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Advancing Health Equity in Health Care Coverage:A Public-Private Partnership to Engage Underserved Communities in Medicaid Expansion
Expanding Medicaid coverage has been demonstrated to reduce health inequities by allowing people with low income to access health care at little or no cost. However, reaching eligible populations to get them enrolled can be difficult. Two private health foundations, one national and one local, worked with a late-adopting Medicaid expansion state to help accelerate enrollment through support of a broad communications campaign coupled with targeted local outreach and enrollment assistance provided by community-based organizations and data analyses to assess program impact and inform evidence-based state policy and program changes. This article presents results from a qualitative evaluation of this funding partnership and describes the culturally nuanced strategies employed by community-based grantees to raise awareness and enroll new immigrants, migrant workers, tribal communities, rural residents, and other under-enrolled groups. We also discuss how the evaluation helped inform broader state policies and replicability of the model in other late-adopting expansion states.
Medicaid, access to care, Medicaid eligibility, Medicaid expansion, health equity, health philanthropy, open enrollment, community health workers, vulnerable populations.
Expanding Medicaid coverage has helped reduce coverage disparities and health inequities between people near or below the poverty line, minority racial/ethnic groups, and rural/urban communities and their counterparts by allowing them to access health care at little or no cost.1–5 However, reaching eligible populations in order to support their enrollment in coverage can be difficult, particularly in the cases of immigrant, tribal, and rural communities.6–9 In 2019, more than one quarter of uninsured Americans were Medicaid-eligible and over one-third were eligible for subsidized coverage purchased through the Affordable Care Act Marketplace.10 Rural residents and people identifying as belonging to a racial or ethnic minority group, including immigrants, continue to have higher un-insurance rates than their urban or White counterparts in both non-expansion and expansion states.11–13 Lower Medicaid and Marketplace enrollment by these eligible groups may be due to lack of awareness about coverage options available to them; difficulty understanding eligibility, application, [End Page 44] and enrollment processes; and systemic barriers and exclusions that have resulted in lack of trust.14–15 Previous efforts to enroll these groups in health coverage or access to health care suggest multi-pronged outreach strategies are needed, using a combination of broad public awareness campaigns and more targeted outreach strategies and messaging; enrollment assistance provided by individuals who are trusted within these communities; and technical assistance to community-based organizations that often are not sufficiently funded to handle some important tasks.5,16–18
In 2019, Maine became the 33rd state to expand its Medicaid program (MaineCare) to cover adults aged 19–64 with incomes less than 138% of the federal poverty level ($18,754 for a single adult in 2022), including adults without children and parents/caregivers who were previously not covered under other categories. While Maine had passed Medicaid expansion by referendum two years before in 2017, the prior governor, who opposed expansion, delayed its implementation despite a series of lawsuits and court orders.19 Maine's new governor signed and enacted MaineCare expansion by an executive order on January 3, 2019, her first day in office, making coverage retroactive to July 2, 2018, the date the expansion would have taken effect had the former governor not blocked it.20 At the time it was estimated this move would expand eligibility to more than 70,000 Maine residents according to the 2018 Memorandum to the Maine Health Access Foundation titled Estimated Budget Impacts of Expanding MaineCare published by Manatt Health. In this memorandum it was noted the newly eligible Mainers were more likely to identify as belonging to a racial or ethnic minority group; to be older adults (aged 55–64); to be uninsured or covered by Tricare, the Veterans' Administration, or the Indian Health Service; and to live in rural areas of the state.21
To help accelerate MaineCare expansion, two private health foundations, one national (the Robert Wood Johnson Foundation [RWJF]) and one local (the Maine Health Access Foundation [MeHAF]), collaborated on a joint funding approach with the Maine Department of Health and Human Services (DHHS) and its Office of MaineCare Services (OMS), Maine's state Medicaid agency, and community-based organizations, to help increase enrollment, particularly among historically hard-to-reach vulnerable groups, and build infrastructure to assess program reach. This public-private funding partnership aligned with the missions of the foundations, both of which have a long history of supporting initiatives to expand health insurance coverage and access to high-quality, comprehensive health care, particularly for vulnerable communities. The private foundation partnership differed from prior coverage initiatives both in its national/local partnership and in providing direct funding to support the state's infrastructure in implementing the new program and measuring program impact to inform evidence-based policy and program changes, rather than supporting external technical assistance to state government. The funders also provided direct funding to community-based organizations* (CBOs) to provide local outreach and support enrollment assistance for specific hard-to-reach communities.22
To assess the impact of this funding model, RWJF commissioned a rapid-cycle [End Page 45] qualitative process evaluation to assess facilitators, barriers, and lessons learned from this unique funding partnership. This article summarizes findings from this evaluation and the perceived impact of this public/private partnership in reducing health care coverage inequities to inform best practices for future partnerships and replicability of the model in other late-adoption expansion states.
