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How the ACA has Changed the Health Insurance Landscape

In 2010, President Obama signed into law a bill that marked one of the biggest overhauls of
the American healthcare system to date. Colloquially referred to as Obamacare, and officially
known as the Affordable Care Act (ACA), the law aimed to make quality health insurance
affordable and accessible for everyone while requiring all Americans to have a healthcare
plan. For the uninsured, this means procuring a health insurance plan during an annual open
enrollment period through an official marketplace website, over the telephone, or with a
health insurance counselor.

Over 49.9 million Americans were uninsured when the ACA first took effect1. As of March
2015, the percentage of the uninsured population has dropped from 15.7% in 2010 to
11.4%2. However, there still remains tens of millions of uninsured Americans in the United
States. These individuals will be eligible to enroll in a health insurance plan for 2016 through
an open enrollment period that begins on November 1st, 2015 and ends on January 31st,
2016. While the federal government has made major improvements to the enrollment
process since 2014, there are several unique aspects and challenges facing this upcoming
enrollment period that will require healthcare plans to address it in a wholly different manner.

In this eBook, we will cover the main challenges facing healthcare enrollment in 2015, how
healthcare organizations can reach key demographics, and mobile strategies for engaging
individuals and driving enrollment.
Introduction
© Copyright 2015, Mobile Commons by Upland.
1

Challenges for
Healthcare
Enrollment
in 2015
2

In 2015, healthcare organizations will need
to engage their audiences well before open
enrollment begins and enroll an estimated
8 million people in just 30 days.3
3

Challenges for Healthcare Enrollment in 2015
This fall marks the second round of open enrollment under the ACA,
but it comes with a unique set of ongoing and new challenges in
terms of reaching, educating, and enrolling the newly insured and
still uninsured populations across the country.

Historically, healthcare organizations have found it diﬃcult to
engage these populations for several reasons. In terms of reach,
healthcare organizations often struggle to connect with the very
demographics most in need of health insurance. These populations
include those who live in underserved areas without proper access
to information, low-income households, minority groups, and young
adults. Education marks the next substantial hurdle in enrolling the
uninsured. Many people do not understand the jargon associated
with enrolling in health insurance. Others are handicapped in their
ability to access resources such as the Internet, an enrollment
counselor, or printed materials. Lastly, many individuals simply
resist enrollment despite access to resources and information. In
particular, many young adults assume that because they are
currently young and healthy, they do not need any type of
healthcare coverage.
4

Challenges for Healthcare Enrollment in 2015
The new challenges facing healthcare organizations this year stem
from the nature of enforcing a new coverage system. Many
individuals who wanted coverage have already enrolled in the first
open enrollment period – in other words, it will be harder to convince
those who are still uninsured to take action this time around. Those
who did enroll in health insurance for the first time will have to
navigate their re-enrollment options, as well as understand new
legislation around taxation and financial assistance. For people who
have switched or lost their jobs, the upcoming period will be the
opportunity to change to a more suitable plan.

This year’s enrollment window is also only open for three months,
which is half the time of the previous enrollment period. This means
that healthcare organizations will need to engage their audiences
well before open enrollment begins, and enroll an estimated 8 million
people in just 30 days4. Lastly, this is the first year that a penalty for
not having insurance will take effect, turning a previously incentive-
driven program into a punitive one, in order to give a wake up call to
people who still resist enrollment.
5

Target Populations for Healthcare Enrollment
Given these challenges, we have identified a few of the most important
demographics that healthcare organizations much reach in order to
inform them about the ACA and ultimately drive enrollment.

Young adults: Young adults ages 18-34 are the most likely to be
uninsured5, and are a prime demographic for health insurance plans. In
2014, half (49.5 percent) of 18-30 year olds without health insurance
expected to remain uninsured, and many of them were likely to forgo
coverage due to the fact that they did not realize that they were eligible
for financial assistance6. Many adults who are 26 years or older will be
procuring health insurance for the first time in 2015, and are a valuable
demographic due to the fact that they are generally a healthier
population that can help lower premiums. But young adults are also
adverse to enrollment because they believe that they don’t need
insurance, cannot afford it, or are simply not paying attention.
6

Latinos: According to a 2013 survey7, 36% of Latinos reported being
uninsured – a higher percentage than any other racial–ethnic groups.
In 2014, the same survey found that 55% of Latinos planned on
remaining uninsured. Unlike young adults, however, this resistance is
not due to perceptions of better overall health – only about half of
Latinos disagreed with the statement “I’m healthy enough that I really
don’t need health insurance.” On the contrary, Latinos are likely to
resist enrollment due to low levels of health insurance literacy (only
23% declared conﬁdence in their understanding of health insurance
ﬁnancial terms8), or fear that having an undocumented family
member will jeopardize their legal status.

