At the Intersection of Health, Health Care and Policy Cite this article as: Katherine Swartz and John A. Graves Shifting The Open Enrollment Period For ACA Marketplaces Could Increase Enrollment And Improve Plan Choices Health Affairs, 33, no.7 (2014):1286-1293 (published online June 25, 2014; 10.1377/hlthaff.2014.0007)
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Web First By Katherine Swartz and John A. Graves 10.1377/hlthaff.2014.0007 HEALTH AFFAIRS 33, NO. 7 (2014): 1286–1293 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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Katherine Swartz (kswartz@ hsph.harvard.edu) is a professor in the Department of Health Policy and Management at the Harvard School of Public Health, in Boston, Massachusetts. John A. Graves is an assistant professor in the School of Medicine at Vanderbilt University, in Nashville, Tennessee.
Shifting The Open Enrollment Period For ACA Marketplaces Could Increase Enrollment And Improve Plan Choices ABSTRACT The next open enrollment period for plans offered in the Affordable Care Act’s (ACA’s) insurance Marketplaces is set to occur between November 15, 2014, and February 15, 2015—just when many lower-income people are financially stressed by demands of the holiday season. Recent research by experimental psychologists and behavioral economists strongly suggests that when people’s decision-making capacity (bandwidth) is stretched thin, either they cannot make decisions or they make poor choices. Using data from nearly a decade of US-based Internet search queries to measure population behavior, we found considerable seasonality in measures of financial stress and in when people seek out information on health insurance plans. A more opportune time for scheduling open enrollment for the ACA Marketplaces may be between February 15 and April 15—weeks when low-income people typically receive income tax refunds and Earned Income Tax Credit payments. Such lumpsum payments could be applied to pay individuals’ share of premiums.
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he state and federally facilitated insurance Marketplaces created by the Affordable Care Act (ACA) are projected to insure twenty-four million otherwise uninsured people by 2020.1 Nearly nineteen million of this total are expected to be low- and moderate-income Americans who are eligible for premium tax credits to subsidize their plan purchase.1 Just as Medicare beneficiaries and workers with employersponsored health insurance must make plan choice decisions during an annual open enrollment period, so, too, will consumers shopping for plans in these Marketplaces. To maximize participation in Marketplace plans, it will be critical to have engaged participation among lower-income people during open enrollment. The ACA grants the secretary of health and human services (HHS) broad authority to determine the annual open enrollment period. The initial enrollment period began October 1, 2013, and ended March 31, 2014. Open enroll1286
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ment for the 2015 plan year was to have taken place between October 15, 2014, and December 7, 2014. In late November 2013 the 2015 enrollment start date was pushed back a month, and in early March 2014 its end date was pushed back another month. Open enrollment will now run between November 15, 2014, and February 15, 2015.2 Without further changes, subsequent open enrollment periods will occur between October 15 and December 15. As we discuss below, enrollment goals may be compromised by scheduling open enrollment during the holiday season—a financially stressful time for many. To be fully enrolled, people must actively select a plan and must pay the first month’s premium. With the focus in 2012 and 2013 on preparing for health insurance coverage to begin in January 2014, little attention was paid to whether people might have difficulty enrolling simply because they would be financially stretched during the holidays. Tight finances and related psychological stress can render con-
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sumers less able to cope with the complex set of choices required by open enrollment. A more opportune time for enrollment might be the first quarter of the calendar year, when low-income people typically file their income tax returns and may receive tax refunds and an Earned Income Tax Credit (EITC). (The EITC subsidizes the earnings of low-income working individuals and families; the amount of the tax credit minus any federal income tax owed is paid as a refund during income tax season.) In this article we draw on insights from experimental psychology and behavioral economics research that are relevant to scheduling open enrollment periods so as to maximize enrollment. We augment this discussion with analyses of nearly a decade of Google search query data that demonstrate considerable seasonality in measures of financial stress and in when consumers seek out information on health insurance plans. Since periods of stress reduce people’s ability to make complex choices, holding an open enrollment season in late fall may undercut both enrollment decisions and consumers’ ability to choose plans wisely.
Background The decision to hold open enrollment for state and federally facilitated Marketplace plans in late fall almost certainly was intended to align the period when a majority of Americans make insurance plan choices. Most employers hold an open enrollment season for a week or two in late October or early November. Medicare beneficiaries can switch between traditional Medicare and Medicare Advantage plans and can choose a prescription drug plan between mid-October and the first week of December each year. These traditional open enrollment periods also facilitate enrollment in insurance policies with annual deductibles that reset on January 1. However, late fall is one of the most financially and emotionally stressful times of the year, particularly for people with limited incomes. The holiday season between Thanksgiving and New Year’s—with pressures for buying presents, travel, and the onset of winter home-heating bills— strains many family budgets. These are not months when lower-income households have extra money for paying premiums for health insurance plans that begin the following January. Indeed, research on people’s reactions to scarcity of time and money suggests that the holiday season may be the worst time of the year to require complex health insurance enrollment decisions.3,4 Psychology And Behavioral Economics Borrowing a term from computer science and
signal processing, behavioral economists use “bandwidth” to describe a person’s capacity to absorb information and make decisions.3 When people are not under stress, their bandwidth is large and flexible. They can consider and process extensive information in making decisions. When people are stressed by financial worries or many obligations, their bandwidth is narrowed. The result is “tunneled” decision making in which people focus on their most pressing problem and make decisions that ignore their full set of choices. Tunneling may resolve the immediate problem while ignoring options that might alleviate the problem in the future. Experimental psychologists describe a similar phenomenon. Experiments suggest that exerting self-control or making a difficult choice in one situation depletes many people’s limited ability to cope and make decisions and reduces performance in a subsequent task. Psychologists term this “ego depletion” and “choice overload.”5,6 Research also suggests that people avoid making choices (and therefore choose to remain with the status quo) when they are worried that there may be high costs if they make the “wrong” choice or if substantial effort is needed to make informed comparisons.6–8 There is mounting empirical evidence that when people are stressed by scarcity of income or time, they do not make “rational” decisions as standard economic models predict.3,9–11 When a low-income person is focused on finding enough money for the holidays, the choice of health insurance plans is less likely to be “inside the tunnel,” and so the choice will not be made or will be poorly considered. A key insight is that many choice situations can have different outcomes depending on whether they come at a time of relative scarcity or plenty—of time or money. Thus, the timing of decisions is a significant factor in whether a public policy might be successful in fulfilling its objective. Bandwidth Needed For Marketplace Enrollment Decisions The importance of adequate bandwidth becomes clear when considering the complexity of enrolling in a state or federally facilitated Marketplace plan. First, people must determine their monthly net cost for each of the alternative plan choices. Second, they must choose a plan that provides the best value for them. Determining the monthly net cost for a plan requires a person to know both the plan’s sticker price and the premium tax credit for which he or she may be eligible. People can elect to take the premium tax credit in advance based on a projection of their income and family composition for the next year. This projection is based on prior years’ tax returns and is calculated at the J u ly 2 0 1 4
