Health Insurance Exchanges: HHS Should Enhance Its Management of Open Enrollment Performance

Since 2014, millions of consumers have purchased health insurance from the exchanges established by the Patient Protection and Affordable Care Act. Consumers can enroll in coverage during an annual open enrollment period. HHS and others conduct outreach during this period to encourage enrollment and ensure the exchanges' long-term stability. HHS announced changes to its 2018 outreach, prompting concerns that fewer could enroll, potentially harming the exchanges' stability.

GAO was asked to examine outreach and enrollment for the exchanges using healthcare.gov. This report addresses (1) 2018 open enrollment outcomes and any factors that may have affected these outcomes, (2) HHS's outreach efforts for 2018, and (3) HHS's 2018 enrollment goals. GAO reviewed HHS documents and data on 2018 open enrollment results and outreach. GAO also interviewed officials from HHS and 23 stakeholders representing a range of perspectives, including those from 4 navigator organizations, 3 issuers, and 6 insurance departments, to obtain their non-generalizable views on factors that likely affected 2018 enrollment.

About 8.7 million consumers in 39 states enrolled in individual market health insurance plans offered on the exchanges through healthcare.gov during the open enrollment period for 2018 coverage. This was 5 percent less than the 9.2 million who enrolled for 2017 and continued a decline in enrollment from a peak of 9.6 million in 2016. Among the 23 stakeholders we interviewed representing a range of perspectives, most reported that plan affordability played a major role in exchange enrollment—both attracting and detracting from enrollment. In 2018, total premiums increased more than expected, and, as a result, plans may have been less affordable for consumers, which likely detracted from enrollment. However, most consumers receive tax credits to reduce their premiums, and stakeholders reported that plans were often more affordable for these consumers because higher premiums resulted in larger tax credits, which likely aided exchange enrollment. Stakeholders had mixed opinions on the effects that other factors, such as the impact of reductions in federal advertising and the shortened open enrollment period, might have had on enrollment.

The Department of Health and Human Services (HHS), which manages healthcare.gov enrollment, reduced consumer outreach for the 2018 open enrollment period:

HHS spent 90 percent less on its advertising for 2018 ($10 million) compared to 2017 ($100 million). Officials told us that the agency's approach for 2018 was to focus on low-cost, high-performing forms of advertising.

HHS reduced funding by 42 percent for navigator organizations—which provide in-person enrollment assistance for consumers—spending $37 million in 2018 compared to $63 million in 2017 due to a shift in administration priorities. HHS allocated the funding using data that it acknowledged were not reliable in December 2016. The lack of quality data may affect HHS's ability to effectively manage the navigator program.

Unlike in prior years, HHS did not set any numeric targets related to 2018 total healthcare.gov enrollment; officials told us that they instead focused on enhancing the consumer experience for the open enrollment period. Setting numeric targets would allow HHS to monitor and evaluate its overall performance, a key aspect of federal internal controls. Further, while HHS reported meeting its goal of enhancing the consumer experience, such as by improving healthcare.gov availability, it did not measure aspects of the consumer experience it had identified as key in 2017, such as successful outreach events. Absent a more complete assessment, HHS may not be able to fully assess its progress toward its goal of enhancing the consumer experience and may miss opportunities to improve other aspects of the consumer experience.

GAO is making three recommendations to HHS, including that it ensure the data it uses for determining navigator organization awards are accurate, set numeric enrollment targets, and assess other aspects of the consumer experience. HHS agreed with two recommendations, but disagreed with the need to set numeric targets. GAO maintains that such action is important.

Since 2014, millions of consumers have purchased individual market  health insurance plans through the health insurance exchanges—or  marketplaces—established under the Patient Protection and Affordable  Care Act (PPACA). PPACA directed each state to establish an  exchange—referred to as a state-based exchange—or elect to use the  federally facilitated exchange established by the Department of Health  and Human Services (HHS). Each year the exchanges offer an open  enrollment period during which eligible consumers may enroll in or  change their coverage. Consumers enroll in the federally facilitated  exchange though HHS’s healthcare.gov website, and some state-based  exchanges have chosen to also use healthcare.gov for enrollment. HHS  facilitates enrollment for states that use the healthcare.gov website and is  required to perform outreach and education activities to educate  consumers about the exchanges and to encourage enrollment.

Some health policy and insurance industry experts assert that the long- term stability of the exchanges will require sufficient levels of enrollment,  including enrollment among young or otherwise healthy individuals who  might be less likely to purchase health insurance. Specifically, bringing  these younger, healthier individuals into the exchanges would reduce  adverse selection—where less-healthy individuals who expect or plan for  high use of health care services disproportionately enroll in coverage  leading to higher premiums that can ultimately discourage healthy  individuals from enrolling. Some experts have also asserted that  consumer outreach plays a key role in reducing adverse selection. For  example, while sick individuals may be motivated to enroll in exchange  coverage to obtain their needed treatment, healthier individuals may need  to be reminded and encouraged to do so—which these experts contend is  the role of effective outreach.

Beginning with the open enrollment period for 2014 coverage—the  exchanges’ first open enrollment period—HHS conducted broad public  relations and advertising outreach to familiarize the public with the  availability of exchange coverage. However, beginning in 2017, HHS  announced several changes to its exchange outreach activities. For  example, it suspended certain planned marketing and advertising during  the final week of the 2017 open enrollment period and scaled back its  outreach efforts for the 2018 open enrollment period. In addition, the  agency reduced the length of the 2018 open enrollment period for states  using healthcare.gov for enrollment, from about 13 weeks to about 6  weeks. These changes led to questions among various stakeholders,  such as certain research and advocacy organizations, about whether the  number and health needs of those enrolled in the exchanges would meet  expectations or present challenges to the long-term stability of health  insurance markets. However, other research and advocacy organizations  contend that these and other changes collectively helped to simplify or  reduce unnecessary costs of the program. For the 2018 open enrollment  period, for example, HHS emphasized the availability of agents and  brokers that could assist consumers with enrollment and simplified its  enrollment process by allowing consumers to enroll in healthcare.gov  coverage through certain partner websites.

You asked us to examine how 2018 open enrollment period outcomes  compared to those for 2017 and to review how HHS’s outreach efforts  affected 2018 enrollment. In this report, we examine:  1.  how 2018 open enrollment outcomes for healthcare.gov compared  with those for 2017, and any factors that affected 2018 enrollment;  2.  how HHS’s outreach efforts for the 2018 open enrollment period  compared to those for 2017; and  3.  HHS’s 2018 enrollment goals for the health insurance exchanges.