Latinos are also more averse to using the Internet marketplaces like
HealthCare.gov, preferring instead to have a personal connection to
help guide them through the process. As Commonwealth report
author Michelle Doty explains9, “Latinos really like personal contact,
they don’t like to make decisions about healthcare over the Internet.”
7

In 2014, 10.4 percent of Americans
(approximately 33 million people) were
uninsured for the entire calendar year.10
8

Low-income households: Low-income households have been a
traditionally difficult target for health insurance providers. A 2014
survey showed that nearly four in ten adults with low incomes were
uninsured9, and only 36.5% of these adults believed that they would
have to pay a fine. Another survey by the Urban Institute found that
nearly two out of three uninsured adults did not purchase coverage
in 2013 because of affordability, but these very same populations are
often unaware of subsidies that make coverage affordable11.

Populations in rural areas: People living in remote and underserved
areas are more at risk of not enrolling in healthcare insurance due to
a lack of access to resources. This year, over a dozen states (most
of which are in the South) did not expand Medicaid, landing many
inhabitants in a “coverage gap,” meaning that these populations
earn too much to qualify for Medicaid but believe that they also
don’t make enough to afford an ACA plan12. These populations are
often not aware of the subsidies available to them or do not know
how to reach a financial counselor in order to find a way to receive
affordable coverage.
9

Why Mobile is
the Best Way to
Drive Healthcare
Enrollment
10

As of February 2015, HealthCare.gov
sent 23 million text messages to
consumers interested in learning more
about their health care options.13
11

How Mobile Drives Healthcare Enrollment
Despite the diversity present in target populations for healthcare
enrollment, they all share one important common denominator:
almost everyone has a mobile phone, and all mobile phones can
send and receive text messages.

90% of Americans own a cell phone14, and text messaging is the #1
used app on phones. The ubiquity of cellular devices in the U.S.
means that virtually any uninsured American is already equipped with
the tool they need in order to connect with healthcare organizations –
no Internet connection or smartphone necessary. In other words, text
messaging has the widest reach – thereby effectively addressing the
first obstacle presented to health plans.

Text messaging is also an effective tool for educating the public about
the ACA. A 2015 report notes that HealthCare.gov has already sent 23
million text messages to consumers interested in learning more about
their healthcare options15.
12

Text messaging as a one-to-one communication channel gives people
a flexible channel to interact with healthcare organizations based on
their specific needs and concerns. People can text in their questions
and receive accurate information to help dispel myths, rumors and
fears about the ACA. If the person has a smartphone, organizations
can also text out helpful links to subsidy calculators or an official
marketplace website in order to learn more and begin the enrollment
process directly on their phones.

Communicating with the uninsured through text messaging allows
organizations to offer consistent support to individuals, while breaking
down the complications of the enrollment process via step-by-step
instructions no longer than 160 characters each.

From the healthcare organization’s end, text messaging’s convenience
demonstrates itself in its ability to communicate with several different
people at the same time, as opposed to making timely (and costly)
individual phone calls.
13

Research suggest that sending short,
scheduled text messages before and
during open enrollment heightens the
probability of the uninsured following
through with enrollment.16
14

Text messaging is also the only communication tool that allows
healthcare organizations and their audience alike to
communicate on a timeline that makes sense to them. People
don’t need an Internet connection, email account, or to be at
the right place in the right time to send or receive a message –
as long as they have a cell phone, every place is the right place
and the right time.

Text messaging also allows healthcare organizations to start
promoting enrollment early and stay in touch with people
throughout. Several researchers suggest that using short,
scheduled messages before and during open enrollment
heightens the probability of the uninsured following through with
enrollment17. Text messaging provides exactly this high level of
feedback at a low ask for subscribers. It allows organizations to
consistently communicate with the uninsured on a device that
makes sense for them.
15

What’s more, text messaging is also the preferred communication
channel for the exact populations that plans will be trying the hardest
to reach in 2015. Just look at these statistics:

•  Latinos and African Americans over-index for text messaging:
Hispanics are signiﬁcantly more likely to use their cell phones to
send or receive text messages, texting 1.56 times more than
Caucasians. African Americans text even more, exchanging 2.24
more texts than Caucasians18.
•  Low-income households text twice as much as high-income
households: Households that make less than $30,000/year send
twice as many text messages as those that make over $75,000/
year19.
•  Millennials are the “texting generation”: Millennials prefer text
messaging over email, phone calls, and in some cases, even face
to face interactions20.
•  Older adults are texting more than ever: People ages 55-64
send and receive an average of 80 text messages per month, and
senior citizens average 32 text messages per month21!
16

