- Massachusetts had several years' experience in state health care reform implementation prior to implementation of the ACA, and public health had been instrumental in outreach and enrollment in these efforts.
- A critical strength of the Boston Public Health Commission's approach was its reliance on key partners to reach targeted groups, some of which were the hardest-to-reach populations. This approach builds on the neighborhood focus of Boston. This means that people are connected to community-based organizations, which, in turn, facilitates word-of-mouth information-sharing.
- BPHC did successfully identify and target its outreach efforts to those most likely to be eligible for insurance coverage through the use of census-level data.
- The lead navigator agency, the Boston Public Health Commission (BPHC), is at the forefront of identification, outreach, and enrollment efforts.
- Paper enrollment applications that were substituted for the inoperable website will become a challenge in the upcoming enrollment season because many people who enrolled using paper applications will need to reenroll through the electronic portal in the 2014–2015 open-enrollment period.
- Navigators could not sufficiently address technical and financial implications for small-business owners, so BPHC had to scale back engagement of these groups.
- Community health centers allowed BPHC staff to connect newly insured people with primary health care.
- Longstanding relationships and trust that community partners have with Boston-area residents facilitated residents' engagement with the health care system.
The Patient Protection and Affordable Care Act (ACA)1 laid the groundwork for a substantial increase in the number of people who have access to health insurance through Medicaid expansion or health insurance marketplaces.2 During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible individuals. Typically, federal and state funding was used to develop navigator programs in each state. The design of these programs differed by location,3 and, although many stakeholders were involved in these efforts, state and local public health departments (LHDs) were, and remain, a relatively untapped resource.4 This is somewhat surprising, given that LHDs serve as trusted entities in communities, can reach the most-vulnerable populations, and have access to data and resources that might facilitate ACA outreach and enrollment.
This is one in a series of studies designed to highlight innovative models and best practices that leverage LHD involvement in ACA outreach and enrollment and to facilitate knowledge transfer to other geographic regions looking to leverage the full range of roles for LHDs in ACA outreach and enrollment. Potential roles include serving as a coordinator for community activities, being a trusted source of health care information for consumers, and leveraging community partners to increase capacity for outreach and enrollment. These studies identify compelling models for how LHDs can implement similar activities in their own communities. Further, they provide guidance and insight into the role LHDs can play now, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage. Each case study was designed to capture nuanced differences in how health departments support these efforts in their communities, identify facilitators and barriers to these approaches, and develop lessons learned from these activities.
Context of Health Care Reform in Boston and Massachusetts
In 2006, Massachusetts became the first state in the United States to pass comprehensive health care reform, which required most residents to obtain health insurance. Prior to the state health care reform efforts and continuing through implementation of the ACA, Massachusetts operated an expanded state Medicaid program, MassHealth, under a series of Section 1115 Medicaid waivers.5 The waivers allowed Massachusetts to expand MassHealth eligibility and coverage to low-income pregnant women, parents or adult caretakers, infants, children, and individuals with disabilities and provide premium subsidies to some individuals enrolled in qualified health plans that meet the minimum standards set by the ACA. As a result of these policy changes and financial support for the state Safety Net Care Pool program, by 2013, Boston had a 95.2-percent insurance rate among residents, and there were high levels of awareness of the legal requirements for and benefits of health coverage.6
Identifying Case-Study Sites and Activities
RAND researchers and National Association of County and City Health Officials (NACCHO) staff identified state and local health departments that represented a range of models for participation in outreach and enrollment activities. An initial environmental scan, which included literature reviews, website analysis, and semistructured interviews with national and local stakeholders, identified a range of activities. Discussions with key staff at 15 health departments were conducted to learn more about their specific approaches and to understand more about the community and population context. In consultation with staff at the Office of the Assistant Secretary for Planning and Evaluation (ASPE), we selected seven sites that highlight a variety of models of LHD involvement and contexts in which the public health departments were operating. The sites reflect differences in expansion status, urbanicity, region, use of public health data, participation of public health in partnerships, and leadership by public health: Boston, Massachusetts; Eagle, Pitkin, and Garfield counties, Colorado; Houston, Texas; Illinois (state and local); New Orleans, Louisiana; Tacoma and Pierce County, Washington; and West Virginia (state).