To examine how 2018 open enrollment outcomes compared with those  for 2017 and any factors that may have affected 2018 enrollment, we  examined HHS data on 2017 and 2018 open enrollment period results for  the 39 states that used the federal healthcare.gov website for enrollment.  We also reviewed HHS data on open enrollment period results for 2016  for additional context. To assess these data for reliability, we reviewed  supporting documentation, examined trends reported in these data, and  interviewed HHS officials. We found the data sufficiently reliable for the  purposes of our reporting objective. We also analyzed HHS information,  interviewed health policy experts, and reviewed publications by these  experts related to exchange enrollment to identify factors that had the  potential to affect 2018 enrollment. (See app. I for a list of these factors.)  Using this list of factors, we conducted structured interviews with officials  from 23 stakeholder organizations to gather their viewpoints as to  whether and how these or other factors affected 2018 health insurance  exchange enrollment. We selected organizations to reflect a wide range  of perspectives and included HHS-funded navigator organizations that  provide in-person consumer enrollment assistance, issuers, state  insurance departments, professional trade organizations, research and  advocacy organizations, and state-based exchanges. We identified  themes for reporting according to our analysis of the frequency with which  the stakeholders we interviewed identified factors as having a certain  impact. While we selected stakeholders to include a broad range of  perspectives, their viewpoints are not generalizable beyond the 23  organizations included in our interviews. Additional information about the  stakeholders we interviewed is presented in appendix II.

To examine how HHS’s outreach efforts for the 2018 open enrollment  period compared to those for 2017, we obtained and reviewed HHS data  from both periods, including its budgets for advertising and navigator  funding, and its allocation of that funding to various advertising  techniques and to navigator organizations. We also reviewed associated  HHS documentation, including a study on the effectiveness of advertising  during the 2017 open enrollment period and documentation of HHS’s  navigator organization funding process. In addition, we reviewed relevant  PPACA provisions and HHS regulations and guidance and interviewed  officials from HHS to learn more about the agency’s outreach efforts for  both open enrollment periods. We interviewed representatives from our  selected navigator organizations and a group that hosts an online  community for navigators to obtain additional context. We reviewed self- reported data that all navigator organizations provided to HHS on the  number of outreach events they performed during the 2017 and 2018  open enrollment periods. We also reviewed information HHS published  about its outreach for both open enrollment periods, and compared HHS’s  outreach efforts to relevant standards for internal control in the federal  government.

To examine HHS’s 2018 enrollment goals for the health insurance  exchanges, we interviewed HHS officials to understand their goals for the  enrollment period and compared them to relevant federal internal control  standards. To examine the agency’s performance with respect to its  goals, we reviewed relevant performance data. To assess these data for  reliability, we interviewed agency officials and examined trends in the  data. We found the data sufficiently reliable for the purposes of our  reporting objective.

We conducted this performance audit from September 2017 to July 2018  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Considerations for Exchange Enrollment and Plan Selection

Qualified health plans sold through the exchanges must meet certain  minimum requirements, including those related to benefits coverage.  Beyond these requirements, many elements of plans can vary, including  their cost and availability. Those who opt to enroll in a plan generally pay  for their health care in two ways: (1) a premium to purchase the  insurance, and (2) cost-sharing for the particular health services they  receive (for example, deductibles, coinsurance, and co-payments).

Qualified health plans are offered at one of four metal tiers that reflect the  out-of-pocket costs that may be incurred by a consumer. These tiers  correspond to the plan’s actuarial value—a measure of the relative  generosity of a plan’s benefits that is expressed as a percentage of the  covered medical expenses expected to be paid, on average, by the issuer  for a standard population and set of allowed charges for in-network  providers. In general, as actuarial value increases, consumer cost- sharing decreases. The actuarial values of the metal tiers are: bronze (60  percent), silver (70 percent), gold (80 percent), and platinum (90  percent). If an issuer sells a qualified health plan on an exchange, it  must offer at least one plan at the silver level and one plan at the gold  level; issuers are not required to offer bronze or platinum plans.

Individuals purchasing coverage through the exchanges may be eligible,  depending on their incomes, to receive financial assistance to offset the  costs of their coverage. According to HHS, more than 80 percent of  enrollees obtained financial assistance in the first half of 2017, which  came in the form of premium tax credits or cost-sharing reductions.

Premium tax credits. These are designed to reduce an eligible  individual’s premium costs, and can either be paid in advance on a  monthly basis to an enrollee’s issuer—referred to as advance  premium tax credits—or received after filing federal income taxes for  the prior year. To be eligible for premium tax credits, enrollees must  generally have household incomes of at least 100, but no more than  400, percent of the federal poverty level. The amount of the  premium tax credit varies based on enrollees’ income relative to the  cost of premiums for their local benchmark plan—which is the second  lowest cost silver plan available—but consumers do not need to be  enrolled in the benchmark plan in order to be eligible for these tax  credits.

Cost-sharing reductions. Enrollees who qualify for premium tax  credits, have household incomes between 100 and 250 percent of the  federal poverty level, and enroll in a silver tier plan may also be  eligible to receive cost-sharing reductions, which lower enrollees’  deductibles, coinsurance, and co-payments.

To reimburse issuers for reduced cost-sharing from qualified enrollees,  HHS made payments to issuers (referred to as cost-sharing reduction  payments) until October 2017, when it discontinued these payments.  Despite HHS’s decision to discontinue cost-sharing reduction payments,  issuers are still required under PPACA to offer cost-sharing reductions to  eligible enrollees. Since consumers who receive these reductions are  generally enrolled in silver plans, insurance commissioners in most states  instructed the issuers in their states to increase 2018 premiums for silver  plans offered on the exchanges to reflect the discontinued federal  payments. This has been referred to as “silver-loading” and resulted in  substantial increases in exchange-based silver plan premiums for 2018. (See fig.1.) Because the amount of an eligible enrollee’s premium tax  credit is based on the premium for the enrollee’s local benchmark plan  (the second lowest cost silver plan available to an enrollee), the value of  this form of financial assistance also increased significantly for 2018.