How to Use Mobile to
Drive ACA Enrollment
117

Mobile Strategies to Drive Enrollment
In order to use text messaging to help people enroll in health
insurance, organizations first need to get their attention by posting a
single call to action on all marketing outreach collateral. Simply
include the keyword (e.g. ENROLL) and shortcode (e.g. 12345) on all
printed and digital materials, such as billboards, posters, pamphlets,
and flyers. Posting a call to action on social media accounts and
websites is also a quick and effective way of getting out the word.
Since a text message call to action is short and easy to remember, it
can also be broadcast at live events and announced in TV and radio
ads. Once people have successfully opted in, organizations can use
text messaging to engage them in a variety of ways.
18

19
Connect to
Spanish
speakers
Answer
questions in
real-time
Determine
eligibility for
health plans
Guide people
to enrollment
centers
Schedule
appointments
and send
reminders
Collect
feedback for
future periods

Connect to Spanish speakers in the
language they are comfortable with

Since Latinos are an important demographic for health
insurance providers, text messaging’s multilingual
capabilities are a big advantage in reaching this
population. In order to enroll a person in a foreign language
campaign, simply create messages and an appropriate
keyword in that language. For example, ask Spanish
speakers to text “SEGURO” instead of “ENROLL” to begin
the conversation. Once they are enrolled, they will receive
automated text messages in their preferred language to
guide them through the enrollment process.

Note: Keep in mind that not all text messaging platforms
will allow you to send and receive text messages with
special language characters, so be sure to ask potential
providers about this functionality if it is an important part of
your outreach strategy.
20

Answer people’s questions about the
enrollment process in real-time

One of the most common reasons that people remain uninsured
is because of confusion over the ACA itself. Navigating online
resources is time-consuming and people often don’t know
where to start. By hosting a live chat session where trained
counselors can answer questions from the public about the
enrollment process, healthcare professionals can answer
questions via text message in real-time . The ﬂexibility of text
messaging allows people to text in their questions from any
place, at any time during the session. This removes the
traditional barriers associated with in-person or online
information sessions, such as proximity to the location, good
Internet access, and scheduling conﬂicts.
21

Determine eligibility and help people find the right
plan using automated surveys

Helping people find an appropriate insurance plan is an important step in
ACA enrollment. To help people decide, healthcare organizations can
survey individuals in order to find out important information, such as their
income level, age, work status, if their partners are insured, and how many
dependents they have. Having people answer a series of short multiple
choice questions via text messaging can save time and lead them straight
to the plan they need without a lot of the guesswork. People who are
updating or changing their healthcare insurance can go through a separate
process that takes into consideration their current coverage. By
segmenting subscribers based on their personal situation, healthcare
plans can use more targeted conversations to drive better results.
22

Guide people to the enrollment center nearest them

Many uninsured Americans would prefer to receive in-person enrollment assistance rather than completing the
process online. When this is the case, a text message locator service can lead individuals to the nearest enrollment
center by simply by asking them to text in their zip code. The zip code up is automatically matched up to an existing
database, and an automated response is sent back to the person with information about the nearest enrollment
center, such as the address and hours. To take it one step further, enrollment centers can ask people who used the
locator service if they wish to set up an appointment or attend an event at that center, and then ask for their
information as an RSVP. If they are unable to make it, advisors can call the individuals and see if they want to speak to
someone about enrollment over the phone. Either way, text messaging can be a valuable tool in connecting people
with the resources most convenient to them.
23

Schedule appointments and send reminders for
enrollment counselor appointments

For those individuals who wish to complete the enrollment process in
person, text messaging is an easy way to not only guide them to a
counselor, but to help them arrange the initial appointment. Once a
person connects with an enrollment center, a text message can be sent
asking them what time of day works best for them to meet with a
counselor: morning, afternoon, or evening. Once an open appointment
slot that ﬁts their needs is found, text them the appointment details and
have them conﬁrm with “YES” or “NO.” After that, sending reminders
leading up to the date is a good way to ensure that they don’t forget
about the appointment. And in case their plans change, people can
simply text in to reschedule their appointments without having to pick up
the phone or go online.
24

