Health Insurance Television Advertising Content And The Fifth Open Enrollment Period Of the Affordable Care Act Marketplaces
On November 1, 2018, the sixth open enrollment period for the Affordable Care Act (ACA) health insurance Marketplace began. Just as with the fifth open enrollment period, outreach and enrollment for the ACA under the Trump Administration looks very different than it did prior to 2017. In particular, earlier this year, the Department of Health and Human Services announced that they would be cutting funding for navigators, groups that help people enroll in plans available through the Affordable Care Act, for the second year running. The funding was reduced to $10 million (total) for 2019, from $36 million for the 2018 open enrollment period. For comparison, the funding for navigator programs and enrollment and other outreach was $62.5 million during the fourth open enrollment period under the Obama administration.
Funds for advertising and promotion were also reduced from $100 million under Obama to $10 million, as announced in late August 2017, with television advertising for the Marketplace completely eliminated. For the current 2019 enrollment period, navigators have also been encouraged to inform consumers about other non-ACA compliant plans, including association health plans and short-term limited-duration insurance. The Trump administration has justified the cuts to the enrollment and outreach spending by noting that consumers can learn about their health plan options through digital marketing and many other mechanisms, including from high levels of advertising by insurance companies and by private-sector brokers and agents.
This response prompts an important question: what are the trends in volume and content of advertisements from non-federal sponsors? We sought to answer this question by examining the volume of health insurance advertising from all sponsors over time and providing a detailed description of the volume of advertising during the most recently completed (fifth) open enrollment period. (The fifth open enrollment period for federally-facilitated marketplace states was from November 1, 2017 to December 15, 2017). In addition, we examined the specific messages aired in advertisements from non-federal sponsors during this time frame.
Advertising data came from Kantar Media/CMAG and included every English-language ad categorized by Kantar Media/CMAG as about health insurance that aired between from May 14, 2013 to December 15, 2017 on broadcast television, as well as national network and national cable. The data included the Kantar-provided sponsor name and the date, time, and station of airing. We categorized sponsors as private, federal, state, or other; the latter category included ads sponsored by non-profit advocacy organizations and public service announcements. For the fifth open enrollment period only, we further categorized the sponsor as a health insurance company, a health insurance company that is integrated with a health care delivery system, , health system or hospitals, and brokers or insurance agencies. The sponsor categories provided by Kantar were verified by two independent coders who reviewed the creatives and, if necessary, re-categorized them.
To assess the specific messages conveyed in the advertising from the fifth open enrollment period, 6 trained coders viewed all 1,025 creatives that had been aired a total of 338,018 times across the United States during this time period (November 1-December 15, 2017). Ads ranged from 10 seconds to 2 minutes. We constructed and applied a coding instrument to track the policy-relevant content in advertising.
On November 1, 2018, the sixth open enrollment period for the Affordable Care Act (ACA) health insurance Marketplace began. Just as with the fifth open enrollment period, outreach and enrollment for the ACA under the Trump Administration looks very different than it did prior to 2017. In particular, earlier this year, the Department of Health and Human Services announced that they would be cutting funding for navigators, groups that help people enroll in plans available through the Affordable Care Act, for the second year running. The funding was reduced to $10 million (total) for 2019, from $36 million for the 2018 open enrollment period. For comparison, the funding for navigator programs and enrollment and other outreach was $62.5 million during the fourth open enrollment period under the Obama administration.
Funds for advertising and promotion were also reduced from $100 million under Obama to $10 million, as announced in late August 2017, with television advertising for the Marketplace completely eliminated. For the current 2019 enrollment period, navigators have also been encouraged to inform consumers about other non-ACA compliant plans, including association health plans and short-term limited-duration insurance. The Trump administration has justified the cuts to the enrollment and outreach spending by noting that consumers can learn about their health plan options through digital marketing and many other mechanisms, including from high levels of advertising by insurance companies and by private-sector brokers and agents.
