Abstract
Every year during the open enrollment period, hundreds of thousands of individuals across the Affordable Care Act marketplaces begin the enrollment process but fail to complete it, thereby resulting in coverage gaps or going uninsured. To investigate if low-cost ($0.55 per person) letters can increase health insurance enrollment. This intent-to-treat randomized clinical trial was conducted during the final 2 weeks of the 2015 open enrollment period among the 37 states on the HealthCare.gov platform. The trial targeted 744 510 individuals who started the enrollment process but had yet to complete it. Data were analyzed from January through August 2021. Study participants were randomized to either a no-letter control group or to 1 of 8 letter variants that drew on evidence from the behavioral sciences about what motivates individuals to take action. The primary outcome was the health insurance enrollment rate at the end of the open enrollment period. Of the 744 510 individuals (mean [SD] age, 41.9 [19.6] years; 53.9% women), 136 122 (18.3%) were in the control group and 608 388 (81.7%) were in the treatment group. Most lived in Medicaid nonexpansion states (72.7%), and a plurality were between 30 and 50 years old (41.0%). For race and ethnicity, 3.0% self-identified as Asian, 14.0% as Black, 5.1% as Hispanic, 39.8% as non-Hispanic White, and 38.2% as other or unknown. By the end of the open enrollment period, 4.0% of the control group enrolled in health insurance coverage. Comparatively, the enrollment rate in the pooled treatment group was 4.3%, which demonstrated an increase of 0.3 percentage points (95% CI, 0.2-0.4 percentage points; P<.001), yielding 1753 marginal enrollments. Letters that used action language caused larger enrollment effects, particularly among Black individuals (increase of 1.6 percentage points; 95% CI, 0.6-2.7 percentage points; P = .003) and Hispanic individuals (increase of 1.5 percentage points; 95% CI, 0.0-3.0 percentage points; P = .046) in Medicaid expansion states. This randomized clinical trial shows that letters designed with best practices from the behavioral sciences literature were a low-cost way to increase health insurance enrollment in the Affordable Care Act marketplaces. More research is needed to understand what messages are most effective amid the recently passed American Rescue Plan. ClinicalTrials.gov Identifier: NCT05010395.
Highlights
Through the expansion of Medicaid eligibility and the creation of health insurance marketplaces, the Affordable Care Act (ACA) has helped reduce the uninsured rate to record lows.[1]
Letters that used action language caused larger enrollment effects, among Black individuals and Hispanic individuals in Medicaid expansion states. This randomized clinical trial shows that letters designed with best practices from the behavioral sciences literature were a low-cost way to increase health insurance enrollment in the Affordable Care Act marketplaces
The study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines, its protocol was approved by the California Health and Human Services Agency’s institutional review board (Supplement 1), and it was overseen by an interdisciplinary team at the Office of Evaluations Sciences in the US General Services Administration and the Centers for Medicare & Medicaid Services Office of Communications in the US Department of Health and Human Services (HHS)
Summary
Through the expansion of Medicaid eligibility and the creation of health insurance marketplaces, the Affordable Care Act (ACA) has helped reduce the uninsured rate to record lows.[1]. Gaps in coverage or prolonged bouts of being uninsured cause disruptions in access to care and medication, increased financial strain, higher rates of medical debt, and lower levels of self-reported health.[2-4]. Identifying effective strategies to help individuals who have started the enrollment process obtain health insurance remains a priority for policy makers.[5]. A recent set of nonexperimental studies, for example, found an association between the volume of health insurance TV advertisements and reductions in the uninsured rate, as well as in ACA marketplace enrollment.[10,11]. Randomized clinical trials (RCTs) have found that nudges using emails, letters, and telephone outreach increased health insurance take-up.[12-14] A recent set of nonexperimental studies, for example, found an association between the volume of health insurance TV advertisements and reductions in the uninsured rate, as well as in ACA marketplace enrollment.[10,11] And randomized clinical trials (RCTs) have found that nudges using emails, letters, and telephone outreach increased health insurance take-up.[12-14]
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