Improving Medicaid Access in Times of Health Policy Change: Solutions from Focus Groups with Frontline Enrollment Workers

Abstract

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.

Health insurance enrollment strategies during the Affordable Care Act (ACA): a scoping review on what worked and for whom

“…Most of the studies identified [16][17][18][19][20][21][22] individual assistance as a key strategy used by healthcare providers and community-based organizations to help people enroll for health insurance. The terminology used to describe individual assistance varied.…”

“…Some FQHCs and community-based organizations had assistance programs prior to the implementation of the ACA. These organizations expanded their capacity to help more people once the ACA coverage expansion took effect by hiring more assisters [17][18][19][20][21][22]. Other organizations such as The Weill Cornell Community Clinic (WCCC) utilized their licensed social worker to screen patients for coverage eligibility and collaborated with another community organization to help their patients complete the enrollment process [18].…”

“…Raymond-Flesch et al [21] California (urban & rural areas) ▪ Provided in-person assistance for people enrolling for coverage (Medicaid or private insurance) and other entitlement programs.…”

“…Enrollment training varied among organizations and was impacted by constant policy changes (e.g., changes in the ACA, immigration and tax rules) in states [17,21,22]. Technical problems with the enrollment system was also a common problem that delayed the process [17,21,22]. The online SMHP program of Missouri's marketplace website was also effective in helping to increase users' health insurance literacy and their self-efficacy to decide an appropriate coverage plan for their need [20].…”

“…▪ Provide structured approach to helping individuals enroll for coverage and maintain records on the number enrollees [17,18]. ▪ Identified knowledge gap on enrollment and the ACA policy, barriers to enrollment, and technical issues [21].…”