Site visits were conducted over two- or three-day periods between June and October 2014 with LHD leadership or staff and other key players in regional outreach and enrollment efforts (e.g., health care systems, social services, community-based organizations, or state or local government officials). RAND and NACCHO staff conducted four of the case studies; RAND staff alone conducted two; and NACCHO staff alone conducted one. Prior to arriving on site, RAND and NACCHO staff conducted telephone and email discussions to coordinate logistics and plan the topics to be covered in the in-person meetings. The discussions used an open-ended discussion guide that provided a consistent structure to each interview while allowing sufficient flexibility to capture all relevant information from participants. Discussions focused on implementation strategy (e.g., outreach and enrollment activities, funding, partnerships, and resources), evaluation, sustainability, and replicability. In a few cases, follow-up phone calls were made to staff who could not attend the in-person meetings.
Boston Case Study
RAND and NACCHO conducted the site visit to Boston on September 9 and 10, 2014. Our team conducted five meetings with the LHD's network involved in outreach and enrollment activities, including partners at Bunker Hill Community College; the South Bay House of Correction; and the Bureau of Addictions Prevention, Treatment and Recovery Support Services at the Boston Public Health Commission (BPHC), which administers the local LHD's needle-exchange and addiction treatment programs.
Rationale for Selecting This Case Study
Boston was selected as a case-study site for several reasons. First, Massachusetts had several years' experience in state health care reform implementation prior to national efforts, and public health had been instrumental in outreach and enrollment prior to implementation of the ACA. Thus, Boston was a natural place to explore the role of public health in identification, outreach, and enrollment for expanded coverage.
Second, the case study provides a model for how public health can operate at the forefront of identification, outreach, and enrollment efforts as a navigator agency. BPHC is a locally governed LHD and operates under a strategic plan shaped by a focus on health equity and social justice principles. BPHC provides a range of direct services and supports core public health functions throughout the city. Boston is a large urban community; as a result, the LHD operates a variety of public health programs. BPHC was able to build on these experiences and resources to develop a range of outreach and enrollment activities. Thus, its experience illustrates comprehensive steps that public health can take to educate consumers about the advantages of health care coverage, as well as educating newly insured persons about how to use their health insurance.
Third, Boston is unique in that the city has a significant health and hospital infrastructure, including several major academic centers, which provide opportunities for frequent collaboration between health care and public health. The community health center network in Boston is a vast and important resource that serves residents throughout the city; most neighborhoods in the city and the surrounding area have at least one community health center.
Model of Local Health Departments' Involvement and How They Came to Be in This Role
For many years, BPHC has dedicated significant resources to connecting residents with health care coverage and services. Since 1986, BPHC has operated the Mayor's Health Line, which is a toll-free phone line monitored by trained LHD staff that connects residents to information about available services in the community. The Mayor's Health Line promotes a variety of resources, including health insurance coverage, primary care, housing, energy assistance, and access to translation and interpreter services. The Mayor's Health Line is one of the key ways in which residents connect to enrollment assistance and, in many cases, makes the first health care appointment for newly enrolled individuals to begin connecting with care.
In 2013, BPHC applied for and was awarded funding from the Massachusetts Health Connector to become a navigator agency, training nine LHD staff to be certified application counselors. The $304,690 grant partially funded salaries for nine navigators, who worked through the Mayor's Health Line and supported marketing and coordinated efforts to outreach to hard-to-reach populations during the 2013–2014 open-enrollment period.7 The LHD applied for additional funding to continue its outreach and enrollment work for a second year, although the focus for the 2014–2015 grant year was adjusted to meet the population and geographic needs of those who were eligible but have not yet enrolled in health coverage.
