Identifying interventions to increase Affordable Care Act uptake through a systematic review and meta-analysis

What did we evaluate?

The passage of the American Rescue Plan Act (ARP) in 2021 and Inflation Reduction Act (IRA) in 2022 dramatically expanded the Affordable Care Act’s (ACA) subsidies through the end of 2025. These policies have contributed to record-high marketplace enrollment.¹ Despite these coverage gains, an estimated 10.9 million individuals eligible for subsidized health insurance remained uninsured in 2021, possibly due in part to a lack of awareness of low-cost coverage options available through the marketplaces.² In addition, with the end of the federal COVID-19 Public Health Emergency in April 2023, approximately 15 million individuals are projected to lose Medicaid and Children’s Health Insurance Program coverage.³ The Department of Health and Human Services (HHS) and state-based marketplaces seek to understand what types of outreach are most effective at increasing ACA uptake among prospective marketplace enrollees.

How did the evaluation work?

This study uses a systematic review and meta-analysis to summarize evidence on interventions meant to increase ACA marketplace enrollment. This approach facilitates comparing the efficacy of various interventions on enrollment, providing decision-makers in state health exchanges and the federal marketplace with useful evidence as they consider approaches to encouraging enrollment.

What did we learn?

Based on a meta-analysis of 34 studies with a combined sample size of over 18 million people, we found that on average, the rate of enrollment was close to one percentage point higher for those who received an intervention, a 24% increase relative to the control group. The average base rate of enrollment in control groups, weighted by control group sample size, was 3.7%.

Interventions providing enrollment support tended to be more effective than those providing information alone. Support-based interventions increased enrollment by 2 percentage points, while information-based interventions increased enrollment by 0.6 percentage points.

Figure 1. Support-based interventions increased ACA enrollment more than information alone, based on a meta-analysis covering 58 interventions

From this, we learned that outreach interventions can increase take-up. Increasing enrollment through addressing administrative burdens will be most effective when focused on providing information and support, rather than information alone.

Notes:

1. Ortaliza, Jared, Krutika Amin, Cynthia Cox. As ACA Marketplace enrollment reaches record high, fewer are buying individual market coverage elsewhere. 2023. KFF.
2. McDermott, Daniel, Cynthia Cox. A closer look at the uninsured Marketplace eligible population following the American Rescue Plan Act. 2021. KFF.
3. Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches (Issue Brief HP-2022-20) Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. August 19, 2022.

Verify the upload date of our analysis plan on GitHub.