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Web First time of enrollment.12 People can elect to take a full or partial advance credit but must reconcile the total value of advance subsidies and the final credit value when they file their taxes for the enrollment year.13 Any unused portion of the advance tax credit will be available as an additional tax refund, while overclaiming advance subsidies may result in a lower refund or an additional tax liability. This means that people choosing subsidized health plans must consider the accuracy of the information they used to project their monthly subsidy and must elect to take none, part, or all of their advance credit—no doubt adding an extra layer of uncertainty as to their out-of-pocket costs for health insurance. Enrollment choices also require processing a volume of information about the options available at each of the four levels of Marketplace plans. There are currently sixteen state-run Marketplaces plus the District of Columbia Marketplace and federally facilitated Marketplaces for the remaining thirty-four states. Many state Marketplaces have fifty or more different plan choices among the four metal benefit levels: platinum, gold, silver, and bronze (Exhibit 1). Determining the relative value of each plan choice requires a person to estimate his or her likely health care use in the coming year and calculate the out-of-pocket cost for each plan choice. Although benefits covered by plans are standardized by each state, plans are competing in terms of their provider networks, prescription drug formularies, and rules for cost sharing when a person obtains care from providers outside the network. Information about these differences among plans is not generally found on the Marketplaces’ websites and can be time consuming to find on insurers’ websites. Clearly, choosing a health plan in the Marketplaces can be complicated for anyone and overwhelming for those whose bandwidth is
Exhibit 1 Plan Choice Statistics For States With Federally Facilitated Marketplaces As Of March 1, 2014 Number of plans available (across all four benefit levels) Average Median Minimum Maximum Interquartile range
44 37 7 181 25–53
SOURCE Authors’ analyses of plan data for states with federally facilitated Marketplaces from the Center for Consumer Information and Insurance Oversight. NOTE Benefit levels are bronze, silver, gold, and platinum.
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strained. In particular, processing this information requires far more bandwidth than is needed by most people choosing an employer-sponsored insurance plan, when there are rarely more than two or three options and no projection of future income is required. Lessons From Federal Tax Filings And The Earned Income Tax Credit Just as financial stress associated with the November–December holidays may shrink decision-making bandwidth, the February–March period may be a time when lower-income people experience expanded bandwidth. Many receive income tax refunds and EITC payments. For example, among tax filers who did not receive Social Security benefits in 2008, the average refund for those with incomes between $1 and $25,000 was $2,313 (more than 90 percent received a refund); similarly, the average refund was $2,637 for those with incomes between $25,001 and $50,000, and $3,337 for those with incomes between $50,001 and $75,000 (Daniel Feenberg, National Bureau of Economic Research, personal communication, February 28, 2014). As noted earlier, the 2015 tax filing season will also be when an additional refund may be available to Marketplace enrollees who take a partial advance credit or who are otherwise undersubsidized during 2014. To reduce the complexity and stress of filing taxes, the majority of households with income less than $50,000 use professional tax preparers.14 Most also file and receive refunds well before the April 15 deadline: Over half of all filings are submitted before March 1, and twothirds are submitted prior to the third week in March. Among tax filers with EITC refunds, the majority are received in February.15–17 The specific experience of the EITC provides a relevant illustration of individual behavior. The average EITC refund in 2011 was $2,905 for a family with children and $264 for a family without children.18 Prior to 2011, beneficiaries could receive the EITC as either a lump-sum payment or a prorated addition to their paychecks during the year. In practice, only 1 percent of beneficiaries chose the prorated option, and starting in 2011 the option was dropped.16 Choosing a lumpsum payment is consistent with research showing that low-income people appear to use the lump-sum option as a form of forced savings. In the language of behavioral economics, it provides a different “mental account” for their income than their paychecks.9,19 Analyses show that the majority of EITC payments and tax refunds are spent paying balances due on bills and purchasing durable goods or services including furniture, appliances, used cars, or car repairs.16,19
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Choosing a health plan in the Marketplaces can be complicated for anyone and overwhelming for those whose bandwidth is strained.
The EITC experience is instructive also because there is substantial overlap of income eligibility for the EITC and the ACA’s premium tax credit. For the 2013 tax year, a married couple with two children filing a joint income tax return is eligible for the EITC if their adjusted gross income is less than 205 percent of the federal poverty level.20 A married couple with one child is eligible if their income is less than 221 percent of poverty. People without children face a much lower income eligibility maximum: 125 percent of poverty. Since a quarter of the nonelderly uninsured in 2012 had 2011 incomes between of 138–250 percent of poverty,21 many people who are eligible for the advance tax credit premium subsidies for the ACA also are likely to be claiming an EITC.
Study Data And Methods To test our proposition that the holiday season may reduce bandwidth and that the first quarter of the calendar year may offer a better time for open enrollment, we turned to weekly data on US-based Google search queries between January 2004 and December 2013. The use of Internet search data as a public health population– surveillance tool is well established in studies on seasonality in mental health conditions and infectious disease outbreaks.22,23 To our knowledge, our study is among the first to apply this indirect observation method to the problem of optimally designing social policy. We used the Google Trends tool to extract weekly time-series data on queries related to financial security and health insurance. To investigate when during the year people feel the most financially stressed, we created a composite financial insecurity index measure based on aggregate search volume for the terms “cash advance,” “payday loan,” or “payday advance.”
