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

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

Enrollment strategy Advantages Disadvantages
Individual assistance
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 outreach
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].
Health Education & Promotion (HE&P)
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].