Methods
The study team selected a rapid-response developmental systems-change process qualitative evaluation to assess facilitators, barriers, and lessons learned from the funding partnership to inform program improvements and future private foundation collaborations.23 The evaluators initially sought to answer the following questions:
• How did the funding approach help the state government and MeHAF prepare for and support implementing MaineCare expansion? Did this funding help the state do something different from what it would or could have done relying on government funding alone?
• How did the state use and leverage funds to build capacity for monitoring and improving Medicaid expansion coverage and expand access to vulnerable populations over the longer term? How did it inform subsequent program or policy changes?
• How did the funding contribute to other partnerships (e.g., with community-based organizations) and how did these partnerships help engage specific at-risk communities?
• What are the lessons learned from the initiative in terms of how similar funding approaches may be applied in other rural late-adopting Medicaid expansion states?
Interview protocols were developed based on these questions and were tailored to the specific key informant being interviewed. In response to the onset of the COVID-19 pandemic in 2020, we added questions in the second year of the evaluation to understand how the pandemic, and the racial and rural health inequities it revealed, affected Medicaid expansion communication and outreach efforts.
The study was reviewed by the University of Southern Maine's Office of Research Integrity and Outreach and received a determination that the evaluation was not human subject's research. (Human Research Protection Program protocol #103019).
From November 2019 through August 2021, the evaluation team conducted 43 interviews with 35 key informants. The list of key informants was developed in consultation with MeHAF and RWJF and included senior leaders at RWJF and MeHAF, the Maine DHHS Commissioner's Office and the Office of MaineCare Services, data partners at the Maine Health Data Organization and the University of Southern Maine, media campaign advisors, and representatives from the nine CBOs who received direct funding (described below). We interviewed funders quarterly and state officials and the CBO [End Page 46] grantees bi-annually during the grant period to capture their evolving perspective on the funding partnership's perceived impact on MaineCare expansion implementation and changes to their implementation plan over time and (in 2020/21) in response to the pandemic. Informed consent was obtained orally at the beginning of each interview.
The CBO grantees who were also being interviewed about the perceived impact of their MaineCare expansion outreach activities as part of a separate outreach evaluation conducted by the University of Southern Maine on behalf of DHHS ("outreach evaluation") risked respondent burden.24–25 To minimize this, they were interviewed jointly by both evaluation teams, with questions specific to the RWJF/MeHAF funding added to interview protocols.
Two to three members of the study team conducted the approximately hour-long interviews over Zoom, using customized semi-structured interview guides based on the evaluation questions. Interviews focused on program activities, facilitators, and challenges; value of the grant funding for MaineCare expansion implementation; perceived impact on targeted vulnerable communities; and recommendations for states undertaking new outreach and enrollment initiatives and foundations considering a similar funding approach in other states.
Interviews for the funding partnership evaluation were audio-recorded and transcribed. Two evaluators developed a provisional coding structure based on the interview guide and reviewed the transcripts to identify themes and synthesize findings.
The evaluation team members also engaged in the interviews and had access to results from interview transcripts and quantitative data collected from grantees for the separate outreach evaluation. These included the interviews with CBO grantees and state officials for whom we had added specific funding partnership questions. For the outreach evaluation, these interviews had been transcribed and thematically coded and analyzed for themes using QSR NVivo qualitative analysis software. (QSR International Pty Ltd. (2018) NVivo (Version 12), https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home). Summary findings from these outreach evaluation interviews and secondary data collected were reviewed for the funder rapid cycle evaluation along with other communications, meeting minutes, and other materials, data, and reports generated with the RWJF/MeHAF funding. These are included in findings reported in this article.
