Health insurance enrollment outreach & support

Evidence Rating  
Scientifically Supported
Evidence rating: Scientifically Supported

Strategies with this rating are most likely to make a difference. These strategies have been tested in many robust studies with consistently positive results.

Health Factors  

Health insurance enrollment outreach and support programs assist individuals whose employers do not offer affordable coverage, who are self-employed, or unemployed with health insurance needs; individuals may be uninsured or need assistance renewing coverage. Such programs can be offered by a variety of organizations, including the federal and state health insurance marketplaces, government agencies, schools, community-based or non-profit organizations, health care organizations, and religious congregations. Outreach efforts vary greatly and can include community health worker (CHW) outreach, other person-to-person outreach, mass media and social media campaigns, school-based efforts, case management, or efforts in health care settings. Outreach can occur at local events, via hotlines, online, or at fixed locations (e.g., community centers, non-profit offices, barbershops, etc.) and are often supported through grants from federal agencies or private foundations.

Expected Beneficial Outcomes (Rated)

  • Increased health insurance coverage

Other Potential Beneficial Outcomes

  • Increased awareness of health insurance availability

Evidence of Effectiveness

There is strong evidence that enrollment outreach and support efforts increase enrollment in health insurance programs among working-age adults and children1, 2, 3, 4, 5.

Outreach programs such as Enroll America have been shown to increase Affordable Care Act (ACA) enrollment3, 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 uninsured7, 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 organizations7, 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 populations5, 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 US, 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 insurance19, 20, 21, 22. Efforts to increase quality health insurance coverage, especially among racial minorities with low incomes, can improve access to care and health outcomes19, 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 conditions19, 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.

Equity Analysis

Potential to decrease disparities: Supported by strong evidence

There is strong evidence that health insurance enrollment outreach and support efforts have the potential to decrease disparities in health insurance coverage among working-age adults1, 2, 3 and children4. Studies in multiple cities and states indicate that such outreach and support efforts increased enrollment in Medicaid and marketplace health insurance plans among individuals who were previously uninsured1, 2, 3, 4. Telephone-based outreach efforts in California increased enrollment for Hispanics and for individuals with low incomes1. As of 2020, individuals in the US who are less likely to have health insurance include individuals living below the poverty line, those who work part-time or are currently unemployed, those who are non-US citizens, Hispanic, or Black, and those that live in states that did not expand Medicaid33.

Historical Context

The US health insurance system is regulated by public and private agencies and can vary greatly by state. Health insurance in the US emerged as a benefit to recruit workers for private businesses during World War II; these private, employer-based insurance plans were seen as an attractive benefit once the federal government issued wage controls as a way to prevent inflation during the war. Historically, the American Hospital Association (AHA), the American Medical Association (AMA), and the private health insurance industry opposed the creation of a universal, national health insurance system and lobbied against it. The establishment of Medicare and Medicaid in 1965 provided no- and low-cost health insurance coverage to senior citizens and individuals with low incomes or disabilities, respectively, expanding coverage to those who could not expect to receive health insurance through employment. In 2010, the Affordable Care Act (ACA) increased access to health insurance for individuals with low incomes by expanding Medicaid eligibility and providing subsidies for those of moderate income to purchase private insurance coverage. The process of understanding health insurance eligibility standards and applying for coverage continues to grow more complex, as the health care system overall has become a mix of public and private regulation which can vary greatly from state to state34, 35.

Equity Considerations

  • How can outreach strategies be modified to better reach individuals without internet access, cell phones, or transportation to sites offering enrollment assistance?
  • How can programs tailor outreach and support materials to feature culturally appropriate messaging and languages that engage uninsured communities?
  • What partnerships can outreach programs build with community organizations to better connect with hard to reach populations?
  • What steps can programs take to secure long-term funding to support households with their ongoing health insurance enrollment needs?
  • What other solutions can outreach programs implement to address historical drivers of health insurance disparities?

Implementation Examples

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 populations10, 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.

