Health insurance enrollment strategies during the Affordable Care Act (ACA): a scoping review on what worked and for whom

Abstract

Background: The Affordable Care Act (ACA) provided an opportunity for millions of people in the U.S. to get coverage from the publicly funded Medicaid program or private insurance from the newly established marketplace. However, enrolling millions of people for health insurance was an enormous task. The aim of this review was to examine the strategies used to enroll people for health insurance and their effectiveness after implementing the ACA’s coverage expansion. Methods: The PRISMA Extension for Scoping Review (PRISMA-ScR) guided this review. Included studies were empirical studies that met the inclusion criteria and published between 2010 and 2020. Studies were searched mainly from two scholarly databases, CINAHL Plus and Medline (PubMed) using keyword searches. Hand searches from the references of selected journals were also performed. Content analysis was conducted by two authors in which codes were inductively developed to identify themes. Results: There were 2213 potential studies identified from the search, but 10 met the inclusion criteria. The research design of the studies varied. Two studies were randomized trials, one quasi-experimental trial, three mixed-methods, two qualitative and two quantitative. All studies focused on strategies used to inform and help people enroll for either Medicaid or private insurance from the marketplace. This review identified three key strategies used to help enroll people for coverage: 1) individual assistance; 2) community outreach; and 3) health education and promotion (HE&P). Conclusion: Community-based organizations were likely to use a combination of the three strategies simultaneously to reach uninsured individuals and directly help them enroll for health insurance. Other organizations that aimed to reach a wider segment of the population used single strategies, such as community outreach or HE&P.