Participatory Evaluation of a Community Mobilization Effort to Enroll Wyandotte County, Kansas, Residents Through the Affordable Care Act

Abstract

Successful implementation of the Affordable Care Act (ACA) depends on the capacity of local communities to mobilize for action. Yet the literature offers few systematic investigations of what communities are doing to ensure support for enrollment. In this empirical case study, we report implementation and outcomes of Enroll Wyandotte, a community mobilization effort to facilitate enrollment through the ACA in Wyandotte County, Kansas. We describe mobilization activities during the first round of open enrollment in coverage under the ACA (October 1, 2013–March 31, 2014), including the unfolding of community and organizational changes (e.g., new enrollment sites) and services provided to assist enrollment over time. The findings show an association between implementation measures and newly created accounts under the ACA (the primary outcome).

KEY FINDINGS

• ▪ Community mobilization resulted in expanded access to places for enrollment and people to support residents in enrolling for health insurance.

• ▪ Funding support made it possible to hire staff who helped to coordinate the work in creating these new settings and in recruiting and supporting volunteers.

• ▪ Collaboration with an existing coalition, the Latino Health for All Coalition, helped engage community partners in planning, implementation, and participatory evaluation.

Minority populations experience the greatest disparities in health and associated access to health care.^1,2 The Affordable Care Act (ACA)³ is landmark federal legislation intended to increase health care access among those who need it.⁴ State-level supports for access vary enormously; some states have attempted to erect barriers to impede enrollment.⁵ Thus, ensuring enrollment through the ACA is typically a local matter requiring community mobilization and partnerships.

In this empirical case study, we report implementation and outcomes of Enroll Wyandotte, a community mobilization effort to facilitate enrollment through the ACA (October 1, 2013–March 31, 2014) in Wyandotte County, Kansas. We describe mobilization activities, including community and organizational changes (e.g., new enrollment sites, expanded hours for enrollment) and services provided (e.g., instances of enrollment assistance). The report provides data on the association between implementation measures and newly created accounts under the ACA (the primary outcome). We describe how participatory research methods were used to systematically reflect on progress and use the data to make adjustments.

COMMUNITY MOBILIZATION FOR ENROLLMENT

Wyandotte County (Kansas City; population = 160 384)⁶ is an area with low incomes and high disparities in health outcomes; it ranks 96 of 98 in the county health rankings for the state of Kansas.⁷ This culturally diverse community has limited access to health care services, and its residents are 24.4% African American and 26.9% Latino.⁸

Enroll Wyandotte has the mission of ensuring access to health care for all Wyandotte County residents by enabling enrollment in health insurance. To support enrollment through the ACA, Enroll Wyandotte engaged multiple partners from different sectors; for instance, governmental health organizations (Wyandotte County Health Department), public institutions (e.g., libraries), hospitals and health care organizations (e.g., safety net clinics), community and cultural organizations (e.g., El Centro), universities (e.g., University of Kansas), and community health coalitions (e.g., Latino Health for All Coalition).

Enroll Wyandotte used a community mobilization approach to increase awareness, accessible settings, and human resources to make enrollment through the ACA easier for residents. The Sidebar outlines the core intervention components and elements of this strategy and illustrative activities.

PARTICIPATORY EVALUATION OF ENROLL WYANDOTTE

This participatory evaluation engaged both community partners—staff and leadership of Enroll Wyandotte (J. J., L. J., and W. M.)—and a research partner, the Work Group for Community Health and Development at the University of Kansas (S. B. F. and C. E. S.). Community and research partners worked together to identify key evaluation questions and related indicators to support participatory sensemaking and program improvement.

Identifying Indicators of Success

The vision for Enroll Wyandotte was ensuring conditions for widespread enrollment through the ACA and associated access to needed health care, especially among those experiencing health disparities. Community partners identified several key indicators of success: (1) community and organizational changes (i.e., new or modified programs, policies, or practices to facilitate enrollment through the ACA, such as expanded enrollment hours at the health department, new sites at local public libraries, and community organizations), (2) services provided (e.g., media communications to promote awareness, direct assistance in enrollment sites), and (3) created accounts (the total number of family accounts created within the ACA Web site at 3 enrollment sites).

Table 1 shows the monitoring and evaluation system used with Enroll Wyandotte, including evaluation questions, indicators, and type of measurement.

TABLE 1—

Monitoring and Evaluation System Used With the Enroll Wyandotte Effort: Wyandotte County, Kansas, August 2013–March 2014

Evaluation Question	Indicators	Measurement	Frequency	Person Responsible	Related Activities
Goal 1: Engage in community mobilization and change efforts to enable access to health insurance
Is the initiative bringing about changes in communities and systems related to the mission?	No. and type of community and organizational change	Project records	Summarized monthly in online documentation and support system	Project documenters	Quarterly sensemaking and reports to funders
		Documented in online documentation and support system (community and organizational change)
Goal 2: Ensure information and support services for those enrolling in health insurance
Are we providing information and support services to uninsured residents?	No. of services provided to enrollees	Project records	Summarized monthly in online documentation and support system	Project documenters	Quarterly sensemaking and reports to funders
		Documented in online documentation and support system (services provided)
Goal 3: Increase enrollment in health insurance among residents of Wyandotte County
Is there an increase in enrollment applications completed?	No. of enrollment applications completed	Project records	Summarized in online documentation and support system after each available measurement (e.g., quarterly, annual)	Project documenters	Biannual sensemaking and reports to funders
		Documented in online documentation and support system (indicators database)

Documenting Implementation and Outcomes

The Work Group for Community Health and Development team designed an online documentation and support system⁹ that included prompts and supports to (1) capture instances of community and organizational changes and services provided (i.e., what was done when and by whom toward what goal), (2) code by type of activity (i.e., using definitions of community and organizational change and services provided), (3) characterize the activity (e.g., by goal, strategy used, sector in which implemented), and (4) communicate progress (e.g., graphs of the unfolding of community and organizational changes over time).

