California HealthCare Foundation was managing partner of this complex project involving several states, a federal agency, a design firm, and seven other foundations.

On June 8 Enroll UX 2014, a foundation-initiated project to develop the design of a consumer-friendly, online enrollment experience for health insurance exchanges, released its final design products. This was the culmination of more than a year of work through a public-private partnership that brought together the Centers for Medicare and Medicaid Services, eleven states, a global design and innovation firm, and a total of eight foundations that jointly provided $3 million to finance this ambitious effort.

The genesis of the project was the Affordable Care Act of 2010’s requirement that the state and federal health insurance exchanges develop self-service, online enrollment that provides a consumer-friendly, “first-class” user experience. Specifically, policy guidance from the Centers for Medicare and Medicaid Services states that “customers should experience this process as representing the highest level of service, support, and ease of use, similar to that experienced by customers of leading service and retail companies and organizations doing business in the United States.” This is not the kind of online environment that most Medicaid enrollees—or even most people who try to choose private insurance online—enjoy right now.

The Enroll UX 2014 project was undertaken in response to this challenge. (“UX” is short for user experience.) The design represents a modern, online approach for consumers to enroll in public and private health insurance and provides a model for health insurance exchanges operated by the federal government and states.

The Enroll UX 2014 design guides the user through an easy-to-use experience for determining eligibility for coverage, selecting and enrolling in a plan, and paying premiums. The design includes a scenario-based, interactive prototype that simulates the actual online enrollment experience. The prototype is intended to help both federal and state policy staffs and enrollment-system developers to understand the flow of the enrollment and plan-selection processes.

A complementary, 300-page, detailed design specifications manual helps with state customization of enrollment-system design, and a policy and implementation supplement identifies key policy issues that states will have to address as they implement the design. A set of original graphic elements—icons, typography, color palettes, and illustrations are also customizable. The design is flexible–allowing states to meet their unique policy, programmatic, and implementation needs. It will also work with any new or existing state enrollment system.

History of the Collaboration

Enroll UX 2014 has been a dynamic project—not only because of its content, but also because of the structure of the public-private partnership that brought it about.

In January 2011 California HealthCare Foundation initiated conversations with the Centers for Medicare and Medicaid Services about partnering on developing an online process that would be easy for consumers to understand and could be used as a model to assist the federal government and states with meeting the agency’s Americans with Disabilities Act and other accessibility requirements. The foundation presented a concept for the project at a March 2011 meeting of states designated by the Centers for Medicare and Medicaid Services as “early innovator” states (Kansas, Maryland, Massachusetts, New York, Oklahoma, Oregon, and Wisconsin).

Several states and the federal agency then committed to participate in the proposed project. To ensure that the project was grounded in the most current federal policy, staffs from the Center for Medicaid and CHIP Services and the Center for Consumer Information and Insurance Oversight agreed to meet weekly with project staff, with the Office of the National Coordinator for Health Information Technology (at the U.S. Department of Health and Human Services) providing guidance as needed. With the project a “go,” three additional categories of players became involved.

* Foundations

Eight foundations—the Atlantic Philanthropies, Blue Shield of California Foundation, the California Endowment, California HealthCare Foundation, the Colorado Health Foundation, Kaiser Permanente Community Benefit, New York State Health Foundation, and the Robert Wood Johnson Foundation—contributed more than $3 million to support the project’s consumer research, design, and communications activities.

* State Design Partners

Eleven diverse states agreed to participate in the project as design partners. The states were encouraged to establish small teams that represented the various state-level offices that would be engaged in exchange planning, development, and execution; several states also included consumer representatives and other stakeholders on their teams. Participating states included Alabama, Arkansas, California, Colorado, Illinois, Massachusetts (in partnership with Vermont and Rhode Island), Minnesota, Missouri, New York, Oregon, and Tennessee. During the design-refinement phase, several additional states—Arizona, Kansas, Maryland, Michigan, New Mexico, Virginia, and Washington—participated in later project activities.

* Design Firm

The foundations selected IDEO, a global design and innovation firm, to lead the research and consumer-focused design effort. IDEO is known for simplifying the design of complex systems for commercial, governmental, and nonprofit clients and is widely viewed as an innovator in understanding the needs and desires of end users and then translating them into design principles. (IDEO, in fact, recently redesigned the online process for people enrolling in Social Security benefits.)

Hands On, Hands Off

Both the complexity of the design task and state resource constraints required a model that included state involvement and was responsive to variation from state to state.

The federal and state teams worked closely with IDEO and the Enroll UX 2014 project staff throughout the process. State team members participated in interactive design sessions throughout, including regular project webinars to share updates and gather input; a strategy workshop to review emerging design approaches; small-group sessions with subject-matter experts to understand requirements and develop design iterations; and two in-person workshops.

At these two-day workshops (held in September 2011 and January 2012), participants reviewed and provided feedback on the design. To keep state teams involved and informed, the project also used an online collaborative workspace to provide project updates and to preview the evolving design.

At a final meeting today (June 8) in San Francisco, the Enroll UX 2014 design deliverables were presented to Centers for Medicare and Medicaid Services staffers and representatives from sixteen states, as well as staffers from several of the participating foundations. There, project staff reviewed the design, state customization options, and implementation requirements for the states.

Many state team members specifically noted that the opportunity to work closely and substantively with colleagues from other states was the most valuable aspect of their participation. Others noted that the consumer research and industrial design had never before been applied to improve public insurance enrollment design.

By contrast, most of the eight funding partners on the project were not involved in its week-to-week activity. California HealthCare Foundation was the managing partner of the project; it hired a project director, Terri Shaw, and other consultants. The foundation met weekly with the design firm and kept leadership at the Centers for Medicare and Medicaid Services and the other funders updated on the project. Several funders attended the workshops and participated in project webinars, but others did not. The Tides Foundation served as fiscal agent for the pooled foundation funds.

Enroll UX 2014 has been a complex undertaking, with the constraints of limited state resources and still-emerging federal policy and guidance. From California HealthCare Foundation’s perspective, it has been gratifying to work with the committed and creative teams from the Centers for Medicare and Medicaid Services and the states and to help model another way for philanthropy to pool its resources to address common concerns.

The final design deliverables, a timeline of the project’s development, communications materials, a short video, and other resources are available at