An automatic enrollment strategy for health insurance programs may not only increase the total number of enrollees but may also decrease some enrollment disparities.
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
automatic enrollment approaches.
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
enroll than other subgroups.
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.
Am J Manag Care. 2014;20(8):e311-e319
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.1 Employers
are increasingly sponsoring wellness programs as a way to
possibly decrease costs and increase productivity across a
large component of the workforce.2 However, despite the
use of various approaches, enrollment in wellness programs
often remains low.3-5 Although many of these programs and
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
factors.7 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
to enroll because of the severity of their underlying condition.
A recent review of enrollment into a variety of public
benefit programs identified multiple barriers to voluntary enrollment
and suggested automatic enrollment of all eligible
participants as a preferential strategy.8 There is little current,
“real-world” data on patient-level differences comparing
“voluntary” and “automatic” enrollment approaches. Such
information may be useful in the design of future health promotion
or insurance benefit programs.
Data from the rollout of the SHP at 11 self-insured employers
of the Diabetes Health Plan (DHP)—the first disease-specific
health insurance plan for employees and their covered
dependents with diabetes or prediabetes—provides a unique
opportunity to assess the effectiveness of these 2 enrollment
strategies. The DHP is offered by different employer
groups, some using a voluntary enrollment approach requiring
employees to sign up, others an automatic enrollment
approach that directly enrolls all eligible employees.
We hypothesized that the automatic enrollment strategy
would enroll a larger and more representative sample of
the underlying population, compared with the voluntary
Study Design, Setting, and Participants
The Diabetes Health Plan (DHP), initiated in 2009, represents an innovative approach to care for individuals
with diabetes or prediabetes.9 Purchased by several medium
and large self-insured employers across the United
States, the DHP eliminates or reduces co-payments for
medications and physician visits in order to incentivize
evidence-based care. Eligible employees and their eligible
covered dependents have the option of maintaining their
standard plan or switching to a DHP plan. The latter adds
DHP benefits to the standard plan while maintaining the
same premium cost to the employee. The DHP also includes
enhanced access to wellness programs at no additional
cost to the employee. shows the variations
in features between the DHP and the standard plan.
In addition to these program benefits, the DHP was
originally designed by the health plan to include several
requirements to be met each year in order to maintain
enrollment for the following year. These “compliance
criteria” were ultimately determined by each employer,
but potentially included a combination of the following:
laboratory evaluations such as biannual A1C testing, annual
cholesterol blood testing and/or annual microalbuminuria
screening, biannual primary care visits, annual
retinal exams, biannual mammography, and/or colon
cancer screening for persons aged 50 years or more. Required
tests were offered free to the enrolled DHP member.
Although the DHP enrolled both
employees with diabetes and prediabetes,
the current analysis is limited
to the sample with diabetes. In order
to be considered eligible for the DHP,
an employee (or dependent) with diabetes
had to meet at least 1 of the following
criteria during the prior 1 year:
(1) 1 or more medical claims with an
International Classification of Diseases,
Ninth Revision, Clinical Modification
() diagnosis code of 250.xx from a doctor’s office,
clinic visit, or inpatient hospital stay; (2) any glycated
hemoglobin (A1C) value of ≥6.5%, fasting plasma glucose
>125 mg/dL, or 2-hour oral glucose tolerance test ≥200
mg/dL; (3) any prescription filled for insulin or an oral
antiglycemic agent other than metformin; (4) direct referral
from a medical provider or as a result of onsite biometric
When the DHP was first introduced in early 2009, all
participating employer groups offered the plan under a
voluntary enrollment strategy. Some employers limited
DHP eligibility to persons who had existing diagnoses of
diabetes and these persons could voluntarily enroll. Other
employers offered on-site biometric screenings to detect
new cases of diabetes, and allowed those with either new or existing diagnoses to voluntarily enroll.
