Table 2 Advantages and disadvantages of enrollment strategies from selected studies between January 2010 and December 2020

In-person assistance

▪ Helped individuals understand their options for coverage and get support to complete enrollment process [16–18, 22].

▪ Offered support and resources to individuals new to health insurance, immigrants and undocumented migrants living in rural and semi-urban areas [17].

▪ Established trust and respect from individuals [17].

▪ Provide structured approach to helping individuals enroll for coverage and maintain records on the number enrollees [17, 18].

▪ Identified knowledge gap on enrollment and the ACA policy, barriers to enrollment, and technical issues [21].

▪ Time consuming [16–18].

▪ Unable to provide support to everyone in need due to limited capacity [16–18].

▪ Unable to enroll individuals when technical and operations problems with enrollment system occurs [16, 17, 21, 22].

▪ Updated training to assisters can be challenging especially with ongoing changes in the ACA and other enrollment policies [17, 21, 22].

Online decision aid

▪ Improve individual knowledge on health insurance, plan selection[20].

▪ increase individual confidence in selecting a marketplace plan [20].

▪ Could reduce the need for in-person assistance to enroll for a marketplace plan [20].

▪ Cannot determine specific aspects of an online decision aid (e.g., educational materials, cost calculator, values component) that helped individuals decide a Marketplace plan [20].

▪ Only used by people living within a 90-mile radius of St Louis City [20].

Community events (e.g., health fairs, 5 K-runs, school visits)

▪ Encouraged populations to learn about health insurance coverage [16, 17].

▪ Informed populations about resources to help with enrollment [16, 17].

▪ Helped increase private insurance enrollment in non-expanded state [19].

▪ Informed populations that were less likely to be informed about their coverage options under the ACA (e.g., young adults, immigrants) [17, 19, 22].

▪ Time consuming [16, 17].

▪ Dependent on capacity and ability to organize events [17].

Educational events (e.g., workshops, health sessions)

▪ Provided health insurance information and enrollment resources during health-related workshops [17].

▪ Time-consuming and may require multiple sessions for people to absorb the information [17].

Educational/ promotional materials

▪ Simplified information on health insurance and coverage eligibility for people had a wide reach [16].

▪ Informed large segment of the population about the ACA [17].

▪ Some people continue to struggle with the enrollment process [16].

▪ Segment of the populations were not exposed to the educational materials or campaigns [16, 17].

Social media/ online campaigns

▪ Informed people how to access educational materials and resources to enroll for coverage [16].

Advertisement campaigns (e.g., print, radio, TV ads)

▪ Reach larger segment of the population with minimal resources [17, 24].

▪ The public positively responded to health insurance information from TV advertisement. High volume of advertisements during open enrollment was associated with increase enrollment for coverage [24].

▪ Require multiple exposure for people to absorb the information [17].

▪ The source of the information mattered. People can be negatively affected by certain TV ads. Negative political advertisement on the ACA was associated with declining Medicaid enrollment [24].

Nudging system (paper-based or online)

▪ Encouraged people to visit the marketplace website and review the information [23].

▪ Low-cost tools (letters, emails) were just as effective than higher intensity tools to encourage individuals to enroll for coverage [25].

▪ The enhanced nudging system did not cause many people to switch plan [23].

▪ Segment of the population (e.g., elderly) may not have access to technology and/or have limited skills to utilize it [23].