By Olivia Hoppe and JoAnn Volk

Heading into open enrollment for 2018 marketplace coverage, experts predicted far fewer people would sign up for coverage. To start, the open enrollment period was cut in half, to just six weeks. Navigator organizations responsible for providing enrollment assistance saw a 40% cut in funding for the program, with some individual organizations receiving cuts as great as 92%. The Trump Administration also cut funding for advertising by 90% while the Department of Health & Human Services directed local offices to skip the annual outreach events that bolster enrollment. And just before open enrollment began, the Administration announced plans to withhold cost-sharing reduction (CSR) payments that reimburse insurers for plans that discount out-of-pocket costs for low income enrollees.

Despite the obstacles working against a successful open enrollment, sign-ups came close to last year’s tally: federally facilitated marketplaces (FFMs) logged 8.8 million plan selections, including close to 2.5 million new consumers, by the close of open enrollment on December 15th, nearing the 9.2 million plan selection from the previous year in just half the time. (Some state-based marketplaces and hurricane-affected FFMs are still open for enrollment.) What explains the better-than-expected results? One theory is that consumers found a better deal this year, thanks to bigger tax credits to purchase coverage. In most states, insurers responded to the Administration’s withdrawal of CSR reimbursements by loading the cost of the out-of-pocket discounts onto silver-level plan premiums, driving up premium tax credits. As a result, 80 percent of marketplace enrollees had access to a plan for $75 a month or less.

But only those consumers who came in to shop would know how much financial help they could get and what they could buy. The first step was to get consumers in the door.

Reaching consumers with new strategies and outside help 

To learn more about how Navigators in FFM states got consumers in the door, we talked to Navigator and outreach organizations in 14 states. With far less funding and time, Navigators had to deploy new strategies and rely on outside help to reach consumers.

• Building on a trusted brand and community partnerships. The Navigator groups we spoke to tapped into partnerships developed in previous years to make the most of their efforts this year. For example, Get Covered Mississippi and the Center for Family Services in New Jersey both worked with Head Start centers to make sure whole families had coverage. Others relied on the trusted brand developed over the first few years to get people through the door. For example, the Navigator organization housed at University of South Florida oversees multiple navigator organizations and developed the neutral brand “Covering Florida” to simplify and streamline enrollment assistance across the state. The Affiliated Service Providers of Indiana built relationships with local media, earning a consistent spot in papers sold throughout the open enrollment period. Navigator groups in Ohio and Wisconsin held phonathons with local news stations to answer questions and make appointments with Navigators.
• Making outreach more efficient. Rather than conduct their own, stand-alone outreach events, Navigators joined other community events, such as church meetings, regional library meetings, and back-to-school nights. They targeted middle- to low-income areas where they were likely to find more people who would qualify for subsidies and prioritized cities and big towns over less populous communities to reach more people in a shorter time. They used phone and mailing lists developed over past open enrollments to hold phone banks and send low-cost postcards to remind people of the opportunity to enroll.
• Using volunteers and donations to reach more consumers. Knowing the ACA was under threat, many local foundations, businesses, non-profits and individuals stepped up to donate their money and time. For example, an ad agency in Alaska worked with volunteers to add PSAs before the start of feature films at eleven movie theaters across Southeastern Alaska. Many organizations got in-kind donations of radio time or low-cost ads from local stations, a strategy found to be most successful in rural areas. And volunteers across the country contributed thousands of hours for phone banking, hanging fliers, answering phone calls and listening to voice messages.

Prioritizing outreach and focusing on enrollments left out some consumers and key services

For many Navigators, the above efforts paid off. In their states, enrollment this year was between 92-98% of 2017 enrollment. But there were losses, too. Organizations in states with vast rural areas like Georgia, Wisconsin, and Montana had to cut back on the number of counties they could serve. In other states, like New Jersey and Virginia, prioritizing low income communities meant less outreach to higher-income communities that have concentrations of eligible uninsured people. The organizations we spoke to worried about the people they missed and the regions they could not serve, an absence that experts believe fell disproportionately on African-American and Latino communities.

Navigators also said their focus on enrollment meant less time for other functions. Many talked about having to forego essential consumer education about premiums, deductibles, and how to best use insurance throughout the year. Navigators also provide post-enrollment assistance with appeals, special enrollments, and coverage questions. With reduced funding, the time and staff to devote to those functions will likely drop off.

Looking Ahead

Navigators made limited dollars stretch further this year with revamped efforts, volunteers and monetary and in-kind donations. But the Navigators we spoke to worry that they won’t be able to count on that level of help in future years. It also remains to be seen if their more targeted outreach efforts affect the nature of the marketplace risk pool, and whether the focus on enrollment to the exclusion of post-enrollment insurance literacy will mean fewer consumers understand and use their coverage enough to see value in keeping up their premium payments through the year.

Navigators that sustained funding cuts should be commended for enrolling close to last year’s total in half the time. But the full effects of the funding cuts and efforts to hamper marketplace enrollment may be still to come.