By 2017, 20 million Americans had gained health insurance coverage under the Affordable Care Act (ACA). Television insurance advertising has been a primary method used to communicate about the new insurance options available under the law to uninsured Americans. A primary concern has been convincing healthy, young adults to enroll in state and federal ACA Marketplaces. In theory, advertising campaigns might serve a dual role in targeted outreach to certain uninsured groups such as so-called ‘invincibles’ and in communicating more broadly with the American public about the benefits of new insurance options available. Through the Wesleyan Media Project, we obtained and analyzed Kantar Media/CMAG advertising data from all 210 US media markets to analyze the content of television insurance advertising during the first three ACA open enrollment periods in 2013-14, 2014-15, and 2015-16. Data collected by three trained coders included the socio-demographic and health characteristics of the individuals portrayed in advertisements, and the persuasive messages used to encourage uninsured individuals to enroll. Reliability was measured by use of Kappa statistics, a measure that enabled us to adjust for agreement by chance. Agreement measure from Kappa statistis was high for all variables (
k0.70–1.00). Both English language and Spanish language advertisements were coded, with a random subset of English advertisements double coded to assess inter-rater reliability. Visual content was collected at the unique creative advertisement level (N=876) and, within advertisement, at the focal person level (N=1,679). Differences were detected in the characteristics of people depicted in advertisements and in the persuasive message used to describe the benefits of enrolling over multiple open enrollment periods, by ad sponsor, by the political leanings of the region in which an advertisement aired and by the language (English versus Spanish language) of the ads aired.
Over the study period, the two most common messages focused on plan choice (50.5%) and the availability of low cost plans (49.4%). Other messages used commonly in advertisements were focused the availability of financial assistance (42.0%) and enrollment assistance (42.0%) to purchase health insurance. Less than 1 in 5 advertisements included persuasive messages encouraging enrollment by noting the availability of low cost or free preventive services(19.5%), the simplicity of the enrollment process (18.0%), the ability to access high quality medical care (18.4%) or being able to avoid tax penalties by enrolling (12.2%). Of the focal individuals featured in ads, 22% were children, 17% were young adults, 57% were middle age, and 3% were elderly. 53% of focal people were non-white. Overall, 67.8 percent of unique advertisements were developed by insurance companies and 51.9 percent of airings nationally were of insurance company sponsored ads. Insurance companies sponsored an increasing share of advertisements over the three enrollment periods. The second most important source of advertisements was state Marketplace sponsors, which developed 24.4 percent of unique advertisements and 26.6 percent of total airings.