Results
Broad-based public media campaign designed to reach a diverse population
In August 2019, RWJF provided a $750,000 grant to MeHAF, which served as the primary grantee and received the grant funds directly from RWJF. MeHAF then distributed most of the grant funds to ME DHHS. The state used a portion of these funds to contract with private media vendors to undertake a statewide media campaign, known as CoverME.gov, to promote awareness and enrollment in both MaineCare and MaineCare expansion and health insurance options available through the federal Marketplace. The state also used the private philanthropy funds to draw down federal matching dollars for Medicaid administration thereby increasing the value to the state and the potential return on investment for the foundations. [End Page 47]
According to DHHS representatives interviewed, Maine had not previously had the funding to undertake statewide media campaigns relating to health care insurance, so the private foundation collaborative helped support this approach. The campaign used both traditional and social media and also developed the CoverME.gov website, a full-service destination where people could enroll either in ACA Marketplace plans or be directed to My Maine Connection to enroll in MaineCare. CoverME.gov also contains links to helpful community resources and translation services, information on where to find enrollment assisters, and other information that aims to reduce barriers in applying. (CoverMe.gov remains the primary portal for ACA Marketplace enrollment in 2022.) Respondents from DHHS indicated they sought to support coverage broadly speaking across the state, not any particular program. They found the unified CoverME.gov campaign helped promote all coverage options and was simpler for consumers to understand through its direct message of "the state has coverage options that meet your needs." CoverMe.gov also helped serve as a pilot for the launch of Maine's new state-based Marketplace in 2021,26 as well as positioning the Marketplace as a source of insurance for people who may no longer be eligible for MaineCare after the end of the COVID-19 Public Health Emergency (PHE).
Media consultants interviewed provided technical assistance and evaluation of the state's media campaign. They felt Maine had successfully used effective messaging to emphasize the local nature of MaineCare, via the CoverME.gov brand, a strategy that had been previously implemented successfully in some early-adopting Medicaid expansion states.27 They noted that one challenge for messaging to consumers is the politically charged nature of the topic that often results in consumers ignoring information or thinking there are no insurance options for them. This makes it particularly important for states to acknowledge changes to policies and rules in their messaging, which the CoverME.gov campaign did effectively. Other respondents suggested that using CoverME.gov as the vehicle for promoting all coverage options may also have helped circumvent stigma associated with programs such as MaineCare. Most state leaders interviewed believed the media campaign and grant funding to CBOs (see below) played a role in the higher-than-expected Marketplace and MaineCare/MaineCare expansion enrollment in the fall of 2019 and 2020.
Grant support to target vulnerable populations
In addition to the funding to DHHS, RWJF and MEHAF funds also supported direct funding to nine CBOs working with under-enrolled groups in the state to help raise awareness and enroll people. The grants also supported organizations with expertise in MaineCare and Marketplace eligibility and enrollment to provide training and technical assistance to local CBOs, federally qualified health centers, and community action programs directly working in these communities. MeHAF directly distributed $130,000 from RWJF and an additional $270,000 of its own grant funding to these organizations to support outreach and enrollment assistance for both Medicaid expansion and Marketplace enrollment in 2019 and 2020 (Table 1). MeHAF had pre-existing relationships with many of the organizations, having supported outreach and enrollment efforts for the implementation of the Affordable Care Act.28
The selected grantees included local public health agencies, statewide advocacy organizations, and service providers with experience working in specific communities who [End Page 48]
MEHAF/RWJF GRANTEES, TARGET POPULATIONS, AND ACTIVITIES, 2019–2021
[End Page 49] had historically been under-enrolled or experienced barriers to coverage including new Mainers who were recent immigrants in the state, non-English speakers, members of Native American tribal organizations, people living in rural areas, migrant and seasonal workers, and other uninsured individuals. (Table 1)
Leadership from MeHAF noted that grantees were selected less for their ability to enroll large numbers of people and more because of their trusted relationship with small under-represented communities. Grantees were not necessarily connected to Maine's health care system or providers that could help them enroll, but instead focused their efforts on those who might be experiencing the greatest barriers to enrollment.
