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

A Case Study on Tacoma–Pierce County, Washington

by Nazleen Bharmal, Malcolm V. Williams, Laurie T. Martin, Christian Lopez

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Research Questions

  1. What innovative models and best practices in Tacoma–Pierce County, Washington, 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 Tacoma–Pierce County, Washington, 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 Tacoma--Pierce County, Washington.

Key Findings

The Tacoma–Pierce County Health Department Plays an Important Role

  • The local health department is an important leader in outreach and enrollment efforts in the Tacoma–Pierce County region.

Outreach and Enrollment Efforts Face Challenges

  • The Washington Medicaid renewal policy resulted in unanticipated demand for in-person assisters' (IPAs') time and efforts.
  • IPAs and the Washington Health Benefit Exchange, the official state health exchange system, had a poor relationship.
  • Decreased news coverage and publicity for health care–coverage enrollment required more word-of-mouth efforts from the IPA implementation team.
  • More personnel support was needed to address IPAs' concerns.
  • Some raised concerns about having a public health department as a lead agency. Organizational rigidity within the health department resulted in delayed contracts and payments. Some implementation-team partners perceived that the proportion of funds that the health department used to administer the grant was too large and left less funding for contracted IPA groups to provide services.
  • Some leadership and staff did not feel that reform-related activities were part of the core functions of public health.

Some Factors Help the Local Health Department's Efforts

  • Grant support from the Washington Health Benefit Exchange allowed data to be used to select contractors and formal collaboration with the health sector through a steering committee. The exchange grant allowed the health department to hire a full-time equivalent for outreach and enrollment, expanding the health department's capacity for this work.
  • The collaborative culture among organizations in Tacoma helped support the health department's role as a lead agency for IPAs.

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

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