As the figure shows, this existing infrastructure supported BPHC's identification, outreach, and enrollment efforts and allowed consumers to have access to multicultural, multilingual, and responsive staff who were prepared to assist with their health insurance questions during the 2013–2014 open-enrollment period. The Mayor's Health Line was influential in connecting individuals with the resources available to them as they investigated and enrolled in health coverage. The Mayor's Health Line also served as an important connection between BPHC and community partners. When Mayor's Health Line staff visited community partners and provided enrollment assistance or gave presentations about health insurance, the navigators became the “public face” of the resource, and BPHC found that consumers recognized the service they offer and provided word-of-mouth advertising about the enrollment assistance available through the LHD.
Public Health Roles to Support Outreach and Enrollment
As a result of both the navigator grant and BPHC's existing outreach and enrollment infrastructure, BPHC contributed to identification, outreach, and enrollment as a navigator agency in Boston through a variety of mechanisms, which we describe in this section.
Provided Direct and Indirect Enrollment Assistance
Given the high insurance rates in Boston, BPHC targeted outreach during the 2013–2014 open-enrollment period to people who remained uninsured following state health care reform and those who were newly eligible for coverage. To accomplish this, BPHC provided both direct enrollment assistance and referrals to community agencies that can provide direct enrollment assistance. The navigator staff at BPHC are multilingual and multicultural and have established the trust with the community necessary to successfully reach people who might not otherwise have frequent contact with the public health and health care systems. A staff member from the Mayor's Health Line said, “We started noticing that what allowed our outreach to be effective was to work with people [who] already had an established trust in the community. This helped us get the information out there in an effective and timely way.”
Because Massachusetts had high levels of insurance coverage prior to the implementation of the ACA, the direct enrollment assistance provided by BPHC differed from assistance in other jurisdictions in that plan selection was a less significant component of the enrollment experience than in other jurisdictions because most people were newly eligible for MassHealth coverage, for which there is only one plan. Additionally, because the marketplace website was inoperable, consumers who otherwise would have qualified for plans in the marketplace could not do so. As a result, people were granted temporary MassHealth coverage during this period.
To leverage the grant funding and support the LHD's existing outreach and enrollment efforts, navigator staff from the Mayor's Health Line developed a strategic plan to target and reach out to uninsured or underinsured populations by leveraging existing relationships. Priority populations included newly unemployed people, the long-term unemployed, people recently released from incarceration, select immigrant communities, the homeless, and substance-abusing populations. The Mayor's Health Line staff initially conducted stand-alone presentations about outreach and enrollment at community events. They found that, although consumers were interested in learning about coverage options, they could reach more people by pairing presentations about health insurance with existing community health activities.
To reach the target populations during the 2013–2014 open-enrollment period and throughout the year, BPHC leveraged partnerships with both new and existing community partners. Those with whom it worked closely during the first open-enrollment period included Bunker Hill Community College, South Bay House of Correction, community health centers, homeless-serving agencies, faith-based organizations, a methadone-replacement and substance abuse treatment clinic, and the local needle exchange.
Bunker Hill Community College served as an important partner for BPHC's identification, outreach, and enrollment efforts targeted toward young people, many of whom previously relied on student health insurance plans with limited coverage scopes. The two-year local community college enrolls more than 14,000 students, 67 percent of whom are people of color and older than the typical college student. BPHC and Bunker Hill identified the need to partner to provide enrollment assistance through a meeting focused on college affordability. Prior to ACA implementation, students were required to carry some form of health insurance through family or an employer or purchase the student health insurance plan (SHIP) upon registering for a full course load; however, since the implementation of the ACA, many students, depending on family income, are now eligible for subsidized coverage and do not have to opt for SHIP. The ACA also extended the age to which students were allowed to stay on their parents' insurance to 26, which increased coverage and helped students save on health care costs in order to remain enrolled in school.
