In a Neighborhood Near You: How Community Health Workers Help People Obtain Health Insurance and Primary Care

Lack of health insurance has been linked to decreased preventive services, increased hospitalizations and emergency room visits, and diagnosis at later stages of disease, leaving those without insurance vulnerable to poor health outcomes.¹ In 2006, Massachusetts instituted health care reform that by 2011 resulted in the highest health insurance rate in the country, with over 90% of residents having access to a consistent source of care.^* The Patient Protection and Affordable Care Act (ACA), signed into law in 2010, will extend health coverage to an estimated 32 million uninsured Americans starting in 2014.

Implementing the ACA’s health insurance mandate will require states to reach, educate, and successfully enroll individuals and families who have had little experience with health coverage.² The uninsured are likely to require considerable individualized application and enrollment support. Consumer advocates believe there is a need for ongoing support so that the newly insured retain their coverage, navigate their way effectively through the health care system, and engage in wellness and prevention activities. As many states prepare to enroll millions of low-income uninsured Americans, the experience of Community Health Workers (CHWs) in Massachusetts can inform outreach and enrollment efforts across the country.³

Community health worker is an umbrella term for job titles, such as community health advisor, family advocate, health educator, liaison, promoter, outreach worker, peer counselor, patient navigator, health interpreter, and public health aide.⁴ Effective CHWs understand the populations and communities they serve and are seen as trusted leaders.⁵ In Massachusetts, CHWs are employed by community health centers, and community action, public health, and other community-based agencies to help individuals and families enroll in MassHealth (the Massachusetts Medicaid and Children’s Health Insurance Program) or other state health insurance programs. To support statewide outreach and enrollment efforts, the Massachusetts Health Care Training Forum (MTF), managed by the Massachusetts Area Health Education Center (MassAHEC) program at the University of Massachusetts Medical School, provides accurate and timely information to CHWs, as well as opportunities for CHWs to meet professionals in their field and provide feedback to MassHealth and other public assistance programs.⁶

Despite the achievement of near universal statewide health insurance coverage, the uninsured in Massachusetts (in comparison with the insured) are:

• • More likely to be young (aged 19–34), unmarried, and without a college degree

• • Working full-time or part-time (59%)

• • More difficult to persuade to obtain coverage, perhaps because most of the uninsured report they are in good or excellent health

• • Unlikely to have access to employer-sponsored insurance (ESI), or to have opted out of ESI due to cost

• • More likely to have difficulty accessing primary care, and to use the emergency department for non-emergency care.

• • Likely to be income-eligible for Medicaid or subsidized private insurance under national health care reform.⁷

Outreach, Education and Enrollment

State-funded mini-grants and private funders, such as the Blue Cross Blue Shield of Massachusetts Foundation (the BCBSM Foundation), have supported culturally competent consumer-focused outreach and education services throughout Massachusetts to ensure access to health coverage and increase consumer self-sufficiency to maintain coverage and navigate the health care system. The ACA includes funding for Consumer Assistance Program Grants and requires state exchanges to fund “Navigators” to assist individuals and families in understanding the new law and obtaining coverage.⁸

Outreach, education, and enrollment services in Massachusetts are typically free and provided in the native language of most consumers. “These [services] are a big necessity. The process [of applying for health insurance] is very difficult for the community to understand,” says an outreach supervisor at a health center in a small urban area that processes an average of 3,000 health insurance applications annually.⁹ According to figures reported to the BCBSM Foundation, during the period January–September 2012, CHWs in eight organizations funded to provide outreach and enrollment assistance saw a monthly average of 7,471 individuals through 14,512 encounters.

According to a CHW manager, “It...