As we have previously reported, the number and type of plans available  in the health insurance exchanges varies from year to year. Issuers can  add new plans and adjust or discontinue existing plans from year to year,  as long as the plans meet certain minimum requirements—such as  covering essential health benefits. Issuers can also extend or restrict the  locations in which they offer plans. According to HHS, while individuals  seeking 2018 coverage were able to select from an average of 25 plans  across the various metal tiers, 29 percent of consumers were able to  select from plans from only one issuer.

HHS performs outreach to increase awareness of the open enrollment  period and facilitate enrollment among healthcare.gov consumers— including those new to the exchanges as well as those returning to renew  their coverage. Outreach to these different types of enrollees can vary.  For example, while outreach to those new to the exchanges may focus  more on the importance of having insurance, outreach to existing  enrollees may focus on encouraging them to go back to the exchange to  shop for the best option.

All exchanges are required to carry out certain functions to assist  consumers with their applications for enrollment and financial assistance,  among other things. HHS requires exchanges to operate a website and  toll-free call center to address the needs of consumers requesting  assistance with enrollment, and to conduct outreach and educational  activities to help consumers make informed decisions about their health  insurance options. HHS administers the federal healthcare.gov website,  which allows consumers in states using the website for enrollment to  directly compare health plans based on a variety of factors, such as  premiums and provider networks. HHS also operates a Marketplace Call  Center to respond to consumer questions about enrollment. Consumers  may apply for coverage through the call center, the website, via mail, or in  person (in some areas), with assistance from navigator organizations or  agents and brokers.

Navigators. PPACA required all exchanges to establish “navigator”  programs to conduct public education activities to raise awareness of  the availability of coverage available through the exchanges, among  other things. As part of HHS’s funding agreement with navigator  organizations in states using the federally facilitated exchange, HHS  requires them to maintain relationships with consumers who are  uninsured or underinsured. They must also examine consumers’  eligibility for other government health programs, such as Medicaid,  and provide other assistance to consumers—for example, by helping  them understand how to access their coverage.

Agents and Brokers. Licensed by states, agents and brokers may  also provide assistance to those seeking to enroll in a health plan sold  on the exchanges; however, they are generally paid by issuers. They  may sell products for one issuer from which they receive a salary, or  from a variety of issuers and be paid a commission for each plan they  sell.

Enrollment through Healthcare.gov Was 5 Percent Lower in 2018 than 2017, and Stakeholders Reported That Plan Affordability Likely Played a Major Role in Enrollment

Exchange Enrollment through Healthcare.gov Was 5 Percent Lower in 2018 than 2017

About 8.7 million consumers enrolled in healthcare.gov plans during the  open enrollment period for 2018 coverage, 5 percent less than the 9.2  million who enrolled for 2017. This decline continues a trend from 2016,  when a peak of 9.6 million consumers enrolled in such plans. Since that  peak, enrollment has decreased by 9 percent. Enrollment in plans sold by  state-based exchanges that use their own enrollment website has  remained relatively stable during the same time period, with just over 3.0  million enrollees each year since 2016. Overall, enrollment in federal and  state exchanges has declined 7 percent from a peak of nearly 12.7 million  enrollees in 2016, largely driven by the decrease in enrollment in  exchanges using healthcare.gov. (See table 1.) HHS officials told us that  they did not want to speculate on the specific factors that affected  enrollment this year, but noted that the exchanges are designed for  consumers to utilize as needed, which includes degrees of fluctuation  from year to year. A decreased demand for exchange-based insurance  could be influenced by increases in the numbers of people with other  types of health coverage, such as coverage through other public  programs, or that which is sponsored by their employers.

Enrollees who were new to healthcare.gov coverage comprised a smaller  proportion of total enrollees in 2018 than in 2017, continuing a trend seen  in prior years. The proportion of new enrollees decreased from 33 percent  (3 million) in 2017 to 28 percent (2.5 million) in 2018 (see fig. 2). Some  stakeholders noted the importance of enrolling new, healthy enrollees  each year to maintain the long-term viability of the exchanges. However,  other stakeholders noted that they had expected the number and  proportion of new enrollees to decrease over time because a large  majority of those who wanted coverage and were eligible for financial  assistance had likely already enrolled. The increasing proportion of  enrollees who return to the exchanges for their coverage could also  demonstrate their need for or satisfaction with this coverage option.

The demographic characteristics of enrollees remained largely constant  from 2017 through 2018. For example, the proportion of enrollees with  household incomes of 100 to 250 percent of the federal poverty level  remained similar at 71 percent in 2017 and 70 percent in 2018. In  addition, the proportion of enrollees whose households were located in  rural areas was 18 percent in both years. However, the proportion of  healthcare.gov enrollees aged 55 and older increased from 27 percent in  2017 to 29 percent in 2018. Appendix III provides detailed information on  the characteristics of enrollees in 2017 and 2018.

Stakeholders Reported That Plan Affordability Likely Played a Major Role in 2018 Exchange Enrollment and Plan Selection

According to stakeholders we interviewed, plan affordability likely played  a major role in 2018 exchange enrollment—both attracting and detracting  from enrollment—and enrollees’ plan selection. In 2018, premiums across  all healthcare.gov plans increased an average of 30 percent—more than  expected given overall health cost trends. As a result of these premium  increases, plans were less affordable in 2018 compared to 2017 for  exchange consumers without advance premium tax credits (15 percent in  2018). One driver of these premium increases was the elimination of  federal cost-sharing reduction payments to issuers in late 2017, which  resulted in larger premium increases for silver tier plans (the most popular  healthcare.gov metal tier). For example, among enrollees who did not use  advance premium tax credits, the average monthly premium amount paid  for silver plans increased 45 percent (from $424 in 2017 to $614 in 2018).  Average premiums for these enrollees also increased for bronze and gold  plans, but not by as much—22 percent for bronze plans (from $374 in  2017 to $455 in 2018) and 23 percent for gold plans (from $509 in 2017  to $628 in 2018). Most stakeholders we interviewed told us the decreased  affordability of plans likely resulted in lower enrollment in exchange plans  for these consumers. Some stakeholders we interviewed reported  personally encouraging consumers who were not eligible for premium tax  credits to purchase their coverage off of the exchanges, where they could  often purchase the same health insurance plan for a lower price.