Similarly, to examine when people may feel more financially secure, we investigated searches for information on bank savings accounts and tax refund checks. Finally, we investigated when people seek out information on health insurance, using a composite measure based on queries for “health insurance plans” or “medical insurance plans.” Sensitivity analyses based on alternative search terms—for example, “private health insurance,” specific health insurance companies, and other recurrent expenses such as car insurance—yielded similar results. To isolate seasonal trends, we applied nonparametric decomposition methods to the weekly time series of each search index.24 Values were standardized into z-scores to facilitate comparisons across indices. Using the method outlined by Robert Cleveland and colleagues,24 we applied a series of nonparametric Loess regression models to the standardized data to decompose the overall time series into three components: an overall trend that captured shifts in search frequency over time; a seasonal trend that captured periodic fluctuations in search behavior that repeated each year; and a remainder component that captured the remaining variation. Our main results focus on the seasonal trend. However, the raw time-series data and annotated plots of all three components are provided in the online Appendix.25
Study Results Seasonal trends in financial insecurity were most pronounced in the summer months and just before the holiday season (Exhibit 2). As noted above, this finding is consistent with the notion that many people feel financially pressured during the holidays. Similarly, measures of financial insecurity also peak in the summer: These are months when children are out of school, so child care expenses increase and reduced-cost or free school meals are not an option for low-income families. Consistent with our hypothesis, Internet queries for savings accounts are the most pronounced during January–April. In fact, we found that seasonal patterns based on our index measures of financial security and financial insecurity were nearly inverses of each other for much of the year. This corroborates past research evidence that many people view tax refunds as “forced savings” that can be used to shore up their personal finances. Internet searches for information on health insurance also displayed significant seasonality, with query volume dropping substantially during the holiday season (Exhibit 3). Search volume then spiked considerably just after the holidays and leading into the new year. This evidence J u ly 2 0 1 4
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Web First Exhibit 2 Seasonality In Internet Searches Related To Financial Security Between January 2004 And December 2013
Weekly time series of each index
Open enrollment season
Financial insecurity index
Tax refund check
Financial security index
Week of the year SOURCE Authors’ analysis of Google Trends data. NOTE This exhibit plots the seasonal component of a nonparametric decomposition of search index time-series data from US-based Google queries between January 2004 and December 2013.
is consistent with the notion that people may lack the mental bandwidth to make complex decisions during the holiday season but that once it ends, they begin to think more comprehensively about their plans for the next year. A nearly iden-
tical seasonal pattern was found with searches for car insurance information—another recurrent annual expenditure with some discretion as to the timing of the initial purchase (data not shown).
Exhibit 3 Seasonality In Internet Searches Related To Health Insurance Between January 2004 And December 2013
Weekly time series of search volume index
Open enrollment season
Search volume index
Week of the year SOURCE Authors’ analysis of Google Trends data. NOTE This exhibit plots the seasonal component of a nonparametric decomposition of search index time-series data from US-based Google queries between January 2004 and December 2013.
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Open enrollment for health insurance does not have to occur only in the fall.
Discussion Recent research by experimental psychologists and behavioral economists provides robust evidence that people have varying degrees of mental bandwidth for making complex choices, depending on how stressed they are by finances and demands on their time. The Internet search patterns we observed are consistent with the idea that the year-end holiday season is a period of financial stress for many people. Moreover, our analysis also demonstrates that November and December are the months when people are least likely to seek out information on health insurance and other recurrent financial expenditures. In contrast, the early months of the year appear to be a period when people feel less financial pressure and mental stress because of the receipt of tax refunds, most of which are received in February and March. Given our interest in health plan choices, it is noteworthy that queries about health insurance also grow rapidly and then stabilize in the weeks just after the holidays. Implications Of Seasonal Stress The seasonality of financial and mental stress has serious implications for the ACA’s goals of maximizing enrollment in Marketplace health plans and maintaining a healthy balance of enrollees with low and high risks of having high medical expenses. People at low risk for having high medical expenses are typically younger and healthier than those at higher risk. The implications are especially worrisome with respect to younger low-income people who have not had health insurance and might lack experience choosing among plans. If they cannot make a choice among the health plan options and remain uninsured, the goals of the ACA may be in jeopardy. Policy Options The next open enrollment period for the Marketplace health plans could be shifted from the November 15, 2014–February 15, 2015 period to the two months between February 15 and April 15, 2015. Because this coincides with the time frame within which most low-income households file their tax returns, applicants would have more up-to-date informa-
tion on their total income as a basis for calculating their premium tax credit subsidies.12 Equally important, such a shift coincides with the months when many people receive tax refunds, a portion of which they might want to designate for their share of the premium in the coming year. Families USA, which had been closely following efforts to help people understand their Marketplace choices, released a set of ten recommendations on April 1, 2014, for improving enrollment in the next open enrollment period. Third on its list is to coordinate open enrollment with the tax filing season.26 Open enrollment for health insurance does not have to occur only in the fall. Even though a majority of employers have open enrollment periods in the fall, some employers hold open enrollment in the late spring with the new choices going into effect on July 1. Ultimately, open enrollment periods should be aligned with the start date of insurance policies. Though most insurance policies currently begin on January 1, that does not have to be the case. A twelve-month period could start any time during the year. If the open enrollment period for the Marketplace health plans were shifted to March-April, for example, coverage under the health plans could start June 1 or July 1 and the accounting period for the annual deductible and out-of-pocket maximum would start at the same time. Health plans and insurance companies also might prefer to have the Marketplaces’ open enrollment period occur at a different time than that for employersponsored plans. Usefulness Of Internet Search Data There are several limitations to our use of Google search data to explore when financial stress might be high during the year. Our analyses were not restricted to searches by uninsured people who may be eligible for Marketplace plans. However, focus groups among thousands of Marketplace-eligible uninsured people prior to October 2013 indicated that nearly 80 percent were “frequent” Internet users, and almost every group of uninsured participants ranked “Google/Internet searches” as their top source of information on enrolling in coverage.27,28 Second, although our financial security measures provide strong suggestive evidence, they cannot definitely pinpoint the February-March period as the least financially stressful months of the year. To allay concerns that these months may have other stresses that were not captured here, focus groups could be held with lower-income people to find out when they would feel more comfortable choosing a health plan. Alternatively, a few states could experiment with the timing of open enrollment to determine if there are other J uly 201 4
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Web First months during the year when lower-income people may have less stress.
Conclusion Research by experimental psychologists and behavioral economists has some striking implications for the timing of the Marketplaces’ open enrollment period. This research has shown that people who are financially stressed do not have the mental bandwidth needed to make decisions or that they make a choice that often appears to be not in their best interest over a longer time frame. Holding the Marketplaces’ open enrollment period in the late fall coincides with weeks that our analyses show are particularly financially stressful for many people. These months are likely to be especially stressful for lower-income people, who will account for most of the consumers choosing health plans in the Marketplaces. Given what is known about how financial stress affects people’s bandwidth for making decisions, holding open enrollment just before or during the holiday season is a mistake. The ACA’s goals of maximizing enrollment in the health plans and maintaining a healthy balance of enrollees with low and high risks of having high medical The authors appreciate the thoughtful suggestions of two anonymous reviewers and are grateful for many informative conversations with Brian Haile and George Brandes of Jackson Hewitt Tax Service in Nashville,
Given how financial stress affects bandwidth for making decisions, holding open enrollment just before or during the holiday season is a mistake.
expenses are more likely to be achieved if the open enrollment season is shifted to the two months between February 15 and April 15 each year. Many lower-income people receive their income tax refunds and EITC payments then, so they are more likely to have the mental bandwidth for making decisions about their health insurance options and to enroll in a plan. ▪
Tennessee, as well as with several executives of insurance companies. The authors thank Dan Feenberg of the National Bureau of Economic Research for providing estimates of average income tax refunds in 2008, by income
group, of people who did not receive Social Security benefits. Views expressed are solely those of the authors. [Published online June 25, 2014.]
