Health Care Outreach & Enrollment 2.0: Working to Close the Coverage Gap!

Taken from the November/December 2014 issue of the Women's Health Activist Newsletter.

The ACA has helped to reduce the number of uninsured American adults from 21 down to 17 percent of the population, with the most coverage gains coming form 18-to-34-year-olds.1,2

This is all good news, but more still needs to be done — and there are more people who need to get enrolled. The nation is preparing to gear up for the new open enrollment outreach drive, which runs from November 15, 2014 to February 15, 2015. Reflecting back on the first enrollment period, it is clear that there were many unanticipated challenges and opportunities. Despite the hiccups of the first open health care enrollment season, it is important for advocates to incorporate the important lessons learned in our upcoming outreach efforts in order to maximize enrollment and reduce the coverage gap among our most vulnerable communities.

Historical Context

It is important that we first acknowledge some of the social and historical factors that lead many racial and ethnic minorities to fear government institutions. Many African Americans remember incidents when their communities were denied medical care or subjected to medical procedures without their consent — as occurred in the Tuskegee experiment and forced sterilizations of people of color. These and other traumatic health related incidents are still on the forefront of people’s minds and memories, leading to suspicion about governmental efforts such as the ACA.

Additionally, many members of the Latino/a immigrant community may be hesitant and distrustful of government agencies, for fear that they or a loved one will be reported to Immigrations, Customs, and Enforcement (ICE) and deported. Widespread suspicion and fear of ICE has led to a low health care enrollment among members of the Latino/a community.

It is within these complex social-political-historical dynamics that ACA assisters, organizers, and advocates must navigate in order to successfully enroll people in health care. (The NWHN uses “assisters” to refer to all entities that provide and support outreach and enrollment activities, such as navigators, Certified Application Counselors, and in-person assisters, community health center staff, etc.). We must be aware of and prepared for these fears and barriers as we encourage our friends, families, and community members to consider their healthcare options provided by the ACA.

Lessons Learned

One critical lesson learned from our first open enrollment period is that communities of color and low-income individuals need more frequent, in-person support from assisters in order to enroll. For many uninsured individuals, the enrollment process will be the first time they hear about the various insurance options. People need time and support in order to digest massive amounts of information associated with health care enrollment, create their account, evaluate multiple health plan options, and work through the process on websites and/or at call centers. According to enrollment experts, members of these communities often need to be reached multiple times in order to finish the enrollment process. We now know that one appointment is often not enough time to successfully enroll in a new, comprehensive care health plan.

Second, we have learned that more concerted efforts are needed to build health care literacy, so that unfamiliar insurance industry jargon doesn’t impede enrollment. Trying to understand the myriad of health insurance options is difficult and time-consuming for most people, but is particularly hard for individuals with low health literacy levels (which is also a factor for people with low levels of English literacy). In the last enrollment period, many assisters found themselves extending their hour-long appointments into an hour-and-a-half or even two hours in order to meet the needs of frustrated consumers.

Third, we need more assisters who have technical expertise and better training. We need to support assisters’ efforts to get the skills and information needed to be as helpful as possible for potential enrollees. They must be able to help immigrant communities, Latino/as, and mixed-status families address barriers stemming from immigration status. And, assisters must be trained to be culturally and linguistically competent to work with communities of color. They must be able to work with various family configurations and be technically competent to answer complex coverage and benefits-related questions.

Finally, we must fix the problems with online identity verification procedures, which have made it very difficult for some to register for health care. Many individuals have had to circumvent on-line registration systems by spending countless hours on the phone with call centers in order to get verbal verification of their identify. This was particularly an issue for people who have changed their names; lost their marriage and/or birth certificates in a disaster; were denied birth certificates in the Jim Crow South; or are legally present immigrants or refuges. The process is too slow and cumbersome, and is a major deterrent to enrollment.

Closing the Coverage Gap

As we prepare for the next open enrollment season, we must keep in mind that many states have yet to take action to close the Medicaid coverage gap. Medicaid, the national health insurance program for low-income individuals, was originally envisioned as a core mechanism to cover nearly all low-income adults. Under the original law, the Federal government would expand Medicaid coverage and pay up to 100 percent of the state’s costs in the program’s first 3 years. The 2012 Supreme Court ruling, however, allows states to opt out of Medicaid expansion.

In September, Pennsylvania became the 27th state (including the District of Columbia) to decide to expand Medicaid in order to close the coverage gap and provide health insurance to as many vulnerable residents as possible. At press time, however, 20 states continue to play politics with the lives of their uninsured residents by refusing to close the coverage gap and 3 are undecided.

Unfortunately, that means that as many as five million low-income adults will remain uninsured. Sadly, the states that are not closing the coverage gap are precisely those with large numbers of residents who need insurance (Texas alone is home to more than 20 percent of these adults).[3] The lack of coverage will fall particularly hard on specific groups who are disproportionately more likely to be low-income and therefore to lack coverage, including those who live in the South; women of color; and lesbian, gay, bisexual, transgender, and queer/questioning individuals.

Despite these many challenges, we are optimistic about the upcoming enrollment period. Many organizers, advocates, and assisters have been active throughout the summer, raising awareness about enrollment and working to prepare for a successful enrollment cycle. Much work remains, however. If you live in one of the states that’s not closing the coverage gap, contact your governor, and get involved in other efforts to expand coverage (there’s no time limit for when states can accept Federal funding to close the coverage gap, although 2016 is the last year for states to receive 100 percent Federal funding). For more information about the work the NWHN and our allies are doing in the states and how you can get involved, visit the Raising Women's Voices for the Health Care We Need website at

BOX: Your Role in the Next Open Enrollment Period

If you are uninsured, gather the important information you’ll need to enroll, such as:

  • Social Security Number
  • Last year’s tax returns (they contain important information you need to enroll, like filing status, number of dependents, income verification, etc.)
  • Current employer’s name and address
  • Information about any other health insurance you or other family members may have, like Children's Health Insurance Program (CHIP) or Medicaid
  • Green Card, and/or employment authorization number, if applicable

Start thinking about your health care priorities so you can pick the best plan for you and your family:

  • What do you need from a health care plan?
  • What medications are you taking that have to be covered by the plan?
  • What health care providers do you want to keep seeing (and therefore must be covered by the plan you select)?

You can get help finding in-person assistance and getting questions answered at the ACA enrollment website ( or at 1-800-318-2596. Remember to give yourself lots of time to get enrolled, start the process as early as possible — and be patient!

If you already have health insurance, then tell a relative, friend, or new acquaintance that the next open enrollment is around the corner and connect them with the resources listed above.

Cecilia Sáenz Becerra is a Program Officer at Groundswell Fund and a former Regional Field Manager for the NWHN’s Raising Women’s Voices initiative. With over a decade of activism for reproductive justice, Cecilia continues to work for women’s and transgender rights by co-founding Repeal Coalition and by serving on the board of directors for Access Reproductive Care – Southeast.

Read more from Cecilia Sáenz Becerra.

The continued availability of external resources is outside of the NWHN’s control. If the link you are looking for is broken, contact us at [email protected] to request more current citation information.


1. Ferris S, “Administration: 7.3 million enrolled in healthcare,” The Hill, September 18, 2014. Available online at:

2. Carman KC and Eibner C, “Survey Estimates Net Gain of 9.3 Million American Adults with Health Insurance,” Santa Monica: RAND Corporation, April 8, 2014. Available online at:

3. Kaiser Family Foundation (KFF), The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid, Menlo Park: Kaiser Family Foundation, April 2 2014.