This response prompts an important question: what are the trends in volume and content of advertisements from non-federal sponsors? We sought to answer this question by examining the volume of health insurance advertising from all sponsors over time and providing a detailed description of the volume of advertising during the most recently completed (fifth) open enrollment period. (The fifth open enrollment period for federally-facilitated marketplace states was from November 1, 2017 to December 15, 2017). In addition, we examined the specific messages aired in advertisements from non-federal sponsors during this time frame.
Advertising data came from Kantar Media/CMAG and included every English-language ad categorized by Kantar Media/CMAG as about health insurance that aired between from May 14, 2013 to December 15, 2017 on broadcast television, as well as national network and national cable. The data included the Kantar-provided sponsor name and the date, time, and station of airing. We categorized sponsors as private, federal, state, or other; the latter category included ads sponsored by non-profit advocacy organizations and public service announcements. For the fifth open enrollment period only, we further categorized the sponsor as a health insurance company, a health insurance company that is integrated with a health care delivery system, , health system or hospitals, and brokers or insurance agencies. The sponsor categories provided by Kantar were verified by two independent coders who reviewed the creatives and, if necessary, re-categorized them.
To assess the specific messages conveyed in the advertising from the fifth open enrollment period, 6 trained coders viewed all 1,025 creatives that had been aired a total of 338,018 times across the United States during this time period (November 1-December 15, 2017). Ads ranged from 10 seconds to 2 minutes. We constructed and applied a coding instrument to track the policy-relevant content in advertising.
This was an abbreviated version of a more comprehensive coding process we implemented for ads aired from 2013-2016 which was recently published, and included the following variables: whether the ad focused on Medicare, whether the ad mentioned “enrollment” or “enroll”, Medicaid, or the existence of penalties or fines for not enrolling. In addition, we tracked whether the ad described insurance as low-cost or affordable, referenced the availability of preventive services, and mentioned deadlines by which to enroll. Given that we found significant declines in the likelihood of health insurance advertising mentioning the ACA between 2013 and 2016, we also tracked whether the following terms were mentioned: ‘healthcare.gov’, ‘the ACA’, ‘Obamacare’, or the ‘health care law’. We calculated kappa statistics (a measure of coder inter-rater reliability) and all variables reported here exceeded a kappa of 0.70, indicating good agreement among the coders.
Exhibit 1 shows the weekly volume of insurance advertisings by sponsor, from 2013 through the end of 2017. One important caveat to keep in mind when interpreting the figure is that Exhibit 1 displays the volume of all health insurance ads identified by Kantar Media/CMAG that aired over the period; the figure is not limited to airings by insurance companies that were marketing products available on the Marketplace versus off-Marketplace nor does it exclude ad airings of Medicare Advantage products or employer-sponsored insurance plans. A few patterns are worth noting. First, the 2013-2014 open enrollment period demonstrates a strikingly different pattern than the following periods, both in terms of the length of the open enrollment period (6 months) and the proportion of federal ads among the total. This suggests that it is likely inappropriate to extrapolate relationships between advertising and insurance outcomes in 2014 to the more recent periods.
Still, across all five open enrollment periods, private sponsors (insurance companies, brokers, health care systems) contributed the majority of advertising. Second, the majority of health insurance ads aired during time periods that correspond with the ACA open-enrollment periods (however, note that increases in airings preceded the start of the open enrollment period, likely those were for Medicare Advantage or other health insurance plans). Third, the most recent enrollment period had the highest peaks in weekly volume, but the peaks occurred during a shorter window of time, given that the fifth open enrollment period was only 45 days.
Next, we examined the content of ads aired during the most recently concluded enrollment period. Among the 338,018 total airings, 3.4 percent (n=11,592) had errors in the video that prevented us from coding them. After removing these airings, 1,507 were airings of federally-sponsored ads, of which 97 percent were for Medicare, 3 percent were for the Children’s Health Insurance Program, and none (as expected) were for healthcare.gov. Among the others, 29,631 airings were from state marketplaces, 293,939 were from private sponsors, and 1,349 airings were from other sponsors, like health advocates.
Exhibit 1 shows the weekly volume of insurance advertisings by sponsor, from 2013 through the end of 2017. One important caveat to keep in mind when interpreting the figure is that Exhibit 1 displays the volume of all health insurance ads identified by Kantar Media/CMAG that aired over the period; the figure is not limited to airings by insurance companies that were marketing products available on the Marketplace versus off-Marketplace nor does it exclude ad airings of Medicare Advantage products or employer-sponsored insurance plans. A few patterns are worth noting. First, the 2013-2014 open enrollment period demonstrates a strikingly different pattern than the following periods, both in terms of the length of the open enrollment period (6 months) and the proportion of federal ads among the total. This suggests that it is likely inappropriate to extrapolate relationships between advertising and insurance outcomes in 2014 to the more recent periods.
Still, across all five open enrollment periods, private sponsors (insurance companies, brokers, health care systems) contributed the majority of advertising. Second, the majority of health insurance ads aired during time periods that correspond with the ACA open-enrollment periods (however, note that increases in airings preceded the start of the open enrollment period, likely those were for Medicare Advantage or other health insurance plans). Third, the most recent enrollment period had the highest peaks in weekly volume, but the peaks occurred during a shorter window of time, given that the fifth open enrollment period was only 45 days.
Next, we examined the content of ads aired during the most recently concluded enrollment period. Among the 338,018 total airings, 3.4 percent (n=11,592) had errors in the video that prevented us from coding them. After removing these airings, 1,507 were airings of federally-sponsored ads, of which 97 percent were for Medicare, 3 percent were for the Children’s Health Insurance Program, and none (as expected) were for healthcare.gov. Among the others, 29,631 airings were from state marketplaces, 293,939 were from private sponsors, and 1,349 airings were from other sponsors, like health advocates.
Within the private sponsor category, more than two-thirds of airings focused on Medicare plans. While such ads could still serve as reminders to consumers under age 65 about enrolling, we restrict our remaining content analysis to the non-Medicare focused airings. Among the non-Medicare ad airings by private sponsors, the majority (87.6 percent) were sponsored by insurance companies; the remainder were from health systems that were integrated with insurance providers (e.g., Kaiser) (9.4 percent), health systems (0.7 percent), and insurance brokers or insurance agencies (2.4 percent).
Exhibit 2 reports the frequency with which ads aired included key policy-relevant messages. Almost no ads mentioned Medicaid (<1 percent total) and very few mentioned the existence of penalties or fines for not having health insurance (around 2 percent of airings total, and 2.9 percent of private-sponsor ads). More ads (26.7 percent) referenced affordability of plans, more in state Marketplace ads (43.0 percent) and other sponsors (47.1 percent) than in private sponsor ads (21.5 percent). State-based marketplace ads frequently mentioned free or low-cost preventive services available (benefits attributable to the ACA regulatory changes); this appeal was rarely mentioned in other types of ads. Ads explicitly encouraging people to enroll (using words enroll or enrollment) were relatively common; almost all of the ads by advocate / other sponsors included such an appeal, as did three-quarters (76.8 percent) of state ads, and 22.5 percent of private sector ads.
While it is difficult to distinguish in this type of content analysis which ads, particularly among those sponsored by private insurance companies, have the potential to drive consumers to enroll in the ACA Marketplace, references to the individual Marketplace deadline (December 15, 2017) or referring to the ACA (whether by name or as Obamacare or health care law) offer a clue. Just over 1 in 4 (27.4 percent) ads sponsored by private insurers referenced the December 15 deadline, but only 5.7 percent referenced the health care law explicitly. For comparison, from 2013-2016, we found that 38.8 percent of insurance company ad airings mentioned the health care law, although there were significant declines in references to the law from the 2013-2014 period to the 2015-2016 period.
Consumers in the upcoming 2019 open enrollment period are likely to see high volumes of health insurance ads, if the trends reported in Exhibit 1 persist. Although in many places, they may be crowded out until after the 2018 midterms given the high volume of political advertising. The majority of these ad airings will be from health insurance companies (although states operating their own marketplaces are pursuing creative enrollment approaches as well).