BPHC and Bunker Hill partnered to provide enrollment assistance through a meeting focused on college affordability. Recognizing that many students might now be eligible for other health care coverage options, BPHC and Bunker Hill identified an opportunity to pair course registration with health insurance enrollment. To accomplish this, Bunker Hill developed an electronic message for the class registration portal to inform students about the need to enroll in health insurance and included informational materials in new-student folders. BPHC also provided periodic on-site enrollment assistance, and Bunker Hill referred students to staff at the Mayor's Health Line to connect with navigation assistance. This partnership allowed BPHC consistent access to young people who are often eligible for insurance coverage and has supported Bunker Hill in helping its students obtain affordable coverage and remain enrolled in classes.
BPHC also worked with the South Bay House of Correction, a county correctional facility for inmates serving sentences of 2.5 years or less that integrated MassHealth enrollment into discharge planning for people as they prepared for release from jail. By initiating the enrollment process prior to discharge, the House of Corrections helps incorporate health and wellness into the transition from incarceration to the community, which is particularly useful for inmates who require care for chronic diseases, substance abuse, or psychiatric care.
Additionally, BPHC partnered with the local methadone-replacement clinic and needle-exchange organization to provide outreach and enrollment referrals for people accessing care at those sites. Some of the discussants indicated that this is a key partnership because the staff at the methadone-replacement clinic and needle-exchange program have frequent (often daily) contact with people who are disenfranchised from the health system.
Used Data to Identify Populations and Provided Education
BPHC has access to data that helped in identifying eligible uninsured persons and facilitating outreach and enrollment. During the first grant year, the Mayor's Health Line utilized existing ZIP Code–level census data to identify the populations that were likely uninsured to target for enrollment assistance. The LHD has planned to compare those same data with enrollment data to target and plan outreach for the 2014–2015 open-enrollment period.
BPHC also plays an important role in the community by providing education on a wide range of health topics, including the importance of health coverage. With the expansion of MassHealth and the changes that arose as a result of the requirements of the ACA, BPHC staff and partners served as educators to the community to explain the details of comprehensive health care coverage to consumers and describe the differences between the federal health care reform efforts and previous state-level reforms. Because the Massachusetts Health Connector website experienced significant challenges throughout the 2013–2014 open-enrollment period, staff from the Mayor's Health Line also provided troubleshooting assistance to consumers who could not successfully enroll in coverage online.
Challenges to Outreach and Enrollment
BPHC and its partners experienced a variety of challenges to its outreach and enrollment activities. Case-study participants indicated that a primary challenge was the unreliability of the Massachusetts Health Connector website, which was not functional during open enrollment. The subsequent communication from the Massachusetts Health Connector about the status of improvements and approaches to developing “workarounds” to facilitate enrollment during the time that the website was not operational, was not timely, and was insufficient to address the problems the navigators were experiencing. BPHC staff indicated that, although the Massachusetts Health Connector frequently provided feedback about the challenges the website was experiencing, it encouraged people to continue attempting to enroll through the portal, without providing guidance as to how to do this successfully. LHD staff, including from the Mayor's Health Line, ultimately shifted to enrolling people using paper applications, resulting in a slower process and more staff time spent per application.
The inoperable website created an additional challenge that affects open enrollment in 2014–2015. Those people who enrolled using paper application forms during the 2013–2014 open enrollment needed to reenroll through the electronic portal in the 2014–2015 open-enrollment period.
Initially, one of the key areas of focus for the Mayor's Health Line strategic plan was to work with small-business owners to educate them about enrollment and coverage options for their staff. However, BPHC found that the small-business owners had many questions about the technical and financial implications of the coverage choices that went beyond the navigators' training. As a result, it scaled back direct outreach with groups until it could train staff on how to answer these questions. Additionally, the small-business component of the connector, SHOP, was not functional during this grant period, and the federal government delayed implementation of the small-business-owner coverage requirement, which reduced the urgency from employers to sign up.
