Marketplace Enrollment Boosted by Behaviorally Informed Letters

Letters designed with behavioral science in mind helped increase enrollment in the Affordable Care Act marketplace at a low cost, according to new findings in JAMA Health Forum.

Researchers wrote, “every year during the open enrollment period, hundreds of thousands of individuals who initiate the enrollment process fail to complete it. 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.”

The randomized clinical trial included 811,795 people in 37 states. Participants were assigned to receive either no letter or 1 of 8 letter treatments beginning approximately 2 weeks before the 2015 open enrollment deadline.

“The 8 letters varied behavioral dynamics, including action language, an implementation intention prompt, a picture of then–chief executive officer of the marketplace Kevin Counihan, social norm messaging, a pledge, and loss aversion,” authors noted.

The letters all contained the same core information such as benefits, the enrollment deadline, and a website and telephone number for individuals to seek more information.

The final analysis included 744,510 people. Participants were an average of 41.9 years of age, and just over half (53.9%) were women.

Analysis showed 4% of the control group enrolled, while enrollment increased an average of .3 percentage points by comparison among participants who did receive letters (95% CI, .2-.4 percentage points; P < .001). The overall cost per new enrollee was $191.

Letters that used action language were most effective and bolstered enrollment by .5 percentage points (95% CI, .3-.6 percentage points; P < .001). Authors added that if the best-performing letter was used across the pool of participants, the intervention would have resulted in in 3228 marginal enrollees at a cost of $104 per individual.

Action letters were especially effective among racial and ethnic minority groups in states with expanded Medicaid. The letters boosted enrollment by 1.6% (95% CI, .6-2.7 percentage points; P = .003), 1.3% (95% CI, -.3-2.8 percentage points; P = .11), and 1.5% (95% CI, 0-3 percentage points; P = .046) among Black, Asian, and Hispanic adults, respectively.

Researchers noted these data were “consistent with cost as an enrollment barrier for those living in nonexpansion states where premiums tend to be higher and subsidies are inaccessible to residents with the lowest income.”

“As the Biden administration seeks to expand coverage, particularly among racial and ethnic minorities hard hit by the COVID-19 pandemic, this study provides evidence that low-cost outreach—especially messages informed by the behavioral sciences—could help increase ACA marketplace enrollment,” authors concluded.

Reference:
Yokum D, Hopkins DJ, Feher A, Safran E, Peck J. Effectiveness of behaviorally informed letters on health insurance marketplace enrollment. JAMA Health Forum. 2022;3(3):e220034. doi:10.1001/jamahealthforum.2022.0034