NOTES 1 Congressional Budget Office. CBO’s May 2013 estimate of the effects of the Affordable Care Acton health insurance coverage [Internet]. Washington (DC): CBO; 2013 [cited 2014 May 6]. Available from: http:// www.cbo.gov/sites/default/files/ cbofiles/attachments/43900-201305-ACA.pdf 2 Department of Health and Human Services. Patient Protection and Affordable Care Act; HHS notice of benefit and payment parameters for 2015; final rule [Internet]. Federal Register [serial on the Internet]. 2014 Mar 11 [cited 2014 May 6]. Available from: http://www.gpo .gov/fdsys/pkg/FR-2014-03-11/pdf/ 2014-05052.pdf 3 Mullainathan S, Shafir E. Scarcity: why having too little means so much. New York (NY): Times Books; 2013. 4 Shah AK, Mullainathan S, Shafir E. Some consequences of having too little. Science. 2012;338(6107): 682–5. 5 Baumeister RF, Bratslavsky E,
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Muraven M, Tice DM. Ego depletion: is the active self a limited resource? J Pers Soc Psychol. 1998;74(5): 1252–65. Iyengar SS, Lepper MR. When choice is demotivating: can one desire too much of a good thing? J Pers Soc Psychol. 2000;79(6):995–1006. Lowenstein G. Is more choice always better? Washington (DC): National Academy of Social Insurance; 1999 Oct. (Social Security Brief No. 7). Bundorf MK, Szrek H. Choice set size and decision making: the case of Medicare Part D prescription drug plans. Med Decis Making. 2010; 30(5):582–93. Mullainathan S, Shafir E. Savings policy and decisionmaking in lowincome households. In: Blank RM, Barr MS, editors. Insufficient funds: savings, assets, credit, and banking among low-income households. New York (NY): Russell Sage Foundation; 2009. p. 121–45. Congdon WJ, Kling JR, Mullainathan S. Behavioral eco-
nomics and tax policy. National Tax J. 2009;62:375–86. 11 Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New York (NY): Penguin Books; 2009. 12 Graves JA. Better methods will be needed to project incomes to estimate eligibility for subsidies in health insurance exchanges. Health Aff (Millwood). 2012;31(7):1613–22. 13 To limit the likelihood of reconciliation payments’ being required because the income projection was too low, people may choose to forgo the advance credit or to receive a partial advance credit—so that any remaining premium tax credit amount would be available as an additional refund at tax time. As of this writing, there was not yet information available on what share of Marketplace plan enrollees elected to forgo the advance credit or to take a partial credit. However, focus-group discussions indicate that uninsured people are at least interested in the
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option of deferring or taking a partial credit. See, for example, Consumers Union, Kleimann Communications Group. Helping consumers understand the new premium tax credit [Internet]. Yonkers (NY): Consumers Union; 2013 May 15 [cited 2014 Apr 30]. Available from: http://www.rwjf.org/content/dam/ farm/reports/issue_briefs/2013/ rwjf406124 Internal Revenue Service. Statistics of income (SOI) tax stats, historic, table 2: individual income and tax data, by state and size of adjusted gross income, tax year 2011 [Internet]. Washington (DC): IRS; [cited 2014 May 6]. Available from: http:// www.irs.gov/uac/SOI-Tax-StatsHistoric-Table-2 Internal Revenue Service. 2014 and prior year filing season statistics [Internet]. Washington (DC): IRS; [cited 2014 May 6]. Available from: http://www.irs.gov/uac/2014-andPrior-Year-Filing-Season-Statistics Goodman-Bacon A, McGranahan L. How do EITC recipients spend their refunds? Economic Perspectives. 2008;32(2):17–32. McGranahan L, Schanzenbach DW. The earned income tax credit and food consumption patterns. Chicago (IL): Federal Reserve Bank of Chicago; 2013 Nov. (Pub. No. WP 2013-14). Center on Budget Policy and Priorities. Policy basics: the Earned Income Tax Credit [Internet]. Washington (DC): COB Policy and
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Priorities; [updated 2014 Jan 31; cited 2014 Apr 30]. Available from: http://www.cbpp.org/cms/?fa= view&id=2505 Romich JL, Weisner T. How families view and use the EITC: advance payment versus lump sum delivery [Internet]. Rochester (NY): Social Science Research Network; 2000 Dec [cited 2014 Apr 30]. Abstract available from: http://ssrn.com/ abstract=251092 Internal Revenue Service. Earned income tax credit; do I qualify? [Internet]. Washington (DC): IRS; 2014 Jan [cited 2014 May 6]. Available from: http://www.irs.gov/uac/ Newsroom/Earned-Income-TaxCredit-Do-I-Qualify Authors’ calculations based on data from the March 2013 Current Population Survey (CPS). The CPS is a monthly survey of about 60,000 households that are representative of the US civilian noninstitutionalized population and is conducted by the Census Bureau. Detailed information about health insurance coverage and income, and extensive demographic data, are collected each March. Ayers JW, Althouse BM, Allem JP, Rosenquist JN, Ford DE. Seasonality in seeking mental health information on Google. Am J Prev Med. 2013;44(5):520–5. Carneiro HA, Mylonakis E. Google trends: a web-based tool for real-time surveillance of disease outbreaks. Clin Infect Dis. 2009;49(10):
1557–64. 24 Cleveland RB, Cleveland WS, McRae JE, Terpenning I. STL: a seasonaltrend decomposition procedure based on Loess. J Official Stat. 1990;6(1):3–73. 25 To access the Appendix, click on the Appendix link in the box to the right of the article online. 26 Pollack R, Klein R. Accelerating the Affordable Care Act’s enrollment momentum: 10 recommendations for future enrollment periods [Internet]. Washington (DC): Families USA; 2014 Apr 1 [cited 2014 Apr 30]. Available from: http://familiesusa .org/product/10-enrollment-fixes 27 Perry Undem Research Communication. The uninsured midway through ACA open enrollment: results from a national survey of uninsured adults 18 to 64 conducted December 12–22, 2013 [Internet]. Washington (DC): Perry Undem; 2013 Dec [cited 2014 Apr 30]. Available from: http://www.enroll america.org/wp-content/uploads/ 2014/01/Perry_Undem_ Uninsured_Survey.pdf 28 Perry M, Undem T. Informing Enroll America’s campaign: findings from a national survey [Internet]. Washington (DC): Enroll America; 2013 Feb [cited 2014 Apr 30]. Available from: http://www.enrollamerica .org/wp-content/uploads/old-files/ best-practices-institute/publiceducation-resources/Enroll_ America_Survey_Final_Report.pdf
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Web First By Katherine Swartz and John A. Graves 10.1377/hlthaff.2014.0007 HEALTH AFFAIRS 33, NO. 7 (2014): 1286–1293 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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Katherine Swartz (kswartz@ hsph.harvard.edu) is a professor in the Department of Health Policy and Management at the Harvard School of Public Health, in Boston, Massachusetts. John A. Graves is an assistant professor in the School of Medicine at Vanderbilt University, in Nashville, Tennessee.