Enablers to the Local Health Department's Role in Outreach and Enrollment
BPHC has a large research division, which was able to use census-level data to identify people and neighborhoods most likely to be eligible for insurance coverage and benefit from enrollment assistance. This allowed the Mayor's Health Line staff to target their outreach activities and has set the stage for planning their work for future open-enrollment periods to support continued outreach to eligible but unenrolled individuals and to facilitate reenrollment.
The availability of community health centers, which provided culturally and linguistically appropriate health care, was an especially important resource for LHD staff as they connected newly insured people with primary health care.
Additionally, several interviewees described the connections between neighborhoods in Boston and the ways in which those neighborhoods facilitate residents' engagement with the health care system. Case-study participants noted that, because people are connected at the neighborhood level to the organizations and services that exist in their neighborhoods, these connections helped to facilitate the word-of-mouth information sharing and trust needed for effective outreach and enrollment.
Future Priorities: What Comes Next?
BPHC received continuation funding to support its work providing navigators for the 2014–2015 open-enrollment period.8 The funding, although less than what was awarded in the 2013–2014 open-enrollment period, was used to support salaries for enrollment staff, as well as communication capacity to reach the populations who were not connected to health care coverage during the first open-enrollment season. For open enrollment during 2014–2015, staff will be using the updated ZIP Code–level data compiled during the 2013–2014 open-enrollment period activities. BPHC is also focused on assisting people as they use their health insurance, with a focus on health literacy and encouraging new health care usage patterns that support medical homes. By coordinating reenrollment activities according to ZIP Code of residence, the LHD believes that it will streamline the process while providing a high level of customer service to residents.
Given the existing infrastructure for health care in Boston and the comparatively low numbers of people who do not have access to health coverage, BPHC's work will continue as the populations who are not currently covered and who might lose coverage are identified. BPHC is also focused on assisting people as they use their health insurance, with a focus on health literacy and encouraging new health care usage patterns that support medical homes.
In Boston, public health is a leader in a community-wide effort to engage in outreach and enrollment. This role reflects the approach that many LHDs have taken across the country. But one of the unique aspects of this community is the coordinated nature with which the LHD engaged partners to address outreach and enrollment across the city. This case study provides useful information on several aspects of how LHDs can participate in outreach and enrollment, including focusing on harder-to-reach populations. Primarily, public health was able to leverage its network of partner organizations to implement each aspect of outreach and enrollment. Next, public health administered the navigator grant in a way that made good use of existing LHD resources while hiring new staff to support the outreach and enrollment activities in their communities.
These efforts were facilitated by a variety of factors. BPHC and its partners had a history of working together on a host of related health care and public health activities, and outreach and enrollment received broad support of city and LHD leadership for the shared goal of increasing health insurance coverage in the community. According to some case-study discussants, given the robust public health and health care infrastructure in Boston, BPHC was well positioned to lead many of the outreach and enrollment activities occurring in response to the ACA. A visible executive director supported BPHC and sought to capitalize on the LHD's work by issuing a press release to announce the award of the navigator grant and raise awareness in the community and to state and local politicians that the LHD was engaged in helping people apply for health insurance coverage. Several discussants suggested that, although the navigator grant was not one of the largest monetary grants the LHD received, it was important for providing a needed community service. In addition, Boston might have a unique political environment given its own health care reform efforts.
Other LHDs might use the example of Boston's experience and leadership to identify how to leverage their own partnerships to achieve the goals of outreach and enrollment. In Boston and other communities, public health (and LHDs in particular) can serve as a critical partner and, in some cases, as leader of key outreach and enrollment activities. However, Boston had the advantage of being able to build on experiences, relationships, and lessons learned from the earlier health care reform efforts in the state. As a result, the uninsured rate in the city is very low, and BPHC was able to concentrate on the hardest-to-reach groups. It might be many years before other LHDs gain the experience that Boston has had; as a result, some of these activities might not be replicable today. Nevertheless, the Boston case study provides a view into how LHD outreach and enrollment efforts might evolve over time.