Enrollment navigators and government-employed Medicaid workers were an important element in the Affordable Care Act's (ACA) initial enrollment success. The Centers for Medicare and Medicaid Services eliminated 41% of funding for 2017 navigator programs and 90% of funding for outreach, arguing less investment was needed. Given that many remain uninsured, it is critical to identify effective enrollment practices. This study characterizes barriers and enrollment strategies from the perspective of California's Medicaid government and community-based enrollment workers (n=101 in eight focus groups). Participants identified a need for communication with policymakers, the state exchange, and each other regarding changing enrollment processes. Solutions include increased contact between enrollment workers to share strategies and policy updates regarding application processing, uniform policy interpretation, and details of ACA-related immigration law. Given efforts to weaken the ACA, it is critical to engage frontline workers in problem solving to streamline enrollment strategies, particularly for vulnerable populations.

The San Francisco Health Care Security Ordinance is the country's only local law designed to promote universal health care. It provides access to health services for the uninsured while requiring employers to contribute financially toward employees' health care costs. Enrollment in Healthy San Francisco, a program for the uninsured that is one component of the ordinance, fell significantly after the Affordable Care Act extended other types of coverage. Healthy San Francisco continues as a major source of care for undocumented people. Many other California counties have programs that provide at least some nonemergency care to undocumented residents, which demonstrates the versatility of this approach for localities. San Francisco employer contributions also fund medical reimbursement accounts that help insured people pay their health costs, including through a program added in 2016 to make Marketplace insurance more affordable. The city's experiences show that programs to help people pay for private coverage should be simple and include strong outreach and education and that the affordability of Marketplace coverage would be most easily addressed at the state level.

Americans' health insurance coverage is not static; people cycle in and out of coverage and between sources of coverage during life transitions like losing a job, changing jobs, moving, or divorce. The Affordable Care Act creates an unprecedented opportunity to address the gaps in health coverage caused by life transitions. Achieving the promise of the Affordable Care Act will require attention in federal regulations and actions by the new health insurance exchanges to ensure seamless coverage for those who rely on private insurance, including job-based coverage. This paper analyzes the population experiencing life transitions that lead to a loss of health coverage and makes several policy recommendations to ensure that all Americans can maintain health coverage under the ACA-even during complicated life transitions.

Americans' health insurance coverage is not static; people cycle in and out of coverage and between sources of coverage during life transitions like losing a job, changing jobs, moving, or divorce. The Affordable Care Act creates an unprecedented opportunity to address the gaps in health coverage caused by life transitions. Achieving the promise of the Affordable Care Act will require attention in federal regulations and actions by the new health insurance exchanges to ensure seamless coverage for those who rely on private insurance, including job-based coverage. This paper analyzes the population experiencing life transitions that lead to a loss of health coverage and makes several policy recommendations to ensure that all Americans can maintain health coverage under the ACA-even during complicated life transitions.