Shifting The Open Enrollment Period For ACA Marketplaces Could Increase Enrollment And Improve Plan Choices ABSTRACT The next open enrollment period for plans offered in the Affordable Care Act’s (ACA’s) insurance Marketplaces is set to occur between November 15, 2014, and February 15, 2015—just when many lower-income people are financially stressed by demands of the holiday season. Recent research by experimental psychologists and behavioral economists strongly suggests that when people’s decision-making capacity (bandwidth) is stretched thin, either they cannot make decisions or they make poor choices. Using data from nearly a decade of US-based Internet search queries to measure population behavior, we found considerable seasonality in measures of financial stress and in when people seek out information on health insurance plans. A more opportune time for scheduling open enrollment for the ACA Marketplaces may be between February 15 and April 15—weeks when low-income people typically receive income tax refunds and Earned Income Tax Credit payments. Such lumpsum payments could be applied to pay individuals’ share of premiums.
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he state and federally facilitated insurance Marketplaces created by the Affordable Care Act (ACA) are projected to insure twenty-four million otherwise uninsured people by 2020.1 Nearly nineteen million of this total are expected to be low- and moderate-income Americans who are eligible for premium tax credits to subsidize their plan purchase.1 Just as Medicare beneficiaries and workers with employersponsored health insurance must make plan choice decisions during an annual open enrollment period, so, too, will consumers shopping for plans in these Marketplaces. To maximize participation in Marketplace plans, it will be critical to have engaged participation among lower-income people during open enrollment. The ACA grants the secretary of health and human services (HHS) broad authority to determine the annual open enrollment period. The initial enrollment period began October 1, 2013, and ended March 31, 2014. Open enroll1286
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ment for the 2015 plan year was to have taken place between October 15, 2014, and December 7, 2014. In late November 2013 the 2015 enrollment start date was pushed back a month, and in early March 2014 its end date was pushed back another month. Open enrollment will now run between November 15, 2014, and February 15, 2015.2 Without further changes, subsequent open enrollment periods will occur between October 15 and December 15. As we discuss below, enrollment goals may be compromised by scheduling open enrollment during the holiday season—a financially stressful time for many. To be fully enrolled, people must actively select a plan and must pay the first month’s premium. With the focus in 2012 and 2013 on preparing for health insurance coverage to begin in January 2014, little attention was paid to whether people might have difficulty enrolling simply because they would be financially stretched during the holidays. Tight finances and related psychological stress can render con-
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sumers less able to cope with the complex set of choices required by open enrollment. A more opportune time for enrollment might be the first quarter of the calendar year, when low-income people typically file their income tax returns and may receive tax refunds and an Earned Income Tax Credit (EITC). (The EITC subsidizes the earnings of low-income working individuals and families; the amount of the tax credit minus any federal income tax owed is paid as a refund during income tax season.) In this article we draw on insights from experimental psychology and behavioral economics research that are relevant to scheduling open enrollment periods so as to maximize enrollment. We augment this discussion with analyses of nearly a decade of Google search query data that demonstrate considerable seasonality in measures of financial stress and in when consumers seek out information on health insurance plans. Since periods of stress reduce people’s ability to make complex choices, holding an open enrollment season in late fall may undercut both enrollment decisions and consumers’ ability to choose plans wisely.
Background The decision to hold open enrollment for state and federally facilitated Marketplace plans in late fall almost certainly was intended to align the period when a majority of Americans make insurance plan choices. Most employers hold an open enrollment season for a week or two in late October or early November. Medicare beneficiaries can switch between traditional Medicare and Medicare Advantage plans and can choose a prescription drug plan between mid-October and the first week of December each year. These traditional open enrollment periods also facilitate enrollment in insurance policies with annual deductibles that reset on January 1. However, late fall is one of the most financially and emotionally stressful times of the year, particularly for people with limited incomes. The holiday season between Thanksgiving and New Year’s—with pressures for buying presents, travel, and the onset of winter home-heating bills— strains many family budgets. These are not months when lower-income households have extra money for paying premiums for health insurance plans that begin the following January. Indeed, research on people’s reactions to scarcity of time and money suggests that the holiday season may be the worst time of the year to require complex health insurance enrollment decisions.3,4 Psychology And Behavioral Economics Borrowing a term from computer science and
signal processing, behavioral economists use “bandwidth” to describe a person’s capacity to absorb information and make decisions.3 When people are not under stress, their bandwidth is large and flexible. They can consider and process extensive information in making decisions. When people are stressed by financial worries or many obligations, their bandwidth is narrowed. The result is “tunneled” decision making in which people focus on their most pressing problem and make decisions that ignore their full set of choices. Tunneling may resolve the immediate problem while ignoring options that might alleviate the problem in the future. Experimental psychologists describe a similar phenomenon. Experiments suggest that exerting self-control or making a difficult choice in one situation depletes many people’s limited ability to cope and make decisions and reduces performance in a subsequent task. Psychologists term this “ego depletion” and “choice overload.”5,6 Research also suggests that people avoid making choices (and therefore choose to remain with the status quo) when they are worried that there may be high costs if they make the “wrong” choice or if substantial effort is needed to make informed comparisons.6–8 There is mounting empirical evidence that when people are stressed by scarcity of income or time, they do not make “rational” decisions as standard economic models predict.3,9–11 When a low-income person is focused on finding enough money for the holidays, the choice of health insurance plans is less likely to be “inside the tunnel,” and so the choice will not be made or will be poorly considered. A key insight is that many choice situations can have different outcomes depending on whether they come at a time of relative scarcity or plenty—of time or money. Thus, the timing of decisions is a significant factor in whether a public policy might be successful in fulfilling its objective. Bandwidth Needed For Marketplace Enrollment Decisions The importance of adequate bandwidth becomes clear when considering the complexity of enrolling in a state or federally facilitated Marketplace plan. First, people must determine their monthly net cost for each of the alternative plan choices. Second, they must choose a plan that provides the best value for them. Determining the monthly net cost for a plan requires a person to know both the plan’s sticker price and the premium tax credit for which he or she may be eligible. People can elect to take the premium tax credit in advance based on a projection of their income and family composition for the next year. This projection is based on prior years’ tax returns and is calculated at the J u ly 2 0 1 4
