Addressing Structural Racism: A Study of Efforts to Promote Health Insurance Coverage and Improve Racial Equity

Historical inequities, which are grounded in systematic and structural racism, present challenges to enrolling people from under-resourced communities in health insurance. RWJF has a long history of investing in national organizations, known as funded partners, who support ACA Marketplace and Medicaid/CHIP outreach and enrollment efforts for under-resourced communities and collaborate with community power-building organizations to provide education and outreach and enrollment support to individuals, families, and communities.

In this project, Mathematica and its partners evaluated funded partners’ health insurance outreach and enrollment efforts in the 2022 Marketplace open enrollment period in three communities of interest to RWJF: Broward County, FL; Detroit, MI; and Newark, NJ. 

Mathematica worked with four of RWJF’s funded partners who conduct outreach and/or enrollment activities at a national level and whose insights informed the data collection and analysis. These partners include: Community Catalyst, Young Invincible, Georgetown's Center on Health Insurance Reforms, and Center on Budget and Policy Priorities. Mathematica also worked closely with three evaluation partners who provided methodological expertise and deep knowledge of the three communities of focus.

To capture the experiences of outreach and enrollment navigators, as well as consumers, we conducted 35 interviews with outreach and enrollment staff and fielded a web-based network survey with 20 outreach and enrollment stakeholders to understand the connections between actors within each community. In collaboration with our evaluation partners, we held focus groups with 100 consumers across the three communities of focus. The focus groups provided vital insights into consumers’ understanding of and experiences with enrollment processes, and consumers provided recommendations for how these processes could be improved to become easier to navigate and more equitable.

Findings and recommendations from this evaluation highlight funded partners’ strategies to engage community power-building organizations, address structural racism in outreach and enrollment, align outreach and enrollment and COVID-19 outreach efforts, and measure and advance equity in their outreach and enrollment efforts. 

Key findings include: 

• Historically under-represented and under-resourced groups require innovative strategies to reach and enroll into health insurance.
• Trust is a critical factor to facilitating outreach and enrollment, and community power-building organizations serve as trusted messengers in communities.
• Structural racism manifests before, during, and after enrollment into coverage. In addition to organizational-level strategies for addressing structural racism in outreach and enrollment processes, lasting change requires broader systemic action.
• Outreach and enrollment partners are not consistently measuring their efforts, making it difficult to assess their contributions, and requested more guidance and support in this area.