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 Boston and Massachusetts

Published Jul 8, 2016

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

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Research Questions

  1. What innovative models and best practices in Boston and Massachusetts 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 Boston and Massachusetts 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 Boston and Massachusetts.

Key Findings

The Boston Public Health Commission Plays an Important Role

  • The commission provided direct and indirect enrollment assistance, leveraged partnerships, used data to identify populations, and provided education.

Outreach and Enrollment Efforts Face Challenges

  • A primary challenge was the unreliability of the MassHealth website, which was not functional during open enrollment. People who therefore enrolled using paper application forms during the 2013–2014 open enrollment will need to reenroll through the electronic portal in the 2014–2015 open-enrollment period.
  • 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, the commission scaled back direct outreach with small-business owners until it could train staff on how to answer these questions.

Some Factors Help the Local Health Department's Efforts

  • The commission used census-level data to identify people and neighborhoods most likely to be eligible for insurance coverage and benefit from enrollment assistance.
  • The availability of community health centers has been an especially important resource for health department staff as they connect newly insured people with primary health care.
  • Because people are connected at the neighborhood level to the organizations and services that exist in their neighborhoods, these connections help to facilitate the word-of-mouth information sharing and trust needed for effective outreach and enrollment.


  • Increase outreach to small-business owners to support employee enrollment in the marketplace.
  • Conduct more targeted outreach using ZIP Code–level data compiled during the previous open-enrollment period to facilitate outreach and reenrollment processes.

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

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