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Summary of Barriers to Enrollment in Health Coverage in Colorado

Core Content

This report, commissioned by the Colorado Health Foundation, investigates the reasons why some individuals in Colorado who are eligible for Medicaid and/or subsidized private insurance through the Connect for Health Colorado exchange are not enrolled in health coverage. It was conducted by the RAND Corporation in the spring of 2014, following the implementation of the Patient Protection and Affordable Care Act (ACA), which allowed Colorado to operate its own health insurance exchange and expand Medicaid eligibility.

The study involved focus groups with 108 uninsured or newly insured individuals across various regions and special populations in Colorado, as well as 14 interviews with local stakeholders involved in the enrollment process. The findings were grouped into three categories: barriers related to outreach and awareness, barriers affecting the decision to enroll, and barriers affecting the enrollment process itself.

Main Findings

Barriers to Outreach and Awareness

• Confusion and lack of understanding about Medicaid and private insurance subsidies through the Marketplace.
• Ineffective messaging from media, politicians, and stakeholders that did not emphasize the health benefits of insurance.
• Insufficient funding and data to support local outreach and education efforts.

Barriers Affecting the Decision to Enroll

• Unfavorable attitudes toward the individual mandate.
• Significant mistrust of the system.
• Lack of tailored or actionable messaging.
• Perception that health insurance is unaffordable.

Barriers Affecting the Enrollment Process

• Complexity of plan materials, making it difficult for individuals to choose a plan.
• Lag times and poor communication regarding eligibility-related decisions.
• Misinformation among stakeholders.
• Requirement to apply for Medicaid first and be denied before applying for private insurance.
• Connect for Health Colorado website was not user-friendly.

Key Recommendations

1. Support and expand localized outreach and tailored messaging to better reach diverse populations.
2. Revise marketing and messaging to be clear, actionable, and focused on health benefits to counteract negative or politicized messages.
3. Improve clarity and transparency of insurance costs, enrollment procedures, and health care benefits.
4. Revisit the two-stage enrollment process and enhance Connect for Health Colorado website navigation and technical support.

Special Populations

The report highlights the unique challenges faced by several special populations, including:

• Spanish-speaking individuals and families with mixed immigration status.
• Young adults.
• Rural populations.
• Seasonal workers.

These groups often encounter additional obstacles in understanding and accessing health coverage, which may be exacerbated by language barriers, limited access to information, and distrust of the system.

Study Context

• Colorado is one of 17 states that operates its own health insurance exchange (Connect for Health Colorado) and one of 27 states that expanded Medicaid.
• By the end of the first open enrollment period (April 2013–June 2014), over 310,000 Coloradans had enrolled in health insurance, with 178,504 newly enrolled in Medicaid and CHP+ and 125,402 in Marketplace plans.
• Despite this progress, a significant number of eligible individuals remained uninsured, particularly in the Southeast region, where only 25% of those eligible for tax credits enrolled in the Marketplace.

Study Methods

• Focus groups with 108 individuals, including both uninsured and newly insured.
• Semistructured interviews with 14 local stakeholders.
• The focus groups were conducted in eight regions across Colorado, including urban and rural areas, and included representation from Spanish-speaking individuals, mixed race/ethnicity groups, African Americans, Hispanics, parents with eligible children, and younger individuals (21–29 years of age).
• The study also included individual interviews with participants from La Plata due to scheduling conflicts.

Conclusion

The findings suggest that while Colorado has made progress in expanding health coverage, there are still significant barriers to enrollment that need to be addressed. These barriers are largely related to communication, awareness, affordability, and process complexity. The recommendations aim to improve the effectiveness of outreach and enrollment efforts in the upcoming open enrollment period, which began in November 2014.

Additional Notes

• The study acknowledges that funding allocation and grant usage across the state could be examined to better understand current efforts and inform future investments.
• The data collection occurred in late June 2014, and it is noted that some of the identified barriers may have already been addressed by Connect for Health Colorado or other stakeholders.