Premium tax credits. Enrollment through Healthcare.gov Was 5 Percent Lower in 2018 than 2017, and Stakeholders Reported That Plan Affordability Likely Played a Major Role in Enrollment

		Exchange Enrollment through Healthcare.gov Was 5 Percent Lower in 2018 than 2017

About 8.7 million consumers enrolled in healthcare.gov plans during the  open enrollment period for 2018 coverage, 5 percent less than the 9.2  million who enrolled for 2017. This decline continues a trend from 2016,  when a peak of 9.6 million consumers enrolled in such plans. As a result of these premium  increases, plans were less affordable in 2018 compared to 2017 for  exchange consumers without advance premium tax credits (15 percent in  2018). 3). 4.) Many stakeholders also said that reductions in HHS outreach and  advertising of the open enrollment period likely detracted from 2018  enrollment, in part because any reduction in promoting enrollment  detracts from overall consumer awareness and understanding of the  program and its open enrollment period. HHS Reduced Paid Advertising

HHS reduced the amount it spent on paid advertising for the 2018 open  enrollment period by 90 percent, spending $10 million as compared to the  $100 million it spent for the 2017 open enrollment period. According to HHS  officials, the agency reduced this funding due to a shift in the  Administration’s priorities. 6). This, in turn, could  affect HHS’s ability to meet its objectives, such as its objective of  improving Americans’ access to health care. HHS Did Not Set Numeric Enrollment Targets for 2018, and Instead Focused on Enhancing Certain Aspects of Consumers’ Experiences

HHS did not set any numeric enrollment targets for 2018 related to total  healthcare.gov enrollment, as it had in prior years. According to federal internal control standards, agencies should design  control activities to achieve their objectives, such as by establishing and  monitoring performance measures. HHS leadership decided against setting numeric enrollment targets for  the 2018 open enrollment period and instead focused on a goal of  enhancing the consumer experience, according to HHS officials. Although HHS officials reported that the agency met its goal of enhancing  specific aspects of the consumer experience for the 2018 open  enrollment period, HHS narrowly defined its goal and excluded certain  aspects of the consumer experience that it had identified as key as  recently as 2017. More specifically, in 2017, HHS reported that successful  outreach and education events and the availability of in-person consumer  assistance, such as that provided by navigators to help consumers  understand plan options, were key aspects of the consumer experience. For  example, as noted above, some stakeholders we interviewed told us that  consumer confusion likely detracted from enrollment for 2018, and some  linked this outcome to HHS’s reduced role in promoting exchange  enrollment, including navigator support, which may have resulted in less  in-person consumer assistance through navigators. Absent a more complete  assessment, HHS may not have the information it needs to fully  understand the consumer experience. Recommendations for Executive Action

We are making the following three recommendations to HHS:
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. Consumer understanding of the Patient Protection and Affordable  Care Act and its status. Metal tier of selected plan Bronze

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Appendix IV: Selected Stakeholder Views of Factors Likely Affecting 2018 Enrollment in Healthcare.gov Plans

We identified a list of factors that may have affected 2018 healthcare.gov  enrollment based on a review of Department of Health and Human  Services (HHS) information, interviews with health policy experts, and  review of recent publications by these experts related to 2018 exchange  enrollment.
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 healthcare.gov. 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.

What GAO Found

About 8.7 million consumers in 39 states enrolled in individual market health insurance plans offered on the exchanges through healthcare.gov 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 healthcare.gov 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 healthcare.gov 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 healthcare.gov 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.

What GAO Recommends

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.