Open enrollment into the new health insurance marketplace under the Patient Protection and Affordable Care Act (ACA) began on October 1st, 2013, signaling one of the biggest changes in decades to our health care system. The Marketplace will increase the quality, availability, and affordability of private and public health insurance to the many of the 47.3 million uninsured individuals[1] in the U.S. Community health centers (CHCs) are playing an essential role in the implementation of the Affordable Care Act. Nationwide, health centers have expanded their current outreach and enrollment assistance activities to facilitate the enrollment of millions of eligible health center patients and service area residents into affordable health insurance coverage through the Health Insurance Marketplaces, Medicaid or the Children’s Health Insurance Program. In 2013, the Health Resources and Services Administration (HRSA) provided 1,159 health centers with more than $150 million in additional funding to help their uninsured patients and others in their approved service areas gain affordable health insurance coverage. In 2014, HRSA awarded an additional 58 million to support these efforts.[2]

On December 12, 2013, Health Outreach Partners (HOP) hosted the national Peer-to-Peer Webinar, “Outreach and Enrollment: Open Enrollment Lessons Learned and Strategies Moving Forward” including three panelists:

  • Olivia Riutta, Outreach and Enrollment Project Manager, Montana Primary Care Association
  • Inelda Chavez, Patient Resource Coordinator, One Community Health
  • Shade Grahling, Affordable Care Act Coordinator, Zufall Health Center

Highlighted below are key points and strategies discussed during the webinar.

The State of Outreach and Enrollment

In the first few months of open enrollment, hundreds of thousands of eligible individuals enrolled in private plans in the health insurance marketplace.[3] In addition, states that chose to expand Medicaid[4] were able to begin enrolling newly eligible, low-income individuals for in their Medicaid program.

Medicaid MapSource: Kaiser Family Foundations “Current Status of State Medicaid Expansion Decision“, January 2014

Despite individual state circumstances, CHCs across the country have identified similar challenges to outreach and enrollment and strategies to increase enrollment for underserved populations during this first open enrollment period.

Challenges and Strategies

CHCs serve populations that often face challenges accessing health insurance, health care, and other services. Outreach and enrollment programs saw existing challenges as well as new challenges to outreach and enrollment during the open enrollment period. Peer-to-Peer panelists identified some of these key challenges including:

  1. A Late Start: Many CHCs had little time to adjust to the new changes to the health insurance landscape and many began outreach and enrollment efforts late due to delays in training and certification.
  2. Learning the New Outreach and Enrollment Landscape: Because of the new online health insurance marketplaces, Medicaid expansion, and subsequent new outreach and enrollment processes, CHCs had to adjust and adapt to these changes when conducting outreach and enrollment for open enrollment.
  3. Learning and Troubleshooting New Technology: The new health insurance marketplaces rely on new online technologies. Federally facilitated marketplaces as well as many state marketplaces experienced technological difficulties during the first few months of open enrollment. Due to these difficulties, many CHCs have struggled when providing enrollment assistance.
  4. Barriers to Enrollment: CHCs are critical to providing needed services to underserved populations. However, many of these populations, including many newly eligible populations, can be hard-to-reach and experience barriers to enrollment. Some of the common barriers identified include lack of trust or fear, cost of plans, lack of transportation, language, and computer literacy.

In spite of these challenges and barriers, there are many effective strategies to increase enrollment for CHCs’ most underserved populations. However, no single strategy will work for every population and in every situation. HOP’s Peer-to-Peer panelists use multiple strategies to increase the effectiveness of their outreach and enrollment efforts. Some of the key strategies identified during the webinar include:

  1. In-reach: In-reach is used to identify existing patients who are eligible and already receiving services through the health center but have never been enrolled or who may have been dropped from coverage.[5] In-reach was a requirement of HRSA’s additional funding to outreach and enrollment programs. Examples of in-reach include holding department meetings to educate clinic staff to support enrollment and having outreach and enrollment staff provide enrollment education and/or assistance in waiting rooms.
  2. Provide In-the-Field Outreach and Enrollment: Outreach and enrollment workers can provide enrollment assistance outside of the clinic walls where people live, work, and spend time. Outreach was a requirement of HRSA’s additional funding to outreach and enrollment programs. In-the-field outreach and enrollment may include using mobile technology such as laptops, tablets, mobile Wi-Fi hotspots, etc. and utilizing community resources such as libraries to meet with enrollees.
  3. Focus on Education: Education about health insurance options and the enrollment process can be used to address barriers such as fear, distrust, or access to information. It can also build relationships and empower enrollees through increased health literacy. Peer-to-Peer panelists provided education in many different ways based on the needs of their priority populations including: showing health reform related videos in the waiting room, using visuals and brochures during one-on-one sessions, and via a telephone hotline.
  4. Provide assistance and resources in the native language of the enrollee: Twenty-three percent of marketplace enrollees will speak a language other than English at home.[6] Hiring bi-lingual staff or providing interpretation services to support enrollees with limited English proficiency helps ensure they are not left out.
  5. Collaborate with Community Partners: Community partners can increase access to eligible, uninsured individuals; offer fresh ideas and new energy; share resources; and promote information to a broader audience. Not only is collaborating with community partners one of the most effective outreach and enrollment strategies, open enrollment presents new and additional opportunities for CHCs to work with community partners to increase enrollment. Examples of community partners that can help support outreach and enrollment efforts include businesses, community-based organizations, faith-based organizations, and other community health centers.
  6. Share experiences, strategies, and success stories: Sharing outreach and enrollment experiences and learning what is and is not working from one another can be a powerful tool. In addition, sharing success stories can foster positivity for outreach and enrollment workers and the communities they serve. Consider joining or create an outreach and enrollment work group for application assistors or identifying spokespersons to share their positive enrollment experiences with priority populations.


The Affordable Care Act brings significant changes and improvements to our current health system and increases access to health insurance for uninsured populations. CHCs are critical to ensuring our underserved and vulnerable populations receive the support and assistance they need to enroll in health insurance and access the health care they need. To do so, outreach and enrollment programs must target their outreach and enrollment efforts to strategically address the unique barriers of their priority populations.

To view a recording of the “Outreach and Enrollment: Open Enrollment Lessons Learned and Strategies Moving Forward” Peer-to-Peer webinar, please visit HOP’s Peer-to-Peer page.

Resources and Tools

Health Outreach Partners has created a number of resources to support outreach programs in connecting underserved populations to health insurance and access to health care.

Health and Human Services and Health Resource Services Administration Resources

Additional Resources

For More Information on the Organizations Involved on This Webinar:


This publication was made possible by grant number U30CS09743 from the Health Resources and Services Administration, Bureau of Primary Health Care. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA

[1] “The Uninsured: A Primer – Key Facts about Health Insurance on the Eve of Coverage Expansions”. Kaiser Family Foundation. October 2013. Last Accessed on January 27, 2014.

[2] “Outreach & Enrollment Assistance Awards to Health Centers”. Health Resources and Services Admnistration. Accessed on March 3, 2014.

[3] “December Enrollment Report”. ASPE Office of Health Policy, December Enrollment Report, December 11, 2013.

[4] The Medicaid Expansion provision expands Medicaid eligibility to cover almost all U.S. citizens under 65 with family incomes up to 138% of the FPL.

[5] Kendall, J., & Sullivan, J. (September 2012). Best Practices in Outreach and Enrollment for Health Centers. In Enroll America. Retrieved on October 26, 2012, from

[6] “Profile of Health Insurance Exchange Enrollees”. Kaiser Family Foundation, (March 2011).