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Web First time of enrollment.12 People can elect to take a full or partial advance credit but must reconcile the total value of advance subsidies and the final credit value when they file their taxes for the enrollment year.13 Any unused portion of the advance tax credit will be available as an additional tax refund, while overclaiming advance subsidies may result in a lower refund or an additional tax liability. This means that people choosing subsidized health plans must consider the accuracy of the information they used to project their monthly subsidy and must elect to take none, part, or all of their advance credit—no doubt adding an extra layer of uncertainty as to their out-of-pocket costs for health insurance. Enrollment choices also require processing a volume of information about the options available at each of the four levels of Marketplace plans. There are currently sixteen state-run Marketplaces plus the District of Columbia Marketplace and federally facilitated Marketplaces for the remaining thirty-four states. Many state Marketplaces have fifty or more different plan choices among the four metal benefit levels: platinum, gold, silver, and bronze (Exhibit 1). Determining the relative value of each plan choice requires a person to estimate his or her likely health care use in the coming year and calculate the out-of-pocket cost for each plan choice. Although benefits covered by plans are standardized by each state, plans are competing in terms of their provider networks, prescription drug formularies, and rules for cost sharing when a person obtains care from providers outside the network. Information about these differences among plans is not generally found on the Marketplaces’ websites and can be time consuming to find on insurers’ websites. Clearly, choosing a health plan in the Marketplaces can be complicated for anyone and overwhelming for those whose bandwidth is
Exhibit 1 Plan Choice Statistics For States With Federally Facilitated Marketplaces As Of March 1, 2014 Number of plans available (across all four benefit levels) Average Median Minimum Maximum Interquartile range
44 37 7 181 25–53
SOURCE Authors’ analyses of plan data for states with federally facilitated Marketplaces from the Center for Consumer Information and Insurance Oversight. NOTE Benefit levels are bronze, silver, gold, and platinum.
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strained. In particular, processing this information requires far more bandwidth than is needed by most people choosing an employer-sponsored insurance plan, when there are rarely more than two or three options and no projection of future income is required. Lessons From Federal Tax Filings And The Earned Income Tax Credit Just as financial stress associated with the November–December holidays may shrink decision-making bandwidth, the February–March period may be a time when lower-income people experience expanded bandwidth. Many receive income tax refunds and EITC payments. For example, among tax filers who did not receive Social Security benefits in 2008, the average refund for those with incomes between $1 and $25,000 was $2,313 (more than 90 percent received a refund); similarly, the average refund was $2,637 for those with incomes between $25,001 and $50,000, and $3,337 for those with incomes between $50,001 and $75,000 (Daniel Feenberg, National Bureau of Economic Research, personal communication, February 28, 2014). As noted earlier, the 2015 tax filing season will also be when an additional refund may be available to Marketplace enrollees who take a partial advance credit or who are otherwise undersubsidized during 2014. To reduce the complexity and stress of filing taxes, the majority of households with income less than $50,000 use professional tax preparers.14 Most also file and receive refunds well before the April 15 deadline: Over half of all filings are submitted before March 1, and twothirds are submitted prior to the third week in March. Among tax filers with EITC refunds, the majority are received in February.15–17 The specific experience of the EITC provides a relevant illustration of individual behavior. The average EITC refund in 2011 was $2,905 for a family with children and $264 for a family without children.18 Prior to 2011, beneficiaries could receive the EITC as either a lump-sum payment or a prorated addition to their paychecks during the year. In practice, only 1 percent of beneficiaries chose the prorated option, and starting in 2011 the option was dropped.16 Choosing a lumpsum payment is consistent with research showing that low-income people appear to use the lump-sum option as a form of forced savings. In the language of behavioral economics, it provides a different “mental account” for their income than their paychecks.9,19 Analyses show that the majority of EITC payments and tax refunds are spent paying balances due on bills and purchasing durable goods or services including furniture, appliances, used cars, or car repairs.16,19
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Choosing a health plan in the Marketplaces can be complicated for anyone and overwhelming for those whose bandwidth is strained.
The EITC experience is instructive also because there is substantial overlap of income eligibility for the EITC and the ACA’s premium tax credit. For the 2013 tax year, a married couple with two children filing a joint income tax return is eligible for the EITC if their adjusted gross income is less than 205 percent of the federal poverty level.20 A married couple with one child is eligible if their income is less than 221 percent of poverty. People without children face a much lower income eligibility maximum: 125 percent of poverty. Since a quarter of the nonelderly uninsured in 2012 had 2011 incomes between of 138–250 percent of poverty,21 many people who are eligible for the advance tax credit premium subsidies for the ACA also are likely to be claiming an EITC.
Study Data And Methods To test our proposition that the holiday season may reduce bandwidth and that the first quarter of the calendar year may offer a better time for open enrollment, we turned to weekly data on US-based Google search queries between January 2004 and December 2013. The use of Internet search data as a public health population– surveillance tool is well established in studies on seasonality in mental health conditions and infectious disease outbreaks.22,23 To our knowledge, our study is among the first to apply this indirect observation method to the problem of optimally designing social policy. We used the Google Trends tool to extract weekly time-series data on queries related to financial security and health insurance. To investigate when during the year people feel the most financially stressed, we created a composite financial insecurity index measure based on aggregate search volume for the terms “cash advance,” “payday loan,” or “payday advance.”