Employer groups initially offering the DHP in late 2009
and 2010 had the option to enroll employees using an
automatic enrollment approach. Each employer identified
the eligible employees based on the criteria described
above and notified them of their eligibility. Eligible individuals
were automatically enrolled in the DHP at the beginning
of the next enrollment period unless they made
an active decision to opt out in favor of having a standard
health plan. The opt-out process was relatively simple
for individuals who preferred to remain in the standard
health plan, usually involving a short form that could be
returned to their designated DHP representative.
Using a cross-sectional design, we compared the 6 employer
groups that offered voluntary enrollment and the
5 groups that used automatic enrollment to evaluate differences
in an employee’s likelihood of DHP enrollment.
As shown in , we restricted the sample to persons
who: (1) had no gestational diabetes; (2) were continuously
enrolled with the health insurer 1 year before and 1
year after the DHP was offered; (3) were between the ages
of 18 and 64 years at baseline; (4) were not missing key
demographic variables or information on employee/dependent
status; and (5) had enrollment status in the DHP
The outcome variable for this analysis was enrollment in the DHP. Enrollment data was provided by the health insurer, and individual-level information about reasons why employees did or did not enroll was not available. Predictor variables for this analysis included gender, age group (aged 18-34, 35-44, 45-54, and 55-64 years), and employee vs covered dependent (>18 years) status, all of which were member-reported and were acquired from the eligibility file provided by the health insurer. Other variables included education level (high school graduate or less, some college, bachelor’s degree, and above), race (white, Hispanic, black, Asian, other), and annual household income (<$30K, $30K-$49K, $50K-$74K, $75K- $124K, ≥$125K), all of which were obtained by the health insurer from a third-party consumer marketing services firm that derived them from a combination of census data, an algorithm analyzing first and last names, and an income database. A count of comorbidities was derived from administrative claims data provided by the health insurer; it included each of 15 conditions based on ICD-9-CM codes: hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, atrial fibrillation, end-stage renal disease, osteoarthritis, rheumatoid arthritis, cancer, chronic obstructive pulmonary disease, stroke, peripheral vascular disease, dementia, and schizophrenia and other mental health diagnoses (eg, depression, anxiety).
We compared the unadjusted differences in enrollment within the voluntary and automatic enrollment groups. Using a multivariate logistic regression model to control for demographic and health variables, we determined the marginal predicted probabilities of being enrolled in the DHP. In addition to controlling for various demographic characteristics, we also included “enrollment method” to control for those who were offered the plan under voluntary versus automatic enrollment.
Finally, we conducted the same analysis using employer fixed effects with stratified models to compare the associations estimated among employer groups who offered voluntary enrollment with those who offered automatic enrollment. We chose this specification because of the inherent flexibility, as fixed effects control for any confounding of patient-level effects with employer characteristics, and stratification allows enrollment strategy to fully interact with the other predictors in the model.
None of the employer-level characteristics were significantly different between the automatic and voluntary enrollment groups (Table 2). Of persons meeting our study criteria (aged between 18 and 64 years and continuously enrolled in a UnitedHealth plan for 2 years), 8.7% had diabetes. Of the 1549 eligible persons in the voluntary enrollment group, only 35% enrolled in the DHP, by opting into the program. Of the 3465 persons in the automatic enrollment group, 91% enrolled in the DHP, by not opting out. Chi-square tests revealed significant unadjusted differences by race/ethnicity in the voluntary enrollment groups, with a higher percentage of white and Hispanic individuals and a lower percentage of black individuals represented among those enrolled (Table 3). There were also differences by income and education in the voluntary enrollment groups, with a higher percentage of individuals with annual household income ≥$75K, a lower percentage with a high school diploma or less, and a higher percentage with a bachelor’s degree enrolled in the DHP compared with the sample that did not enroll. Among the automatic enrollment groups, there was a higher percentage of men among DHP (Table 3). There was also a higher percentage of Hispanic individuals among the enrolled as compared with the nonenrolled.
