By Elizabeth Hagan | October 2012
Consumer outreach and enrollment assistance is critical to maximizing the number of people who enroll in health coverage. Yet the programs designed to connect consumers to coverage—and the resources devoted to those programs—vary widely from state to state. This brief explores a promising strategy from Wisconsin, where stakeholders have created regional enrollment assistance networks throughout the state despite limited state and federal resources and the reluctance of state policymakers to embrace implementation of the Affordable Care Act (ACA).
The Landscape of National Outreach and Enrollment Assistance Efforts
State and federal decisions about program design and resource allocation have greatly affected the size and scope of enrollment assistance programs. In states with federally facilitated marketplaces, it has been more difficult to create strong assistance programs. This is due to the limited funding that is available and the often tepid support—or outright opposition—from state policymakers. On the other hand, states with state based and partnership marketplaces have more resources at their disposal, and they also often have state policymakers and agencies invested in ensuring that robust assistance is available. For example, California, a state running its own marketplace with more than 7 million uninsured residents, has secured nearly $58 million for outreach, education, and consumer assistance.1 Texas, which has a federally facilitated marketplace and 6 million uninsured residents, will receive just over $20 million for its navigator and community health center assistance efforts.2
States with federally facilitated marketplaces face an uphill climb: relatively few resources have been dedicated to creating enrollment assistance programs, and the federal funding for navigator programs in these states was not announced until August 15, 2013. This left less than two months for organizations to create programs and hire and train staff before open enrollment began. Stakeholders in these states, such as health care providers, community health centers, hospitals, and community-based organizations, recognize the need to educate and assist the individuals they reach about the new health coverage options, but without state-based marketplaces, there is often little institutional leadership in place to organize and propel individual stakeholder-based assistance efforts.
Why Coordinating Consumer Assistance Is Important
Although the public’s understanding of the ACA is growing, many uninsured consumers who are looking for health coverage are unaware of their new options.3 When these consumers do learn about their options, three out of four express a desire for in-person help with the application and enrollment process.4 One critical factor that determines whether consumers successfully enroll is their ability to find appropriate sources of assistance. Some consumers will want help completing the application. Others will want help understanding their options and selecting a health insurance plan that fits their budget and their health care needs. Some will prefer to get enrollment assistance from an eligibility worker, while others will seek out help from a health care provider. Figure 1 below shows how consumers’ preferred messengers and sources of help vary.
Figure 1: Consumers’ Preferred Messengers and Sources of Help
Preferred Sources of Help
As noted above, consumers have different preferences about how they receive information and get help with applying for coverage. And specific steps in the application and enrollment process will be very different for each consumer. But regardless of who is applying, the application and enrollment experience should be seamless and have limited handoffs from one entity to another. Assistance that is piecemeal will leave many consumers unable to get the help they need.
If groups aren’t working with one other to identify community needs, there could be significant gaps in the kinds of assistance that are available to consumers. For example, a state could have an area where consumers are unable to receive local application assistance, while another area could have a strong network of application assisters but very limited Spanish language assistance.
Different stakeholder groups will assist the populations they serve in different ways. But it is clear that the more states coordinate their outreach and enrollment efforts, the more likely consumers will be to get the help they need from sources they trust. (See Figure 2 on page 3.)
Stakeholder groups that are able to work together will be better positioned to identify and fill gaps that exist and to help one another build capacity where there is none. Collaboration also allows groups to focus on their own strengths rather than be hindered by their limitations. Creating strong networks of assistance will provide individuals and families with the help they need when they apply for and enroll in health coverage. Leveraging these relationships and creating robust assistance networks will ensure that consumers have a place to turn to for help and have positive experiences when seeking health coverage. It will also aid in the critical task of enrolling consumers successfully. And the need for community collaboration to provide in-person assistance is increasingly important for people that may be encountering technical problems with the enrollment process through Healthcare.gov or through their state-based marketplace.
If consumers have frustrating or confusing experiences, they may not complete the enrollment process, which would limit the overall number of people who successfully enroll. Establishing strong, collaborative networks will only enhance consumers’ experiences, thus maximizing enrollment.
Wisconsin’s Regional Enrollment Networks
Wisconsin has taken a collaborative approach that incorporates many of the ideas outlined above to make outreach and enrollment work well. The state has nearly 500,000 uninsured residents,5 has a federally facilitated marketplace, and has received about $2.7 million in federal funding for enrollment assistance programs ($1 million for navigator programs and $1.7 million for community health centers to conduct outreach and enrollment).6 The state is simultaneously expanding and contracting its Medicaid program, known as BadgerCare. Childless adults in Wisconsin stand to gain form the expansion, as they will now be covered up to 100 percent of the federal poverty level. However, parents and caretaker relatives will lose their BadgerCare coverage at the end of this calendar year, and are being directed to apply for health coverage through the Marketplace. All of these factors make successful communication particularly important in the coming months—communication not only with uninsured residents, but also with consumers whose coverage is changing.