As part of the transition to a state-based Marketplace, additional state funds became available to maintain CoverME.gov and provide Marketplace outreach and enrollment assistance. In 2020, the state assumed oversight of outreach for the transitional state-based Marketplace on the federal platform. The state awarded the Navigator grant to a partnership of organizations that included several of the RWJF/MeHAF grantees for the MaineCare expansion initiative. The state also committed a larger amount of funding for Navigators, restoring funding to levels from when the ACA was first introduced. Interviewees from DHHS indicated that these resources could also be leveraged for special enrollment efforts (for example, the expansion of coverage for children and pregnant people).
Role of local foundation in facilitating funding and the state and community partnership
As the local funder, MeHAF was able to contribute its own funds as needed to supplement the RWJF funding, beyond what was initially committed by RWJF and MeHAF in support of the CBOs. For example, MeHAF used its own funds to add a grantee in order to reach immigrants who had not been included in the initial planning in Maine's second largest city. MeHAF funds also provided the flexibility for the CBOs to assist clients with both MaineCare and Marketplace enrollment, allowing the CBOs to discuss different subsidized insurance opportunities in their outreach to client's based on their specific situation, which was a more client-centered approach.
Distributing funding to the CBOs via local philanthropy rather than directly to state government allowed for greater flexibility in implementation; work was able to advance quickly or in a different direction as needed. Interviewees noted that funding the work of the CBOs would have been more challenging if the grants had been funneled through DHHS, because of the lengthy state procurement process likely slowing the release of funds and the CBOs' limited internal capacity to respond to solicitations and write grant proposals. MeHAF also modified its grant process to simplify application and reporting requirements.
Both grantees and state leaders interviewed described the crucial role MeHAF played in implementing the partnership's novel funding approach. Throughout the grant period, MeHAF served as the local convener and connector between DHHS and the grantees. It also dedicated specific funding for Consumers for Affordable Health Care to take the lead in creating opportunities and meetings where grantees could problem-solve and openly share barriers to enrollment with the state. Grantees appreciated the chance to meet with their peers, make new connections with other organizations serving similar populations, share tools/best practices (e.g., translated outreach materials about MaineCare [End Page 50] expansion), and strengthen existing relationships. They also cited the benefits of being able to build on their relationships with DHHS and with each other through the grantee meetings. One grantee spoke about being grateful to have had "the opportunity to think creatively together," and several grantees noted that they reached out to other grantees for advice.
Leaders at Maine DHHS also appreciated MeHAF's role in facilitating regular communication between the CBOs and the state. Staff at OMS also noted that the dynamic of having MeHAF as a broker "shifted the dynamics in the room," creating an environment that allowed the state to build relationships with CBOs based on mutual interests and shared goals. MeHAF played a particularly important role with the CBO grantees, all of whom expressed appreciation for MeHAF's flexibility and ability to meet grantees with realistic expectations, even when the grantees did not have much experience with or capacity for reporting and evaluation. The grantees felt that this approach helped to bring funding to a more diverse group of grantees.
Grantees interviewed indicated RWJF/MeHAF grant funding allowed them to hire new staff and community health workers (CHWs) and devote existing staff time exclusively to outreach and enrollment work. The funding also covered staff time to participate in training to become MaineCare certified assistance counselors as well as trainings conducted by other grantees who were funded to provide technical assistance. It also helped technical assistance grantees expand trainings to include sessions more directly targeted towards Maine's minority populations or that provided more details on issues of particular concern to specific populations (e.g., the public charge rule). Funding also covered development of culturally appropriate eligibility screening tools and allowed those tools to be translated into relevant languages.
The CBOs developed and deepened relationships with key players at DHHS, particularly at OMS, creating a valuable opportunity for the state to learn about barriers to outreach and enrollment to under-represented communities. This information helped inform more targeted campaigns for the subsequent open enrollment period as well as public health messaging during the COVID-19 pandemic (see below).