Follow up with people on the status of their enrollment

Many people will begin the enrollment process, but fail to follow through due a variety of reasons. Sending a text
message asking people where they are in the enrollment process – and if they need any help getting past a certain
step – can be a great way to ensure that people don’t just give up after encountering a diﬃcult question or forget to
complete the process before the deadline passes. It is also useful in tracking how long it takes for people to complete
the enrollment process.
25

Collect feedback to improve enrollment support
for future periods

Healthcare coverage has steadily improved over the years, but many
organizations are still actively trying to make the process as easy and
eﬀective as possible. A quick text message survey is a convenient
way to receive feedback from individuals on what they found diﬃcult
about the process and help organizations gain insight on where they
can improve in the future. Several studies suggest that people are
more likely to provide thoughtful and honest feedback via text
messaging compared to phone calls or email.
26

Encourage people to share enrollment resources with their friends and family

One of the most valuable features of text messaging is the ability for people to share information with their friends and
family. Some text messaging platforms have a built-in sharing function, where subscribers can invite their peers by
sending a message to the organization containing the phone numbers of their friends. Those friends will receive an
invitation from the organization to join their mobile list and start receiving text messages if they accept the invitation.
This capability makes it extremely easy to pass on information about the enrollment process and reach more people
through personal networks.
27

The upcoming open enrollment period poses several ongoing and unique
issues in ensuring that all Americans secure healthcare coverage in 2016. We
covered some of the populations that are most likely to remain uninsured due
to barriers such as lack of access to resources, confusion about the ACA, or
language barriers. However, these challenges can be addressed by
implementing a targeted mobile strategy to reach, educate, and enroll the
uninsured and other target populations.

While 2015 promises to be diﬀerent than previous years, the abundance of
research supporting mobile messaging suggests that if used wisely, text
messaging can make this enrollment period the most successful one to date.
It’s now up to organizations to take advantage of this channel as a primary
way to communicate with target populations and drive them to enroll.

To learn more about how your healthcare organization can use text messaging
as part of your outreach or enrollment strategy, please visit our website at
www.mobilecommons.com or email sales@mobilecommons.com.
Conclusion
28

Sources

1 http://www.cnn.com/2012/06/27/politics/btn-health-care/
2 http://www.gallup.com/poll/182348/uninsured-rate-dips-first-quarter.aspx
3 http://khn.org/news/obamacare-enrollment-second-year-an-even-tougher-challenge/
4 http://khn.org/news/obamacare-enrollment-second-year-an-even-tougher-challenge/
5 http://aspe.hhs.gov/health/reports/2012/uninsuredintheus/ib.cfm
6 http://hrms.urban.org/briefs/anticipated-changes-for-2014.html
8 http://healthaffairs.org/blog/2014/03/18/why-are-hispanics-slow-to-enroll-in-aca-coverage-insights-from-the-health-reform-monitoring-survey/
9 http://ww2.kqed.org/stateofhealth/2014/10/07/second-obamacare-enrollment-likely-to-be-even-tougher-than-first/
10 http://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf
12 http://hrms.urban.org/briefs/uninsured_perceive.html
13 http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
14 http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/
15 http://www.hhs.gov/healthcare/facts/factsheets/2015/02/open-enrollment-by-the-numbers.html
16 http://kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-using-text-messaging-to-reach-and-enroll-
uninsured-individuals-into-medicaid-and-chip/
17 http://kff.org/medicaid/issue-brief/profiles-of-medicaid-outreach-and-enrollment-strategies-using-text-messaging-to-reach-and-enroll-
uninsured-individuals-into-medicaid-and-chip/
18 http://www.pewinternet.org/2011/09/19/americans-and-text-messaging/
19 http://www.pewinternet.org/2011/09/19/americans-and-text-messaging/
20 http://www.pewinternet.org/files/old-media/Files/Reports/2012/PIP_Teens_Smartphones_and_Texting.pdf
21 http://www.nielsen.com/us/en/insights/reports/2012/introducing-boomers--marketing-s-most-valuable-generation.html

29

Mobile Commons by Upland is the leading mobile messaging
platform offering mobile strategy to the most influential brands,
government agencies, healthcare groups, higher education
institutions, and nonprofit organizations in the world, including Enroll
America, the New York City Department of Health and Mental
Hygiene, Planned Parenthood, Centene Corporation, and more. With
our easy-to-use platform and best-in-class features, Mobile
Commons transforms the way society uses mobile to communicate.
Whether you want to help mothers quit smoking, enroll students in
college, protect the environment or engage with consumers, Mobile
Commons helps you drive mobile engagement and see real results.

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