However, despite overall premium increases, plans became more  affordable for the more than 85 percent of exchange consumers who  used advance premium tax credits, because the value of the premium tax  credits increased significantly in order to compensate for the higher  premiums of silver plans. For example, the average value of monthly  advance premium tax credits for those enrolled in any exchange plan  increased 44 percent, from $383 in 2017 to $550 in 2018—the largest  increase in the program’s history. As a result, enrollees who used  advance premium tax credits faced lower net monthly premiums on  average in 2018 than they had in 2017—specifically, enrollees’ average  net monthly premiums across all plans decreased 16 percent from $106  in 2017 to $89 in 2018. According to most stakeholders we interviewed,  the enhanced affordability of net monthly premiums among consumers  who used advance premium tax credits likely encouraged enrollment  among this group. (See fig. 3).

Stakeholders we interviewed also noted that plan affordability likely  played a major role in enrollees’ plan selection, including the metal tier of  their coverage. This finding is consistent with our prior work which  showed that plan cost—including premiums—is a driving factor in  exchange enrollees’ selection of a plan. Specifically, we found that while  silver plans remained the most popular healthcare.gov metal tier,  covering 65 percent of all enrollees in 2018, this proportion decreased 9  percentage points from 2017 as more enrollees selected bronze and gold  plans. (See fig. 4.)

Stakeholders reported that consumers using advance premium tax credits  benefitted from enhanced purchasing power in 2018 due to the impact of  silver loading, which likely served as a driving factor in these consumers’  plan selections. Specifically, they noted that the increased availability of  free bronze and low-cost gold plans (after tax credits were applied) for  such consumers likely explained why many enrollees moved from silver  to bronze or gold plans for 2018. While average monthly net premiums  paid by these consumers decreased overall from 2017 to 2018 due to the  tax credits, the changes were most pronounced for those enrolled in  bronze or gold plans (which decreased 36 and 39 percent, respectively),  compared to silver plans (which decreased 13 percent). Separately, the  enhanced affordability of gold plans, along with the richer benefits they  offer, likely led some consumers to move from silver to gold plans in  2018. While the average monthly net premium amount paid for gold plans  in 2018 ($207) remained higher than that for less generous silver plans  ($88) among those using advance premium tax credits, it was nearly 40  percent lower than the average net premium for gold plans in 2017  ($340). Stakeholders also reported that consumers in some areas were  able to access gold plans for a lower cost than silver plans. The  proportion of enrollees in gold plans using advance premium tax credits  increased from 49 percent to 74 percent—signaling that many enrollees  used their higher tax credits to enroll in richer gold plan coverage.

As the proportion of enrollees with silver plans declined for 2018, so too  did the proportion of enrollees with cost-sharing reductions—which are  generally only available to those with silver plans. Specifically, 54  percent of healthcare.gov enrollees received these subsidies in 2018, 6  percentage points lower than the 60 percent who received these  subsidies in 2017.

Stakeholders Reported That a Variety of Other Factors Likely Affected 2018 Enrollment

Stakeholders we interviewed reported that a variety of factors other than  plan affordability also likely affected 2018 exchange enrollment, but  opinions on the impact of each factor were mixed. Specifically, most  stakeholders we interviewed, including all 4 navigator organizations and 3  professional trade organizations, reported that consumer confusion about  PPACA and its status likely played a major role in detracting from 2018  healthcare.gov enrollment. Some of these stakeholders attributed  consumers’ confusion about the exchanges to efforts to repeal and  replace PPACA. In addition, many stakeholders attributed consumer  confusion to the Administration’s negative statements about PPACA.  Further, many stakeholders reported that as a result of the public debate  during 2017 over whether to repeal and replace PPACA many consumers  had questions about whether the law had been repealed and whether  insurance coverage was still available through the exchanges. However,  other stakeholders reported that this debate likely did not affect  enrollment and consumers who were in need of exchange-based  coverage were likely able to find the information they required to enroll. In  addition, many stakeholders noted that consumer understanding and  enrollment was aided through increased outreach and education events  conducted by many groups, including some state and local governments,  hospitals, issuers, and community groups. Many stakeholders also noted  that the volume of exchange-related news increased significantly before  and during the open enrollment period for 2018 coverage, in part due to  the ongoing political debate about the future of the exchanges. These  stakeholders agreed that this increase in reporting about the exchanges  likely resulted in increased consumer awareness and enrollment, even in  cases where the coverage negatively portrayed the exchanges.

Many stakeholders also said that reductions in HHS outreach and  advertising of the open enrollment period likely detracted from 2018  enrollment, in part because any reduction in promoting enrollment  detracts from overall consumer awareness and understanding of the  program and its open enrollment period. In particular, some  stakeholders reported that outreach and advertising are especially  important for increasing new enrollment, especially among younger and  healthier consumers whose enrollment can help ensure the long-term  stability of the exchanges. However, other stakeholders reported that  these reductions likely had no effect on enrollment, noting that most  consumers who needed exchange-based coverage were already enrolled  in it and were well aware of the program, and also noting that enrollment  in 2018 did not dramatically change compared with that of 2017.

Stakeholders we interviewed were largely divided on the effects of other  factors on 2018 healthcare.gov enrollment, including the shorter 6-week  open enrollment period. For example, about half of the stakeholders said  that the shorter open enrollment period likely led fewer to enroll due to  lack of consumer awareness of the new deadline, as well as to  challenges related to the reduced capacity of those helping consumers to  enroll. However, many others said that the shorter open enrollment period  likely had no effect. In particular, some of these stakeholders noted that  enrollment in 2018 was similar to that for 2017 and that during prior open  enrollment periods the majority of consumers had enrolled by December  15, as this was the deadline for coverage that began in January. Figure  5 displays the range of stakeholder views on factors affecting 2018  healthcare.gov enrollment, and appendix IV provides selected  stakeholder views of factors affecting 2018 healthcare.gov enrollment.

HHS Reduced Consumer Outreach for 2018 and Used Problematic Data to Allocate Navigator Funding

HHS reduced its consumer outreach—including paid advertising and  navigator funding—for the 2018 open enrollment period. Further, HHS  allocated the navigator funding using a narrower approach and  problematic data, including consumer application data that it  acknowledged were unreliable and navigator organization-reported goal  data that were based on an unclear description of the goal, and which  HHS and navigator organizations likely interpreted differently.