Within the pooled regression controlling for demographics and enrollment strategy, we found that individuals within an automatic enrollment setting were 58 percentage points more likely (P <.01) to enroll than those in a voluntary enrollment group. In the stratified adjusted analyses with all predictor variables simultaneously included (Table 4), within voluntary enrollment groups we found that black individuals were more likely to be enrolled in the DHP (+8 percentage points, P = .01) compared with white individuals. We also found that covered dependents were less likely to be enrolled in the DHP than employees (—10, P <.001), and individuals with annual household incomes of ≥$125K were more likely to be enrolled in the DHP than individuals with incomes of under $30K (+17, P = .04). Individuals in the aged 45-54 years group were also more likely to be enrolled in the DHP (+10, P = .03) compared with individuals between 18 and 35 years of age. Examining the automatic enrollment groups, we found no significant differences by patient income or education, but Hispanics were more likely to remain enrolled in the DHP than white individuals (+5, P <.001), and covered dependents were more likely to remain enrolled in the DHP than employees (+2, P =.02). Individuals aged between 55 and 64 years were less likely to remain enrolled in the DHP (–6, P = .02) compared with individuals aged between 18 and 35 years.
Finally, statistically significant differences in enrollment by employer group were observed within both the voluntary and automatic enrollment groups. In particular, rates of DHP enrollment among employers using the voluntary enrollment approach varied from 14% to 88%.
In summary, enrollment rates varied within the groups of employers using voluntary and automatic enrollment approaches, as well as between employers using voluntary enrollment and those using automatic enrollment approaches. In the voluntary enrollment groups, black individuals and high-income individuals were more likely, and covered dependents less likely, to “opt in.” In the automatic enrollment groups, Hispanic individuals and covered dependents were less likely to “opt out.” We also observed significantly higher rates of enrollment acrossall subgroups in the automatic enrollment approach as compared with voluntary enrollment.
The 2 enrollment strategies that we compared require very different levels of patient engagement and initiative. In workplaces offering voluntary enrollment, eligible individuals must take personal initiative to enroll. They must first become aware of the program and then proceed through the proper channels or complete tasks required for enrollment (ie, contact the appropriate representative to request an application form for enrollment, then complete and return the form). However, employees who are automatically enrolled are only required to take any action if they choose not to participate.
In addition, the reasons for not being enrolled under each strategy are likely very different. There are numerous potential barriers to entry in a voluntary enrollment system, which may include poor communication about the program, lack of understanding of the program, and/ or the opportunity cost of the time associated with the enrollment process. Within an automatic enrollment system, employees who choose to opt out may do so because they have an existing competing insurance plan, are insured under another family member’s plan, or for another financial or health reason.
We found that covered dependents were significantly less likely than employees to be enrolled within voluntary enrollment, but were significantly more likely to be enrolled under the automatic enrollment strategy. Covered dependents were required to meet the same eligibility requirements as eligible employees. It is possible that covered dependents were less likely to be aware of the DHP and voluntarily enroll, since they may not have received promotional communications distributed at the workplace. On the other hand, covered dependents may be less likely to have typical “opt out” reasons such as a better benefit through a spouse or a choice of a different health insurance plan. Therefore, they may be less likely to opt out under automatic enrollment.
We also found that affluent individuals (annual household incomes of $125K or more) were much more likely to voluntarily enroll in the DHP than individuals with annual household incomes of less than $30K. Co-payment reductions are more likely to influence adherence among individuals for whom the out-of-pocket cost of medications is a greater burden.10 To the extent that programrelated resources are disproportionately devoted to higher income groups, the DHP goal of reduction in cost-related nonadherence may be less pronounced with use of a voluntary enrollment approach.
Among racial/ethnic groups, we found that Hispanics were least likely to make an “active” enrollment choice about their health insurance by opting out. This is consistent with prior studies showing lower levels of initiating use of outpatient health services by Hispanics compared with other racial/ethnic groups.10-11 Language barriers or beliefs about healthcare have been listed as possible causes of these differences.12-13 An automatic enrollment approach may be one way to overcome racial disparities in employer health program participation. Research has shown that the type of health insurance an individual is offered has the strongest effect on healthcare utilization among Hispanics, as rates of preventive care used among Hispanics were much greater among those enrolled in HMO as opposed to fee-for-service plans, suggesting that co-payment or coinsurance costs may be a major deterrent for seeking preventive care.15 Since the DHP, is designed to minimize or eliminate co-payments, this type of value-based benefit feature combined with an automatic enrollment approach could potentially increase use of both diabetes-specific services (eg, routine A1C checks and retinal exams) as well as general preventive services (eg, mammograms).
