Bridging the Enrollment Gap: The Importance of Providing In-Person Assistance

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By Deepak Madala | August 2012

On October 1, 2013, millions of uninsured Americans and their families will finally gain access to affordable health coverage.1 For many, this will be the first time they will be applying for a public health coverage program, selecting a health plan, and using coverage to obtain services.2 Unfortunately, a significant number of newly eligible people do not yet know about the new benefits or how to enroll.3 It will be essential to ensure that they know that there are new coverage opportunities, that they can enroll in many different ways (online, by phone, in person, or through a traditional mail-in application), and that one-on-one assistance is available to help them navigate the process.

States across the country have invested a significant amount of resources and time in simplifying and streamlining their eligibility and enrollment systems in preparation for the start of enrollment next year.4 These improvements are critical to creating and implementing seamless and consumer-friendly systems. However, not even the best, most technologically advanced online application can replace the one-on-one assistance that an informed, trusted entity can provide.

Providing in-person assistance will be critical to informing people that health coverage is available to them, to educating them about their new coverage options, and to helping them use their benefits. In fact, study after study suggests that, regardless of how people prefer to apply, nearly all those who will be newly eligible for coverage expect that they will need some form of help to enroll, and many want that assistance to be in person.5 The Department of Health and Human Services (HHS) has recognized the importance of in-person assistance by providing states with federal funding to establish in-person assistance programs.

This issue brief examines the importance of providing one-on-one assistance to help applicants understand these new options and get enrolled, and it identifies the ways you can help your state develop a robust outreach and application assistance network.

Why Millions Will Need Help Enrolling in New Coverage

According to the Census Bureau, approximately 50 million people of all ages, races, ethnicities, and income levels are uninsured in the United States.6 In some parts of the country, like Florida, Nevada, and Texas, more than one in five people lacks insurance.7 Fortunately, changes that the Affordable Care Act will make to the private health insurance market and to Medicaid will provide an opportunity to reduce the number of uninsured by more than half.8 Once the coverage expansions take effect in 2014, millions will become eligible for low-cost or free coverage through Medicaid or through tax credits that will help offset the cost of coverage that will be offered through the new health insurance exchanges.9

Experience with previous expansions of health coverage and other public benefits has shown that simply offering new programs does not ensure that people will take advantage of them.10 People have varied abilities and expectations when it comes to enrolling in health coverage, and the application process has traditionally been a significant obstacle, particularly in Medicaid. Long, complicated forms and paper documentation requirements make the application process daunting and tedious. Many people also face challenges such as limited access to technology, low literacy skills, and language or cultural barriers.11

The creation and implementation of the Children’s Health Insurance Program (CHIP) is an excellent example of how enrollment can be challenging—and of how those challenges can be overcome. In 1997, health coverage was extended to millions of low-income children through CHIP. In the early years of the program, a substantial number of families who were eligible for coverage through either CHIP or Medicaid never enrolled and remained uninsured.12 Today, nearly 8 million children are covered through CHIP, and the uninsured rate among children has been reduced by 36 percent.13 However, in many instances, these important coverage gains did not come easily or quickly.

In order to overcome the lower than expected enrollment immediately after the expansion began in 1997, the federal government, states, private foundations, and community-based organizations spent millions of dollars to educate the millions of eligible but uninsured families about the new program and to connect their children to coverage. As a result of these investments in outreach campaigns, enrollment assistance, and simplification of the enrollment process, many states significantly reduced their rates of uninsured children.14 For example, in Oregon, after the state implemented an aggressive marketing and outreach campaign, including providing application assistance in every county, the uninsured rate among children and teens was reduced by half in less than two years.15 Massachusetts is another outreach success story.

Less than two years after the state expanded Medicaid and implemented a new private health insurance subsidy program, it was able to achieve the lowest rate of uninsurance ever recorded by a state.16 One of the key elements of this success was a robust network of health care providers and community-based organizations that provided outreach and in-person enrollment assistance to consumers.17 The state and local foundations provided millions of dollars in grants to develop this critical support system, and more than half of all applications for Medicaid and low-cost private health insurance were completed with the assistance of someone from this network.18

In-Person Enrollment: A Preferred Option For Many

In the world of health coverage that will exist in 2014, consumers will have a variety of ways to enroll in new and existing coverage options. States are required to continue allowing consumers to enroll through traditional channels, like at a county eligibility office with a paper application, and they must also develop new, easy-to-use online enrollment systems and helplines.

Despite this significant improvement in the number of enrollment options, many consumers will still prefer enrolling with the help of a trusted person or organization from their community, such as a health care provider, a consumer-focused nonprofit, or a health insurance broker. Numerous surveys have found that a majority of newly eligible people believe that they will need help to understand their health insurance options and navigate the new eligibility process.19 A large majority of those needing assistance prefers obtaining that assistance in person.20

Many uninsured people tend to trust and feel more comfortable seeking assistance from organizations in their community. For example, an outreach effort with faith-based organizations in California found that the trust engendered by the effort’s affiliation with religious leaders was key to bringing families into the application process.21

Making support available from trusted sources also helps consumers feel more comfortable with enrolling on their own, such as through a health insurance exchange website.22 Many consumers believe that applying for coverage and selecting an appropriate plan is complicated and difficult. They like the idea of being able to apply online, but they are often comfortable starting down that path only if they know there is human support to help them when they need it.

