The president has recently appeared on Quora, on Ellen, and between two ferns to plug Obamacare. It's working, kind of. Younger people are signing up at a slightly faster pace, though the Obama administration is still desperate to recruit Millennials and other healthy people in large numbers.
But perhaps funny videos aren’t the best bait for something as unsexy, yet totally necessary, as health insurance. In fact, insurance is one of those dreary, procrastination-inducing things, like 401ks and organ donation, that’s just begging for some kind of nudgy solution. The kind that would maybe later appear on a Freakonomics episode, beginning with some guy seeing a scary flier about “deadlines” and ending with him getting his appendix removed for just a small co-pay.
The trouble is, scare tactics don't always work, either.
“It’s challenging to reach these people who have been outside of the health insurance system for so long,” Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation, told me. “Many people don't have experience signing up for health insurance coverage. It's hard to get the message to them in a way that will motivate them to take action.”
With the deadline to sign up for coverage just a few days away, health insurance experts think they’ve figured out some of the best strategies for prodding people to buy something they know little about and somehow don’t really like anyway. Here’s a look at some of them.
Make it about the fine
There’s been a tendency for people to think that the penalty for not enrolling in Obamacare will be too small to make a difference. It will only be $95, after all, or 1 percent of income—whichever is greater.
But that “1 percent” will get you. Someone who earns $40,000 would be on the hook for $400. And that’s just for the first year. In 2015, the fee rises to $325 per adult or 2 percent of household income, and in 2016 it’s $695 per adult or 2.5 percent of income. And again, that’s money for nothing—you’re not insured if you pay the fine.
As tax-filing season heats up, the size of the penalty has been taking many Obamacare refuse-nicks by surprise.
“They are not pleased,” tax preparer Susana Veamatahau Pau told KQED in California. “Some are just barely getting refunds. One got a refund that’s like $300. Their penalty is going to pretty much eat that up.”
Some health reform analysts think the state and federal exchanges haven’t done enough to emphasize these fees. Spots like “Between Two Ferns” are great for social media, but they might dwell too much on the cuddly, helpful side of insurance and overlook the razor-sharp teeth of the tax penalty.
Last year, Nevada’s state health exchange held focus groups with Nevadans who qualify for the federal subsidies to buy health insurance.
“All of the focus groups stated that they needed to know that there was a penalty for not having health insurance,” CJ Bawden, communications officer for the Nevada exchange, told me in an email. “None of the focus groups liked the penalty, but felt that it was of utmost importance to inform the public.”
So from August to October, the exchange pushed ads highlighting the penalty, with a voice-over saying things like, "Nevada Health Link is here to protect you from a fine on your taxes by helping you purchase state-approved health plans."
Did you get that? "Fine" and "taxes" = bad guy. Nevada Health Link = hero of the day. In reality, of course, they're part of the same law.
The state later transitioned to commercials like this one, which showcase the benefits of insurance and are backed by uplifting muzak:
Enroll America, a nonprofit that aims to increase Obamacare enrollment, told me they’ve also done some “message testing” to figure out how to frame the penalty. Their research suggested that the word “fine” has a better ring than “fee” or “penalty,” Enroll America spokesman Justin Nisly told me.
A recent email blast from the group included this symbol: "⚠" in the subject line.
“FACT:” it reads. “If you don’t sign up to find a plan soon, you could get hit with a fine.”
This follows the psychological principle of loss aversion, or the idea that people strongly prefer to avoid losing something they have to getting something new. And given the prevailing confusion over Obamacare, making that cost well-known might be a major step in the right direction.
Highlight the savings
Much of the Obamacare PR has extolled the protective perks of health coverage —that it enables a bro to do keg-stands without trepidation, and so forth. But while the benefits of good health are rarely appreciated until one falls ill, the benefits of money tend to be readily apparent to everyone.
Enroll America’s research, as well as that of others, points to affordability as the biggest hurdle to buying health insurance. And that makes sense: For years, people without employer-sponsored insurance had little help with their (typically pretty high) premiums on the open market.
“Because many of the uninsured have tried to purchase insurance in the past but couldn’t afford it, they need to hear that something has changed in order to revisit the possibility of purchasing insurance,” Nisly said.
The thing that’s changed is the subsidies Obamacare created, and groups like Enroll America have been pushing them extensively. The group's Get Covered Calculator is the most popular page on their website, Nisly told me, and ever since they re-tooled their digital ads to promote the subsidies, click-through rates increased by 16 percent.
Sign them up automatically
Of course, not even a Soviet propaganda maestro could craft an email that would coax Obamacare's most obstinate naysayers over to Healthcare.gov.
Pro-Obamacare groups haven’t ruled out analog strategies like door-knocking and phone-calling for demographics that are harder to reach digitally. Still, only 15 percent of the uninsured say they’ve received a phone call or in-person visit about Obamacare recently. Certain states have also put limits on how much help Obamacare advocates can provide.
But social science research suggests that even in-person efforts might not be enough. Humans are allergic to paperwork, it seems, even when the “paper” is a website. A 2005 study of company 401K plans, for example, shows that enrollment spikes from 30 percent to 90 percent when employees are signed up automatically, and then given the option to cancel. And enrollment in food stamps is 80 percent higher when paperwork is not just completed, but submitted, on behalf of the beneficiary. The Washington Post pointed out last year that enrollment in Massachusetts’ mandatory insurance system, the precursor to Obamacare, went smoothly in part because a quarter of the applicants were auto-enrolled. But aside from certain Medicaid patients, there's no auto-enrollment in Obamacare.
It might turn out that these groups just don’t catch everyone this time around. People will slack, they’ll miss the deadline, they won’t trust the site, they’ll live in a state that hasn’t expanded Medicaid—the pitfalls are endless. Some might not be spurred to action until they file their 2015 taxes and are smacked with an even heftier fine.
“It’s important to take the long view,” said Tolbert, the Kaiser Family Foundation analyst. “We're not going to get everyone signed up this year, and possibly not even next year.”
But eventually, she thinks, the Obamacare booster club will wear them down.