New Marketplace

Facilitating Health Insurance Enrollment in an Uncertain Environment

Article · August 22, 2018

Health insurance coverage is essential to improving population health and decreasing mortality through better access to prevention, illness management, medication, and other needed health care services. Extending coverage to as many people as possible is a central goal of the Affordable Care Act (ACA). The political opposition to its full implementation has created a uniquely challenging environment for educating people about their health insurance options and for getting those who are eligible enrolled in ACA marketplace insurance plans.

One attendee at an enrollment event in 2015 was an outspoken ACA supporter. She volunteered her time helping individuals enroll in the ACA marketplace and walking them through the details of plans. She had firmly opposed the program at first. “Government sponsored insurance?” she said. “Why don’t people just get a job? And then, my husband lost his job. And I lost my job at the same time. What are the chances? Suddenly, we were a family of four supporting our two children with no health insurance.” In particular, the thought of her son going without medical care hit her deeply. “I was so grateful for the ability to purchase insurance without worrying about being denied because of his chronic condition.”

Over the past five open enrollment cycles for health insurance through the ACA marketplace, our teams — the Cover Missouri Coalition, Missouri Foundation for Health, Health Literacy Media, and Washington University researchers — have worked with individuals, organizations, and policy officials to educate our population about health insurance and to support enrollment. Groups from across Missouri work together on these shared goals to reduce the number of uninsured in the state.

In many ways, Missouri is a microcosm of the United States: The population is spread over rural, suburban, and urban settings and represents the full spectrum of opinions on “Obamacare.” Many were initially resistant to the ACA, but grew to appreciate its protections. Some who enrolled in ACA marketplace plans begged enrollment counselors not to “make it obvious” to their neighbors.

Despite funding and budget cuts and a shortened enrollment period in 2018, Missouri’s rate of enrollment in the marketplace surpassed the prior year’s numbers. It is difficult to quantify the impact of the strategies described in this paper, but we know that more than 40,000 people met one-on-one with application counselors, and more than 10,000 used our online education and cost calculator. Many more attended public enrollment events, accessed our call center, and watched our online videos. Given the challenges with health insurance reform and policy debates nationwide, we suggest several strategies for health insurance enrollment for 2019 and beyond, based on our collective experiences working to engage consumers and policymakers.

Health Insurance Education

Fewer than 25% of uninsured individuals feel confident that they understand basic health insurance terms and concepts, like deductibles or out-of-pocket maximums. This lack of confidence can keep them from enrolling at all, or prevent them from choosing the best health insurance plan for their needs and budget. Some consumers reach out to their health care providers for guidance, but providers also can be confused about specific aspects of insurance reform. Health insurance education is paramount in addressing pervasive health insurance literacy gaps.

The Cover Missouri Coalition has created health insurance literacy materials for enrollment assisters and health care professionals. Resources include short online health insurance literacy courses; a 10-part video series on how to explain complicated health insurance topics to consumers; printed materials to help structure conversations with consumers; and monthly meetings, webinars, and newsletters.

Coalition members have also developed education materials for consumers that use plain language and narratives to explain complex and important topics. Print, television, and radio ads raise awareness about the ACA marketplace and the financial assistance available to cover the cost of premiums. Other information sources include:

  • Print materials: fact sheets, worksheets, reminder mailings about paying monthly premiums and re-enrolling, and infographics explaining health insurance topics
  • Community events: education, awareness, and enrollment events hosted by Cover Missouri member organizations
  • Call center: for consumers to schedule appointments with an enrollment assister, ask questions about health insurance, and find resources
  • Video: a 10-part Health Insurance Education series shared online via YouTube, Vimeo, Cover Missouri’s website, and social media; Cover Missouri members also play the videos in their waiting rooms and during enrollment appointments
  • Website: educational resources and tools, including downloadable print materials, videos, and a Find Local Help tool
  • Social media messages: via Facebook and Twitter to raise awareness of the marketplace and to promote health insurance literacy

An Interactive Decision Support Tool

To supplement these resources listed above, the Washington University team worked with Cover Missouri members to develop and disseminate a free, web-based decision support tool called Show Me Health Plans based on principles of health literacy and decision science. We evaluated the tool in research studies, and modified it with extensive user feedback.

Show Me Health Plans provides plain language health insurance education written at a sixth-grade reading level, asks consumers what features of health insurance plans matter most to them and their families, and calculates how much consumers might spend on insurance plus health care costs in any given calendar year across plans in the ACA marketplace. It also helps users determine their eligibility for Medicaid or a bridge program called Gateway to Better Health for those in the St. Louis region who would have qualified for Medicaid if Missouri had expanded the program.