How Local Stakeholders Can Help Bridge The Enrollment Gap

Local stakeholders such as small businesses, consumer groups, faith-based organizations, chambers of commerce, insurance brokers, unions, and other community-based organizations have the ability to reach the uninsured in ways that government efforts simply cannot. These organizations often have a better understanding of the barriers that consumers in their community face. Many also have trusted, longstanding relationships with people who are uninsured. States will need these local stakeholders in order to help develop personalized enrollment assistance networks that are tailored to meet local needs and that are effective at enrolling as many uninsured people as possible in the new coverage options. Ways that organizations can help people enroll include the following:

  • Provide assistance to consumers with the enrollment process: Organizations that are interested in providing direct enrollment assistance to the uninsured should begin their efforts by ensuring that the consumers with whom they already enjoy trusted relationships know about the new coverage options and are able to enroll in the new programs. Tax preparers, for example, serve a significant number of uninsured consumers on a regular basis. A new tax credit will be available to reduce the cost of health insurance for consumers who buy coverage through a health insurance exchange, and tax preparers are uniquely positioned to help their clients obtain this assistance.
  • Participate in a navigator program: Some groups that are interested in expanding coverage to uninsured people in their communities may be eligible for funding through the navigator program that is associated with their state’s health insurance exchange.23 Navigator programs will offer training opportunities and funding for organizations that are interested in helping their state exchange do the following:
    • conduct public education and outreach,
    • distribute fair and impartial information about enrolling in coverage and in programs that make insurance more affordable,
    • facilitate enrollment in coverage through the exchange,
    • provide referrals to appropriate state agencies, and
    • provide information in a manner that is linguistically and culturally appropriate to the populations served by the exchange.
  • Serve as a door to your state’s “no wrong door” enrollment system: The Affordable Care Act fundamentally changes the way people will enroll in health coverage. Instead of having to apply for each program separately, people will now be able to enroll in the appropriate program without regard to where or how they apply for that program. Even groups that do not have the capacity to provide personalized enrollment assistance can participate in the new “no wrong door” enrollment system by offering uninsured consumers access to the internet, phones, or other tools that will give applicants the ability to enroll through an exchange’s website or hotline. Any organization with a website, for example, can connect people to the new enrollment system by providing a link to the exchange website.
  • Partner with organizations that are providing enrollment assistance in your community: To successfully cover the millions of uninsured residents, states will need the collective effort of many different community entities. People are uninsured for a wide variety of reasons and will require different types of assistance to overcome these barriers. Organizations and companies can help build and promote a comprehensive assistance network that meets the diverse needs of consumers by educating consumers about the enrollment options in their communities, by participating in community-based coalitions that are working to expand coverage, and by providing financial support to local outreach and application assistance efforts.
  • Spread the word about the new coverage options: Nearly everyone can play a part in educating people in their communities about the new coverage options and the new ways people can enroll in these options. Stakeholders can use materials developed by their states, such as posters and brochures that publicize hotline phone numbers, URLs for exchange websites, and the locations where applicants can get in-person enrollment assistance. Some organizations also have the capacity and the relationships necessary to go even further and use their unique knowledge of segments of the uninsured population to offer targeted outreach and assistance.


While the Affordable Care Act will certainly help simplify the enrollment process and make it more consumer friendly, there will still be many consumers at all income levels who will need the assistance and encouragement of a trained and compassionate advisor to understand their options and enroll in the most appropriate public program or health plan. This need for enrollment assistance will be particularly evident in 2014, when millions of Americans gain access to coverage for the first time. In order to achieve optimal enrollment in the new coverage options and successfully reduce the number of uninsured, states will need the help of many kinds of individuals and organizations to develop effective networks of in-person enrollment assistance providers.


This piece was written by Deepak Madala, Policy Analyst, Enroll America.

Assistance was provided by Jennifer Sullivan, Director of the Best Practices Institute, Jessica Kendall, Director of Outreach, and Rachel Klein, Executive Director, Enroll America.

Enroll America thanks Families USA for their editorial and design support in the production of this piece.


1 Open enrollment for coverage through the new health insurance exchanges begins on October 1, 2013, for coverage that begins on January 1, 2014. See Department of Health and Human Services (HHS), “Establishment of Exchanges and Qualified Health Plans,” Federal Register 77, no. 59 (March 27, 2012): 18,462.

2 About one-quarter of uninsured adults report that they cannot see a physician because of cost, and more than 40 percent of the long-term uninsured did not have a routine checkup in the last two years. John Ayanian, Joel Weissman, Eric Schneider, Jack Ginsburg, and Alan Zaslavsky, “Unmet Health Needs of Uninsured Adults in the United States,” JAMA 284, no.16 (October 25, 2000): 2,061-2,069.

