Health insurance enrollment outreach & support

There is strong evidence that enrollment outreach and support efforts increase enrollment in health insurance programs among working-age adults and children^{1, 2, 3, 4, 5}.

Outreach programs such as Enroll America have been shown to increase Affordable Care Act (ACA) enrollment^{3, 6}. An Oregon-based study indicates that low-cost outreach using enhanced materials (i.e., appropriate health literacy level, step-by-step guidance, etc.) and frequent reminders via mail, phone, and email can increase Medicaid enrollment regardless of age, sex, Spanish-language preference, rural residence, or past Medicaid experience². A study of Covered California, the state’s ACA marketplace, indicates that calls for insurance enrollment and assistance are particularly beneficial to uninsured individuals referred to the program by Medicaid, Hispanics, adults over age 30, individuals with low incomes, and Spanish speakers¹.

Health insurance application support and information by community-based case managers may increase enrollment of uninsured children and reduce the time it takes for them to be enrolled⁴. Providing insurance applications to families seeking care in emergency departments may increase child enrollment as well⁴. Multi-component approaches may also increase new enrollments of children⁵. Based on the experience of programs working to enroll children in public insurance programs, school-based programs and campaigns appear to be successful strategies to reach those who are uninsured^{7, 8}. An evaluation of Covering Kids and Families, a broad effort to reach uninsured children and their families, indicates that the program increases awareness of the availability of public health insurance programs for families with low and moderate incomes, and may increase enrollment⁷.

Partnering with other organizations^{7, 9} and using a mix of targeted messages and approaches is often recommended for successful outreach and enrollment activities⁹. Including technology-based systems (e.g., online benefit applications) in enrollment efforts may maximize enrollment overall⁵, while more traditional methods such as community health worker (CHW) outreach may increase enrollment among hard to reach populations^{5, 10}. Pre-existing local support networks, including health exchange staff, local public health agencies, and advocacy organizations, may work together to offer on-site assistance with health insurance enrollment in places of trust (e.g., barbershops, spas and beauty shops, etc.)¹¹.

Federal or state-sponsored television ads about health insurance marketplaces may feature messages specific to certain geographic areas, which may increase overall health insurance enrollment¹². Television ads tailored to Hispanic populations are generally in Spanish, consider cultural norms, and highlight telephone or in-person assistance rather than online enrollment¹³. Hispanic individuals may be more likely to seek enrollment assistance than white individuals due to language barriers or immigration concerns¹⁴.

Patients may receive enrollment assistance and guidance on using insurance benefits at federally qualified health centers (FQHCs)^{15, 16, 17} and other safety net providers¹⁸. Assistance programs may also help address the complex needs of individuals without insurance, including immigration-related issues, language translations, difficulties reporting income, and concerns about insurance renewal¹⁷. However, lack of staff time and knowledge, funding, and space constraints are often barriers to providing additional support¹⁸.

In the U.S., the likelihood of having health insurance is associated with a person’s income and racial or ethnic status, and people of color with low incomes are the least likely to have adequate health insurance^{19, 20, 21, 22}. Efforts to increase quality health insurance coverage, especially among racial minorities with low incomes, can improve access to care and health outcomes^{19, 20, 22}. Access to health insurance may reduce income inequality both within and across groups by race and ethnicity, age, and education level compared to scenarios without health insurance²³. Having quality health insurance can increase financial stability and protect individuals and families from unexpected financial burdens due to medical bills that result from emergencies or expensive treatment for emerging and chronic medical conditions^{19, 20, 22}. This protection, especially for people of color with low incomes, can improve a family or individual’s ability to pay off debts, preserve income and assets, and build wealth, which over time can help reduce the racial wealth divide²².

The health insurance marketplaces established by the Affordable Care Act (ACA) offer health plan shopping, outreach, and education, as well as enrollment support from Assister Programs, including certified application counselors and navigators, staff at federally qualified health centers (FQHCs), and agents and brokers (i.e., state-licensed professionals that sell private health insurance to individuals and/or businesses)^{17, 24}. Larger Assister Programs are often better equipped to address enrollees’ more complex needs, including language translation, immigration-related problems, and challenges with reporting income¹⁷. Enrollment support is available locally and at a distance²⁵. In 2019, an estimated 7 million individuals were supported by a mixture of paid and volunteer workers in navigating the ACA health exchanges, with many seeking help from the same assister as in previous years¹⁴. In some circumstances, individuals or families that have had their income and household impacted by the COVID-19 pandemic may be able to change their marketplace health insurance plans outside of the traditional open enrollment period²⁶.

Organizations such as Enroll America provide outreach and education to maximize coverage uptake⁶. Some organizations tailor support to specific populations: for example, Young Invincibles offers local enrollment and re-enrollment assistance to young adults²⁷. The Public Library Association provides resources on health insurance outreach and enrollment support methods that libraries can use to develop and distribute printed materials, host workshops or informational sessions, and advertise on TV, radio, and social media using customizable materials from their Outreach Hub²⁸. Tools such as health insurance enrollment tracking add-ins to electronic health records (EHRs) may be used by community health centers to identify patients without insurance, support enrollment, and track acceptance rates¹⁵.

The Minnesota Department of Health’s MNsure Navigators are often based in community organizations, providing services in numerous languages, including basic health insurance education and enrollment assistance for public and private health insurance plans, and offer enrollment resources in 22 languages²⁹. West Virginia’s health insurance help line, WV Navigator, offers assistance via phone and virtual chats³⁰. The Insure Duluth Coalition, a 15-organization partnership of health and social service organizations in Duluth, MN, offers enrollment assistance in-person and by phone, hosts local outreach events, and has supported the integration of outreach and enrollment navigation into the workflow of direct service providers (e.g., homeless outreach organizations, utility assistance program), to connect with hard to reach populations^{10, 31}.

Insurance outreach and support efforts played a large role in the 1997 launch and subsequent expansion of the State Children’s Health Insurance Program (SCHIP). States’ outreach efforts evolved as their programs matured; general outreach and awareness strategies such as mass media campaigns were often replaced with targeted outreach via community organizations for hard to reach populations³².