Key stakeholders at OMS/DHHS noted that two sources of information — their experience working with the MeHAF-funded community groups that focus on underserved communities and the results seen in the outreach evaluation's first-year report — helped them to see gaps in enrollment assistance. This spurred them to start thinking about how to engage organizations that already have established relationships with vulnerable communities. Doing so included structuring outreach and enrollment programs with the flexibility needed to allow small CBOs to become involved. The interviewees noted that reconnection to community organizations has been of central importance for the RWJF/MeHAF outreach and enrollment efforts, as well as other Medicaid outreach efforts. The RWJF/MeHAF funding helped the state reach people they would not have been able to connect with otherwise and allowed the state to develop trust and credibility with the CBOs, while also learning about their strengths and weaknesses. One respondent from OMS noted that the new relationships eliminated the need to "cold call" CBOs to involve them in DHHS initiatives, and that representatives from the CBOs have also become more likely than they might have been previously to reach [End Page 51] out to the department with questions. Staff from DHHS also noted that the outreach evaluation helped inform Marketplace Navigator data-reporting requirements and the expectations of entities applying for outreach and enrollment funding.
Impact of the partnership on the COVID-19 pandemic response
The relationships between DHHS and the CBOs were used in a variety of ways during the COVID-19 Public Health Emergency. Many of the CBOs that were already working with DHHS on MaineCare expansion became engaged in translating and communicating COVID-19-related public health and testing/vaccine information for the communities they serve.
The outreach and education efforts in the second year of grant funding took place during the COVID-19 pandemic. This fundamentally changed the outreach and enrollment methods of the grantees, requiring greater use of virtual platforms (e.g., WhatsApp, Zoom). While initially challenging to implement, virtual enrollment assistance ultimately proved to be very helpful in overcoming barriers encountered for in-person enrollment (e.g., transportation, not having documentation available for the appointment).
The pandemic also brought health care disparities affecting Black, Indigenous, and People of Color (BIPOC) in Maine into focus, when Maine was ranked as having the widest racial disparities nationwide in infection rates during the first few months of the pandemic.28 The Department of Health and Human Services realized that they needed a response to the pandemic that both would affect large numbers of people and also that would reach smaller, diverse populations. Building on the funding partnership described here, they reached out to the grantees as well as other CBOs working with BIPOC populations in Maine to develop strategies for reaching these populations. Community health workers were deployed to help inform their communities about the COVID-19 partial benefit that the state had created for those who were ineligible for MaineCare expansion. It helped cover COVID-19 treatments as well as COVID-19 testing, social distancing, and vaccination messaging supported through grants from the Maine CDC. The state indicated that the racial disparities made more widely known during the pandemic have resulted in greater efforts to improve the state data in tracking race/ethnicity generally, and to track the impact of MaineCare enrollment within these groups.
Representatives from OMS noted that they plan to continue working with the CBO grantee partners for outreach, education, and enrollment of those newly eligible for expanded dental coverage and children and pregnant women under recently expanded coverage for immigrants and post-partum care. Community-based organizations will also be engaged to assist the state with re-enrollment outreach and assistance during the unwinding of the COVID-19 maintenance of effort requirement once the PHE ends.
Support for Maine's data infrastructure to measure impact
Findings from the outreach evaluation conducted for DHHS show that enrollment assisters helped with 5,610 MaineCare/CHIP applications and re-certifications and 5,081 general inquires during the 2020–21 open enrollment period (Table 2).* Data-reporting changes and additional organizations added to the Navigator consortium between years makes it [End Page 52]
ENROLLMENT ASSISTANCE BY MEHAF/RWJF GRANTEES IN 2019–2021
difficult to directly compare over time. However, despite the COVID-19 pandemic necessitating new outreach and enrollment strategies, the number of people assisted with MaineCare applications in the fall 2020/spring 2021 was higher than that number for the same period in the prior year (Year One: 1,013 likely MaineCare eligible; Year Two: 5,610 assisted with MaineCare application/recertification). When compared with total MaineCare applications received by the Office for Family Independence during the same reporting period (Sep 2020–Apr 2021), approximately 2% of all MaineCare applications (or 14% of applicants enrolled in MaineCare expansion) were made with grantee assistance during this period. This was a substantial increase over the prior year (Sep 2019–May 2020) where grantee assistance may have helped approximately 0.2% of all MaineCare applications (or 2% of applicants enrolled in MaineCare expansion).