HHS reduced the amount it spent on paid advertising for the 2018 open  enrollment period by 90 percent, spending $10 million as compared to the  $100 million it spent for the 2017 open enrollment period. HHS officials  reported that their 2018 advertising approach was a success, noting that  they cut wasteful spending on advertising, which resulted in a more cost- effective approach. HHS officials told us that the agency elected to  reduce funding for paid advertising to better align with its spending on  paid advertising for the Medicare open enrollment period. According to  the officials, HHS targeted its reduced funding toward low-cost forms of  paid advertising that HHS studies showed were effective in driving  enrollment, and that could be targeted to specific populations, such as  individuals aged 18 to 34 and individuals who had previously visited  healthcare.gov. For example, for 2018, HHS spent about 40 percent of its  paid advertising budget on two forms of advertising aimed at reaching  these populations.

Specifically, HHS spent $1.2 million on the creation of two digital  advertising videos that were targeted to potential young enrollees, and  $2.7 million on search advertising, in which Internet search engines  displayed a link to healthcare.gov when individuals used relevant search  terms. HHS followed up with individuals that visited the link to encourage  them to enroll. Agency officials said they focused some of their paid  advertising on individuals aged 18 to 34 because in the prior open  enrollment period many individuals in this age range enrolled after  December 15—the deadline for the 2018 open enrollment period. HHS  officials said they did not use paid television advertising because it was  too expensive and because it was not optimal for attracting young  enrollees—although a 2017 HHS study found this was one of the most  effective forms of paid advertising for enrolling new and returning  individuals during the prior open enrollment period. See appendix V for  HHS’s expenditures for paid advertising for the 2017 and 2018 open  enrollment periods.

HHS Reduced Navigator Funding and Used a Narrower Approach and Problematic Data to Allocate It

HHS reduced navigator funding by 42 percent for 2018, spending $37  million compared to the $63 million it spent for 2017. According to HHS  officials, the agency reduced this funding due to a shift in the  Administration’s priorities. For the 2018 open enrollment period, HHS  planned to rely more heavily on agents and brokers—another source of  in-person consumer assistance, who, unlike navigator organizations that  are funded through federal grants, are generally paid for by the issuers  they represent. HHS took steps to highlight their availability to help  consumers and enable consumers to enroll through them. For example,  for the 2018 open enrollment period, HHS made a new “Help on Demand”  tool available on healthcare.gov that connected consumers directly to  local agents or brokers. HHS also developed a streamlined enrollment  process for those enrolling through agents and brokers.

HHS also changed its approach for allocating the navigator funding to  focus on a narrower measure of navigator organization performance than  it had used in the past. According to HHS officials, in prior years, HHS  awarded funding based on navigator organizations’ performance on a  variety of tasks, such as the extent to which navigator organizations met  their self-imposed goals for numbers of public outreach events and  individuals assisted with applications for exchange coverage and  selection of exchange plans. HHS officials said the agency previously  also took state-specific factors, such as the number of uninsured  individuals in a state, into account when awarding funding. HHS  calculated preliminary navigator funding awards for 2018 using this  approach. However, according to HHS officials, the agency later  decided to change both its budget and approach for allocating navigator  funding for 2018 to hold navigator organizations more accountable for the  number of individuals they enrolled in exchange plans. In its new funding  allocation approach, rather than taking into account navigator  organization performance on a variety of tasks, HHS only considered  performance in achieving one goal—the number of individuals each  navigator organization planned to assist with selecting or enrolling in  exchange plans for 2017 coverage. In implementing this new approach,  HHS compared the number of enrollees whose 2017 exchange coverage  applications included navigator identification numbers with each navigator  organization’s self-imposed goal. For navigator organizations that did not  appear to meet their goals, HHS decreased their preliminary 2018 award  amounts proportionately. For navigator organizations that appeared to  meet or exceed their goals, HHS left their preliminary 2018 award  amounts unchanged. Based on this change in approach, HHS offered 81  of its 98 navigator organizations less funding for 2018, with decreases  ranging from less than 1 percent to 98 percent of 2017 funding levels.  HHS offered 4 of the 98 navigator organizations increased funding and 13  the same level of funding they received for 2017 (see fig. 6).

We found that the data HHS used for its revised funding approach were  problematic for multiple reasons. In particular, prior to using the 2017  consumer application data as part of its 2018 funding calculations, HHS  had acknowledged that these data were unreliable, in part because  navigators were not consistently entering their identification numbers into  applications during the 2017 open enrollment period. Specifically, HHS  stated in a December 9, 2016, email to navigator organizations that the  application data were unreliable and thus could not be used. Over 4  million individuals had enrolled in 2017 coverage by December 10, 2016,  so it is likely that many of the applications that HHS used in its 2018  funding calculation included incomplete or inaccurate information with  respect to navigator assistance. HHS provided guidance to navigator  organizations in the December 2016 email on the importance of, and  locations for, entering identification numbers into applications to help  improve the reliability of the data. However, some data reliability issues  may have remained throughout the 2018 open enrollment period, as two  of the navigator organizations we interviewed reported ongoing  challenges entering navigator identification numbers into applications  during this period. For example, representatives from one navigator  organization reported that the application field where navigators enter  their identification number was at times pre-populated with an agent or  broker’s identification number. Consumer application data may therefore  still be unreliable for use in HHS navigator funding decisions that would  be expected later this year for 2019.

Moreover, the 2017 goal data that HHS used in its funding calculation  were also problematic because HHS described the goal in an unclear  manner when it asked navigator organizations to set their goals. As a  result, HHS’s interpretation of the goal was likely different than how it was  interpreted and established by navigator organizations. Specifically, in  its award application instructions, HHS asked navigator organizations to  provide a goal for the number of individuals that they “expected to be  assisted with selecting/enrolling in  (including re- enrollments)” but HHS did not provide guidance to navigator  organizations on how it would interpret the goal. HHS officials told us  that they wanted to allow navigator organizations full discretion in setting  their goals, since the organizations know their communities best. In its  funding calculation, HHS interpreted this goal as the number of  individuals navigator organizations planned to enroll in exchange plans.  However, as written in the award application instructions, the goal could  be interpreted more broadly, because not all individuals whom navigators  assist with the selection of exchange plans ultimately apply and enroll in  coverage. Representatives from one navigator organization we spoke  with said they did interpret this goal more broadly than how it was  ultimately interpreted by HHS—and thus set it as the number of  consumers they planned to assist in a variety of ways, not limiting it to  those they expected to assist through to the final step of enrollment in  coverage. The navigator organization therefore set a higher goal than it  otherwise would have, had it understood HHS’s interpretation of the goal,  and ultimately received a decrease in funding for 2018.