Description of Enroll Wyandotte Intervention Components and Elements and Illustrative Activities: Wyandotte County/Kansas City, Kansas

Components	Intervention Elements With Illustrative Community and Organizational Changes and Services Provided	Type of Activity
Providing information and enhancing skills	Provided one-on-one education through the walk-in enrollment center.	Services provided
	Provided ACA enrollment information to community outreach partners (e.g., community development organizations, neighborhood associations).	Services provided
	Provided ACA education materials through local health fairs and other community settings (e.g., elementary schools, churches, government buildings).	Services provided
	Provided inbound and outbound education through the enrollment center.	Services provided
	Community partners (e.g., neighborhood associations, charities, university medical centers) in collaboration with Enroll Wyandotte provided informal education sessions and distributed education materials within their communities.	Services provided
	Conducted a social marketing campaign that included radio advertisements of education and enrollment events, radio interviews, and print-media coverage.	Services provided
	Conducted a door-to-door education referral campaign (Canvas Kansas City) to identify eligible community residents.	Services provided
	Enroll Wyandotte, in partnership with the Health Care Foundation of Greater Kansas City, called resident referrals identified from the door-to-door campaign.	Community and organizational change
Modifying access, barriers, exposures, and opportunities	Provided one-on-one enrollment assistance through the walk-in enrollment center.	Services provided
	Provided one-on-one enrollment assistance with community residents through satellite enrollment sites (e.g., libraries, charity organizations).	Services provided
	Provided inbound enrollment assistance through the enrollment center.	Services provided
	Conducted community enrollment events in collaboration with community partners (e.g., recreation facilities, charity organizations).	Services provided
Enhancing services and support	Hired a full-time navigator/project coordinator.	Community and organizational change
	Trained a workforce of university volunteers as certified application assistors.	Volunteers engaged
	Expanded the enrollment center from 1 to 5 d/wk.	Organizational change
Modifying policies and broader systems	Established collaborative partnerships with community organizations (e.g., safety net clinics, public libraries, volunteer groups).	Community and organizational change
	Established a walk-in enrollment center in collaboration with the Wyandotte County Health Department.	Community and organizational change
	Established the Wyandotte County Health Department as a certified US Department of Health and Human Services training center for enrollment assistors.	Community and organizational change
	Provided testimony to senate committees: Enroll Wyandotte staff provided testimony to state legislators in opposition of SB 362, a bill that would have required mandatory background checks on navigators and other application assistors at the expense of $300 each.	Community action

Note. ACA = Affordable Care Act.

The Sidebar shows illustrative community and organizational changes (i.e., new or modified programs, policies, and practices) and services provided (e.g., instances of enrollment assistance) associated with implementation of the intervention elements of Enroll Wyandotte.

Figure 1 displays the cumulative number of community and organizational changes, services provided, and created accounts over time for Enroll Wyandotte during the first enrollment period under the ACA. The results show a gradual unfolding of community and organizational changes (n = 9) and services provided (n = 73) to support enrollment of Wyandotte County residents through the ACA. This was associated with a corresponding increase in the outcome indicator of created accounts (n = 539). A statistically significant association was found between created accounts and community and organizational changes and between created accounts and enrollment services provided (Figure 1).

FIGURE 1—

Cumulative number of community and organizational changes, services provided, and created accounts over time for Enroll Wyandotte during the first open enrollment period for the Affordable Care Act: Wyandotte County, Kansas, October 1, 2013–March 31, 2014.

Note. CAC = Certified Application Assistors; CC = community change; HCF = Health Care Foundation of Greater Kansas City; KC = Kansas City; KU = University of Kansas; OC = organizational change; SP = services provided. In a cumulative chart, each new activity is added to all prior activities. CC/OC × created accounts: r(16) = 0.638; P = .004. Enrollment SP × created accounts: r(16) = 0.581; P = .011.

Participatory Sensemaking and Adjustments

The online documentation and support system also supported participatory sensemaking⁹ by pairing graphs of activities and outcomes with reflection questions:

1. What are we seeing? (e.g., the graph shows a marked increase in services provided beginning in late December 2013)

2. What does it mean? (e.g., this increase was associated with hiring an overall coordinator and site coordinators that was made possible by community foundation funding and collaboration with community partners)

3. What are the implications for adjustment? (e.g., to increase enrollment, we need to expand enrollment sites and engage more volunteers to provide support within them)

SUMMARY

This empirical case study was one of the first systematic investigations of the effects of community mobilization to enroll residents in health insurance through the ACA. Community and research partners used data and shared sensemaking to identify features that appear to have supported implementation and outcomes. Population health and health equity require conditions—such as universal access to health care—that reduce the differential vulnerabilities and health consequences that produce health disparities.¹⁰