Personalized Outreach Impacts ACA Enrollment Among Low Income Households

Personalized outreach could improve enrollment in the lowest-cost Affordable Care Act plans among low-income households, a study published in Health Affairs found.

Using the Covered California database, the researchers targeted 27,500 households that fell under their criteria. These households had applied for 2021 coverage and had not enrolled in a $1 per month cost-sharing reduction (CSR) silver 94 plan, despite being eligible. Of these, 11,000 were randomly organized into a control group that did not receive any personalized outreach, and the remaining 16,500 households received personalized letters and emails.

A cost-sharing reduction silver plan is a plan for low-income Californians. The coverage generosity is 94 percent for individuals who are 100 to 150 percent of the federal poverty level.

In 2022, California introduced a policy that offered low-income households access to a zero-dollar premium. During enrollment for 2022, the researchers targeted 11,245 households that had not enrolled in a zero-dollar CSR silver 94 plan despite being eligible. These households were organized into a control group and a personalized outreach group.

“In both experiments, the personalized outreach materials were designed to not only increase enrollment but also simplify the search process by providing households with a clear recommendation to pick a CSR silver 94 plan; this included highlighting the low out-of-pocket expenses with these plans when accessing care, a screenshot of what the plan would look like when consumers entered the shopping portal, and language noting that nine of ten consumers similar to those receiving the materials choose CSR silver 94 plans,” the researchers explained.

For Affordable Care Act enrollment 2021 and 2022, the study observed if the target population enrolled in Affordable Care Act plan, whether they enrolled in a CSR silver plan, and whether they picked the 2021 $1 premium or 2022 zero-dollar CSR silver 94 plan for which they were eligible.

During 2021 enrollment, 2.2 percent of the control group enrolled in a Covered California plan, of which 85.8 percent enrolled in a CSR silver plan and of those 54.6 percent enrolled in a $1 per month CSR silver 94 plan.

Meanwhile, among households who received personalized outreach, there was a statistically significant 1.1-percentage-point increase in Affordable Care Act enrollment. CSR silver plan selection increased by 0.8 percentage points and $1 per month CSR silver 94 plan uptake grew by 5.5 percentage points.

Personalized outreach by email proved particularly effective. Enrollment among individuals with an email address increased 1.4 percentage points, while enrollment among those without an email address increased 0.7 percentage points. Additionally, enrollment was higher among those who did not have an adverse health effect in 2020.

Enrollment also increased in Asian and Black populations as well as among those who had paid the state’s mandate penalty.

In 2022, the results were similar. Five percent of the control group enrolled in Affordable Care Act coverage. Over 68 percent chose a CSR silver plan and 35.8 percent chose the zero-dollar premium CSR silver 94 plan.

There was a 1.4 percentage point increase in enrollment rate among those who received personalized outreach during 2022 enrollment. CSR silver plan uptake grew by 1.2 percentage points. Zero-dollar premium CSR silver 94 uptake rose 5.2 percentage points.

The 2022 enrollment season similarly saw increased uptake among Asian enrollees, those who did not have an adverse health event in 2020, and those who paid the state’s mandate penalty.

“As Marketplaces weigh competing approaches to targeting low-income, uninsured consumers, our evidence suggests that personalized outreach that makes salient the availability of high-quality free coverage options should feature prominently in policy makers’ toolkits,” the researchers concluded.

Personalized outreach through phone calls and emails has proven critical to Medicaid enrollment in California as well, researchers in a separate study uncovered.