As a result, we found that two of the three inputs in HHS’s calculation of  2018 navigator organization awards were problematic (see fig. 7).

HHS’s reduced funding and revised funding allocation approach resulted  in a range of implications for navigator organizations. According to HHS  officials, eight of the navigator organizations that were offered reduced  funding for 2018—with reductions ranging from 50 to 98 percent of 2017  funding levels—declined their awards and withdrew from the program.  HHS reported asking the remaining navigator organizations to focus on  re-enrolling consumers who had coverage in 2017 and resided in areas  where issuers reduced or eliminated plan offerings for 2018, and  informing consumers about the shortened open enrollment period for  2018 coverage. Representatives of the navigator community group we  interviewed reported that many navigator organizations did focus their  resources on enrollment and cut back on outreach efforts, particularly in  rural areas. According to self-reported navigator organization data  provided by HHS, navigator organizations collectively reported conducting  68 percent fewer outreach events during the 2018 open enrollment period as compared to the 2017 period. Representatives from the navigator  organizations we interviewed also reported making changes to their  operations; for example, officials from one of the navigator organizations  reported cutting staff and rural office locations. Officials from another  navigator organization said that they focused their efforts on contacting  prior exchange enrollees to assist them with re-enrollment, instead of  finding and enrolling new consumers, and de-prioritized assistance with  Medicaid enrollment. The three navigator organizations we spoke with  that had funding cuts for 2018 also reported that their ability to perform  the full range of navigator duties during the rest of the year would be  compromised because they needed to make additional cuts in their  operations—such as reducing staff and providing less targeted assistance  to underserved populations—in order to reduce total costs. One of the  three navigator organizations reported that it may go out of business at  the end of the 2018 award year.

HHS’s narrower approach to awarding funding; lack of reliable, complete  data on the extent to which navigator organizations enrolled individuals in  exchange plans; and lack of clear guidance to navigator organizations on  how to set their goals could hamper the agency’s ability to use the  program to meet its objectives. Federal internal control standards state  that management should use quality information to achieve the agency’s  objectives, such as by using relevant, reliable data for decision-making.  Without reliable performance data and accurate goals, HHS will be  unable to measure the effectiveness of the navigator program and take  informed action as necessary. Further, because HHS calculated awards  using problematic data, navigator organizations may have received  awards that did not accurately reflect their performance in enrolling  individuals in exchange plans. Additionally, HHS’s narrow focus on  exchange enrollment limited its ability to make decisions based on  relevant information. Moving forward, this may affect navigator  organizations’ interests and abilities in providing a full range of services to  their communities, including underserved populations. This, in turn, could  affect HHS’s ability to meet its objectives, such as its objective of  improving Americans’ access to health care.

HHS Did Not Set Numeric Enrollment Targets for 2018, and Instead Focused on Enhancing Certain Aspects of Consumers’ Experiences

HHS did not set any numeric enrollment targets for 2018 related to total  healthcare.gov enrollment, as it had in prior years. In prior years, HHS  used numeric targets to monitor enrollment progress during the open  enrollment period and focus its resources on those consumers that it  believed had a high potential to enroll in exchange coverage. For  example, HHS established a target of enrolling a total of 13.8 million  individuals during the 2017 open enrollment period and also set numeric  enrollment targets for 15 regional markets that the agency identified as  presenting strong opportunities for meaningful enrollment increases,  partly due to having a high percentage of eligible uninsured individuals.  HHS used these regional target markets to focus its outreach, travel, and  collaborations with local partners. According to agency officials, during  prior open enrollment periods, HHS monitored its performance with  respect to its targets and revised its outreach efforts in order to better  meet its goals.

According to federal internal control standards, agencies should design  control activities to achieve their objectives, such as by establishing and  monitoring performance measures. HHS has recognized the importance  of these internal controls by requiring state-based exchanges to develop  performance measures and report on their progress. Without developing  numeric targets for healthcare.gov enrollment, HHS’s ability to both  perform high level assessments of its performance and progress and to  make critical decisions about how to use its resources is hampered. HHS  may also be unable to ensure that it meets its objectives—including its  current objective of improving Americans’ access to health care, including  by stabilizing the market and implementing policies that increase the mix  of younger and healthier consumers purchasing plans through the  individual market.

HHS leadership decided against setting numeric enrollment targets for  the 2018 open enrollment period and instead focused on a goal of  enhancing the consumer experience, according to HHS officials.  Specifically, HHS officials measured the consumer experience based on  its assessment of healthcare.gov availability and functionality, and call  center availability and customer satisfaction. HHS officials told us that  they selected these measures of the consumer experience because  healthcare.gov and the call center represent two of the largest channels  through which consumers interact with the exchange. HHS reported  meeting its goal based on consumers’ improved experiences with these  two channels, some of which had been problematic in the past. (See fig.  8.)

Healthcare.gov. According to HHS officials, the healthcare.gov  website achieved enhanced availability and functionality for the 2018  open enrollment period, continuing a trend in improvements over prior  years. While HHS scheduled similar periods of healthcare.gov  downtime for maintenance in 2017 and 2018, the website had less  total downtime during the 2018 open enrollment period because the  agency needed to conduct less maintenance. HHS officials  attributed the increased availability in part to an operating system  upgrade and comprehensive testing of the website that they  conducted before the 2018 open enrollment period began. In addition,  unlike prior years, HHS officials said that the agency published  scheduled maintenance information for 2018 to reduce scheduling  conflicts for consumers and groups providing enrollment assistance.  HHS also reported enhancing the functionality of the website for the  2018 open enrollment period, including by adding new tools, such as  a “help on demand” feature that links consumers with a local agent or  broker willing to assist them, as well as updated content that included  more plain language. Many stakeholders we interviewed told us that  healthcare.gov functioned well during the open enrollment period and  was more available than it had been in prior years.

