5 States With High Marketplace Enrollment Rates

Success in marketplace enrollment under the Affordable Care Act has varied widely during the open enrollment periods, although some similar factors contributed to high enrollment rates in these 5 states.

Success in marketplace enrollment under the Affordable Care Act (ACA) has varied widely during the open enrollment periods. Two new reports from the Urban Institute have taken a look at the factors that have contributed to high and low enrollment rates.

The Urban Institute used a detailed microsimulation model that enabled researchers to estimate anticipated enrollment in qualified health plans when the law is fully implemented. The institute assumes there would only be two-thirds of full enrollment in 2015 and that 2016 will represent full enrollment.

After identifying the 5 states that had high enrollment rates in 2015 and the 5 with low enrollment rates, the Urban Institute conducted in-depth interviews with diverse stakeholders to determine what factors may have contributed to the different enrollment outcomes.

All 5 states shared some important characteristics. They all had highly collaborative and coordinated outreach and enrollment assistance efforts; they all conducted grassroots community-based outreach; and they all had pre-existing outreach and enrollment networks and systems that had been successful.

In addition, all 5 states were building upon previous success. During the first open enrollment period, all 5 states had high enrollment rates, and the Urban Institute noted that “earlier success bred greater success” in the second open enrollment period.

Here are the 5 states with some of the highest enrollment rates and what they did to see success.


Enrollment as Percentage of Projections: 93.4%

Total 2015 Effectuated Enrollment: 92,000

Connecticut is the only state of the 5 analyzed by the institute that used its own website and information technology platform for enrollment: Access Health CT. Although Connecticut’s effectuated enrollment did not exceed the 2015 projections set forth by the institute, the state still exceeded the national enrollment rate.

Furthermore, Access Health CT was straightforward and easy to use, according to respondents. During the second open enrollment period, 42% of all customers who signed up for coverage on the marketplace did so online and by themselves.

Perhaps one of the biggest factors that contributed to Connecticut’s success was the strong political leadership and the culture of support for healthcare reform.

“With a Democratic governor and a state legislature controlled by Democrats, there was almost none of the anti-ACA political backdrop that existed in many other states,” according to the report.

One thing that was unique to Connecticut was the fact that the state is home to several major insurance carriers, which has made consumers more familiar with health insurance and meant they recognized and trusted the names of major carriers.


Enrollment as Percentage of Projections: 143.3%

Total 2015 Effectuated Enrollment: 1,315,000

Florida had the highest enrollment rate in 2015, but unlike in Connecticut, there was not a culture of strong, unified support for the ACA. Controversy over whether and how to expand Medicaid was in the news leading up to the second open enrollment period, which may have raised public awareness and led many consumers to seek information and coverage, according to the Urban Institute.

Simply put, one reason Florida may have seen such high marketplace enrollment in 2015 is because the state had such a high uninsured rate to begin with. However, beyond that, Florida had the largest and well-coordinated navigator network. Outreach organizations, navigators, other in-person assisters, and hospitals coordinated and relied heavily on local community partners.

“The assister systems in Florida were heavily dominated by local organizations and community leaders who were known to community residents, who spoke their language, and who were trusted messengers,” according to the report. “Local agencies reportedly hired navigators from local communities.”

Another factor that contributed to Florida’s success was word-of-mouth momentum. The marketplace had greater credibility during the second open enrollment period because of the “friends and family effect.”

New Hampshire

Enrollment as Percentage of Projections: 107.1%

Total 2015 Effectuated Enrollment: 45,000

New Hampshire took a different approach than Florida when it came to outreach: it hired an outside consulting firm to coordinate outreach and enrollment. The state is also one of the only states that exceeded enrollment expectations for the unsubsidized population.

Similar to Florida, the debate regarding the state’s Medicaid expansion drew attention to coverage options. Unlike Florida, New Hampshire did end of expanding the Medicaid program. Interestingly, controversy during the first open enrollment period benefitted the second open enrollment period: a perceived lack of attractive plan options built anticipation for when 4 new insurers entered the marketplace.

During the first open enrollment only Anthem offered plans through the marketplace, but in the second open enrollment period, Harvard Pilgrim, Minuteman Health, Assurant Health, and Maine Community Health Options joined.

“Controversy about overall poor offerings helped to galvanize providers—many of whom were not included in the marketplace plans’ provider networks—as well as to frustrate the public in a way that was cited as contributing to the strength of [the second open enrollment],” according to the report.

While stakeholders anticipate the third open enrollment period will continue to be successful with outreach, the remaining uninsured is dominated by single, young men who remain resistant to the ACA.


Enrollment as Percentage of Projections: 111.7%

Total 2015 Effectuated Enrollment: 398,000

Pennsylvania has managed to find success with ACA enrollment despite the initial resistance from the state’s political leadership. Although the Republican governor had joined the lawsuit challenging the ACA and was initially opposed to Medicaid expansion, he eventually supported the program’s expansion.

There are 3 primary reasons for the state’s high marketplace enrollment:

  1. Extensive collaborations among stakeholders across the state and significant coordination of both outreach and enrollment assistance efforts.
  2. The debate over Medicaid expansion and the state’s alternative program to standard expansion generated consumer awareness about enrollment opportunities.
  3. Qualified health plans have some of lowest premium prices in the country.

“Low premiums are particularly important for attracting the population that is not eligible for financial assistance and that benefits most directly from lower-cost plans,” according to the report.

Despite high enrollment in 2015, the respondents noted renewals and re-enrollments were challenging and it remains difficult to reach people who live in the deep pockets of rural Pennsylvania.


Enrollment as Percentage of Projections: 116.6%

Total 2015 Effectuated Enrollment: 327,000

Virginia has faced considerable opposition to the ACA. Regardless, the state had a high enrollment rate in 2014, which only got better in 2015. The injection of $13 million of federally awarded funds for outreach, education, and assistance was a huge part of why the state saw enrollment success.

The funding was used to invest in a highly coordinated strategy and build on existing infrastructures of consumer advocates, providers, and legal aid offices. Some of the money the state received had initially been to develop its own health insurance marketplace, but the federal government granted Virginia the ability to use those funds instead for public outreach and education.

As in other states, anti-ACA messaging and the battle over Medicaid expansion actually backfired. The advertising only served to raise consumer awareness and may have actually helped enrollment.

Similar to Pennsylvania, respondents said that more needs to be done to enroll people in rural areas moving forward. Another challenge is that health insurance literacy remains a challenge among consumers in Virginia.