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Health Insurance Exchanges: HHS Should Enhance Its Management of Open Enrollment Performance

GAO-18-565 Published: Jul 24, 2018. Publicly Released: Aug 23, 2018.
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Fast Facts

We examined 2018 enrollment in Affordable Care Act health insurance exchanges and federal efforts to encourage enrollment.

We found:

About 8.7 million people bought insurance in 2018 through the federal website (, 5% less than in 2017.

Health and Human Services reduced its advertising and other consumer outreach. The 23 stakeholders we interviewed had mixed views about the effects of these reductions on enrollment.

HHS did not set enrollment targets for 2018, but reported meeting its goal of enhancing specific aspects of consumer experience.

We recommended that HHS take steps to better manage its performance. Enrollees, 2017 and 2018

In 2017, there were 9.2 million enrollees, and in 2018, there were 8.7 million.

In 2017, there were 9.2 million enrollees, and in 2018, there were 8.7 million.

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What GAO Found

About 8.7 million consumers in 39 states enrolled in individual market health insurance plans offered on the exchanges through during the open enrollment period for 2018 coverage. This was 5 percent less than the 9.2 million who enrolled for 2017 and continued a decline in enrollment from a peak of 9.6 million in 2016. Among the 23 stakeholders we interviewed representing a range of perspectives, most reported that plan affordability played a major role in exchange enrollment—both attracting and detracting from enrollment. In 2018, total premiums increased more than expected, and, as a result, plans may have been less affordable for consumers, which likely detracted from enrollment. However, most consumers receive tax credits to reduce their premiums, and stakeholders reported that plans were often more affordable for these consumers because higher premiums resulted in larger tax credits, which likely aided exchange enrollment. Stakeholders had mixed opinions on the effects that other factors, such as the impact of reductions in federal advertising and the shortened open enrollment period, might have had on enrollment.

The Department of Health and Human Services (HHS), which manages enrollment, reduced consumer outreach for the 2018 open enrollment period:

HHS spent 90 percent less on its advertising for 2018 ($10 million) compared to 2017 ($100 million). Officials told us that the agency's approach for 2018 was to focus on low-cost, high-performing forms of advertising.

HHS reduced funding by 42 percent for navigator organizations—which provide in-person enrollment assistance for consumers—spending $37 million in 2018 compared to $63 million in 2017 due to a shift in administration priorities. HHS allocated the funding using data that it acknowledged were not reliable in December 2016. The lack of quality data may affect HHS's ability to effectively manage the navigator program.

Unlike in prior years, HHS did not set any numeric targets related to 2018 total enrollment; officials told us that they instead focused on enhancing the consumer experience for the open enrollment period. Setting numeric targets would allow HHS to monitor and evaluate its overall performance, a key aspect of federal internal controls. Further, while HHS reported meeting its goal of enhancing the consumer experience, such as by improving availability, it did not measure aspects of the consumer experience it had identified as key in 2017, such as successful outreach events. Absent a more complete assessment, HHS may not be able to fully assess its progress toward its goal of enhancing the consumer experience and may miss opportunities to improve other aspects of the consumer experience.

Why GAO Did This Study

Since 2014, millions of consumers have purchased health insurance from the exchanges established by the Patient Protection and Affordable Care Act. Consumers can enroll in coverage during an annual open enrollment period. HHS and others conduct outreach during this period to encourage enrollment and ensure the exchanges' long-term stability. HHS announced changes to its 2018 outreach, prompting concerns that fewer could enroll, potentially harming the exchanges' stability.

GAO was asked to examine outreach and enrollment for the exchanges using This report addresses (1) 2018 open enrollment outcomes and any factors that may have affected these outcomes, (2) HHS's outreach efforts for 2018, and (3) HHS's 2018 enrollment goals. GAO reviewed HHS documents and data on 2018 open enrollment results and outreach. GAO also interviewed officials from HHS and 23 stakeholders representing a range of perspectives, including those from 4 navigator organizations, 3 issuers, and 6 insurance departments, to obtain their non-generalizable views on factors that likely affected 2018 enrollment.

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GAO is making three recommendations to HHS, including that it ensure the data it uses for determining navigator organization awards are accurate, set numeric enrollment targets, and assess other aspects of the consumer experience. HHS agreed with two recommendations, but disagreed with the need to set numeric targets. GAO maintains that such action is important.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services The Secretary of HHS should ensure that the approach and data it uses for determining navigator award amounts accurately and appropriately reflect navigator organization performance, for example, by 1. providing clear guidance to navigator organizations on performance goals and other information they must report to HHS that will affect their future awards, 2. ensuring that the fields used to capture the information are functioning properly, and 3. assessing the effect of its current approach to funding navigator organizations to ensure that it is consistent with the agency's objectives. (Recommendation 1)
Closed – Implemented
HHS concurred with this recommendation and since our report was released, modified the formula it uses to determine navigator award amounts. Specifically, for the 2019 and 2020-2021 award periods, HHS largely based navigator awards on the size of the remaining eligible uninsured population in each state using the federally facilitated exchanges. In addition, HHS notified navigator organizations that future funding may be linked to navigators' self-identified performance goals and their ability to meet those goals. HHS has also taken several steps to improve the accuracy of the information it gathers with respect to navigator performance. For example, in September 2019, HHS reported expanding the training that it provides to navigators with respect to performance information they are required to submit. HHS also reported updating the application to hold multiple navigator and agent/broker identification numbers.
Department of Health and Human Services The Secretary of HHS should establish numeric enrollment targets for, to ensure it can monitor its performance with respect to its objectives. (Recommendation 2)
HHS does not concur with this recommendation. In October 2018, the agency noted that there are numerous external factors, such as the state of the economy and plan premiums, that may affect the number of people who decide to enroll in coverage. HHS also stated that it does not believe that numeric enrollment targets are relevant to assess the performance of objectives related to a successful open enrollment period. We continue to believe that the development of numeric enrollment targets is important for effective monitoring of the program and management of its resources. As of July 2023, HHS had not provided any additional information about steps to implement this recommendation. The status of this recommendation will be reconsidered once relevant action is taken.
Department of Health and Human Services Should the agency continue to focus on enhancing the consumer experience as a goal for the program, the Secretary of HHS should assess other aspects of the consumer experience, such as those it previously identified as key, to ensure it has quality information to achieve its goal. (Recommendation 3)
HHS initially concurred with our recommendation and reported examining ways to enhance the consumer experience as a goal for the program. However, in June 2021, HHS reported that it did not agree with the recommendation because it had previously assessed a range of aspects of the consumer experience and determined that the activities it had previously identified as key did not lead to measurably different results in terms of numbers of consumers enrolling. As of July 2023, HHS had not provided us with information about steps taken to address this recommendation. The status of this recommendation will be reconsidered once relevant evidence is provided. Specifically, HHS should provide GAO with a report of its recent assessment of factors that lead to measurably different enrollment results. HHS should also provide GAO with a list its revised goals for the program.

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