Call Center Assistance. According to HHS officials, the call center  reduced wait times and improved customer satisfaction scores in  2018, continuing a trend in improvements over prior years. HHS  officials reported average wait times of 5 minutes, 38 seconds for the  2018 open enrollment period—almost four minutes shorter than the  average wait time experienced during a comparable timeframe of the  2017 open enrollment period. HHS officials attributed this reduction  in wait times to improvements in efficiency, including scripts that used  fewer words and generated fewer follow-up questions. In addition,  there was a modest reduction in call center volume during similar  timeframes of the 2017 and 2018 open enrollment periods. Officials  from many stakeholders we interviewed reported that call center  assistance was more readily available this year than it had been in  prior years. HHS officials also reported an average call center  customer satisfaction score of 90 percent in 2018 compared to 85  percent in 2017, based on surveys conducted at the end of customer  calls.

Although HHS officials reported that the agency met its goal of enhancing  specific aspects of the consumer experience for the 2018 open  enrollment period, HHS narrowly defined its goal and excluded certain  aspects of the consumer experience that it had identified as key as  recently as 2017. More specifically, in 2017, HHS reported that successful  outreach and education events and the availability of in-person consumer  assistance, such as that provided by navigators to help consumers  understand plan options, were key aspects of the consumer experience.  However, HHS did not include these key items when measuring progress  toward their 2018 goal of enhancing the consumer experience. Federal  internal control standards state that agencies should identify risks that  affect their defined objectives and use quality information to achieve  these objectives, including by identifying the information required to  achieve the objectives and address related risks. By excluding key  aspects of the consumer experience in its evaluation of its performance,  HHS’s assessment of the consumer experience may be incomplete. For  example, as noted above, some stakeholders we interviewed told us that  consumer confusion likely detracted from enrollment for 2018, and some  linked this outcome to HHS’s reduced role in promoting exchange  enrollment, including navigator support, which may have resulted in less  in-person consumer assistance through navigators. HHS’s assessment of  the consumer experience, which focused only on consumers who used  the website or reached out to the call center during open enrollment, did  not account for the experiences of those who interacted with the health  insurance exchanges through other channels, such as through navigators  or agents and brokers.

Some experts have raised questions about the long-term stability of the  exchanges absent sufficient enrollment, including among young and  healthy consumers. To encourage exchange enrollment, HHS has  traditionally conducted a broad outreach and education campaign,  including funding navigator organizations that provide in-person  enrollment assistance. For the 2018 open enrollment period, HHS  reduced its support of navigator organizations and changed its approach  for allocating navigator funding to focus on exchange enrollment alone.  HHS allocated the funding based on performance data that were  problematic for multiple reasons, including because some of the  underlying data were unreliable. As a result, navigator organizations  received funding that reflected a more limited evaluation of their  performance than HHS had used in the past, and that may not have  accurately reflected their performance. This raises the risk that navigator  organizations will decrease the priority they place on fulfilling a range of  other duties for which they are responsible, including providing assistance  to traditionally underserved populations, which some navigator  organizations we interviewed reported they had either decreased or  planned to decrease due to reduced funding. HHS’s lack of complete and  reliable data on navigator organization performance hampers the  agency’s ability to make appropriately informed decisions about funding.  Moreover, its focus on enrollment alone in awarding funding may affect  navigator organizations’ ability to fulfill the full range of their  responsibilities, which could in turn affect HHS’s ability to use the  program as a way to meet its objective of enhancing Americans’ access  to health care.

In addition, the lack of numeric enrollment targets for HHS to evaluate its  performance with respect to the open enrollment period hampers the  agency’s ability to make informed decisions about its resources. HHS  reported achieving a successful consumer experience for the 2018 open  enrollment period based on enhancing its performance in areas that had  been problematic in the past. However, the agency’s evaluation of its  performance did not include aspects of the consumer experience that it  identified in 2017 as key, and for which stakeholders reported problems in  2018. As a result, its assessment of its performance in enhancing the  consumer experience was likely incomplete. Absent a more complete  assessment, HHS may not have the information it needs to fully  understand the consumer experience.

We are making the following three recommendations to HHS:

The Secretary of HHS should ensure that the approach and data it  uses for determining navigator award amounts accurately and  appropriately reflect navigator organization performance, for example,  by  1.  providing clear guidance to navigator organizations on  performance goals and other information they must report to HHS  that will affect their future awards,  2.  ensuring that the fields used to capture the information are  functioning properly, and  3.  assessing the effect of its current approach to funding navigator  organizations to ensure that it is consistent with the agency’s  objectives. (Recommendation 1)

The Secretary of HHS should establish numeric enrollment targets  for healthcare.gov, to ensure it can monitor its performance with  respect to its objectives. (Recommendation 2)

Should the agency continue to focus on enhancing the consumer  experience as a goal for the program, the Secretary of HHS  should assess other aspects of the consumer experience, such as  those it previously identified as key, to ensure it has quality  information to achieve its goal. (Recommendation 3)

We provided a draft of this report to HHS for comment. In its comments,  reproduced in appendix VI, HHS concurred with two of our three  recommendations. HHS also provided technical comments, which we  incorporated as appropriate.

HHS concurred with our recommendation that it ensure that the approach  and data it uses for determining navigator awards accurately and  appropriately reflect navigator organization performance. In its comments  on our draft report, HHS stated that it had notified navigator organizations  that their funding would be linked to the organizations’ self-identified  performance goals and their ability to meet those goals. On July 10, 2018,  HHS issued its 2019 funding opportunity announcement for the navigator  program, which required those applying for the award to set performance  goals, including for the number of consumers assisted with enrollment  and re-enrollment in exchange plans, and also states that failure to meet  such goals may negatively impact a recipient’s application for future  funding. In its comments, HHS also noted that it is in the process of  updating the healthcare.gov website so that individual applications can  hold the identification numbers of multiple entities, such as navigators,  agents or brokers, and will work to ensure that the awards align with  agency objectives.

HHS also concurred with our recommendation that the agency assess  other aspects of the consumer experience, such as those it previously  identified as key, to ensure it has quality information to achieve its goal.  HHS noted that it had assessed the consumer experience based on the  availability of the two largest channels supporting exchange operations,  and also noted that it will consider focusing on other aspects of the  consumer experience as needed.

HHS did not concur with our recommendation that the agency establish  numeric enrollment targets for healthcare.gov, to ensure that it can  monitor its performance with respect to its objectives. Specifically, HHS  noted that there are numerous external factors that can affect a  consumer’s decision to enroll in exchange coverage that are outside of  the control of HHS, including the state of the economy and employment  rates. HHS stated that it does not believe that enrollment targets are  relevant to assess the performance of a successful open enrollment  period related to the consumer experience. Instead, it believes a more  informative performance metric would be to measure whether everyone  who utilized healthcare.gov, who qualified for coverage, and who desired  to purchase coverage, was able to make a plan selection.