The outreach evaluation described the strategies used by the grantees to reach specific [End Page 53] populations and highlighted the value of engaging CHWs in outreach and enrollment efforts. Several grantees that work with migrant workers, tribal communities, and immigrant communities hired and trained CHWs to serve as cultural brokers, seeking to build trust and provide information about MaineCare and the Marketplace in targeted communities in their community's native language. They were able to overcome barriers with their communities such as a lack of understanding of the U.S. health care and health insurance systems, fear or mistrust of public systems in general, and myths about MaineCare. Many grantees said the use of CHWs was the most successful strategy and essential for reaching specific target populations and improving health equity. The currency that CHWs have with their communities also helped earn trust for the organization that employed them. Community health workers were particularly helpful in communicating public health messages to their communities during the COVID-19 pandemic.
I would say our strengths are that we are able to contact our patients through their CHWs, who are people they work with on a regular basis and trust. So they're able to have those conversations and work out questions with CHWs, and because they have that connection they feel comfortable reaching out to me or to other staff to [help them enroll in insurance] … CHWs being on the ground kind of plant those seeds … Once that contact has been made either with the CHW or if they've connected them to me, they share that information with family members and that builds another level of trust that allows those people who might not have been as engaged beforehand to engage with us and get coverage …
I can connect them with a CHW who can navigate the system and explain all these cultural facts on enrollment rather than interpretive services that literally just translate what one person and another person say.
The whole point of a CHW is a bit different than an employee of a health center, that there's someone in the community that folks trust and they go to them. Because when you're the person who speaks that person's language and you've walked a similar journey, especially with our refugee immigrant community, there are many more topics that are covered in a conversation that are important to that conversation and getting that person connected to services that the state pays for that would lower the cost for the state for this particular person or family in the long run, if they just knew they could get connected to those services.
Grantees also highlighted the need to diversify CHWs to tailor messaging and materials to the language and literacy levels that are appropriate for specific immigrant communities and how they modified their approaches during the pandemic.
Using a community advocate is working very well. For example, all the Somalians came from different parts of Africa. For example, Djiboutis speak Somali and French. The Somali Ethiopians speak Somali and Amharic, and there are Somalis from Somalia and Somalis from Kenya. So if we have a family who came from Djibouti we use a CHW who came from Djibouti because they know the language, the culture, have the same religion and background. They know each other, so they are very helpful to them. [End Page 54] I don't think that only the translated document is right for people who sometimes don't write in their own language. Having someone like a CHW, like a cultural broker. Comparing West Africans to the Congo, Togo, those communities, they speak French and can write and read in French. They're really well-educated. Still when it comes to education, the policy re eligibility, all those things are very complicated for them. So we need well-trained CHWs in their own community …We know there's a lot of fear of DHHS because of immigration status. They don't trust to give permission to you unless you have their own different cultural worker on the contents there.
Based on use of CHWs for MaineCare expansion and during the COVID-19 pandemic, state leaders in the Office of MaineCare Services interviewed indicated that they are exploring new payment models. These models would incentivize primary care providers and health systems to engage CHWs in care models to assist with patients in navigating and using health care post-enrollment. Maine is pursuing grants to push forward these efforts. The Department of Health and Human Services is interested ensuring that CBOs (not just medical organizations) can sustainably employ CHWs. (Office of MaineCare Services webinar, Community Health Workers and Primary Care Plus, October 29, 2021).
The outreach evaluation's examination of MaineCare application and enrollment trends during the study period also suggests the state's public awareness and outreach and enrollment efforts were successful. In the first year of expansion (2018–2019), roughly 60,000 Mainers (85% of the estimated eligible population) enrolled for the first time. Across the three-year period (2018–2021) more than 110,000 people were enrolled for the first time (ever enrolled) in the MaineCare expansion, exceeding 2019 American Community Survey (ACS) five-year estimates of total Mainers eligible (70,168). While the COVID-19 pandemic temporarily decreased new MaineCare expansion enrollments in early 2020, in the November/December 2020 open-enrollment period, new expansion applications and enrollments were higher than during the same period in 2019. Furthermore, most counties in Maine enrolled more than 75% of the estimated eligible population. Only Cumberland (Maine's most populated county), Franklin, Piscataquis, and Sagadahoc had less than 75% of the total estimated eligible population enrolled.
