Last week, we wrote about how cost is THE factor in how Americans shop for health insurance, driving decisions on if and how they enroll and creating negative perceptions of the health insurance system as a whole. In this post, we’ll talk about what advertising and communication outreach programs can do to break through to uninsured audiences who are deciding that health insurance is simply beyond their reach.

Marketing for Change has conducted consumer research for federal and state health insurance enrollment projects for two decades. This year, we went a step further, conducting our own national survey to better understand the nuances and dynamics of the 2026 enrollment landscape. 

Our survey was conducted immediately after the close of open enrollment for the national Health Insurance Marketplace. Respondents were asked how they currently feel about health insurance. Their response options were designed to quickly segment them into profiles that show where they are in their health insurance decision-making journey:

• “I don’t ever want it” – The Nevers
• “I want it eventually, but not right now” – Future Buyers
• “I want it now, but I can make do without it” – Healthcare Hackers
• “Going without it would be difficult for me” or “It’s a necessity, I can’t go without it” – High Need

Some audiences are easier to reach than others. The High Need group already sees insurance as essential, while the Nevers (making up only 7% of uninsured) represent a much more resistant audience.

The middle two groups, Future Buyers and Healthcare Hackers, represent the greatest opportunities because they are actively deciding the role health insurance plays in their lives.

For many uninsured Americans, the decision to go without health insurance is not ideological or even permanent. Our research suggests that a large segment of uninsured consumers see coverage as something they will eventually buy once life becomes more stable, finances improve, or responsibilities increase. Others believe they can hack the healthcare system by postponing all non-urgent care, using free clinics, practicing a healthy lifestyle, and praying that a serious illness or injury won’t befall them. These audiences are weighing timing, affordability, trust, and (perceived) necessity.

For marketing campaigns to get audiences to enroll in health insurance, understanding where consumers are at in their journey and identifying their unique beliefs, attitudes and behaviors will make outreach strategies more effective.

Let’s take a deeper look at the two most movable audiences.

The “Future Buyers”

Future Buyers (27% of the uninsured audience) recognize the emotional and practical value of insurance, even if they are not actively shopping for coverage today. Nearly two-thirds of this group (64%) say health insurance is worth it for the peace of mind it provides. Most (69%) feel confident that they understand health insurance well enough to make good choices about plans.

Perhaps most notably, 57% disagree with the statement that they are “not at a point in life where they need health insurance.” In other words, though they view health insurance as a “future problem”, many also recognize that coverage is relevant to their current stage of life.

These findings run counter to many traditional assumptions about the uninsured, which often focus on awareness gaps or lack of perceived relevance. Instead, for many Future Buyers, the issue is less about whether they value insurance and more about whether now feels like the right time. 

The issue is less about whether they value insurance and more about whether now feels like the right time. 

This audience may be delaying action because they expect their circumstances to change soon: a new job, more stable income, marriage, children, aging, or a health event. Others may simply be postponing a complicated financial decision. This is supported in the focus groups and in-depth interviews we have conducted with uninsured Americans who believe their circumstances need to radically change in order for health insurance to be a viable option.

For communicators, that means outreach should not treat these consumers as disengaged or opposed to coverage. Instead, messaging should focus on closing the gap between “someday” and “today.” For instance, messaging can:

• Lead with a reason for “why now” that creates triggers beyond life changing events
• Make it easier to enroll today – simplifying actionable next steps so enrollment feels manageable now, not later
• Emphasize immediate and small benefits like proactive wellness benefits rather than focusing on catastrophic protection

Messaging to Future Buyers should also respect their existing knowledge and decision-making ability. They have a high self-efficacy around health insurance, many believe they can evaluate and compare plans on their own. Basic “Insurance 101” messages may feel patronizing. Instead, Future Buyers need an invitation to enroll now versus waiting for a life changing event.

The Healthcare Hacker

Healthcare Hackers (40% of the uninsured audience) realize that not having health insurance leaves them financially vulnerable, but instead of enrolling in coverage, they attempt to navigate the system without it. 

Their attitudes and beliefs reveal a striking tension. An overwhelming 93% worry about medical costs if they become sick or injured. Two-thirds (67%) say they have delayed medical tests because of cost concerns. More than half (52%) agree that having health insurance is normal for people like them. However, at the same time, 53% believe that all health insurance is a scam.

This seeming contradiction is important. Healthcare Hackers are not carefree risk takers. Many are deeply worried about healthcare costs. But they also distrust insurers, or feel that premiums, deductibles, and coverage limitations make insurance a poor value.

Healthcare Hackers are not carefree risk takers. Many are deeply worried about healthcare costs.

Many have developed alternative strategies for surviving without healthcare coverage. In our focus groups with uninsured Americans, group discussions often turn into uninsured individuals sharing and comparing notes on the creative and ingenious ways they work to meet their healthcare needs. 

Healthcare hacking may be especially common among consumers who have had disappointing experiences with insurance, faced high premiums or unaffordable deductibles, or struggled with denied claims and billing complexity. For them, going without may feel less risky than paying for coverage they do not trust.

Going without may feel less risky than paying for coverage they do not trust.

As a result, outreach focused exclusively on fear-based messaging is likely to have limited impact. Many Healthcare Hackers are already worried about their health and how they will pay for potential future illness or injury. The challenge is not convincing them that medical costs are dangerous. Instead, messaging needs to focus on rebuilding trust. For instance, messaging could include:

• Helping the consumer not overpay for coverage – sharing tips, tricks and resources
• Extreme transparency and details in costs
• Using relatable humor to point out the inevitable risks of hacking the system
• Authentic and empathetic language instead of corporate or overly salesy language

This audience is likely to respond poorly to messaging that feels institutional, overly technical, or disconnected from their own experiences.

Understanding Where People Are in the Decision-Making Journey

One of the clearest themes from our research is that many uninsured consumers are not making a simple yes-or-no decision about health insurance. Many recognize its value but continue delaying enrollment because they think they can wait. Still others want coverage but are attempting to make do without it because of affordability concerns or distrust. These are very different psychological barriers.

Contrary to traditional thinking, the uninsured already recognize the benefits of health insurance. That’s not what they need to be sold on. They need help moving forward in their decision-making process.

The uninsured already recognize the benefits of health insurance. That’s not what they need to be sold on. They need help moving forward in their decision-making process.

This creates an opportunity for marketers and advertisers to think less about uninsured consumers as either “in” or “out,” and more about where they currently are in their journey. The challenge is not reaching uninsured audiences – it is understanding what is keeping them from taking the next step.

Aaron Metzger leads the agency’s consumer research for the federal Health Insurance Marketplace as well as for state exchanges in Illinois and Nevada.