Increasing Health Insurance Enrollment Among Uninsured Americans

Office of Evaluation Sciences

Status: Completed

Conditions: Health Behavior

Treatments: Behavioral: Letter intervention

Study type: Interventional

Funder types: Other U.S. Federal agency

Identifiers

NCT05010395

02152015

Details and patient eligibility

About

This randomized evaluation used behaviorally-informed letters to increase health insurance take-up on the Affordable Care Act (ACA) Marketplaces.

Full description

During Open Enrollment Periods for the ACA Marketplaces, qualifying individuals can purchase health insurance plans through the Federal Health Insurance Marketplace (FHIM). As of early February 2015, many people had visited HealthCare.gov and started an online account, but not yet selected a plan. The Department of Health and Human Services (HHS), in collaboration with the Office of Evaluation Sciences (OES), developed and sent letters to assist these individuals with completing their enrollment before the deadline.

To evaluate the effect of the letters, the team used a randomized controlled trial.

Enrollment: 811,795 patients

Sex: All

Volunteers: No Healthy Volunteers

Inclusion criteria

• Those with an English language preference; those who had not enrolled in an ACA plan as of early February 2015

Exclusion criteria

• Those with a Spanish language preference

This intervention was a program evaluation and did not go through Human Subjects Protection Review.

Trial design

Primary purpose: Other

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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811,795 participants in 9 patient groups

Control

No Intervention group

Description:

Individuals in this arm did not receive a letter.

Arm 1: Basic Letter

Experimental group

Description:

Individuals received a letter with information about the benefits of enrolling, the February 15th sign-up deadline, the HealthCare.gov website, and the call center phone number.

Treatment:

Behavioral: Letter intervention

Arm 2: Action

Experimental group

Description:

Individuals in this arm received a letter that emphasized only minimal marginal effort is required; and used adjectives and verbs connoting action (e.g., "almost done," "quick," "act now," and "fast").

Treatment:

Behavioral: Letter intervention

Arm 3: Action, Implementation

Experimental group

Description:

Individuals in this arm received a letter similar to Arm 2, but with the addition of a calendar that draws attention to the February 15th deadline; and provided fill-in blanks in which the recipient can write the planned month, day, and time when they intend to enroll.

Treatment:

Behavioral: Letter intervention

Arm 4: Action, Implementation, Picture

Experimental group

Description:

Individuals in this arm received a letter similar to Arms 2 and 3, but with the addition of an image of then HealthCare.gov Chief Executive Officer Kevin Counihan

Treatment:

Behavioral: Letter intervention

Arm 5: Norm

Experimental group

Description:

Individuals in this arm received a letter that included the following social norm sentence: "Americans are enrolling but you haven't joined them."

Treatment:

Behavioral: Letter intervention

Arm 6: Norm, Pledge

Experimental group

Description:

Individuals in this arm received a letter that included a statement, to be checked in agreement, that "I pledge to Get Covered at Healthcare.gov."

Treatment:

Behavioral: Letter intervention

Arm 7: Loss Aversion

Experimental group

Description:

Individuals in this arm received a letter that warned "You risk paying a fee of $325 or 2% of your income-whichever is higher."

Treatment:

Behavioral: Letter intervention

Arm 8: Kitchen Sink

Experimental group

Description:

Individuals in this arm received a letter that includes all behavioral dynamics except for the pledge (due to space limitations).

Treatment:

Behavioral: Letter intervention