Implementation Resources

Healthcare.gov-Get help - Healthcare.gov. Get help applying and more: Find local help or get contacted.

CMS InsureKidsNow - Centers for Medicare & Medicaid Services (CMS). InsureKidsNow: Connecting kids to coverage national campaign.

PLA-ACA - Public Library Association (PLA). Libraries connecting you to coverage: Affordable Care Act. American Library Association, Community Catalyst, and Robert Wood Johnson Foundation.

Kreuter 2014* - Kreuter MW, McBride TD, Caburnay CA, et al. What can health communication science offer for ACA implementation: Five evidence-informed strategies for expanding Medicaid enrollment. Milbank Quarterly. 2014;92(1):40-62.

Urban-State ACA implementation - Urban Institute, Health Policy Center. States and the Affordable Care Act (ACA): Monitoring and tracking ACA implementation and effects.

Footnotes

* Journal subscription may be required for access.

1 Myerson 2022 - Myerson R, Tilipman N, Feher A, et al. Personalized telephone outreach increased health insurance take-up for hard-to-reach populations, but challenges remain. Health Affairs. 2022;41(1):129-137.

2 Wright 2017a - Wright BJ, Garcia-Alexander G, Weller MA, Baicker K. Low-cost behavioral nudges increase Medicaid take-up among eligible residents of Oregon. Health Affairs. 2017;36(5):838-845.

3 Orzol 2018* - Orzol S, Hula L. Impact of Enroll America on the number of individuals covered through the federally facilitated marketplace. Health Services Research. 2018;53(1):341-365.

4 Cochrane-Jia 2014* - Jia LY, Yuan BB, Paul G. Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database of Systematic Reviews. 2014;(11):CD008194.

5 Cousineau 2011 - Cousineau MR, Stevens GD, Farias A. Measuring the impact of outreach and enrollment strategies for public health insurance in California. Health Services Research. 2011;46(1):319-335.

6 Mathematica-Orfield 2015 - Orfield C, Hoag S, Orzol S. Maximizing coverage through outreach: Second year experiences of Enroll America in North Carolina and Ohio. Ann Arbor, MI: Mathematica Policy Research (MPR); 2015.

7 Courtot 2009 - Courtot B, Klein A, Howell E, Benatar S. Covering Kids & Families evaluation. Performing outreach with limited resources: CKF grantees' successes and challenges over three years. Mathematica Policy Research (MPR); Urban Institute; Health Management Associates; Robert Wood Johnson Foundation (RWJF); 2009.

8 Mathematica-Irvin 2006 - Irvin C, Trenholm C, Rosenbach M. Detecting enrollment outbreaks in three states: The link between program enrollment and outreach. Princeton: Mathematica Policy Research (MPR); 2006.

9 Urban-Courtot 2012 - Courtot B, Coughlin TA. Best practices in SHAP outreach, eligibility, and enrollment activities. Issue Brief #30. Minneapolis, MN: University of Minnesota State Health Access Data Assistance Center (SHADAC), Washington, DC: Urban Institute; 2012.

10 Dauner 2015 - Dauner KN. Assessing a coalition for outreach and enrollment in Minnesota’s health insurance exchange. Qualitative Report. 2015;20(3):251-267.

11 Hatch 2019 - Hatch M, Yurman R, Amirkhanyan AA, Johnston J. Barber shops, salons, and spas: The complexity – and simplicity – of implementing outreach and enrollment contracts under the Affordable Care Act. Journal of Public Management & Social Policy. 2019;26(2):19-47.

12 NBER-Aizawa 2020 - Aizawa N, Kim YS. Government advertising in market-based public programs: Evidence from the health insurance marketplace. National Bureau of Economic Research (NBER). 2020: Working Paper 27695.

13 Kemmick Pintor 2020 - Kemmick Pintor J, Alberto CK, Arnold KT, et al. Targeting of enrollment assistance resources in health insurance television advertising: A comparison of Spanish- vs. English-language ads. Journal of Health Communication. 2020;25(8):605-612.