Similarly, to examine when people may feel more financially secure, we investigated searches for information on bank savings accounts and tax refund checks. Finally, we investigated when people seek out information on health insurance, using a composite measure based on queries for “health insurance plans” or “medical insurance plans.” Sensitivity analyses based on alternative search terms—for example, “private health insurance,” specific health insurance companies, and other recurrent expenses such as car insurance—yielded similar results. To isolate seasonal trends, we applied nonparametric decomposition methods to the weekly time series of each search index.24 Values were standardized into z-scores to facilitate comparisons across indices. Using the method outlined by Robert Cleveland and colleagues,24 we applied a series of nonparametric Loess regression models to the standardized data to decompose the overall time series into three components: an overall trend that captured shifts in search frequency over time; a seasonal trend that captured periodic fluctuations in search behavior that repeated each year; and a remainder component that captured the remaining variation. Our main results focus on the seasonal trend. However, the raw time-series data and annotated plots of all three components are provided in the online Appendix.25
Study Results Seasonal trends in financial insecurity were most pronounced in the summer months and just before the holiday season (Exhibit 2). As noted above, this finding is consistent with the notion that many people feel financially pressured during the holidays. Similarly, measures of financial insecurity also peak in the summer: These are months when children are out of school, so child care expenses increase and reduced-cost or free school meals are not an option for low-income families. Consistent with our hypothesis, Internet queries for savings accounts are the most pronounced during January–April. In fact, we found that seasonal patterns based on our index measures of financial security and financial insecurity were nearly inverses of each other for much of the year. This corroborates past research evidence that many people view tax refunds as “forced savings” that can be used to shore up their personal finances. Internet searches for information on health insurance also displayed significant seasonality, with query volume dropping substantially during the holiday season (Exhibit 3). Search volume then spiked considerably just after the holidays and leading into the new year. This evidence J u ly 2 0 1 4
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Web First Exhibit 2 Seasonality In Internet Searches Related To Financial Security Between January 2004 And December 2013
Weekly time series of each index
Open enrollment season
Financial insecurity index
Tax refund check
Financial security index
Week of the year SOURCE Authors’ analysis of Google Trends data. NOTE This exhibit plots the seasonal component of a nonparametric decomposition of search index time-series data from US-based Google queries between January 2004 and December 2013.
is consistent with the notion that people may lack the mental bandwidth to make complex decisions during the holiday season but that once it ends, they begin to think more comprehensively about their plans for the next year. A nearly iden-
tical seasonal pattern was found with searches for car insurance information—another recurrent annual expenditure with some discretion as to the timing of the initial purchase (data not shown).
Exhibit 3 Seasonality In Internet Searches Related To Health Insurance Between January 2004 And December 2013
Weekly time series of search volume index
Open enrollment season
Search volume index
Week of the year SOURCE Authors’ analysis of Google Trends data. NOTE This exhibit plots the seasonal component of a nonparametric decomposition of search index time-series data from US-based Google queries between January 2004 and December 2013.
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Open enrollment for health insurance does not have to occur only in the fall.
Discussion Recent research by experimental psychologists and behavioral economists provides robust evidence that people have varying degrees of mental bandwidth for making complex choices, depending on how stressed they are by finances and demands on their time. The Internet search patterns we observed are consistent with the idea that the year-end holiday season is a period of financial stress for many people. Moreover, our analysis also demonstrates that November and December are the months when people are least likely to seek out information on health insurance and other recurrent financial expenditures. In contrast, the early months of the year appear to be a period when people feel less financial pressure and mental stress because of the receipt of tax refunds, most of which are received in February and March. Given our interest in health plan choices, it is noteworthy that queries about health insurance also grow rapidly and then stabilize in the weeks just after the holidays. Implications Of Seasonal Stress The seasonality of financial and mental stress has serious implications for the ACA’s goals of maximizing enrollment in Marketplace health plans and maintaining a healthy balance of enrollees with low and high risks of having high medical expenses. People at low risk for having high medical expenses are typically younger and healthier than those at higher risk. The implications are especially worrisome with respect to younger low-income people who have not had health insurance and might lack experience choosing among plans. If they cannot make a choice among the health plan options and remain uninsured, the goals of the ACA may be in jeopardy. Policy Options The next open enrollment period for the Marketplace health plans could be shifted from the November 15, 2014–February 15, 2015 period to the two months between February 15 and April 15, 2015. Because this coincides with the time frame within which most low-income households file their tax returns, applicants would have more up-to-date informa-
tion on their total income as a basis for calculating their premium tax credit subsidies.12 Equally important, such a shift coincides with the months when many people receive tax refunds, a portion of which they might want to designate for their share of the premium in the coming year. Families USA, which had been closely following efforts to help people understand their Marketplace choices, released a set of ten recommendations on April 1, 2014, for improving enrollment in the next open enrollment period. Third on its list is to coordinate open enrollment with the tax filing season.26 Open enrollment for health insurance does not have to occur only in the fall. Even though a majority of employers have open enrollment periods in the fall, some employers hold open enrollment in the late spring with the new choices going into effect on July 1. Ultimately, open enrollment periods should be aligned with the start date of insurance policies. Though most insurance policies currently begin on January 1, that does not have to be the case. A twelve-month period could start any time during the year. If the open enrollment period for the Marketplace health plans were shifted to March-April, for example, coverage under the health plans could start June 1 or July 1 and the accounting period for the annual deductible and out-of-pocket maximum would start at the same time. Health plans and insurance companies also might prefer to have the Marketplaces’ open enrollment period occur at a different time than that for employersponsored plans. Usefulness Of Internet Search Data There are several limitations to our use of Google search data to explore when financial stress might be high during the year. Our analyses were not restricted to searches by uninsured people who may be eligible for Marketplace plans. However, focus groups among thousands of Marketplace-eligible uninsured people prior to October 2013 indicated that nearly 80 percent were “frequent” Internet users, and almost every group of uninsured participants ranked “Google/Internet searches” as their top source of information on enrolling in coverage.27,28 Second, although our financial security measures provide strong suggestive evidence, they cannot definitely pinpoint the February-March period as the least financially stressful months of the year. To allay concerns that these months may have other stresses that were not captured here, focus groups could be held with lower-income people to find out when they would feel more comfortable choosing a health plan. Alternatively, a few states could experiment with the timing of open enrollment to determine if there are other J uly 201 4
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Web First months during the year when lower-income people may have less stress.
