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

A Case Study on Eagle, Garfield, and Pitkin Counties, Colorado

Published Jul 8, 2016

by Malcolm V. Williams, Laurie T. Martin, Nazleen Bharmal, Christian Lopez, Courtney Armstrong, Kate Heyer

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Research Questions

  1. What innovative models and best practices in three Colorado counties 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 in three Colorado counties serve as a gateway to identifying and enrolling eligible individuals in the expansion of Medicaid and the implementation of the health insurance marketplace?
  3. Are there barriers or facilitators to full engagement in outreach to and enrollment in Medicaid expansion and the health insurance marketplace by public health?
  4. What role can public health play in maintaining 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. During the first open-enrollment season, states used a variety of strategies to reach out to and enroll newly eligible people. Typically, they used federal and state funding to develop navigator programs. Program design differed by location, and, although many stakeholders were involved in these efforts, state and local health departments (LHDs) were, and remain, a relatively untapped resource. This report is one in a series 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. 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. These reports identify compelling models for how state and local health departments 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 moving forward. This report focuses on a case study on three Colorado counties.

Key Findings

Both the Mountain West Regional Health Alliance and Local Health Departments Play Important Roles

  • The local health department is an important partner in the Mountain West Regional Health Alliance, which applied for and received state funding for outreach and enrollment.
  • During the first open-enrollment season (2013–2014), the alliance's outreach and enrollment activities consisted primarily of certified health coverage guides providing one-on-one support to individuals, families, and small businesses looking for health insurance through Connect for Health Colorado.
  • Alliance members secured funding; hired all health coverage guides; provided infrastructure, training, and staff support; facilitated organizations' access to uninsured populations; created a broad network of local health departments and other providers of social services; and supplied trusted expertise in health.

Outreach and Enrollment Efforts Face Challenges

  • Challenges include inconsistencies between national and state enrollment processes, the fact that a major grant was not actually awarded until just before open enrollment began, underestimations of time required to complete enrollments, and high insurance costs.

Some Factors Help Local Health Departments' Efforts

  • These factors include trust and strong communication; complementary, not competing, interests; strong community presence; ability to influence policy; and shared decisionmaking across the alliance.


  • Identify methods of working more closely with consumers to provide assistance in choosing among health insurance options.
  • Focus on improving utilization of services among newly insured people.
  • Figure out how to reach small businesses to support employee enrollment in the marketplace.
  • Work with brokers, insurers, and private physicians to reach more uninsured persons seeking care.

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

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