Effect of Email Nudges on Plan Switching and Healthcare Utilization Among Unemployment Insurance Recipients

In March 2021, President Biden signed into law the American Rescue Plan Act of 2021 (ARP), a landmark federal economic relief and stimulus package designed to provide support to Americans hit by the economic recession brought about by the COVID-19 global pandemic. The law provides increased federal premium tax credits (PTC), and ensures that consumers will pay no more than 8.5 percent of household income on health insurance premiums in 2021 and 2022, if enrolled through an Affordable Care Act marketplace like Covered California.

The ARP also provides additional PTC and cost-sharing reduction (CSR) benefits to eligible marketplace enrollees who report receiving unemployment insurance benefits (UIB) for at least one week in 2021. Under the law, for 2021 only, Covered California consumers will have their household income level treated as if it were at 138.1 percent of the federal poverty level (FPL), regardless of their projected annual income, which will make them eligible for a Silver 94 plan, and which offers the greatest value on cost-sharing benefits.

But in order to access those cost-sharing benefits, households must be in silver tier plans, but over 40,000 were not. This project's goal is to assess the effects of an informational email on plan switching into Cost Sharing Reduction Silver plans and downstream healthcare utilization.

The project's research design is a randomized intervention among approximately 42,500 enrolled households with an email address in non-silver tier plans. The investigators randomly assigned to either two informational emails or to a no email control group. The investigators then collected administrative data to examine plan switching behavior and healthcare utilization among households in the study.

Study Overview

• Status: Completed
• Conditions: Health Behavior
• Intervention / Treatment: Behavioral: Standard notice of eligibility determination; Behavioral: Two informational emails with plan information

• Study Type: Interventional
• Enrollment (Actual): 42470
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Sacramento, California, United States, 95815
      • Covered California

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Has email address, in a non-silver plan and reported unemployment insurance in 2021

Exclusion Criteria:

• In a silver plan, no email address

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Control Group with a standard eligibility notice; Control group was assigned to receive no email outreach in June and July beyond an eligibility redetermination notice.	Behavioral: Standard notice of eligibility determination; No extra outreach during intervention period.
Experimental: Treatment group with a standard eligibility notice and assigned two email nudges; Assigned to receive an eligibility redetermination notice along with two informational emails about the benefits of Cost-Sharing Reduction Silver plans.	Behavioral: Two informational emails with plan information; Informational emails about the benefits of Cost-Sharing Reduction Silver plans.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cost-Sharing Reduction Silver Enrollment	Percent of households enrolled in a Cost-Sharing Reduction Silver Plan	1 month
Office Visit	Percent of households with an office visit	6 months
Prescription drug use	Percent of households with a prescription drug fill	6 months
Emergency room visit	Percent of households with an emergency room visit	6 months
Hospitalization	Percent of households with a hospitalization	6 months

Collaborators and Investigators

• Sponsor: Office of Evaluation Sciences
• Investigators: Principal Investigator: Andrew Feher, PhD, Covered California

Study record dates

Study Major Dates

• Study Start (Actual): June 25, 2021
• Primary Completion (Actual): December 31, 2021
• Study Completion (Actual): December 31, 2021

Study Registration Dates

• First Submitted: February 14, 2023
• First Submitted That Met QC Criteria: June 2, 2023
• First Posted (Actual): June 6, 2023

Study Record Updates

• Last Update Posted (Actual): June 6, 2023
• Last Update Submitted That Met QC Criteria: June 2, 2023
• Last Verified: June 1, 2023

More Information

Terms related to this study

• Keywords: randomized controlled trial; Affordable Care Act; nudge; American Rescue Plan; unemployment insurance
• Other Study ID Numbers: 022023

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The researchers are committed to sharing as much data as possible for replication, consistent with the privacy and security requirements of the state agency that govern the re-disclosure of the data.
• IPD Sharing Time Frame: Data will be available with investigator support upon publication
• IPD Sharing Access Criteria: Replication data can be accessed via request to the primary investigator upon publication.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No