On November 1, consumers began enrolling in health insurance coverage for 2016. The launch of the third open enrollment period (OE3) in the marketplaces created by the Affordable Care Act (ACA) presents new challenges for consumers and officials alike.

To shed light on these challenges, the Urban Institute has published two studies: one analyzing factors that contributed to certain states’ low enrollment rates in 2015 and another examining certain states’ high enrollment rates in 2015. These studies offer insights into what worked well in those high enrollment states and where the greatest pitfalls were in those low enrollment states. They also identify some common challenges that are likely to continue in OE3.

We conducted these studies because states had such a wide range of enrollment rates in 2015, based on a comparison of actual enrollment numbers to the Urban Institute’s projections of what 2015 enrollment should have been according to state population characteristics. Those varied enrollment results did not seem to follow any consistent patterns based on geography, population, political support for the ACA, or the type of marketplace. States that used the federal website HealthCare.gov to enroll consumers performed on average better than states that used their own web sites and information technology (IT) platforms in 2015.  But there were high-performing state-based marketplaces (SBMs) that used their own IT platforms and low-performing states that used HealthCare.gov. The Urban Institute selected five states with relatively low enrollment rates—Colorado, Iowa, Minnesota, Washington, and West Virginia—and five states with relatively high enrollment rates—Connecticut, Florida, New Hampshire, Pennsylvania, and Virginia—and interviewed diverse stakeholders in each state. 

Our research found a few reasons for the dramatically different enrollment rates. Coordinated, collaborative grassroots outreach and enrollment systems were critical in high-enrollment states, while insufficient outreach and enrollment assistance resources prevailed in low-enrollment states. A few more of our key findings on low-enrollment states:

• All five low-enrollment states’ pre-ACA uninsurance rates were near or below the national average and thus their uninsured were likely harder to reach.
• In all five states, stakeholders reported that high premiums for higher wage groups made coverage unaffordable for many.
• The states that used their own IT platforms reported problems that created difficulties and negatively affected enrollment. Significant media attention to the IT problems exacerbated this effect.
• There was a shortage of navigators and assisters in all or parts of these states.

In the five high-enrollment states, we found:

• All five states had highly collaborative and coordinated outreach and enrollment assistance systems.
• All five states had pre-existing outreach and health enrollment networks and systems that had functioned successfully before the ACA. These networks and systems were leveraged in both 2014 and 2015 to enroll low-income consumers in the marketplace.
• In all five states, outreach and enrollment organizations emphasized grassroots, community-based outreach in places where people already tend to congregate and relied on trusted and familiar messengers to recruit and assist consumers.
• All five states had high enrollment rates in OE1 and some people reported that earlier success bred greater success in OE2.

As IT systems continue to improve and enrollment assisters throughout the country develop greater knowledge and experience, all states may see higher enrollment rates in OE3. But going forward, stakeholders in both sets of states identified several challenges:

• Shrinking resources for consumer outreach and enrollment assistance.
• Low rates of insurance literacy among the eligible population.
• Populations that remain uncovered are likely to be disproportionately comprised of harder-to-reach groups – e.g., the young and healthy, legal immigrants, rural populations, and those ideologically opposed to the law.

 Over the next weeks and months, we will learn whether enrollment will continue to increase in all states despite these remaining challenges.