Carol M. Mangione, MD

Many health programs struggle with low enrollment rates.

To compare the characteristics of populations enrolled in a new 

health plan when employer groups implement voluntary versus 

We analyzed enrollment rates resulting from 2 different strategies: 

voluntary and automatic enrollment. We used regression 

modeling to estimate the associations of patient characteristics 

with the probability of enrolling within each strategy. The subjects 

were 5014 eligible employees from 11 self-insured employers who 

had purchased the Diabetes Health Plan (DHP), which offers free 

or discounted copayments for diabetes related medications, testing 

supplies, and physician visits. Six employers used voluntary 

enrollment while 5 used automatic enrollment. 

The main outcome of interest was enrollment into the DHP. 

Predictors were gender, age, race/ethnicity, dependent status, 

household income, education level, number of comorbidities, and 

Overall, the proportion of eligible members who were enrolled 

within the automatic enrollment strategy was 91%, compared 

with 35% for voluntary enrollment. Income was a significant predictor 

for voluntary enrollment but not for automatic enrollment. 

Within automatic enrollment, covered dependents, Hispanics, 

and persons with 1 nondiabetes comorbidity were more likely to 

Employer group was also a significant correlate of enrollment. 

Notably, all demographic groups had higher DHP enrollment 

rates under automatic enrollment than under voluntary 

For employer-based programs that struggle with low enrollment 

rates, especially among certain employee subgroups, an automatic 

enrollment strategy may not only increase the total number 

of enrollees but may also decrease some enrollment disparities.

The Diabetes Health Plan included variation in enrollment strategy across employer groups, with some using voluntary enrollment and others using automatic enrollment.

	• Utilizing voluntary enrollment, 35% of eligible employees were enrolled, and annual income ≥$125,000 and black race were associated with much higher rates of enrollment.

	• Utilizing automatic enrollment, 91% of eligible employees were enrolled, and dependents and employees of Hispanic ethnicity were somewhat more likely to be enrolled than other employees.

	• Automatic enrollment strategies can increase overall enrollment and provide participants with the opportunity to “opt out,” and may also decrease some enrollment disparities.

Despite extensive recruitment efforts by health 

plans, state and local governments, and other 

stakeholders, many eligible individuals do not 

voluntarily enroll in health promotion or insurance benefit 

programs designed to improve health outcomes.

are increasingly sponsoring wellness programs as a way to 

possibly decrease costs and increase productivity across a 

use of various approaches, enrollment in wellness programs 

benefits may improve access and outcomes among the subset 

of persons who are enrolled, with limited reach they 

are unlikely to improve the health of the overall targeted 

Many employer health programs use a voluntary enrollment 

approach, which employees must actively join in order 

to be enrolled. However, voluntary program enrollees may 

have different demographic characteristics than the underlying 

population, in terms of gender, age, race/ethnicity, 

income, risk for chronic conditions or disability, and other 

 Voluntary program enrollees may also have different 

clinical characteristics than the underlying population, 

potentially representing either the “worried well” who may 

have less need for services or a sicker subgroup motivated 

Articles

An automatic enrollment strategy for health insurance programs may not only increase the total number of enrollees but may also decrease some enrollment disparities.

Carol M. Mangione, MD

Articles

Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan