By Justin Nisly | March 2017
INTRODUCTION: The Hardest Problem in America
On the morning of March 23, 2010, President Obama sat down in the East Room of the White House and used 22 pens to sign the Patient Protection and Affordable Care Act (ACA) into law.1
That signature capped the most contentious fight of his presidency with perhaps his most significant achievement.
He was surrounded by hundreds of health care leaders, some of whom had spent decades pushing for reform, including Ron Pollack, the man who would later found Enroll America. It was a moment to reflect and celebrate, given the long and frustrating history of health reform in America.
That history of failed attempts at reform stretched back almost a century to Teddy Roosevelt in 1912 and continued with President Franklin D. Roosevelt in the 1930s, and again with President Harry Truman in the 1940s.2 In 1965, President Lyndon Johnson made significant progress when he signed Medicare and Medicaid into law, providing coverage for those 65 and over as well as for some low-income and disabled people. In the 70s, leaders ranging from Senator Ted Kennedy to President Richard Nixon put forward national health insurance plans, but none actually passed. In the 90s, President Bill Clinton and then-First Lady Hillary Rodham Clinton tried again, an attempt which failed and left many convinced that national reform was permanently dead. By the time President Obama was elected in 2008 there was considerable grassroots momentum for coverage expansion and reform, but it would still take more than a year to successfully pass the law.
Finally, on a spring morning in 2010, with a few strokes of President Obama’s pens, it was done.
But in truth, the hard part was just beginning.
The new law did a lot to reform the broken U.S. health care system: eliminating lifetime caps on coverage, allowing children to stay on their parents’ plans until 26, defining essential benefits all plans must cover. But at its core, the ACA envisioned reducing the uninsured rate — then at a dire 16 percent among non-elderly adults — by expanding Medicaid to cover very low-income individuals, and by providing tax credits to help make private insurance plans affordable for the rest of the uninsured.
That meant that the more than 40 million3 people newly eligible for affordable coverage — the vast majority of whom had never heard of the ACA — would need to actively enroll in a system that didn’t even exist yet. And for many, they would have a time-limited yearly enrollment period in which to do it.
As any veteran of a national election or a commercial marketing campaign can tell you, getting millions of people to take a particular action is never easy — and it’s even more difficult when the action is something they’ve never done before. But if people didn’t sign up, this historic, hard-fought opportunity to finally extend affordable health coverage to millions of Americans would crash and burn, setting back reform efforts indefinitely — or even permanently.
The ACA tasked the Department of Health and Human Services (HHS) with creating the necessary policy and overseeing the creation of the infrastructure for online enrollment, and there was some budget for in-person application assistance and advertising. But the law did not contain any provisions or budget for coordinating an intensive, organized outreach effort. So who would be responsible for actually finding the millions of uninsured where they live, convincing them to enroll, and then answering their questions and shepherding them through the process?
Pollack, who had founded the prominent health care advocacy organization Families USA decades earlier, had been thinking about that question since well before the ACA was passed, and he discussed it with a broad range of leaders — from advocacy groups, to social service providers, hospitals, insurers, and pharmaceutical companies. To answer that question, in 2011, they announced the creation of Enroll America.
Pollack envisioned Enroll America as a temporary organization, a burst of energy and organizing to shepherd enrollment through the most difficult and critical early years. This is the story of Enroll America — how an organization that started with a handful of people in a wing of the Families USA office would transform into a massive field operation with more than 260 staff in 16 states, and then go on to build a lasting coalition of 6,700 partner organizations in all 50 states. But it’s also a story about America — and how a smart and scrappy group of organizers transformed the country, cutting the national uninsured rate nearly in half, lowering the uninsured rate across every demographic group, and giving millions of Americans the peace of mind that comes with quality, affordable health insurance.
It’s a story with timely lessons for organizations and movements in the years ahead.
ONE: The First Million is the Hardest
Things would get worse for the health reform efforts before they would get better. When ACA marketplace enrollment opened for the first time on October 1, 2013, with the whole world watching the most covered and controversial news story of the year, the HealthCare.gov website failed entirely.
No one in the 36 states that relied on the HealthCare.gov platform could get through to enroll. Weeks passed and journalists scrambled to find a single, actual person who had successfully enrolled. The conventional wisdom began to grow that the ACA was permanently doomed — the website would never fully recover, and the brand was so damaged that no one would enroll even if it did. The 7 million enrollee estimate from the Congressional Budget Office (CBO) certainly seemed out of reach.4 Opponents crowed that the health reform experiment was over, and even writers at sympathetic outlets began to question whether the ACA could succeed. In late November, for instance, Thomas B. Edsall headlined his weekly opinion column at The New York Times “The Obamacare Crisis” and asked “Is the federal government capable of managing the provision of a fundamental service through an extraordinarily complex system?” He went on to suggest that the website failures might be fatal not just for the ACA, but for future progressive initiatives as well.
So how did the ACA survive?
In his cover story “Code Red” for TIME 5 Stephen Brill has vividly told the story of the technical team brought in to rescue HealthCare.gov and the government leaders who fought to steady the ship, but far less known is the equally impressive story of the people who made sure that — despite the negative press, the website frustration, and the lost time — there would still be actual Americans lined up and ready to enroll if the website finally became usable.
Enroll America led that effort and the strengths that allowed them to successfully weather that storm were the result of careful planning in the year before the marketplace opened.
Back in January of 2013, Anne Filipic, who served as field director for President Obama’s crucial 2008 Iowa caucus victory and later held leadership roles at HHS and the White House, was hired as president of Enroll America. She was tasked with planning the Get Covered America campaign, a massive consumer-facing enrollment effort aimed at making sure the first enrollment period was a success.
Led by Filipic and Managing Director Chris Wyant, Enroll America’s leadership began weighing the daunting question of how to build a national outreach campaign more or less from scratch.
They started with a few principles: they would always keep the needs of consumers foremost, they would always be driven by data and metrics, and they would be grassroots focused and coalition-based.
There were a few similar efforts to draw lessons from — the enrollment effort in Massachusetts for instance — but none of the same scale or complexity. So Enroll America staff were determined to take cutting-edge techniques and technologies developed by electoral campaigns and private sector marketing efforts and apply them in innovative ways to the non-profit enrollment campaign they were developing.
The initial messaging research they did in the year before enrollment opened laid out the challenge in stark terms: 78 percent of uninsured consumers were unaware that new coverage options were available, and that number was even higher among Latinos and African Americans. Most people assumed they wouldn’t be able to afford a plan. So the enrollment coalition would need to overcome deep skepticism about the affordability and availability of plans, and that would take more than just a single conversation or advertisement.6
The next question was one of resources and of scale: in early 2013, Enroll America was able to quickly secure multi-million dollar grants to build a large outreach campaign from key organizations like the Robert Wood Johnson Foundation and Kaiser Permanente, but there would of course never be enough money to hire staff in every single community and state. It was here that the commitment to data paid dividends: analysis of 2011 and 2012 Census data showed that fully two-thirds of the uninsured lived in just 13 states, and half lived in just 4 percent of counties.7 That meant Enroll America could focus their staff, advertising, and other resources to maximize impact in those critical states, while continuing to support and coordinate with partners in all 50 states. To help direct resources at an even more granular level, Enroll America worked with the data firm Civis Analytics — using techniques pioneered during President Obama’s electoral campaign — to build the first accurate predictive model of who the uninsured were, and where they lived.8
Based on that data, Enroll America chose to focus the majority of their Get Covered America (GCA) campaign staff in 11 critical states with large uninsured populations: Arizona, Florida, Georgia, Illinois, Michigan, New Jersey, North Carolina, Ohio, Pennsylvania, Tennessee, and Texas. They also hired additional staff in five other states, including five Regional State Assistance Managers who would serve as conduits to and from partners in the unstaffed states.
By the time the Operations team, led by Jason Sparks,9 finished opening offices and onboarding these critical state organizing staff, the organization had grown from 8 staff in January 2013, to 186 staff in October 2013, peaking at 262 staff in January 2014.
Those organizers would become the life-blood of Enroll America, and the strength that set Enroll America apart from most other national and local groups. National groups could run ads and develop materials, and local groups had a finger on the pulse in their community; but neither could gather real time information from hundreds of communities across the country, collect it in one central place to analyze and develop guidance, and then share that guidance back out with the communities, as well as with national policymakers, politicians, and press.
When the website crashed at the beginning of October 2013, it was those organizers, and the local leaders they had engaged, that continued working behind the scenes to make sure the ACA could still be saved. As Stephanie Palla,10 who at the time oversaw communications for several Get Covered America campaign states, said, “There wasn’t really anything we could do except keep working and building our pool of partners and uninsured lists to make sure we were ready once [the website] finally was.” The relationships those organizers built with churches, synagogues, school districts, health clinics and food banks would eventually develop into the robust enrollment coalition still in place today. And critically, the conversations they were having with uninsured Americans were light years from the apocalyptic conversation in Washington, DC: people were frustrated, yes, but they were still hungry for affordable options and eager to learn more.
While opponents of the law gloated about the ongoing website problems, HHS retreated from the public eye to focus on repairing the website as quickly as possible. But because Enroll America was separate from the website issues and had a plan to follow and an ear to the ground, they were uniquely positioned to share a realistic but positive message that other national progressive groups could rally around. In October, for instance, Politico wrote:
Filipic said the problems aren’t such a big deal because advocates expected people to gather information in the first month — not necessarily enroll. “We never really expected October to be an enrollment month,” she said. She expects people to spend October learning about options and making choices. The big question right now is “Are people beginning that process?” she said.11
And in a November article titled “Website Problems Won’t Stop Obamacare Outreach,” the National Journal covered Filipic’s optimism, quoting her saying “With the disappointing rollout of HealthCare.gov, it’s become clear our role on the ground has never been more important.” Through much of October and November, that message was one of the only things maintaining the morale of the pro-reform coalition.
But by December, HHS’ incremental improvements to HealthCare.gov reached a point where they were visible to anyone visiting the website. Enrollments started to pick up, and Enroll America’s much-mocked confidence began to be vindicated. The question now was whether there was sufficient time for enrollment numbers to reach expectations.
The GCA campaign went into high gear, in coordination with national outreach efforts from groups like SEIU and Planned Parenthood. Since consumers needed more than one contact to enroll, Enroll America ramped up outreach in three different areas: 1) earned media, especially local TV and radio, 2) digital outreach, through targeted online advertising and social media, and 3) on-the-ground outreach using data driven grassroots organizing and trusted messengers like faith leaders, doctors, and public officials. The uninsured data model helped staff, volunteers and partners determine where to hold enrollment events, where to table and canvass, which ZIP codes should receive targeted digital ads, and which local news stations would be best to partner with to hold phone-a-thons. Once uninsured consumers were identified, Enroll America would connect them with assisters — navigators, Certified Application Counselors, and other organizations certified to provide enrollment assistance — to finish the enrollment process.
Of course, no plan survives first contact fully intact, and the structures Enroll America had built allowed them to quickly determine what was working, and then pivot the entire field team, volunteers, and partners in that direction. One early example of that was canvassing. A number of Enroll America employees came from political campaigns where canvassing — door to door targeted outreach by volunteers — is one of the most crucial tactics. The assumption was that it would play a central role in their new campaign as well.
But when organizers on the ground began to report up the chain that they were having more success tabling in high-traffic locations — grocery store parking lots, bus stops, malls — in their most critical turf, the Data & Analytics team, led by Matthew Saniie, decided to look at the problem empirically. They designed an experiment, and then, during a “Weekend of Action,” dispatched almost a dozen data staffers to different parts of the country with clickers, to shadow field staff and count how many consumer conversations it took to find an uninsured consumer using both methods. What they found clearly backed up the intuition of field staff: it was much more efficient to use the data model to target tabling outreach to high-traffic locations likely to have many uninsured people, than to spend time canvassing door to door. The switch was made, and the number of uninsured consumers identified began to accelerate.
Enrollment began to accelerate as well. By mid-January 2014, nearly 2.2 million people had enrolled, and interest was growing every day.12 To help assisters deal with the influx of demand, Enroll America organizers began experimenting with the most efficient ways to hold mass enrollment events. An early proof-of-concept came from Palm Beach county in Florida, where then organizer Florence French13 worked with the Health Foundation of South Florida to do focused outreach in a targeted ZIP code, inviting residents to an end-of-month event — more than 60 people attended, and about three quarters were able to enroll. Organizers collected best practices from similar successful events, and shared them across the country.
By the time the final March 31 deadline arrived, so many people were anxious to enroll that when Enroll America organizers Edward Vargas and Doris McNary helped organize a massive event in San Antonio at the Alamodome itself, lines stretched around the stadium, an image that played across every national cable news channel.14
When the dust settled and enrollment closed, Enroll America had reached 5 million Americans with enrollment information, through a combination of digital outreach, emails, enrollment events, and the efforts of more than 31,000 volunteers and more than 2,300 partner organizations.15 That work paid off: against all odds and expectations, more than 8 million people had enrolled in coverage through the marketplace, far exceeding the 7 million estimate from CBO.16 Another 4.8 million had already gained coverage through Medicaid and CHIP, which were open for enrollment year-round. By all accounts, the first enrollment period was a success.
TWO: Avoiding the Sophomore Slump
In the afterglow of the successful first enrollment period, the ACA enjoyed a belated honeymoon. Staff and partners who had been working long hours — sometimes seven days a week — for the previous six months were finally able to take well-deserved vacations. Press coverage was more positive than it had ever been — when The New York Times ran the first in what would be a yearly series of maps using Enroll America and Civis Analytics data to show the reduction in the uninsured rate thanks to the ACA, it was the most visited and shared article that month.17
But while it was tempting to savor the victory, Enroll America staff were also well-aware that they had just half a year to prepare for what would be, in many ways, an even trickier enrollment period: the easiest Americans to reach were already enrolled, so enrolling the smaller pool of remaining uninsured would be even more difficult. And, for the first time, almost 8 million Americans would also need to renew their coverage. Then there were the 2014 midterm elections, which would fall just days before the open enrollment period began, and would doubtless feature confusing misinformation from opponents of the law. All this, plus a much shorter window to enroll, cut from six months to just three.
So it was critical that Enroll America take a look at what just happened, learn what lessons they could, and make sure the coalition was prepared for what was to come.
The foundational question to answer before all of the others was whether or not Enroll America’s outreach and enrollment efforts actually had an impact, or if people would simply have enrolled anyway. The Robert Wood Johnson Foundation was also keenly interested in this question — as Enroll America’s largest funder, they had already invested millions in the effort; and given their long history of commitment to data-driven, effective giving, they wanted independent verification that their money was being well spent. So in early 2014, they hired the well-respected firm Mathematica Policy Research to conduct a rigorous evaluation of the Get Covered America Campaign, using both qualitative interviews with staff and partners, and quantitative analysis of official enrollment data.
After 5 months of close study during and after the first enrollment period, Mathematica posted their report, which found that Enroll America created
“an innovative outreach approach that uses data-driven, campaign-style methods to increase enrollment under the ACA… The Enroll America approach prioritized efficiency and evidence in ways more commonly associated with the private sector… This model included real-time tactical support conducted at a level of scope, rigor, and sophistication never seen, to our knowledge, in a public coverage program outreach effort.”18
Just as significantly, they analyzed the final enrollment data from the first enrollment period and found that states where Enroll America focused its efforts had 20 percent higher enrollment relative to enrollment estimates, compared to other states.19
So it was clear that the outreach was working — the next step was to determine which specific tactics were most effective, and then make sure staff, volunteers, and partners were ready to use them in the challenging open enrollment period to come. Enroll America focused on applying three major lessons from the first open enrollment period:
- Best Practices in Outreach and Enrollment
Midway through the first enrollment period, Enroll America commissioned a survey from communications research firm PerryUndem to determine the greatest obstacle to enrollment, and the most effective message to encourage enrollment. The results were clear: the chief obstacle was that people assumed (based on past experience) coverage was unaffordable, and the best message was the simple fact that financial help was available to help pay for a plan. Fully 8 in 10 Americans said they would purchase a plan if they could afford it, but 7 in 10 had no idea financial help was available.20 So Enroll America put together a Communicators Guide, shared it with partners, and used it to shape every press release, report, interview, brochure, graphing, training, and call script they created going forward.
- The need for repeated follow-up.
Though historically underinsured groups like young adults, African Americans and Latinos were initially more skeptical than others that they could afford coverage, data from the first enrollment period showed that consistent follow up could change that. African Americans, Latinos, and young people were all about twice as likely to enroll after their third follow-up conversation.21 So in addition to continuing direct outreach, Enroll America forged and expanded partnerships with groups that already had strong ties in those communities, including Young Invincibles; League of United Latin American Citizens; National Association of Hispanic Nurses; and Delta Sigma Theta Sorority, Incorporated; the prominent sorority with a commitment to service in the African-American community.
- The importance of in-person assisters.
Enroll America’s data from the first enrollment period showed that those who had help were almost twice as likely to successfully enroll.22 And assistance was particularly critical in historically underserved communities — African Americans and Latinos were 43 percent more likely to seek in-person assistance than their white counterparts.23
But Enroll America knew that actually connecting Americans to the assisters available in their community was difficult. Assisters were well-trained and dedicated, but federal funding was limited, so capacity was limited. To make matters worse, assisters might sit for hours unutilized during the week, only to be overwhelmed by demand at a weekend event, leading to long lines, long wait times, and fewer people helped. If there was a way to move some of those people in line to other time slots, and to help assisters plan for the right amount of demand, the number of people they could help would increase significantly.
Enroll America’s Digital team, led by Adam Stalker, considered the problem. In the first enrollment period, they had built a digital tool called the Get Covered Calculator, which allowed people to quickly get a personalized estimate of their premium costs and financial help, and a Get Covered Locator, which gave people the address of their nearest assister. The tools proved massively popular. What if there was also a tool that allowed Americans to go online and make a specific appointment with an assister in their area? And, on the backend, what if the tool functioned as an organizing system for assisters to see when they had appointments and assign the appropriate number of staff accordingly?
Again, Enroll America turned to the states for inspiration — during the first enrollment period, Legal Aid of North Carolina had built a statewide scheduling system and toll-free number that allowed callers to chat with an administrator who could slot them in to an appointment anywhere across the state. The Digital team set to work on a national version of that tool called the Get Covered Connector, which featured a simple webpage where anyone could find appointments just by entering their ZIP code. They also added features like text and email appointment reminders. The Field team, led by John Gilbert,24 set to work recruiting assister organizations across the country to add their appointments to the tool.
As the summer progressed and the November 15 open enrollment launch approached, Enroll America’s preparations flew largely under the radar. Unlike the first enrollment period, national attention was focused on the upcoming November 4, 2014 midterm elections. That meant it was much more difficult to share enrollment information through the press, and when opponents of the law gained ground in the election, there were fears that Americans would be discouraged from enrolling.
But when enrollment launched, it was clear the Administration had dramatically improved the consumer experience for enrollees, and all the hard work Enroll America had done during the summer of 2014 paid off. The Connector was up and running, and over the course of the enrollment period would offer nearly half a million appointments with more than 300 assister organizations in 24 states. The emphasis on building relationships with new partners also paid off, and the number of organizations engaged with enrollment outreach rose from 2,300 in the first enrollment period to 6,700 in the second. And with Enroll America’s guidance, the entire coalition was sending a unified message to both new enrollees and those who needed to renew. As Joanne Kenen wrote in Politico, “The themes this year, for the administration and its allies, are affordability and assistance, a more clearly defined zone than the general ‘go get yourself health insurance’ message of the opening year.”25
Nowhere was the increasing strength of the coalition more evident than in the final rush of demand before the February 15 deadline. In the first open enrollment period, people worked long hours and improvised clever solutions to keep the line moving in the face of overwhelming demand. In the second, experience and preparation meant the coalition was ready for whatever could be thrown at them. In San Antonio, for instance, where lines around the Alamodome had captivated the national imagination just a year before, there were no lines. There were no lines not because of reduced interest — more people were enrolling than ever — but because the coalition had split the Alamodome event into 10 Latino focused clinic events in different regions of the city, made them available through the Connector, and then distributed individual assisters to make sure that there was appropriate capacity at each site.26
In the last weekend of the second enrollment period alone, Enroll America helped host more than 275 mass enrollment events in 93 cities.27 Ultimately, in the face of reduced press coverage and volunteer base, Enroll America reached 6 million people, an increase of over a million from the previous year.28 And most importantly, enrollment continued to grow, reaching 11.7 million, a 46 percent increase over the previous year.29 The health insurance marketplace was not just a one-hit wonder. It was growing and getting stronger.
THREE: Preparing to Pass the Baton
By the spring of 2015, the enrollment effort was running smoothly, but Enroll America had a new and novel problem to solve: putting themselves out of business.
That had been the plan since Ron Pollack first dreamed up Enroll America: serve as the rocket fuel to get ACA enrollment into a stable orbit, and then step back. Sometimes that was a strength; as Jennifer Sullivan,30 Enroll America’s Vice President for Programs, said, “Being temporary freed us up to be nimble and get buy-in from partners that might otherwise have labeled us competitors or adversaries.”
But it also came with real risk; Enroll America’s digital tools, outreach best practices, and coalitions had become critical to the yearly enrollment effort. If those disappeared along with Enroll America, consumers would lose some of the critical support they needed to enroll. And with a Presidential election looming, there was no guarantee consumers could rely on the government for that support.
Enroll America staff saw a challenge, but also an opportunity. They had pioneered what Mathematica called an “innovative outreach approach” that “differs from those applied in the past by both community-based organizations and government funded agencies” by drawing on “real-time data and analytics to inform the activities of field organizers and volunteers.”31 What if they could make that model permanent, not by pursuing funding in perpetuity, but by embedding it in the longstanding local organizations that could continue the work for years to come?
But real, significant knowledge transfer between organizations is incredibly difficult, and typical one day trainings wouldn’t come close to actually allowing partners to implement and institutionalize the tactics Enroll America had pioneered.
So in the spring of 2015 — working from a model pioneered in Texas under the leadership of State Director Mimi Garcia — Enroll America’s national Training team began creating in-depth curriculum for a new program called the Get Covered Academy. Organizations who committed to joining the Academy would take part inintensive, multi-day, in-person workshops to develop the strengths and skills needed to run effective outreach campaigns. Then, they would put those skills to use during the third enrollment period, with regular, personalized coaching from experienced Enroll America staff. And they would set goals and track their progress so they could evaluate their strengths and weaknesses at the end of the process.
Interest was high, and in the summer of 2015, the initial Academy class kicked off with 166 organizations in 16 states participating.
But that wasn’t the only innovation happening during the summer of 2015. At Enroll America, the Best Practices Institute and the Digital team worked with Clear Health Analytics to build the Get Covered Plan Explorer, a plan comparison tool that for the first time used artificial intelligence technology to give users a personalized estimate of their health care costs for the year under each plan available to them. In the Communications shop, Paydon Miller oversaw the growth of the Get Covered Communicators program, which empowered more than 1,100 people from across the country to be spokespeople for the ACA to their local media. Enroll America expanded into significant new partnerships with hospital systems to help their patients get covered. Meanwhile, HHS continued to make improvements to HealthCare.gov, refined their own outreach and marketing tactics, and implemented a more robust program to follow up with those who started but did not finish applications.
So after the Supreme Court ruled in favor of the law in King v Burwell in June of 2015 — a lawsuit brought by political opponents against the financial assistance so critical to the ACA’s success — everything was in place for a successful third enrollment period.
When enrollment opened for the third time in November 2015, the Get Covered Academy proved to be a resounding success; graduates of the program more than doubled the number of Connector appointments they were able to schedule, compared to the average Connector user. Enrollment continued to grow as well: by the end of the third enrollment period, more than 12.7 million had enrolled through the marketplace.32
In its second year, during the summer of 2016, the Academy continued to grow, with 177 organizations representing 25 states taking part in the program, and Enroll America geared up for a successful enrollment period that would clear the way for them to step aside.
Then on November 8, 2016 — one week after the launch of the fourth enrollment period — Donald Trump was elected president, after running on a platform that called for the repeal of the Affordable Care Act.
Pundits predicted that the result would scare away enrollees, and ACA opponents promised to repeal the law on President Trump’s first day in office. But all of the lessons Enroll America and the coalition had learned — through the website failure, the midterms, King v Burwell — had taught them that Americans didn’t care about political posturing from Washington, they cared about what the law meant for them personally. In fact, the day after the election saw the highest number of marketplace enrollments in HealthCare.gov history — more than 100,000 people enrolled that day alone.33 So Enroll America kept organizing, kept holding enrollment events, and kept encouraging people to enroll.
For most of the enrollment period, enrollment was actually trending higher than the previous year. Then, in the final weeks, the new Administration pulled down some ACA advertising and follow-up, and enrollment slowed.
But despite all of those obstacles, more than 12.2 million ultimately enrolled, within 4 percent of the total from the previous year.34 While enrollment would likely have been higher if not for the Trump Administration’s decision to withhold some enrollment resources, demand remained strong for affordable health care options, and the enrollment coalition Enroll America helped to build was able to help millions find coverage in the face of overt political opposition.
CONCLUSION: Legacy and Lessons for an Uncertain Future
So what comes next?
On the one hand, millions have found coverage, and the uninsured rate has never been lower. The enrollment coalition is experienced, strong, and ready to build on that success, even once Enroll America closes its doors in the summer of 2017.
On the other hand, many leaders in Washington continue to insist they will repeal the ACA, returning Americans to the days when those with pre-existing conditions could be denied coverage, when there was no financial assistance to make sure coverage was affordable, and when insurers could end coverage just when consumers needed it most. The battle for health reform is now entering a new chapter, and no matter what happens in Washington, the success of the Enroll America experiment holds important lessons, not just for the health care sector but also for a wide range of other civic projects ranging from social program enrollment and voter registration drives to coalition efforts around immigration and climate change.
- Be specific in your mission — don’t try to boil the ocean.
An important aspect of Enroll America’s success was defining a clear, focused mission, and avoiding spreading the organization too thin. As Mathematica noted in their evaluation, “When we asked partners who would be doing this work if Enroll America were not, they consistently said that no one else in their state was doing this work; Enroll America was filling a need, not usurping an existing group’s work.”35 That sometimes meant worthy tasks — advocating for Medicaid expansion, becoming a Certified Application Counselor — were left to other capable groups so Enroll America could focus effectively on outreach.
- Make data your servant, not your master.
Enroll America found that “big data” can be an incredible tool, but only if it is placed in the service of smart, on-the-ground organizing. Just as on-the-ground experience taught Enroll America that tabling — and not canvassing — was the most effective way to use the revolutionary uninsured model data, decisions must come from both data and experience. Data can help organizers understand where and how to focus their work, who to recruit and train, and what tactics are most effective. But data needs to be interpreted by people with actual connections to the communities in which they work — otherwise it is prone to misinterpretation and mistakes.
- Trusted voices speak the loudest.
Over and over again, Enroll America found that the most effective messengers were the people that communities already trusted — the long-time city councilwoman, the imam or pastor or rabbi that knew everyone’s name, the school principal, the local doctor. Parachuting in simply doesn’t work. It’s much more effective to cultivate relationships with community leaders, ask them what they need, and then empower them to communicate to the target audience. As José Medrano,36 the Regional Director for the Rio Grande Valley put it, “People know their own communities. A game plan is good, but sometimes in that game you may need to […] change things up, listen to options, and just when you think you’ve got it, check yourself, again.”
- Digital tools aren’t just a flashy add-on — they’re critical to organizing diverse communities.
Sometimes it seems like every organization has an app, but no one has really thought about what the app is for. But in the smartphone era, many people — particularly young people and people of color — get much of their news online. So well-designed digital tools are an important way of reaching those communities. For instance, Enroll America allowed people to search the Get Covered Connector for appointments in the language of their choice, and during the third enrollment period, people scheduled appointments in 18 different languages. Those appointments were among the best-attended and most likely to result in an enrollment.37
- Make coalitions concrete.
It can be easy to dismiss talk of “partners” and “coalitions” because slapping some partner names on a website without any detail is a simple way for an organization that isn’t doing concrete work to exaggerate its impact. But the truth is that when done correctly, coalition work can exponentially expand the reach and effectiveness of a campaign. Enroll America was able to build successful coalitions by offering organizations real value that helped them fulfill their missions (trainings, event support, the Connector), making concrete asks (share information, host events), and carefully and honestly tracking the results of that work.
- Make coalitions broad.
One of Enroll America’s strengths was their ability to work with a broad coalition of partners — including some who were initially opposed to the passage of the ACA. By laying out a clear, specific mission — make it easier for Americans to enroll — they could effectively evaluate which unconventional partners might help further that goal, and which potential partners simply did not share sufficient common ground. That allowed Enroll America to work closely with progressive advocacy organizations, social service providers, insurers, web brokers, and both non-profit and for-profit hospital systems to support Americans looking for coverage.
Ultimately, following those guidelines allowed Enroll America to accomplish almost everything they set out to accomplish. Their part of the work is done — millions have enrolled, and the enrollment coalition is strong. If leaders in Washington give them the opportunity, the enrollment coalition is now perfectly capable — even without Enroll America’s help — of continuing to build on and expand the enrollment success seen thus far. Those leaders have a responsibility to do the right thing, and for the millions who rely on this coverage the stakes could not be higher.
Whether or not the ACA is ultimately repealed, replaced, repaired, or improved, Enroll America’s legacy will never be erased. Because the American people, having seen the progress that can be made when people come together to take care of each other and make health care accessible, will never be satisfied with reverting to the old status quo. Progress is not a straight line, but the country has been irrevocably changed by what Enroll America, and the enrollment coalition as a whole, has accomplished.
And in a more fundamental way, the Enroll America legacy can never be erased because that legacy is the people who are alive today because of the ACA and the efforts of the outreach coalition. People who went on to have kids, to start businesses, to take care of their aging parents, to play with their grandkids, to live. For Enroll America — staff, volunteers, partners — those lives, those family trees that have changed forever, are the best and most lasting legacy.
This report was written by Justin Nisly, National Communications Director.
Assistance was provided by Andrea Patton, Anne Filipic, Jason Sparks, Jennifer Sullivan, Kim Lehmkuhl, Meaghan Hardy, Molly Warren, and Sophie Stern.
The author would like to thank all of the dedicated Enroll America staff who have given so generously of their time, energy, and talent to make the world a kinder place for the most vulnerable in our communities. You wrote this history.
Enroll America would like to sincerely thank the dozens of funders, thousands of partner organizations, tens of thousands of volunteers, and all of the government and local leaders whose ongoing commitment has made the enrollment effort a success.
This report is dedicated to our constant guiding star: the everyday people we’ve had the honor to serve. You welcomed us into your lives and communities, you shared your stories with us, and you continue to inspire us every day.
1 “Obama Signs Health Care Overhaul Bill, With a Flourish,” by Sheryl Gay Stolberg and Robert Pear. New York Times, March 23, 2010. http://www.nytimes.com/2010/03/24/health/policy/24health.html.↩
2 “National Health Insurance—A Brief History of Reform Efforts in the U.S.” Kaiser Family Foundation, March 2009. https://kaiserfamilyfoundation.files.wordpress.com/2013/01/7871.pdf.↩
3 Centers for Medicare and Medicaid Services’ analysis of the 2011 American Community Survey. https://data.cms.gov/dataset/The-Number-of-Estimated-Eligible-Uninsured-People-/pc88-ec56.↩
4 “Health-care goal: 7M in 6 months,” by Jennifer Haberkorn. Politico, June 24, 2013. http://www.politico.com/story/2013/06/kathleen-sebelius-says-exchange-goal-is-7-million-by-march-093301.↩
5 “Code Red: Inside the nightmare launch of HealthCare.gov and the team that figured out how to fix it,” by Steven Brill. Time Magazine, March 10, 2014. https://blog.newrelic.com/wp-content/uploads/80893.pdf.↩
6 “State of Enrollment: Lessons Learned from Connecting America to Coverage, 2013-2014.” Enroll America, June 2014. https://s3.amazonaws.com/assets.getcoveredamerica.org/20140613_SOEReportPDFlr.pdf.↩
7 Census Bureau, Current Population Survey, March 2011 and 2012.↩
8 “A Formula to Find the Uninsured Around the Country,” by Margot Sanger-Katz and Kevin Quealy. New York Times, October 29, 2014. https://www.nytimes.com/2014/10/30/upshot/a-formula-to-find-the-uninsured-around-the-country.html.↩
9 Jason Sparks began his work at Enroll America as the National Operations Director, and was later promoted to Chief Operating Officer.↩
10 Stephanie Palla began her work at Enroll America as a Regional Communications Director, and was later promoted to National Regional Director↩
11 “Filipic: I feel ACA site ‘frustration’,” by Abby McIntyre. Politico, October 30, 2013. http://www.politico.com/story/2013/10/anne-filipic-healthcaregov-frustration-099089.↩
12 “HEALTH INSURANCE MARKETPLACE: JANUARY ENROLLMENT REPORT.” Office of the Assistant Secretary for Planning and Evaluation, January 13, 2014. https://aspe.hhs.gov/system/files/pdf/177611/ib_2014jan_enrollment.pdf.↩
13 Florence French was later promoted to Regional Director.r↩
14 “Just Hours Left Until Obamacare Deadline,” video by NBC Nightly News. March 31, 2014. http://www.nbcnews.com/video/nightly-news/54831372#54831372.↩
15 “INFOGRAPHIC: What Enroll America Accomplished.” Enroll America, April 1, 2014. https://www.enrollamerica.org/press-releases/2014/04/infographic-what-enroll-america-accomplished/.↩
16 “HEALTH INSURANCE MARKETPLACE: SUMMARY ENROLLMENT REPORT FOR THE INITIAL ANNUAL OPEN ENROLLMENT PERIOD.” Office of The Assistant Secretary for Planning And Evaluation, May 1, 2014. https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period.↩
17 “Obama’s Health Law: Who Was Helped Most,” by Kevin Quealy and Margo Sanger-Katz. New York Times, October 29, 2014. https://www.nytimes.com/interactive/2014/10/29/upshot/obamacare-who-was-helped-most.html?abt=0002&abg=0.↩
18 “Evaluation of Enroll America: An Implementation Assessment and Recommendations for Future Outreach Efforts,” by Sheila Hoag, Sean Orzol, and Cara Orfield. Mathematica Policy Research, July 28, 2014. PP. 20, 21 https://www.mathematica-mpr.com/our-publications-and-findings/publications/evaluation-of-enroll-america-an-implementation-assessment-and-recommendations-for-future-outreach.↩
19 “Evolution of Outreach: Evaluation of Enroll America’s Efforts to Support ACA Enrollment,” by Sheila Hoag, Cara Orfield, and Sean Orzol. Mathematic Policy Research, November 20, 2015. PP. 32, 33 https://www.mathematica-mpr.com/our-publications-and-findings/publications/evolution-of-outreach-evaluation-of-enroll-americas-efforts-to-support-aca-enrollment.↩
20 “The Uninsured Midway through ACA Open Enrollment: Results from a National Survey of Uninsured Adults 18 to 64 Conducted December 12 – 22, 2013.” PerryUndem Research/Communication. January 9, 2014. https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/uploads/2014/01/Perry_Undem_Uninsured_Survey.pdf.↩
21 “State of Enrollment: Lessons Learned from Connecting America to Coverage 2013-2014.” Enroll America, June 2014. PP. 40. https://s3.amazonaws.com/assets.getcoveredamerica.org/20140613_SOEReportPDFlr.pdf.↩
23 “In-Person Assistance Maximizes Enrollment Success.” Enroll America, March 2014.
24 John Gilbert was later promoted to Managing Director.↩
25 “The selling of Obamacare 2.0,” by Joanne Kenen. Politico, November 13, 2014.
26 “ObamaCare sprints across finish line,” by Sarah Ferris and Peter Sullivan. The Hill, February 15, 2015. http://thehill.com/policy/healthcare/232828-obamacare-sprints-across-finish-line.↩
27 “‘Countdown to Get Covered’ Update: 2 Days to the February 15 Deadline.” Enroll America, February 12, 2015. https://www.enrollamerica.org/press-releases/2015/02/countdown-to-get-covered-update-3-days-to-the-february-15-deadline/.↩
28 “INFOGRAPHIC: Enroll America Contacted 6 Million Consumers During Second Affordable Care Act Enrollment Cycle.” Enroll America, February 17, 2015. https://www.enrollamerica.org/press-releases/2015/02/infographic-enroll-america-contacted-6-million-consumers-during-second-affordable-care-act-enrollment-cycle/.↩
29 “HEALTH INSURANCE MARKETPLACE 2015 OPEN ENROLLMENT PERIOD: MARCH ENROLLMENT REPORT.” Office of the Assistant Secretary for Planning and Evaluation, March 10, 2015. https://aspe.hhs.gov/pdf-report/health-insurance-marketplace-2015-open-enrollment-period-march-enrollment-report.↩
30 Before her promotion to Vice President for Programs, Jennifer Sullivan was the Director of the Best Practices Institute at Enroll America.↩
31 “Institutionalizing Outreach: A Review of Enroll America’s Get Covered Academy Training Program,” by Cara Orfield, Amy Mangum, Sheila Hoag, and Sean Orzol. Mathematica Policy Research, September 16, 2016. https://www.mathematica-mpr.com/our-publications-and-findings/publications/institutionalizing-outreach-a-review-of-enroll-americas-get-covered-academy-training-program.↩
32 “HEALTH INSURANCE MARKETPLACE 2016 OPEN ENROLLMENT PERIOD: FINAL ENROLLMENT REPORT.” Office of the Assistant Secretary for Planning and Evaluation, March 11, 2016. https://aspe.hhs.gov/pdf-report/health-insurance-marketplaces-2016-open-enrollment-period-final-enrollment-report.↩
33 “Day after Trump victory, 100,000 people signed up for Obamacare,” by Jennifer Haberkorn. Politico, November 10, 2016. http://www.politico.com/story/2016/11/new-obamacare-sign-ups-trump-victory-231189.↩
34 “HEALTH INSURANCE MARKETPLACES 2017 OPEN ENROLLMENT PERIOD FINAL ENROLLMENT REPORT: NOVEMBER 1, 2016 – JANUARY 31, 2017.” Centers for Medicare & Medicaid Services, March 15, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-03-15.html.↩
35 “Evaluation of Enroll America: An Implementation Assessment and Recommendations for Future Outreach Efforts,” by Sheila Hoag, Sean Orzol, and Cara Orfield. Mathematica Policy Research, July 28, 2014. PP. 21 https://www.mathematica-mpr.com/our-publications-and-findings/publications/evaluation-of-enroll-america-an-implementation-assessment-and-recommendations-for-future-outreach.↩
36 Before his promotion to Regional Director, José Medrano was an Organizer at Enroll America.↩
37 “Making the Connection 2.0: Insights Into In-Person Assistance From the Get Covered Connector,” by Molly Warren. Enroll America, May 2016. https://www.enrollamerica.org/making-the-connection-2-0-insights-into-in-person-assistance-from-the-get-covered-connector/.↩