To provide support to consumers who are looking for help applying for, enrolling in, and retaining health coverage, stakeholders in Wisconsin— including the Wisconsin Primary Health Care Association, Covering Kids and Families-Wisconsin, and the Department of Health Services or DHS (which administers Wisconsin’s Medicaid program)—created a plan to develop Regional Enrollment Networks (RENs). The plan called for 12 RENs across the state to be made up of local entities working on reaching out and enrolling consumers in health coverage. While participation in the RENs is voluntary, they create a basic infrastructure that allows organizations to interact and coordinate with one another. Organizations and volunteers who participate in the RENs will not be funded for their participation, though some have external funding sources that make their collaboration and participation possible.
This statewide plan was adapted from the existing Milwaukee Enrollment Network (MKEN) model. This Network has developed over the past several years, and focuses on supporting the enrollment of Milwaukee County residents in health coverage and includes more than 70 health care and community-based organizations. MKEN partners range from hospital systems and other providers to community health centers and the Milwaukee County Department of Health and Human Services. The Network was created by the Milwaukee Health Care Partnership, which is a broader public-private partnership focused on the overall health of low-income residents in the Milwaukee area.
Acknowledging that each REN is different in terms of its existing enrollment infrastructure and the characteristics of its uninsured populations, the 12 RENs will be able to tailor their structure and goals based on their specific needs and desires. The regions are working with different partners and are at varying stages of integration with those partners, so regional networks can—and likely will—look very different from one another.
The Work of RENs
Ensuring that uninsured consumers learn about their new and/or changing health coverage options and are able to successfully apply for coverage through the marketplaces presents a unique set of circumstances. In Wisconsin, large numbers of consumers who will be applying for health coverage through the Marketplace won’t have had coverage previously. And although many consumers will be applying for coverage for the first time, there are also many consumers who will have to transition from one type of coverage to another.7 The goal of the RENs is to have local groups collaborate to ensure that trusted messengers help consumers learn about available coverage and how they can get help with enrolling in and retaining health coverage. Additionally, the RENs are working together to coordinate handoffs between various organizations and various levels of enrollment staff. With a very limited number of certified application counselors (CACs) and navigators available, it is critical for these RENs to coordinate and ensure that there is no unnecessary duplication of efforts. For example, some regions have developed volunteer plans to help alleviate some pressure on the CACs by preparing consumers for their enrollment appointments.
Many diverse groups with different capacities and strengths will be working on outreach and enrollment, so supporting each other will be a key part of making the RENs successful. Bringing together the groups helping consumers apply and enroll (such as navigators and community health centers) with “mobilizers” (those who have influence in their communities—such as faith groups and civic groups) will provide residents with the help they will need. Wisconsin’s navigator grantees will be key partners in the RENs. However, the RENs will also need the support of other enrollment stakeholders, such as CACs, community health centers, providers, businesses, and community organizations that have access to uninsured consumers and that can provide them with application assistance or information about the new Marketplace.
Who Created the RENs?
Enrollment for Health Wisconsin (E4Health) is the primary driving force behind the creation of the 12 RENs. E4Health is a public-private coalition, which began in May 2013 to coordinate statewide outreach and enrollment and to facilitate statewide communication about the implementation of Wisconsin’s marketplace. The group has been successful in retaining a wide variety of partners, in large part, because of their commitment to keeping politics outside of enrollment. While E4Health itself is not funded or staffed, a few key organizations have made the work of enrollment possible, including the Wisconsin PrimaryHealth Care Association, Covering Kids and Families-Wisconsin and the Milwaukee Health Care Partnership. DHS serves as a key partner on the REN initiative, and has devoted staff time to help advance the goals of the networks. Additionally, DHS has funded the placement of nine AmeriCorps members through the Primary Care Association’s “Wisconsin HealthCorps”program to coordinate the work of the RENs.
Staffing and Support
Each of the Wisconsin regions will have a “Regional Enrollment Network Organizer” and a “Regional Enrollment Network Lead” who will work closely to facilitate the work being done in that region.
- The “Organizers” will be AmeriCorps members, and their role will be identifying and coordinating with organizations and people in each region who already work on outreach and enrollment and have a good understanding of what the region’s needs are.
- The “Leads” in each region will be local community leaders who are well known in the community as people who have multiple collaborative relations and can build successful coalitions. These individuals will serve as the main conveners of the RENs.
- The DHS employs Area Administration staff who currently serve as the primary link with local county human service agencies in a broad range of program areas. They are also providing support to the RENs.
Figure 3 (on page six of the PDF) shows the basic structure for how the RENs will be organized— many diverse groups are serving important roles. Some of these groups may not be traditional partners and may not have worked together in the past, so it may be challenging to forge new relationships. The success of this plan relies on groups of all types to build new coalitions and partnerships and leverage the relationships they already have.
As noted earlier, the organizations that are participating in the RENs will not be funded for their participation. The only full-time staff who will be working exclusively to support the RENs work are the AmeriCorps members. And, since the majority of the AmeriCorps members are brand new to this type of service, they are only able to be successful if they have strong volunteer leadership in their respective communities. The limited funding for the RENs will require partners on the ground to assist the networks in whatever ways they can, including giving financial support, lending expertise, or providing access to staff and volunteers.