Overall, MaineCare applicants tended to be more diverse than the ACS 2019 population estimates, which may be an indicator of successful outreach and enrollment efforts focused on engaging these populations. MaineCare and MaineCare expansion applicants/enrollees were more likely than the population as a whole to be Black, Indigenous, or People of Color and to have a primary language other than English. The diversity of different primary languages of MaineCare expansion members (57) further supports the need for application and outreach materials to be available in multiple languages. The linguistic diversity may be an indicator of the success of CHW outreach efforts and grantees' provision of materials in many languages.
In addition to the outreach evaluation, the state also used philanthropic funds to work with the University of Southern Maine (USM) and a sister state-data agency (the Maine Health Data Organization) to enhance data infrastructure and analyze MaineCare eligibility and claims administrative data with Maine's All-Payer Claims Database. They did so to assess whether MaineCare expansion was reaching previously uninsured [End Page 55] persons, to monitor who was enrolling, and to measure access to services once enrolled. These analyses helped confirm the state was reaching previously uninsured people and also helped measure availability of primary care and behavioral health providers to meet the needs of new MaineCare members. State leaders reported that these analyses and reports have allowed DHHS to track change over time, which can be useful for budgeting and planning to target resources.
The analyses of primary care and behavioral health providers and the proportion of those serving MaineCare members confirmed greater than expected provider availability and shorter than expected travel distances to new members' closest primary care provider. Interviewees from OMS noted that these analyses, examining how people are enrolling in MaineCare and how they are interacting with the health care system have been helpful for OMS's internal data analytics team; for example, USM's work has helped OMS to prepare for analyses related to increased enrollment and provider capacity concerns in the context of COVID-19.
Partnership's impact on state policy direction and community engagement efforts
As a direct outgrowth of the funded work—as well as work done with CBOs (including the grantees) during the pandemic—Maine state government, MeHAF and other philanthropic organizations, and key stakeholders are currently engaged in conversations about how to award grants and contracts in a way that better supports small CBOs working with underserved populations in Maine. These CBOs may have limited infrastructure to do the type of data collection and grant-reporting typically required under state contracts. They require technical assistance and/or back-office support, both in applying for the grant and completing any reporting requirements. The state may need to be more flexible in how they structure funding opportunities, for example, allowing sub-awardees or multiple organizations to pool resources and submit a proposal together.
The CBOs are particularly under-resourced to provide quantitative data; these data are necessary to demonstrate the value and implications of grantmaking, but CBOs are not well positioned to collect it, due to staffing limitations. Additionally, the CBOs often need to piece together their core funding from different foundations with different reporting requirements, which adds to the data collection challenge. Leadership from MeHAF noted that the data collection challenges identified by the CBO grantees are precipitating conversations within the foundation about how to address them in grantmaking. In recent years, they have been funding more operational support for CBOs, which requires less data collection than project grants do. MeHAF is also having their program officers conduct interviews with grantees as a substitute for grant reporting, with the program officers responsible for entering the results into the internal grants database.
Increased visibility of barriers to coverage that informed policy changes
Regular meetings with the grantees and the state convened and facilitated by MeHAF as a neutral party, helped increase the state's understanding of barriers to enrollment and helped CBOs work together with advocacy organizations providing technical assistance. In this work they problem-solved and troubleshot specific eligibility concerns/barriers, while also advocating for policy changes that would help overcome enrollment barriers. As one grantee noted, external policy factors often affect eligibility and enrollment. For example, the Trump administration's public charge rule that went into [End Page 56] effect in February 2020, which counted the use of specific health or human services programs or expected future use of those services as a negative when evaluating specific immigrants' applications for green cards or entry into the United States, discouraged all immigrants' public benefit enrollment, including Medicaid, both leading up to and after it went into effect. While the public charge rule only applied to a small segment of the immigrant community, and was reversed by the Biden administration in 2022, the law had a chilling effect on all immigrants who chose to avoid applying for Medicaid for fear that their immigration status might be impacted.
