Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care Act

Reaching and Enrolling the Uninsured: Early Efforts to Implement the Affordable Care ActACA Implementation—Monitoring and TrackingIan Hill, Brigette Courtot, and Margaret Wilkinson Urban InstituteOctober 2013Urban Institute ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues2With support from the Robert Wood Johnson Foundation (RWJF), the Urban Institute is undertaking a comprehensive monitoring and tracking project to examine the implementation and effects of the Patient Protection and Affordable Care Act (ACA) of 2010. The project began in May 2011 and will take place over several years. The Urban Institute will document changes to the implementation of national health reform in Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island, and Virginia to help states, researchers, and policy-makers learn from the process as it unfolds. This report is one of a series of papers focusing on particular implementation issues in these case study states. Cross-cutting reports and state-specific reports on case study states can be found at www.rwjf.org and www.healthpolicycenter.org. The quantitative component of the project is producing analyses of the effects of the ACA on coverage, health expenditures, affordability, access, and premiums in the states and nationally. For more information about the Robert Wood Johnson Foundation’s work on coverage, visit www.rwjf.org/coverage. INTRODUCTIONMuch of the success of the Affordable Care Act (ACA) will depend on the degree to which states and the federal government can enroll the target population of newly eligible, uninsured persons into health coverage. The law is currently projected to provide health insurance—and by extension, improved access to comprehensive care—to 14 million individuals in 2014 after coverage expansions are first implemented, and to an estimated 25 million by 2016.1 Such gains are to occur as a result of the ACA’s provisions to expand Medicaid to cover poor and near-poor adults, and to create new health insurance marketplaces (referred to in the law as “exchanges”) where individuals will be able to shop for insurance among competing health plans and receive federal subsidies—in the form of premium tax credits and cost-sharing reductions—to help pay for coverage, depending on their level of income.Meeting enrollment goals will hinge on multiple factors, including whether the new streamlined eligibility and IT systems called for in the ACA are implemented successfully, and whether eligible populations find marketplace premiums affordable. Equally important, however, are two precursors to the ultimate goal of enrollment: • Outreach and marketing campaigns that effectively raise eligible populations’ awareness of the availability of new coverage options and inform them of how to access that coverage; and• Enrollment assistance structures that provide diverse populations with a variety of ways to get help with the application process.This issue brief describes early efforts in 10 focal states (see Table 1) to publicize expanded coverage under health care reform, and to design and set up application assistance programs to facilitate individuals’ enrollment into health insurance. Data were collected via telephone interviews with state officials during the spring of 2013, supplemented with information obtained from state and media reports during the summer of 2013. The analysis finds that:• States establishing state-based marketplaces (as opposed to defaulting to federally facilitated marketplaces) have created comprehensive and innovative marketing campaigns—supported by extensive market research—that are being unveiled this summer and fall in advance of the inaugural marketplace open enrollment period that began October 1, 2013. • Furthermore, these campaigns appear well-supported by new programs to provide direct enrollment assistance to persons who hear about new opportunities, but need help navigating the application process. • The federal government, too, is poised to launch its marketing and navigator efforts in the 34 states where federally facilitated marketplaces and federally facilitated ACA Implementation—Monitoring and Tracking: Cross-Cutting Issues3marketplace-partnerships will operate. And already, national efforts such as Organizing for America and Enroll America are spreading the word about the ACA and enlisting the support of individuals and partner organizations “on the ground” that will help individuals and families enroll in coverage. • Differences in the intensity of efforts across the states are stark. Those that have chosen to establish their own state-based marketplace have developed state-specific marketing campaigns showcasing unique themes and concerns of residents, and have also targeted substantial resources to support enrollment assistance networks. In contrast, states that have deferred to federal and national-level efforts to promote coverage (e.g., federally facilitated m