We compared health insurance knowledge and confidence between a group that used Show Me Health Plans and one that used to shop for plans. Those who used Show Me Health Plans had significantly higher health insurance knowledge and more confidence making plan choices. They were also more likely to choose plans that matched their health needs and preferences.

Counselors from urban, suburban, and rural areas of the state who support consumer enrollment suggested that tools such as Show Me Health Plans might better prepare individuals for in-person enrollment meetings:

“. . . if there were interactive tools like this there so that they could learn about health insurance, I think it would help them come in more informed and ask better questions.”

Missouri Show Me Health Plans Cost Calculator for Health Insurance Enrollment screen shot - health insurance education

  Click To Enlarge.

Cost Calculator

Without a clear idea of their total health care costs, it’s easy for consumers to focus too narrowly on monthly premiums. Enrollment facilitators repeatedly mentioned how difficult it was for their clients to calculate their total health care costs and use that information to choose a health insurance plan. Cover Missouri developed a cost-sharing worksheet to support counselors in their conversations with consumers. The worksheet provides simple explanations of cost-sharing terms and aims to help consumers think through their anticipated health care costs for the year, with prompts to count the number of doctor visits, prescriptions, and specific tests or procedures. They can then balance these costs against the costs of premiums and deductibles for each plan.

Our web-based tool, Show Me Health Plans, also includes a cost calculator that estimates these costs across plans. It uses Medical Expenditure Panel Survey data from the Agency for Healthcare Research and Quality, nationally representative data of health care expenses across age groups, genders, and common health conditions. It also adjusts for the potential risk of unusually high costs; for example, older individuals or those with multiple chronic conditions have a higher chance of spending more than average, compared with those who are younger and healthier. Some older adults might underestimate their health care needs because they regard themselves as healthy compared with their peers; the cost calculator helps them estimate more accurately.

Show Me Health Plans displays side-by-side comparisons among plans, which counselors have told us is helpful. It also allows consumers to compare the differences between copayments, coinsurance, and higher versus lower deductible arrangements, which can substantially affect their out-of-pocket expenses.

In-Person and Phone-based Support

Online tools work for many, but not for all. Some consumers don’t use the Internet, or don’t trust Internet-based tools for personal areas like health and finance. Counselors commented that subpopulations such as older adults or those with lower computer literacy may be intimidated by online tools and might prefer to seek support in person or by phone. Others said space limitations at enrollment centers or social service organizations would make it impractical for people to use online tools on site.

In-person or phone-based support from trained enrollment counselors is an essential supplement to online tools. Counselors can also address consumer anxiety about health insurance choices in a way that online tools cannot. One counselor regularly reassures her clients that their choice isn’t permanent and they will be able to change it at the next open enrollment.

In Missouri, grant-funded organizations under the umbrella of the Missouri Foundation for Health’s Expanding Coverage initiative conducted more than 42,000 counseling sessions over the first five open enrollment periods. Of these, 5,713 counseling sessions were conducted for 2018 open enrollment, and people attended an average of two counseling sessions, each about an hour. Although these sessions primarily assisted consumers with enrollment questions and made eligibility determinations, the fourth most common activity was providing education about health insurance, which occurred in three out of five counseling sessions during 2018 open enrollment.

Certain subpopulations are more likely to seek out, and benefit from, in-person assistance, including racial and ethnic minorities, immigrants, LGBT populations, or individuals with specific chronic diseases. Having community organizations provide counselors who are trusted by these groups is vital to their getting, keeping, and using health insurance.


In the current climate, fewer federal resources are likely to be available to facilitate consumer education and outreach about health insurance. The most recent ACA open enrollment was 6 weeks shorter than usual, and consumer engagement was critical to our enrollment success.

Education in multiple formats — online, in person, print based, and phone based — is of utmost importance, no matter what happens with health insurance reform. It is likely that consumer-directed options will play a greater role in any reforms implemented, and the success of these options depends heavily upon consumers having a good understanding of their choices.

Cost transparency for both insurance and health care services is also essential. Despite some promising efforts, it is currently nearly impossible to compare costs for procedures across hospitals and across providers. Cost calculators can help consumers learn about the value of insurance by comparing estimated costs of care to costs of insurance.

Empowering language used in educational materials and counseling may also help overcome the resistance and perceived stigma of using the ACA or other federally supported programs. One counselor tells her clients, “You’ve worked hard your whole life. You’re not taking something away from anyone else by accepting this help. You are not alone in needing this help.” Statements like those can help individuals feel more comfortable enrolling in services when they find themselves unable to access health insurance through other avenues.

Education and support will only go so far to solve coverage problems, in the absence of expanded Medicaid and given premium increases for those who don’t qualify for premium subsidies. But as states prepare for changes in health insurance reform, with limited federal resources, it is more important than ever to provide free, accessible, evidence-tested support to help consumers get the most appropriate coverage available.

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