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The open enrollment period for Marketplace coverage under the Affordable Care Act (ACA) has ended and supporters of the legislation are finished celebrating the accomplishment of exceeding enrollment goals despite a rocky start. Nonetheless, this continues to be an important time for ACA outreach and enrollment efforts. Enrollment in Medicaid and the Children's Health Insurance Program (CHIP) is open year round, and people who experience certain changes in life circumstances (including young adults who age-out of Medicaid, CHIP, or parental coverage) will be able to enroll in Marketplace coverage as they qualify. Important work is also needed to maximize the reach and effectiveness of Marketplace enrollment systems in time for the next open enrollment period that begins November 15 and lasts only 90 days. And, as disenrollment becomes a concern over time, it will be important to focus on improving program retention.

A new issue brief I authored for the bipartisan children's advocacy organization First Focus identifies important lessons from over twenty years of work on outreach, enrollment, and retention for the Children's Health Insurance Program (CHIP) and children's Medicaid that can inform the next phases of ACA implementation. This brief lists many good practices developed for CHIP and children's Medicaid. It also explores in greater depth issues related to hard-to-reach populations, retention, and cross system data matching that will take on increasing importance as ACA implementation moves to its next stage.

Many innovative policies and practices developed for CHIP and children's Medicaid were incorporated into the ACA, including options to enroll online, by phone, or in-person, a "no-wrong-door" enrollment system, and trained, community-based enrollment assistors. But the brief also points to other lessons learned that can be applied particularly in states to boost enrollment now and during subsequent Marketplace open enrollment periods:

  • Employ communications designed for hard-to-reach communities, with tested, accessible, culturally relevant messages and trusted messengers;
  • Ensure that those covered during the initial open enrollment period have a positive experience, contributing to strong retention of the enrolled and positive word-of-mouth perception among eligible-but-uninsured communities;
  • Employ technology assertively and creatively, but avoid over-reliance on Web-based enrollment tools, which experience with CHIP suggests may be less useful for communities of color and other hard-to-reach populations; and
  • Assertively pursue opportunities to simplify re-enrollment processes, to maximize the likelihood that eligible individuals and families will retain coverage.

It took years of effort and experimentation under CHIP and children's Medicaid to establish effective outreach, enrollment, and retention practices and drive the uninsured rate among children to record low levels. That experience as well as the recent ACA experience, underscore the need to focus on more than policy - effective implementation is ultimately the key to making policies succeed.

State and federal officials will need to be vigilant to identify problems early and move quickly to correct them. The recent experience in California is encouraging in that regard. Despite respectable enrollment numbers in California during the recent open enrollment period, it appeared that Latinos were substantially underrepresented among new enrollees. The state moved quickly to address that issue by significantly increasing the number of enrollment counselors and culturally appropriate outreach in Latino communities. By the time the open enrollment period closed, the proportion of Latinos among all enrollees had risen by over 50 percent.

Utilizing the CHIP-proven approach of proactive problem solving should help set the ACA up for the same kind of success and widespread support that CHIP now enjoys.


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