The strongest determinant of enrollment rates within both voluntary and automatic enrollment groups was the employer. We believe that these differences may be driven by variation in marketing the plan to employees, use of financial incentives for participation at the employee level, and implementation of compliance criteria. Although the study team did not collect this information in a standardized manner, communications with the health plan design team indicate that employers with the highest voluntary enrollment rates tend to be those that offer multiple wellness programs or incentives, and have designated wellness champions or wellness committees who take an active role in decisions about health programs.
Our analysis has 2 notable limitations. First, no small or medium-sized employers (<1000 employees) purchased the DHP so the analysis is limited to large employers. We are therefore unable to generalize these results to smaller companies. However, because of this, the results are unlikely to be affected by changes caused by the Affordable Care Act, as these individuals eligible for the DHP were with larger companies already offering insurance. Secondly, potential ceiling effects may limit the ability of our analyses to detect differences in enrollment rates with the automatic enrollment strategy.
The first and arguably most important barrier to access for any health plan or health program is enrollment of eligible individuals. Our findings of increased enrollment of blacks and higher income individuals with voluntary enrollment, as well as a higher probability of remaining enrolled for Hispanics and covered dependents with automatic enrollment, may help inform future policies that involve employer health programs. It is important to note that employees who are automatically enrolled may be less likely to fully engage with the benefits and features available, which may diminish the overall effectiveness of the program. The administrative burden of including these less engaged individuals in a health program may present an excessive burden in certain cases. Conversely, programs that use a voluntary enrollment approach are likely to have more engagement among participants but will likely need to make a large upfront investment in time and financial resources to drive enrollment.
Forthcoming analyses will evaluate the effectiveness of the DHP in terms of key outcomes such as control of cardiovascular risk factors, utilization of care, and total costs. However, based on previous research, we expect that lower cost-sharing applied across entire populations will enhance medication adherence and may also drive these more distal outcomes.17-18 In a quickly evolving health policy environment, innovative ideas and a strong push in the direction of wellness and population management will likely result in millions of dollars being spent on new health promotion programs. If these programs enroll only small and unrepresentative proportions of targeted individuals, it will be very difficult not only to evaluate the likely impact on the larger population, but also to disseminate effective programs to a broad spectrum of eligible individuals. An automatic enrollment approach may prove critical in overcoming entrance barriers that hinder participation in health promotion programs that may ultimately decrease costs and lead to better health outcomes.4-6,19
Author Affiliations: Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (LBK, JL, NT, SLE, CMM, OKD); Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health at UCLA, Los Angeles (CMM, SLE); and Department of Medicine and HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles (TM).
Funding Source: Funding received from the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases as part of the Natural Experiments for the Translation of Diabetes (NEXT-D) Study (Grant number DP002722). Dr Moin is supported by VA Office of Academic Affiliations, Health Services Research and Development, through the Health Services Fellowship Training Program (TPM65-010), VA Greater Los Angeles Healthcare System. Dr Mangione and Dr Duru are supported in part by the University of
California, Los Angeles, Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684. Dr Duru is supported in part by the Career Development award K08 AG033630.
Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (LK, OKD, SLE, CMM, JL, NT); acquisition of data (LK, OKD, CMM, JL, TM, NT); analysis and interpretation of data (LK, SLE, SMM, JL, TM, NT); drafting of the manuscript (LK,); critical revision of the manuscript for important intellectual content (LK, OKD, SLE, CMM, TM); statistical analysis (LK, SLE, JL); provision of study materials or patients (LK); obtaining funding (LK, OKD); administrative, technical, or logistic support (LK, CMM); and supervision (LK, OKD, CMM).
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