Cover: Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage

Assessing the Role of State and Local Public Health in Outreach and Enrollment for Expanded Coverage

Seven Case Studies from Local and State Health Departments

Published Jul 8, 2016

by Malcolm V. Williams, Laurie T. Martin, Courtney Armstrong, Nazleen Bharmal, Julia Joh Elligers, Laura Runnels, Kate Heyer, Christian Lopez

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Research Questions

  1. What innovative models and best practices can leverage local health departments' involvement in Patient Protection and Affordable Care Act outreach and enrollment?
  2. How can state or local public health entities and agencies serve as a gateway to identifying and enrolling eligible people in the expansion of Medicaid and implementation of the health insurance marketplace?
  3. What are the challenges or facilitators to full engagement in outreach and enrollment in Medicaid expansion and the health insurance marketplace by public health?
  4. What role can public health play in maintaining enrollment?
  5. What are the best ways to facilitate information sharing in outreach and enrollment?

The Patient Protection and Affordable Care Act (ACA) 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. This report summarizes seven case studies — Eagle, Garfield, and Pitkin counties, Colorado; Tacoma-Pierce County, Washington; New Orleans, Louisiana; Boston, Massachusetts; West Virginia; Houston, Texas; and Illinois — that leverage local health department (LHD) efforts in ACA outreach and enrollment to facilitate knowledge transfer to other geographic regions. Potential LHD roles include serving as a coordinator for community activities, being a trusted source of health care information for consumers, and leveraging relationships with community partners to increase capacity for outreach and enrollment. Also, the case studies provide guidance and insight into the current role of LHDs, and help redefine that role in the future, as states continue to enroll residents in health insurance coverage.

Key Findings

Challenges to outreach and enrollment

Challenges to outreach and enrollment include inconsistencies between national and state enrollment processes, lack of access to major grant funding, underestimations of the time required to complete enrollments, and high insurance costs.


LHDs can be creative with limited resources and serve as an important liaison between state agencies and community organizations or residents.

Some factors — such as a long history of partnership and strong communication; complementary, not competing, interests; strong community presence; the ability to influence policy; and shared decisionmaking across alliances — help LHDs' efforts.


Trust established between LHDs and residents facilitated LHD communication to harder-to-reach residents facing barriers to enrolling in health insurance and the public about the availability of health services.

LHDs are skilled at contracting with local community-based organizations that have reach into specific communities for outreach and enrollment.

Policy and Practice

The diverse perspective of LHDs is critical to understanding the ACA, for successful outreach and enrollment efforts, and helping to shape the dialogue around health insurance within the community.

LHDs found creative ways to apply the practice of public health to outreach and enrollment.

Case study discussants identified different ways that national and federal agencies can support LHDs and their partners including:

  • Deploying national messaging to illustrate the importance of insurance.
  • Funding and education to support LHD participation in outreach and enrollment, especially in nonexpansion states.
  • Real-time enrollment information.
  • New staffing models to help LHDs link consumers to care after enrollment.

Research conducted by

The research described in this report was conducted by RAND Health.

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