Lessons from the ACA's Medicaid expansion front-lines: Perspectives of enrollment workers

Background: While millions of Americans have received insurance under the ACA, clients who are eligible for Medicaid but remain uninsured rely on front-line workers to facilitate enrollment. This study explores strategies that front-line workers, including government enrollment workers and Certified Enrollment Counselors (CECs), use to enroll Californians in Medicaid and the structural barriers they encounter in the enrollment process.

Methods: Eight focus groups with 7 to 19 enrollment workers took place in the Bay Area, Central Valley, Inland Empire, and Los Angeles, California.  Managers were also interviewed in each location. Topics covered included: successful enrollment practices, barriers to enrollment, technological challenges, and communication between the state health care exchange and Medicaid.

Results: Participants reported enrollment barriers including limited knowledge about immigrant client eligibility and changes in the enrollment computer systems. They reported a need for faster communication between policy makers, the state exchange, and front-line workers regarding changes in the enrollment process and Medicaid eligibility. Participants proposed solutions including increased contact between government enrollment workers and CECs to facilitate application processing and uniform interpretation of enrollment policies; additional training on ACA related tax and immigration law; and regular meetings among front-line workers to share application problem-solving strategies, technology workarounds, and receive policy updates.

Conclusion: The ACA offers new opportunities to enroll previously ineligible and underserved populations in health care.  Increased cooperation between government enrollment workers and CECs, improved communication about technology and policy implementation challenges, and improved training on tax and immigration issues can facilitate enrollment.