Conclusion Research by experimental psychologists and behavioral economists has some striking implications for the timing of the Marketplaces’ open enrollment period. This research has shown that people who are financially stressed do not have the mental bandwidth needed to make decisions or that they make a choice that often appears to be not in their best interest over a longer time frame. Holding the Marketplaces’ open enrollment period in the late fall coincides with weeks that our analyses show are particularly financially stressful for many people. These months are likely to be especially stressful for lower-income people, who will account for most of the consumers choosing health plans in the Marketplaces. Given what is known about how financial stress affects people’s bandwidth for making decisions, holding open enrollment just before or during the holiday season is a mistake. The ACA’s goals of maximizing enrollment in the health plans and maintaining a healthy balance of enrollees with low and high risks of having high medical The authors appreciate the thoughtful suggestions of two anonymous reviewers and are grateful for many informative conversations with Brian Haile and George Brandes of Jackson Hewitt Tax Service in Nashville,
Given how financial stress affects bandwidth for making decisions, holding open enrollment just before or during the holiday season is a mistake.
expenses are more likely to be achieved if the open enrollment season is shifted to the two months between February 15 and April 15 each year. Many lower-income people receive their income tax refunds and EITC payments then, so they are more likely to have the mental bandwidth for making decisions about their health insurance options and to enroll in a plan. ▪
Tennessee, as well as with several executives of insurance companies. The authors thank Dan Feenberg of the National Bureau of Economic Research for providing estimates of average income tax refunds in 2008, by income
group, of people who did not receive Social Security benefits. Views expressed are solely those of the authors. [Published online June 25, 2014.]
NOTES 1 Congressional Budget Office. CBO’s May 2013 estimate of the effects of the Affordable Care Acton health insurance coverage [Internet]. Washington (DC): CBO; 2013 [cited 2014 May 6]. Available from: http:// www.cbo.gov/sites/default/files/ cbofiles/attachments/43900-201305-ACA.pdf 2 Department of Health and Human Services. Patient Protection and Affordable Care Act; HHS notice of benefit and payment parameters for 2015; final rule [Internet]. Federal Register [serial on the Internet]. 2014 Mar 11 [cited 2014 May 6]. Available from: http://www.gpo .gov/fdsys/pkg/FR-2014-03-11/pdf/ 2014-05052.pdf 3 Mullainathan S, Shafir E. Scarcity: why having too little means so much. New York (NY): Times Books; 2013. 4 Shah AK, Mullainathan S, Shafir E. Some consequences of having too little. Science. 2012;338(6107): 682–5. 5 Baumeister RF, Bratslavsky E,
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nomics and tax policy. National Tax J. 2009;62:375–86. 11 Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New York (NY): Penguin Books; 2009. 12 Graves JA. Better methods will be needed to project incomes to estimate eligibility for subsidies in health insurance exchanges. Health Aff (Millwood). 2012;31(7):1613–22. 13 To limit the likelihood of reconciliation payments’ being required because the income projection was too low, people may choose to forgo the advance credit or to receive a partial advance credit—so that any remaining premium tax credit amount would be available as an additional refund at tax time. As of this writing, there was not yet information available on what share of Marketplace plan enrollees elected to forgo the advance credit or to take a partial credit. However, focus-group discussions indicate that uninsured people are at least interested in the
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option of deferring or taking a partial credit. See, for example, Consumers Union, Kleimann Communications Group. Helping consumers understand the new premium tax credit [Internet]. Yonkers (NY): Consumers Union; 2013 May 15 [cited 2014 Apr 30]. Available from: http://www.rwjf.org/content/dam/ farm/reports/issue_briefs/2013/ rwjf406124 Internal Revenue Service. Statistics of income (SOI) tax stats, historic, table 2: individual income and tax data, by state and size of adjusted gross income, tax year 2011 [Internet]. Washington (DC): IRS; [cited 2014 May 6]. Available from: http:// www.irs.gov/uac/SOI-Tax-StatsHistoric-Table-2 Internal Revenue Service. 2014 and prior year filing season statistics [Internet]. Washington (DC): IRS; [cited 2014 May 6]. Available from: http://www.irs.gov/uac/2014-andPrior-Year-Filing-Season-Statistics Goodman-Bacon A, McGranahan L. How do EITC recipients spend their refunds? Economic Perspectives. 2008;32(2):17–32. McGranahan L, Schanzenbach DW. The earned income tax credit and food consumption patterns. Chicago (IL): Federal Reserve Bank of Chicago; 2013 Nov. (Pub. No. WP 2013-14). Center on Budget Policy and Priorities. Policy basics: the Earned Income Tax Credit [Internet]. Washington (DC): COB Policy and
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Priorities; [updated 2014 Jan 31; cited 2014 Apr 30]. Available from: http://www.cbpp.org/cms/?fa= view&id=2505 Romich JL, Weisner T. How families view and use the EITC: advance payment versus lump sum delivery [Internet]. Rochester (NY): Social Science Research Network; 2000 Dec [cited 2014 Apr 30]. Abstract available from: http://ssrn.com/ abstract=251092 Internal Revenue Service. Earned income tax credit; do I qualify? [Internet]. Washington (DC): IRS; 2014 Jan [cited 2014 May 6]. Available from: http://www.irs.gov/uac/ Newsroom/Earned-Income-TaxCredit-Do-I-Qualify Authors’ calculations based on data from the March 2013 Current Population Survey (CPS). The CPS is a monthly survey of about 60,000 households that are representative of the US civilian noninstitutionalized population and is conducted by the Census Bureau. Detailed information about health insurance coverage and income, and extensive demographic data, are collected each March. Ayers JW, Althouse BM, Allem JP, Rosenquist JN, Ford DE. Seasonality in seeking mental health information on Google. Am J Prev Med. 2013;44(5):520–5. Carneiro HA, Mylonakis E. Google trends: a web-based tool for real-time surveillance of disease outbreaks. Clin Infect Dis. 2009;49(10):
1557–64. 24 Cleveland RB, Cleveland WS, McRae JE, Terpenning I. STL: a seasonaltrend decomposition procedure based on Loess. J Official Stat. 1990;6(1):3–73. 25 To access the Appendix, click on the Appendix link in the box to the right of the article online. 26 Pollack R, Klein R. Accelerating the Affordable Care Act’s enrollment momentum: 10 recommendations for future enrollment periods [Internet]. Washington (DC): Families USA; 2014 Apr 1 [cited 2014 Apr 30]. Available from: http://familiesusa .org/product/10-enrollment-fixes 27 Perry Undem Research Communication. The uninsured midway through ACA open enrollment: results from a national survey of uninsured adults 18 to 64 conducted December 12–22, 2013 [Internet]. Washington (DC): Perry Undem; 2013 Dec [cited 2014 Apr 30]. Available from: http://www.enroll america.org/wp-content/uploads/ 2014/01/Perry_Undem_ Uninsured_Survey.pdf 28 Perry M, Undem T. Informing Enroll America’s campaign: findings from a national survey [Internet]. Washington (DC): Enroll America; 2013 Feb [cited 2014 Apr 30]. Available from: http://www.enrollamerica .org/wp-content/uploads/old-files/ best-practices-institute/publiceducation-resources/Enroll_ America_Survey_Final_Report.pdf
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