Exhibit 2 reports the frequency with which ads aired included key policy-relevant messages. Almost no ads mentioned Medicaid (<1 percent total) and very few mentioned the existence of penalties or fines for not having health insurance (around 2 percent of airings total, and 2.9 percent of private-sponsor ads). More ads (26.7 percent) referenced affordability of plans, more in state Marketplace ads (43.0 percent) and other sponsors (47.1 percent) than in private sponsor ads (21.5 percent). State-based marketplace ads frequently mentioned free or low-cost preventive services available (benefits attributable to the ACA regulatory changes); this appeal was rarely mentioned in other types of ads. Ads explicitly encouraging people to enroll (using words enroll or enrollment) were relatively common; almost all of the ads by advocate / other sponsors included such an appeal, as did three-quarters (76.8 percent) of state ads, and 22.5 percent of private sector ads.
While it is difficult to distinguish in this type of content analysis which ads, particularly among those sponsored by private insurance companies, have the potential to drive consumers to enroll in the ACA Marketplace, references to the individual Marketplace deadline (December 15, 2017) or referring to the ACA (whether by name or as Obamacare or health care law) offer a clue. Just over 1 in 4 (27.4 percent) ads sponsored by private insurers referenced the December 15 deadline, but only 5.7 percent referenced the health care law explicitly. For comparison, from 2013-2016, we found that 38.8 percent of insurance company ad airings mentioned the health care law, although there were significant declines in references to the law from the 2013-2014 period to the 2015-2016 period.
Consumers in the upcoming 2019 open enrollment period are likely to see high volumes of health insurance ads, if the trends reported in Exhibit 1 persist. Although in many places, they may be crowded out until after the 2018 midterms given the high volume of political advertising. The majority of these ad airings will be from health insurance companies (although states operating their own marketplaces are pursuing creative enrollment approaches as well).
Our analysis of the 2018 period suggests that while the volume of advertising was high overall, the messages in these health insurance company ads were unlikely to fill the gap in messaging left by federal marketing. First, as noted in media reports, the goal of health insurer ads (as differentiated from navigators’ assistance and/or healthcare.gov marketing) is to promote a particular product, not the Marketplace in general.
Advertisements for non-ACA compliant plans are also likely to appear during the 2019 open enrollment period. Second, while some ads aired in 2017 did include messages about the federal deadline for enrollment, three-quarters did not, suggesting the ad appeals were not targeted to consumers using the federal Marketplace; they also rarely noted the still-in-existence penalty for not enrolling in health insurance. Third, few ads explicitly referenced the ACA, continuing a trend we observed in our recent research of private sector “submerging” of the federal government role in health insurance expansions.
These messages that consumers see will, along with other policy changes, likely influence enrollment. These messages also have political consequences for how the public understands the role of the ACA in shaping the health insurance options available to them in a rapidly changing political and health insurance environment.
Acknowledgements
We thank our Wesleyan Media Project coding team, including Sofia Headley, Dolly Haddad, Helen Klass-Warch, Daniel Meek, Ben Sullivan, and Sophie Townsend. We previously presented these findings at the June 2018 AcademyHealth Annual Research Meeting. We also acknowledge collaborators and co-authors on our paper available in advance view now in the Journal of Health Politics, Policy and Law referenced in this post, including Sachini Bandara, Kimberly T. Arnold, Jessie K. Pintor, Jeff Niederdeppe, and Pinar Karaca-Mandic.
Acknowledgements
We thank our Wesleyan Media Project coding team, including Sofia Headley, Dolly Haddad, Helen Klass-Warch, Daniel Meek, Ben Sullivan, and Sophie Townsend. We previously presented these findings at the June 2018 AcademyHealth Annual Research Meeting. We also acknowledge collaborators and co-authors on our paper available in advance view now in the Journal of Health Politics, Policy and Law referenced in this post, including Sachini Bandara, Kimberly T. Arnold, Jessie K. Pintor, Jeff Niederdeppe, and Pinar Karaca-Mandic.