As Federal Leaders Debate, Open Enrollment is in Full Swing

Post-election, federal leaders are debating changes to the ACA (Affordable Care Act) and whether it will continue in light of the goals put forth by the incoming Administration. Meanwhile, open enrollment for the health insurance marketplaces is in full swing, with some states reporting increased or record enrollment figures during these first weeks of enrollment (CO, MN, federally-facilitated marketplace states).
Leading up to this enrollment period–and drawing on lessons from previous years–states were hard at work developing new strategies and system improvements to ensure the ability of their marketplaces to provide access to affordable, competitive coverage options to the communities they serve.
The more you know- using state resources to gather information
Data sources such as U.S. Census surveys and reports issued by the Office of the Assistant Secretary of Health and Human Services have provided valuable information for states hoping to better understand their uninsured and marketplace populations. However, beyond national data sources, several marketplaces have tapped into information collected by other agencies to help map out the uninsured in their state. For example, Oregon’s Health Insurance Marketplace uses a biannual survey issued by the Office of Health Analytics, to understand detailed information about health insurance coverage and impacts of the ACA on access and utilization. Vermont’s Household Health Insurance Survey collects information on uninsured residents as well as details about insured residents and their coverage options.
MNsure, Minnesota’s SBM leverages the state Department of Health’s Health Access Survey to learn more about the uninsured in Minnesota, as well as to measure the impact of MNsure on that group. The large-scale telephone survey, conducted in partnership with the University of Minnesota, collects information about health insurance and health care access. In addition to providing information on demographic shifts in the non-group market, the survey allowed for the collection of information on uninsured residents’ awareness of MNsure, and their reasons for not pursuing coverage. Results from 2015 found that while many Minnesotans were aware of MNsure, many did not know about premium subsidies or realize that they would be eligible for them.
Refined marketing and outreach strategies to target the remaining uninsured
Nationally, the uninsured rate was 9 percent in 2015 and of the 15 SBMs, all but three are at or below this national rate. To best target pockets of the remaining uninsured, states are launching new outreach and marketing strategies and are refining successful strategies from previous years in efforts to attract populations that remain elusive.
In Massachusetts, where 96.4 percent of residents are insured, the marketplace, known as the Massachusetts Health Connector (Connector), has identified three key populations where it will “focus and deepen” its outreach and marketing efforts–Latinos, workers at risk of losing employer coverage, and new state residents. As reported by the Connector, these populations have a greater risk of being uninsured or experiencing gaps in coverage. Through research conducted through state and local data sources, and in tandem with engagement of community partners, the Connector has honed in on campaign methods that best resonate with these populations. For example, the Connector learned that for those in volatile industries who may be at risk of losing employment and health coverage or with uncertain employment, cost is a huge perceived barrier in gaining insurance. This is particularly so for those who may have variable income for a time and are uncertain how to report it. Outreach to this population recognizes the high stress of economic uncertainty and educational materials explain how to make reporting that income easier. In Massachusetts, Latino individuals are significantly more likely to be uninsured than any other ethnic group. For OE4 the Connector has partnered with the Latino Chamber of Commerce and other civic organizations to increase awareness and create clearer messaging from within the community. Outreach targeting new residents focuses on awareness of special enrollment periods—the designated time many individuals who move may qualify for enrollment.
Last year, Covered California found great success with their “hotspot” maps of subsidy eligible populations these will be continued this year. To inform its OE4 outreach plans, Covered California conducted qualitative and quantitative research with uninsured residents including evaluation of over 31 focus groups in five languages. In total, 3,427 insured and uninsured people were surveyed across multi-segment, African American, Asian, Hispanic, and LGBTQ communities. Covered California found that across all segments, the remaining uninsured have adopted “coping strategies” to deal with their lack of coverage, including relying on the emergency room for care to avoid a doctor’s appointment. This makes it harder to convince the long-term uninsured population to buy coverage. In addition, Covered California found that consumers want specifics of what is offered through the marketplace, but simultaneously are overwhelmed by the insurance selection process. In response, Covered California adjusted its advertisements by adding carrier brand names and logos to ads, appeasing the need for more specificity. It has also strengthened efforts to show empathy for consumers seeking in-person assistance, stressing the availability of free expert help. Covered California also tested several marketing strategies and found that their “It’s Life Care” campaign, which “emotionally conveys the value of coverage” tested well with all groups, with slight variations and areas of nuance in certain segments.
Colorado’s marketplace, Connect for Health Colorado (C4HCO), worked with community-based organizations to collect data about high-uninsured areas. C4HCO required community organizations seeking to join Colorado’s assistance network to include their targeted zip codes and outreach work plans as part of their applications to become assisters. It has partnered with Enroll America to cross-reference those zip codes with data collected by the Colorado Health Institute about the location of the state’s uninsured. Enroll America was then able to create individualized maps of targeted zip codes to deliver to assister organizations. The data also informs a highly targeted digital marketing campaign. C4HCO has partnered with the Colorado’s Medicaid agency to capture contact information on consumers who are denied Medicaid eligibility and have not enrolled in a marketplace plan. Those residents — many thousands believed to be subsidy Eligible But Not Enrolled (EBNE) — will be contacted by email and by phone in a multi-pronged outreach campaign during OE4.
Looking Ahead
The lessons of the marketplaces, and the steps they have taken to respond to the needs of the constituencies of their states, will serve as important resources to inform future debate about the delivery of coverage across states. No matter what the congressional outcome is on the ACA, the fact remains that millions of Americans are getting their health insurance through the state exchanges and many more are continuing to sign up. This open enrollment period ends in January, and NASHP will continue to provide updates on the efforts of the marketplaces throughout. Future blogs in this series will examine the other ways that SBMs have improved their systems in preparation for open enrollment, from new consumer tools to new technologies, to innovative outreach strategies and community partnerships. Have questions or information to share about the marketplaces? We invite you to join one of our discussions to continue the conversation and think about how this work could inform the national policy debate