There is also concern that there will be regions that don’t have enough organizations that are interested in working with the RENs. Though assisting with outreach and enrollment is a natural extension of the work that several groups have been doing for years, some regions and groups have limited experience in this arena. Building these networks to the fullest extent possible will be a challenge, but stakeholders agree that working together to ensure their efforts are coordinated and complementary (and not duplicative) will be well worth the effort.
Steps for Coordinating Assistance in Your State
Facilitating coordination across enrollment assistance entities in your state, region, or locality will help ensure the most seamless, consumer-friendly enrollment process possible. Below we list several immediate action steps that enrollment stakeholders can take to make outreach, education, and enrollment assistance work effectively:
- Determine which other organizations are working on outreach, enrollment, and application assistance, and talk with them about ways to collaborate.
- Identify the gaps in your region and think about logical ways they can be filled.
- Create a list of comprehensive goals you would like to achieve as an individual organization and as a region/state.
- Identify your organization’s strengths and decide what role you can play in meeting those goals.
- Build an organizational plan to meet those goals (think about outreach best practices),8 and assign tasks to specific staff members.
A number of key stakeholders, including the Primary Care Association, Covering Kids and Families, the Wisconsin Hospital Association, Alliance of Health Insurers, and others are have been meeting on a bi-weekly basis since before open enrollment began to discuss implementation successes and challenges with both the DHS and the Office of the Insurance Commissioner. In addition, a smaller team is convening the REN leads for similar purposes. The RENs have each completed draft operational plans to help guide their work moving forward. These plans take a first attempt at delineating the roles and responsibilities of organizations in each region and identifying partners’ capacities and needs. Although operation plans are flexible, and each enrollment network will likely come up with its own individual goals, the enrollment networks do provide a strong framework for the first open enrollment period.
When enrollment stakeholders coordinate their efforts, consumers are less likely to fall through the cracks and go without the assistance they need. Coordination can be even more effective when state or local government is at the table and engaged in the effort. Wisconsin’s approach draws on community groups’ strengths and emphasizes their collective potential to create positive change. Their efforts suggest a model that other states, particularly those with limited enrollment assistance infrastructures and funding, can consider as they work to connect consumers to coverage.
Special thanks to reviewers: Jessica Kendall, Sophie Stern, and Jenny Sullivan from Enroll America; Ingrid VanTuinen from Families USA; and Lisa Olson from the Wisconsin Primary Health Care Association.
1 Covered California, Covered California Awards Community Organizations $37 Million in Grants for Outreach and Education (Los Angeles, CA: Covered California, May 14, 2013), available online at http://www.coveredca.com/news/press-releases/pr-05-14- 13.html; U.S. Department of Health And Human Services, Health Resources and Services Administration, California Health Center Outreach and Enrollment Assistance (Washington: HRSA, July 10, 2013), available online at http://www.hrsa.gov/about/news/2013tables/outreachandenrollment /ca.html.
2 Centers for Medicare and Medicaid Services (CMS), Navigator Grant Recipients (Washington: CMS, August 15, 2013), available online at http://www.cms.gov/CCIIO/Programs-and- Initiatives/Health-Insurance-Marketplaces/Downloads/navigator-list- 8-15-2013.pdf; U.S. Department of Health And Human Services, Health Resources and Services Administration, Texas Health Center Outreach and Enrollment Assistance (Washington: HRSA, July 10, 2013), available online at http://www.hrsa.gov/about/news/2013tables/outreachandenrollment /tx.html.
3 Kaiser Family Foundation, Kaiser Health Tracking Poll: August 2013 (Washington: Kaiser Family Foundation, August 2013).
4 See Informing Enroll America’s Campaign: Findings from a National Study, available online at /wp-content/uploads/old-files/best-practices-institute/publiceducation- resources/EA_Final_Report.pdf.
5 Centers for Medicare and Medicaid Services (CMS), The Number of Estimated Eligible Uninsured People for Outreach Targeting (Baltimore: CMS, April 18, 2013), available online at https://data.cms.gov/dataset/The-Number-of-Estimated-Eligible- Uninsured-People-/pc88-ec56 .
6 Centers for Medicare and Medicaid Services (CMS), Navigator Grant Recipients, op. cit. and U.S. Department of Health And Human Services, Health Resources and Services Administration, Wisconsin Health Center Outreach and Enrollment Assistance (Washington: HRSA, July 10, 2013), available online at http://www.hrsa.gov/about/news/2013tables/outreachandenrollment /wi.html.
7 Wisconsin’s Department of Health Services (DHS) estimates that 68,567 parents and caretaker relatives and 5,283 childless adults and 3,622 children will transition from their Medicaid program, BadgerCare Plus, to the marketplace.
8 See Enroll America’s Outreach Planning 101, available online at https://www.enrollamerica.org/wp-content/uploads/2013/11/Outreach_1011.pdf.