Similarly, Maine's more restrictive rules around estate recovery prior to November 2021 had a significant impact on enrollment through expansion for Mainers aged 55 to 64, which led to the state's decision to align with less restrictive federal guidelines. As one DHHS leader put it,
As part of the governor's budget, Maine aligned its estate recovery policy with federal guidelines. Previously the state's policy had been stricter than the federal guidelines in that it considered all Medicaid-related expenses, while the federal requirement only includes LTC, HCBS waiver expenses, and associated pharmacy costs. The ongoing evaluation of the [Medicaid expansion] enrollment and estate recovery barriers identified drove this policy decision.
In both these examples, it was critical to provide regular feedback to the state to advocate for solutions at the policy level in addition to education and informational pieces on these issues.
Discussion
Findings from this qualitative evaluation revealed that private foundation partnerships with state government may help late-adopting Medicaid expansion states support greater awareness of new coverage options in diverse communities that require culturally appropriate approaches. Direct funding to CBOs working with new immigrants, migrant workers, tribal communities, and rural residents helped give these organizations opportunities to discuss barriers to enrollment and to problem-solve solutions directly with the state; historically such opportunities were not available to these populations. Direct private funding allowed greater flexibility and more timely fund distribution than would have been possible through state contracting to hire and train enrollment assisters and CHWs and to provide culturally appropriate messaging to raise awareness and get people enrolled. The partnerships formed between the grantees and the state also fostered relationships that informed both the state's roll-out of its state-based Marketplace and facilitated its COVID-19 public health efforts. Further research, such as a survey of members of the targeted groups, might help support the evaluation findings and make them more generalizable.
Evaluation of outreach efforts revealed the difficulty in measuring the perceived impact of specific outreach strategies on improving healthy equity for targeted groups that represent a small number of the total eligible population. The heterogeneity of Medicaid expansion target populations even within a relatively homogeneous predominantly White state presents challenges in measuring the impact within specific [End Page 57] groups. This pointed to the value of collecting qualitative information from people in the field to identify barriers to enrollment and develop more targeted communication strategies. In addition to critical qualitative data, states may also consider collecting more data at enrollment to better capture cultural considerations, as well as race and ethnicity (for example, country of origin, language spoken, engagement of a CHW or navigator in enrollment assistance). More data will also make it possible to assess how people learned about the program and what assistance they used. This makes it feasible to target resources more effectively to promote Marketplace/low-income subsidy options, other Medicaid eligibility expansions (e.g., post-partum 12-month eligibility expansion), and the redetermination process from the unwinding of the maintenance of effort requirement under the PHE.
Both authors are affiliated with the Muskie School of Public Service, University of Southern Maine.
Acknowledgments and Grant Support
This study was funded by a grant from the Robert Wood Johnson Foundation. The authors would like to thank Tara Oakman at the Robert Wood Johnson Foundation and Barbara Leonard at the Maine Health Access Foundation for their guidance and support and valuable feedback. We would also like to thank state partners at Maine DHHS Michelle Probert, Sarah Grant, David Jorgenson at the Office of MaineCare Services, Megan Garratt-Reed ME DHHS Office of Health Insurance Marketplace and Katherine Fritzsche, ME DHHS Director of Research and Evaluation for their leadership and all the other state agency partners and stakeholders who participated in key informant interviews for offering their time and insights on the impact of the funding partnership. A special thanks to colleagues Yvonne Jonk, Carolyn Gray, and Cathy McGuire for sharing the results of data analyses for this evaluation. Finally, we especially want to thank all the MeHAF/RWJF grantees for their time and insights despite facing significant obstacles during COVID-19 in providing outreach and engaging the vulnerable communities they serve.
References
Footnotes
* The RWJF/MeHAF grantees were a mix of advocacy organizations, public health organizations, and service providers, some of whom do not necessarily consider themselves to be CBOs in the traditional sense. However, they were referred to as CBOs by the funders and evaluators in a broad sense of not-for-profit organizations that serve their communities, who may be underrepresented or underserved in some capacity, and have deep ties to their communities and often leadership within it.
*. Total self-reported aggregate people and family/household members assisted by grantees across reporting months. Numbers may be duplicative if individuals or family members sought assistance more than once across months or from different grantees.
