Study Background, Purpose, and Approach
In implementing the Patient Protection and Affordable Care Act (ACA), Colorado is one of 17 states* that decided to operate its own health insurance exchange for individuals (called Connect for Health Colorado) and one of 27 states to expand Medicaid (Kaiser Family Foundation, 2014). Colorado had more than 300,000 individuals newly enrolled in Medicaid (178,000 enrollments) or health insurance through the Marketplace (125,000 enrollments) between October 1, 2013, and March 31, 2014, with continued enrollments to date (Connect for Health Colorado, May 2014; U.S. Department of Health and Human Services, 2014). Among states that operated their own exchanges, Colorado had the fourth-highest number of people sign up for private insurance through the Marketplace during the first open enrollment period (25 percent of eligible individuals) (Kaiser Family Foundation, April 2014). Despite this success, there continues to be a diverse mix of individuals in Colorado who remain eligible for but not enrolled in either private insurance or Medicaid. The Colorado Health Foundation commissioned the RAND Corporation to conduct a study to better understand why these individuals are not enrolled in health insurance coverage and to develop recommendations for how Colorado can strengthen its outreach and enrollment efforts during the next open enrollment period, which starts in November 2014.
RAND engaged a total of 108 uninsured or newly insured individuals who were representative of various regions and special populations across the state to understand their perspectives on why they had or had not enrolled in health insurance in Colorado. RAND also completed a total of 14 30–45-minute phone-based interviews with community stakeholders involved in the policymaking and insurance enrollment process who provided insight into outreach efforts in the community and barriers they perceive the uninsured face when seeking to enroll in health care coverage.
Respondents identified a number of barriers to enrollment. While there was some regional variability, there was a high level of concordance across regions as to the major barriers to enrollment and reasons why individuals were not enrolling. We grouped these barriers into three categories: those related to outreach and general awareness of health insurance and health insurance reform, those that affected the decision to enroll, and those that affected the enrollment process.
Barriers that affected outreach and awareness:
- Significant confusion and little understanding about Medicaid and private insurance subsidies through the Marketplace
- Messaging consumers were hearing (e.g., from media, politicians, stakeholders) about insurance was not compelling and did not discuss the health benefits of insurance
- Not enough funds or data to support local outreach and education.
Barriers that affected the decision to enroll:
- Unfavorable attitudes toward the individual mandate
- Significant mistrust of the system
- Messaging was often not tailored or actionable
- Health insurance coverage is not affordable.
Barriers that affected the enrollment process:
- Complexity of plan materials makes plan selection difficult
- Lag times and poor communication about eligibility-related decisions
- Misinformation across stakeholders
- Must apply for Medicaid and be denied before applying for private insurance
- Connect for Health Colorado website was not user-friendly.
A closer examination of the barriers to outreach and enrollment that were identified suggests that many are related. Collectively, they point to a set of four priority recommendations that stakeholders in Colorado may wish to consider:
- Support and expand localized outreach and tailored messaging.
- Revise marketing and messaging to be (1) clear, (2) actionable, and (3) focused on the health benefits of insurance (to overcome negative or politicized messaging consumers are hearing).
- Improve the clarity and transparency of insurance and health care costs and enrollment procedures.
- Revisit the two-stage enrollment process and improve Connect for Health Colorado website navigation and technical support.
Though outside the scope of this study, it may also be beneficial to examine how funds were disbursed across the state and how assistance sites that received federal and private grant funding allocated it to accomplish their objectives. This information may help to shed light on the current study findings and may help to inform future investments to maximize return. It should be noted that given the lag time between our data collection efforts in late June 2014 and the release of this study, Connect for Health Colorado or other stakeholders within Colorado may have already begun to address one or more of the barriers listed above.
Connect for Health Colorado. (May 2014). Marketplace Dashboard. Denver, CO. As of August 21, 2014:
Kaiser Family Foundation. (2014). Status of State Medicaid Expansion as of 2014. As of August 21, 2014:
Kaiser Family Foundation. (April 2014). Marketplace Enrollment as a Share of Potential Marketplace Population. As of August 21, 2014:
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (2014). Profile of Affordable Care Act Coverage Expansion Enrollment for Medicaid/CHIP and the Health Insurance Marketplace: 10-1-2013 to 3-31-2014: Colorado. Washington, DC. As of August 21, 2014:
* Includes the District of Columbia.
This research was sponsored by the Colorado Health Foundation and conducted within RAND Health.