14 KFF-Pollitz 2020 - Pollitz K, Tolbert J, Hamel L, Kearney A. consumer assistance in health insurance: Evidence of impact and unmet need. Menlo Park: Henry J. Kaiser Family Foundation (KFF); 2020.

15 Hatch 2020 - Hatch B, Tillotson C, Huguet N, et al. Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial. BMC health services research. 2020;20(1):428.

16 Askelson 2021* - Askelson NM, Brady PJ, Wright B, et al. Communicating a complicated Medicaid waiver program to enrollees in Iowa: How Federally Qualified Health Centers support Medicaid members. Journal of Ambulatory Care Management. 2021;44(1):12-20.

17 KFF-Pollitz 2016a - Pollitz K, Tolbert J, Semanskee A. 2016 Survey of health insurance marketplace assister programs and brokers. Menlo Park: Henry J. Kaiser Family Foundation (KFF); 2016.

18 Yarger 2017* - Yarger J, Daniel S, Biggs MA, Malvin J, Brindis CD. The role of publicly funded family planning sites in health insurance enrollment. Perspectives on Sexual and Reproductive Health. 2017;49(2):103-109.

19 Lee 2021 - Lee DC, Liang H, Shi L. The convergence of racial and income disparities in health insurance coverage in the United States. International Journal for Equity in Health. 2021;20:96.

20 KFF-Artiga 2021 - Artiga S, Hill L, Orgera K, Damico A. Health coverage by race and ethnicity, 2010-2019. San Francisco: Kaiser Family Foundation (KFF); 2021.

21 Brookings-Young 2020 - Young CL. There are clear, race-based inequalities in health insurance and health outcomes. Washington, DC: USC-Schaeffer Center for Health Policy & Economics, Brookings Institution; 2020.

22 TCF-Taylor 2019 - Taylor J. Racism, inequality, and health care for African Americans. New York: The Century Foundation (TCF); 2019.

23 Buettgens 2021 - Buettgens M, Blavin F, Pan C. The Affordable Care Act reduced income inequality in the US. Health Affairs. 2021;40(1):121-129.

24 CMS-Marketplace - Centers for Medicare & Medicaid Services (CMS). Health Insurance Marketplace: The official marketplace information source for assisters and outreach partners.

25 Healthcare.gov-Get help - Healthcare.gov. Get help applying and more: Find local help or get contacted.

26 Healthcare.gov-COVID-19 - Healthcare.gov. Marketplace coverage and coronavirus.

27 Young Invincibles - Young Invincibles. Get help for open enrollment. Washington, DC.

28 PLA-ACA - Public Library Association (PLA). Libraries connecting you to coverage: Affordable Care Act. American Library Association, Community Catalyst, and Robert Wood Johnson Foundation.

29 MDH-Health insurance - Minnesota Department of Health (MDH). COVID-19: Resources to find low cost healthcare or get health insurance.

30 WV Navigator - WV Navigator. West Virginia’s health insurance help line. First Choice Services.

31 Insure Duluth - Insure Duluth. A Duluth community resource for navigating MNsure, the state’s health insurance exchange. Duluth, MN.

32 Mathematica-Rosenbach 2007 - Rosenbach M, Irvin C, Merrill A, et al. National evaluation of the state children's health insurance program: A decade of expanding coverage and improving access. Princeton: Mathematica Policy Research (MPR); 2007.

33 US Census-Health insurance coverage 2020 - Keisler-Starkey K, Bunch LN. Health insurance coverage in the United States: 2020. Current Population Report No. P60-274. US Bureau of the Census; 2021.

34 KFF-Hoffman 2009 - Hoffman C. National health insurance - A brief history of reform efforts in the US. Menlo Park: The Henry J. Kaiser Family Foundation (KFF); 2009.

35 Rovner 2019* - Rovner J. The complicated, political, expensive, seemingly eternal US healthcare debate explained. The BMJ. 2019;367:15885.

Date Last Updated