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

A Case Study on Illinois

by Malcolm V. Williams, Laurie T. Martin, Christian Lopez, Courtney Armstrong

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Research Questions

  1. What innovative models and best practices in Illinois 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 Illinois 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 Illinois.

Key Findings

Partnerships and Dispersed Personal Help Characterize Outreach and Enrollment in Illinois

  • The Illinois Department of Public Health (IDPH) and Get Covered Illinois worked together to partner with organizations and providers statewide to provide in-person assistance to people wanting to enroll in health care coverage.
  • IDPH made grants to six local health departments (LHDs) and funded the Illinois Association of Public Health Administrators to grant funds to other LHDs statewide.
  • Some LHDs set up programs targeted at difficult-to-enroll populations, such as people with low literacy, immigrants, and people recently released from prison.

Outreach and Enrollment Efforts Face Challenges

  • Challenges include difficulties with the federal Healthcare.gov website, the amount of information in-person assisters had to convey during enrollment appointments, low levels of literacy, weak understanding of insurance, inadequate computer experience, and clients choosing lowest-premium plans for expediency even though those plans might not be the most cost-effective for them in practice.
  • Enrolling immigrants and people in households with mixed citizenship status also proved difficult. For some, confusion about eligibility was a barrier to seeking information about enrollment. In some cases, non–English-language resources were perceived to be unhelpful. Also, grant-receiving organizations did not all have experience in these kinds of outreach and enrollment activities and took longer to develop effective strategies.

Some Factors Help Outreach and Enrollment Efforts

  • The primary facilitators were trust, partnership, and the availability of federal resources for enrollment.
  • LHDs are vital in outreach and enrollment efforts because they can leverage existing partnerships with other community organizations.

Recommendations

  • Continue developing software and systems to provide a method for scheduling the work of the in-person assisters in the different regions and to enhance data collection and quality.
  • Have full-time rather than part-time in-person assisters, and have them available during nonstandard business hours.
  • Write outreach and enrollment materials for people with low levels of English literacy.

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

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