
  17. Centers for Medicare and Medicaid Services, “Marketplace 2022 Open Enrollment Period Report: Final National Snapshot,” fact sheet, Jan. 27, 2022.
  18. Longer enrollment windows have been associated with higher marketplace enrollment. See Joshua Peck, “Why Marketing Matters for HealthCare.gov,” Get America Covered, Feb. 7, 2018.
  19. CMS, “Marketplace 2022 Open Enrollment,” 2022.
  20. 2022 Marketplace Open Enrollment Period Public Use Files,” Centers for Medicare and Medicaid Services; and “2021 Marketplace Open Enrollment Period Public Use Files,” Centers for Medicare and Medicaid Services.
  21. Patient Protection and Affordable Care Act; Updating Payment Parameters, Section 1332 Waiver Implementing Regulations, and Improving Health Insurance Markets for 2022 and Beyond,” 86 Fed. Reg. 53412 (Sept. 27, 2021).
  22. “2022 Marketplace Open Enrollment,” CMS; and “2021 Marketplace Open Enrollment,” CMS.
  23. “2022 Marketplace Open Enrollment,” CMS; and “2021 Marketplace Open Enrollment,” CMS.
  24. “2022 Marketplace Open Enrollment,” CMS; and “2021 Marketplace Open Enrollment,” CMS.
  25. ASPE, Reaching the Remaining Uninsured, 2021.
  26. Minal R. Patel et al., “Knowledge of Health Insurance Terms and the Affordable Care Act in Racially and Ethnically Diverse Urban Communities,” Journal of Immigrant and Minority Health 22, no. 3 (June 2020): 456–66.
  27. “2022 Marketplace Open Enrollment,” CMS; and “2021 Marketplace Open Enrollment,” CMS.
  28. Inflation Reduction Act of 2022, Pub. L. No. 117-169, § 12001, 136 Stat. 1818 (2022) (extending the ARPA’s expanded premium tax credits through Plan Year 2025).
  29. Sara R. Collins and Gabriella N. Aboulafia, “Will the American Rescue Plan Reduce the Number of Uninsured Americans?,” To the Point (blog), Commonwealth Fund, Mar. 22, 2021. Another recent study found that 38.1 percent of the nonelderly uninsured population is eligible for a subsidized marketplace plan (including basic health plan coverage in Minnesota and New York). See Kendal Orgera, Robin Rudowitz, and Anthony Damico, A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP (Henry J. Kaiser Family Foundation, Nov. 18, 2021).
  30. Sabrina Corlette et al., Preparing for the Biggest Coverage Event Since the Affordable Care Act (Urban Institute, Mar. 2022).

Publication Details

Date

Contact

Rachel Schwab, Senior Research Associate, Center on Health Insurance Reforms, Georgetown University Health Policy Institute

[email protected]

Citation

Rachel Schwab, Rachel Swindle, and Justin Giovannelli, State-Based Marketplace Outreach Strategies for Boosting Health Plan Enrollment of the Uninsured (Commonwealth Fund, Oct. 2022). https://doi.org/10.26099/27tp-8k06