Behaviorally Informed Letters Boost Affordable Care Act Enrollment
Affordable Care Act marketplace enrollment increased by 0.3 percentage points among individuals who received behaviorally informed letters during the final weeks of the open enrollment period.
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- Low-cost behaviorally informed letters sent to individuals seeking healthcare coverage on HealthCare.gov helped increase Affordable Care Act (ACA) marketplace enrollment, a study published in JAMA Health Forum found.
Every year during the open enrollment period, a handful of individuals begin the ACA enrollment process but do not complete it. Researchers sent out letters to individuals during the final weeks of the 2015 open enrollment period to increase enrollment among this population.
There were eight letter variants, each catering to different behavioral dynamics—analyses of internal behavior patterns that motivate external behavior. Researchers included certain components in the letters to encourage marketplace enrollment, including action language and a picture of the then-chief executive officer (CEO) of the marketplace.
Some letters included implementation intention language, which presents potential actions in an “if-then” manner. Others used social norm messaging—language that highlights the rules, beliefs, attitudes, and behaviors considered socially acceptable.
One letter’s messaging centered around loss aversion, which refers to the concept of individuals perceiving an actual or potential loss as more severe than an equivalent gain.
Researchers also distributed a basic letter and a letter that included all behavioral dynamic features.
The letters included vital information about enrollment benefits, including the signup deadline, the HealthCare.gov website, and the call center phone number.
Out of over 744,500 individuals, slightly more than 136,000 did not receive a letter, forming the control group. The remaining nearly 608,400 individuals received one of the eight letter options between the beginning of February 2015 and February 15, 2015—the end of the open enrollment period. The researchers analyzed the data between January and August 2021.
At the end of the open enrollment period, 4.0 percent of the control group had enrolled in an ACA plan through HealthCare.gov, while the enrollment rate for individuals who received a letter was 4.3 percent. This indicated a seven percent increase above the control group’s mean enrollment and led to 1,753 marginal enrollments, the study stated.
Each letter cost $0.55 per individual, indicating that this method successfully increased ACA marketplace enrollment while also maintaining low completion costs. With 1,753 new enrollees, the total cost per enrollee was $191.
Although the letters helped increase enrollment overall, the researchers found that some letter types were more effective than others.
For example, letters that used action language produced the most significant results and increased enrollment by 0.5 percentage points. Action language included phrases like “you’re almost done,” which emphasized minimal effort was required to finish enrolling.
The most effective variant was the letter group that used action language, an implementation prompt, and a picture of the then-CEO. The researchers estimated that if they sent this letter to all individuals in the study, it would have resulted in 3,228 marginal enrollees and cost $104 per new enrollee.
Effectiveness also varied by the race of individuals. Hispanic adults saw a 0.7 percentage point increase in enrollment. Asian adults saw a 0.6 percentage point increase, though the researchers noted that may have been due to the small sample size.
Additionally, action letters were more effective among racial and ethnic minorities in states that had expanded Medicaid. In Medicaid expansion states, enrollment increased by 1.6 percent points among Black enrollees, 1.5 percentage points among Hispanic enrollees, and 1.3 percentage points among Asian enrollees.
The researchers said this pattern was consistent with the notion that individuals in nonexpansion states face cost barriers to ACA marketplace enrollment due to higher premiums and inaccessible subsidies.
Although the study results represented data from 2015, more than 50 percent of uninsured adults lack awareness of marketplace insurance and subsidies today, according to the researchers. This indicates that letters could be a successful tactic to inform individuals about the ACA marketplace and the new subsidies available under the American Rescue Plan Act.
Other outreach methods, such as phone calls, have helped increase marketplace enrollment numbers in specific populations as well.
“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,” the study concluded.
