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 Houston, Texas

Published Jul 8, 2016

by Laura Runnels, Kate Heyer, Courtney Armstrong, Malcolm V. Williams, Laurie T. Martin

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Research Questions

  1. What innovative models and best practices in Houston, Texas, 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 Houston, Texas, 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 brief 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 briefs 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 brief focuses on a case study on Houston, Texas.

Key Findings

Through an Incident Command System–Based Model, the Houston Department of Health and Human Services Contributes to Outreach and Enrollment Efforts

  • The department leverages its reputation in the community to gain quick buy-in for a coordinated strategy, provides a strength-based framework for response, and coordinates the efforts of the Gulf Coast Health Insurance Marketplace Collaborative.

Outreach and Enrollment Efforts Face Challenges

  • The notices of award and timelines for funding differed from partner to partner.
  • The collaborative does not always have access to accurate and timely data from state and federal agencies, which makes it difficult to ensure accuracy when determining areas of highest need.
  • Some people will remain uninsured because they know that the hospital will provide comprehensive care at a cost that is lower than insurance premiums or potential tax penalties. Because Texas did not expand Medicaid, insurance is still relatively expensive for those who did not qualify for subsidies in the marketplace.

Some Factors Help Those Efforts

  • Because many public health– and health care–oriented partners in Houston have long histories of collaboration and a commitment to ensuring access to health care for all residents, the concept of using an incident command system to maximize resources and reach a shared goal has been readily accepted. Likewise, partnerships with grassroots organizations are essential in encouraging people to enroll, particularly in a state that strongly values individual autonomy and in which many residents mistrust the government.


  • Public health and health care system will need to collectively engage in identification, outreach, enrollment, and education for years to come.

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

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