3 Approximately 78 percent of consumers who will be eligible for new health coverage under the Affordable Care Act have never heard of the health insurance exchanges where they will be able to shop for coverage beginning in 2014, and 60 percent said they will need help navigating the new system. CVS Caremark, Press Release: CVS Caremark Research Finds 78 Percent of Consumers Who Qualify for Health Care Reform Subsidies Never Heard of State Insurance Exchanges (Woonsocket, RI: CVS Caremark, June 1, 2012), available online at newsroom/press-releases/cvs-caremark-research-finds-78-percent-consumers-whoqualify- health-care-ref.

4 The federal government is supporting investments in modernizing Medicaid eligibility systems by matching state contributions at a rate of 90 percent. As of August 12, 2012, nearly every state in the country (48 states plus the District of Columbia) has developed plans to implement new, state-of-the-art Medicaid eligibility and enrollment systems. Findings based on an Enroll America analysis and a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. Performing under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Practices in Medicaid and CHIP, 2011-2012 (Menlo Park, CA: Kaiser Family Foundation, January 2012), available online at medicaid/8272.cfm.

5 Lake Research Partners, Preparing for 2014: Findings from Research with Lower- Income Adults in Three States (Washington: Robert Wood Johnson Foundation, June 2012): slide19, available online at jsp?id=74456.

6 U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplements, March 2010 (Washington: U.S. Census Bureau, 2011), available online at

7 The rate of uninsured is at least 20 percent in five states: Texas (25 percent), New Mexico (21 percent), Nevada (21 percent), Florida (21 percent), and Georgia (20 percent). Kaiser State Health Facts Online, Health Insurance Coverage of the Total Population (Menlo Park, CA: Kaiser Family Foundation, 2010), available online at, accessed on August 12, 2012.

8 Congressional Budget Office, Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision (Washington: Congressional Budget Office, July 2012).

9 The Supreme Court has allowed states to opt out of the Medicaid expansion. States that opt out will reduce the number of uninsured residents that gain coverage through the Affordable Care Act. Congressional Budget Office, op. cit.

10 Only 40 percent of the Medicare beneficiaries who are eligible for subsidies under Medicare Part D but not auto-enrolled in the program received the benefit. Laura Summer, Jack Hoadley, and Elizabeth Hargrave, The Medicare Part D Low- Income Subsidy Program (Washington: Kaiser Family Foundation, September 2010), available online at Millions of uninsured children are eligible for but not enrolled in Medicaid or CHIP. Michael Perry and Julie Paradise, Enrolling Children in Medicaid and SCHIP: Insights from Focus Groups with Low-Income Parents (Menlo Park, CA: Kaiser Family Foundation, May 2007), available online at

11 See Daphna Gans, Christina Kinane, Greg Watson, Dylan Roby, Jack Needleman, Dave Graham-Squire, Gerald Kominski, Ken Jacobs, David Dexter, and Ellen Wu, Achieving Equity by Building a Bridge from Eligible to Enrolled (Los Angeles: UCLA Center for Health Policy Research, 2012), available online at http://healthpolicy.

12 Genevieve Kenney, Victoria Lynch, Allison Cook, and Samantha Phong, “Who and Where Are the Children Yet to Enroll in Medicaid and the Children’s Health Insurance Program?” Health Affairs 29, no. 10 (October 2010): 1,920-1,929.

13 According to the National Center for Health Statistics, the percentage of children under age 18 who were uninsured at least part of the year was 18.1 percent in 1997 and 11.6 percent in 2011. Robin Cohen and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January-June 2011 (Atlanta: National Center for Health Statistics, September 2011).

14 Carolyn Needleman, Follow-Up Evaluation of the Covering Kids and Families Access Initiative: Lessons from 18 CKF-AI Grantees (Princeton, NJ: Robert Wood Johnson Foundation, March 2008), available online at product.jsp?id=27391.

15 Kaiser Family Foundation, Secrets to Success: An Analysis of Four States at the Forefront of the Nation’s Gains in Children’s Health Coverage (Menlo Park, CA: Kaiser Family Foundation, January 2012), available online at medicaid/8273.cfm.

16 Stan Dorn, Ian Hill, and Sara Hogan, The Secrets of Massachusetts’ Success: Why 97 Percent of State Residents Have Health Coverage (Washington: Urban Institute, November 2009), available online at

17 Ibid.

18 Ibid.

19 CVS Caremark, op. cit.

20 Lake Research Partners, op. cit.

21 University of Southern California Division of Community Health, Reaching Out and Reaching In: Understanding Efforts to Identify and Enroll Uninsured Children into Health Insurance Programs (Los Angeles: The California Endowment, January 2006), available online at id=6&ItemID=42#.

22 Lake Research Partners, Results of a Statewide Survey on the Exchange in Vermont (Washington: Lake Research Partners, April 2012).

23 States have considerable flexibility in how they design their navigator programs, provided these programs meet some basic statutory requirements. The Affordable Care Act and associated regulations from HHS outline the basic eligibility criteria, required duties, training standards, and conflict of interest prohibitions for all navigator entities. See Tricia Brooks and Jessica Kendall, Countdown to 2014: Designing Navigator Programs to Meet the Needs of Consumers (Washington: Georgetown University Health Policy Institute Center for Children and Families, July 2012).

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