We continue to believe that the development of numeric enrollment  targets is important for effective monitoring of the program and  management of its resources. Without establishing numeric enrollment  targets for upcoming open enrollment periods, HHS’s ability to evaluate  its performance and make informed decisions about how it should deploy  its resources is limited. We also believe that these targets could help the  agency meet its program objectives of stabilizing the market and of  increasing the mix of younger and healthier consumers purchasing plans  through the individual market. Furthermore, HHS has previously  demonstrated the ability to develop meaningful enrollment targets using  available data. For example, in prior years, HHS developed numeric  enrollment targets based on a range of factors, including the number of  exchange enrollees, number of uninsured individuals, and changes in  access to employer-sponsored insurance, Medicaid, and other public  sources of coverage. In addition, the agency set numeric enrollment  targets for regional markets that took these and other factors into  account. Once these targets were established, HHS officials were able to  use them to monitor progress throughout the open enrollment period and  revise its efforts as needed.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of HHS. In  addition, the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or dickenj@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix VII.

Appendix I: GAO List of Factors That May Have Affected 2018 Healthcare.gov Enrollment

We identified a list of factors that may have affected 2018 healthcare.gov  enrollment based on a review of Department of Health and Human  Services information, interviews with health policy experts, and review of  recent publications by these experts related to 2018 exchange  enrollment.

Factors related to the open enrollment period:

Open enrollment conducted during a shorter 6-week open enrollment  period.

Consumer awareness of this year’s open enrollment deadline.

Factors related to plan availability and plan choice:

Plan affordability for consumers ineligible for financial assistance.

Plan affordability for consumers eligible for financial assistance.

Consumers’ perceptions of plan affordability.

Availability of exchange-based plan choices.

Availability of off-exchange plan choices.

Factors related to outreach and education:

Reductions in federal funding allocated to outreach and education,  and lack of television and other types of advertising.

Top Administration and agency officials’ messaging about the health  insurance exchanges and open enrollment.

National and local media reporting on the exchanges and open  enrollment.

Local outreach and education events conducted by federally funded  navigator organizations.

Outreach and education efforts and/or advertising by some states,  issuers, advocacy groups, community organizations, and agents and  brokers.

Factors related to enrollment assistance and tools:

Availability of one-on-one enrollment assistance from federally funded  navigator organizations.

Availability of one-on-one enrollment assistance from agents and  brokers.

Updates to the content and function of the healthcare.gov website.

Availability of the healthcare.gov website during the open enrollment  period.

Availability of assistance through the call center during the open  enrollment period.

Consumer understanding of the Patient Protection and Affordable  Care Act and its status.

Automatic re-enrollment occurred on the last day of the open  enrollment period.

Appendix II: Information about Stakeholders Interviewed

4    Navigator organizations were selected to reflect a range in:  (1) amount of 2018 award from the Department of Health and Human Services (HHS);  (2) change in HHS award amount from 2017;  (3) region; and  (4) target population.

Insurance departments in six states that use the federally facilitated exchanges were  selected to reflect a range with respect to:  (1) 2018 healthcare.gov enrollment outcomes;  (2) strategies used for calculating 2018 premiums to compensate for the loss of federal  cost-sharing reduction payments;  (3) changes in 2018 navigator organization award amounts; and  (4) the number of issuers offering 2018 exchange coverage in the state.  3    Three issuers were selected who offered 2018 plans on healthcare.gov exchanges;  two of which sold exchange plans in multiple states.  5    Five research and consumer advocacy organizations were selected to provide a range  of perspectives with respect to the law and issues related to exchange outreach and  enrollment. 3    Three professional trade associations were selected to collectively represent the  perspectives of regulators, issuers, and consumer assisters.   2    Two state-based exchanges were selected based on the length of their open  enrollment periods—one had one of the shortest open enrollment periods and the  other had one of the longest open enrollment periods for 2018.

Navigator organizations, among other things, carry out public education activities and help consumers enroll in a health insurance plan offered through  the exchange. HHS awards financial assistance to navigator organizations that provide these services in states using the federally facilitated exchange.  An issuer is an insurance company, insurance service, or insurance organization that is required to be licensed to engage in the business of insurance  in a state.  State-based exchanges are able to set their own budget and strategy for promoting exchange enrollment and set the length of their open enrollment  periods.

Appendix IV: Selected Stakeholder Views of Factors Likely Affecting 2018 Enrollment in Healthcare.gov Plans

We identified a list of factors that may have affected 2018 healthcare.gov  enrollment based on a review of Department of Health and Human  Services (HHS) information, interviews with health policy experts, and  review of recent publications by these experts related to 2018 exchange  enrollment. Using this list, we conducted structured interviews with  officials from 23 stakeholder organizations to gather their viewpoints as to  whether and how these or other factors affected 2018 health insurance  exchange enrollment. Organizations interviewed were selected to reflect  a wide range of perspectives and included HHS-funded navigator  organizations that provide in-person consumer enrollment assistance,  issuers, state insurance departments, professional trade organizations,  research and advocacy organizations, and state-based exchanges. Table  2 displays a range in stakeholder views about the impact of these factors.

Appendix V: HHS Paid Advertising Expenditures for 2017 and 2018 Open Enrollment Periods

Appendix VI: Comments from the Department of Health and Human Services

Appendix VII: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Gerardine Brennan, Assistant  Director; Patricia Roy, Analyst-in-Charge; Priyanka Sethi Bansal; Giao N.  Nguyen; and Fatima Sharif made key contributions to this report. Also  contributing were Muriel Brown, Laurie Pachter, and Emily Wilson.

We examined 2018 enrollment in Affordable Care Act health insurance exchanges and federal efforts to encourage enrollment.

About 8.7 million people bought insurance in 2018 through the federal website (healthcare.gov), 5% less than in 2017.

Health and Human Services reduced its advertising and other consumer outreach. The 23 stakeholders we interviewed had mixed views about the effects of these reductions on enrollment.

HHS did not set enrollment targets for 2018, but reported meeting its goal of enhancing specific aspects of consumer experience.

We recommended that HHS take steps to better manage its performance.