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 West Virginia

Published Jul 8, 2016

by Julia Joh Elligers, Nazleen Bharmal, Laurie T. Martin, Malcolm V. Williams, Courtney Armstrong

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Research Questions

  1. What innovative models and best practices in West Virginia 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 West Virginia 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 West Virginia.

Key Findings

Two Collaborations Drove Outreach and Enrollment in West Virginia

  • The West Virginia Department of Health and Human Resources (DHHR) inROADS system permitted federally approved fast-track enrollment.
  • DHHR market research showed that programs should frame outreach and enrollment in terms of increased coverage and access to care and that in-person assisters (IPAs) should not reference "Obamacare" or the Patient Protection and Affordable Care Act (ACA).
  • West Virginians for Affordable Health Care and its Implementation Coalition and DHHR's Health Innovation Collaborative conducted outreach and enrollment activities.
  • The Kanawha–Charleston Health Department educated stakeholders about ACA implementation and publicly encouraged Medicaid expansion.

Outreach and Enrollment Efforts Faced Challenges

  • Describing the exchange to consumers was difficult.
  • Staff spent most of their time at county DHHR offices, hospitals, or community health centers, so hard-to-reach populations were difficult to enroll.
  • Only one qualified health care plan was offered through the exchange, and many consumers felt that it was not affordable.
  • So-called "Obamacare" is unpopular in the state, which discouraged people from enrolling.

Some Factors Helped Local Health Departments' Efforts

  • The dire health conditions in West Virginia motivated people from different sectors to work together to support outreach and enrollment.
  • Most people in West Virginia have known each other for years and in diverse settings, thus forging strong bonds of trust.
  • Local health officials are seen as well-informed, credible, and trusted sources of information.


  • About 30,000 people in the state are uninsured and difficult to reach and enroll. New strategies will have to be used to enroll these remaining uninsured.

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

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