Journal of Public Management & Social Policy


This article examines the implementation of The Patient Protection and Affordable Care Act (ACA) with a particular focus on the states’ contracted outreach and enrollment services. Having collected administrative and perceptual data from key informants, we examined outreach and enrollment contracts in six states that have reduced the uninsured rate by at least 20% of ACA-eligible population. Our findings suggest that the complexity of the law and its structure, as well as the characteristics of contracting were, in effect, “drowned out” by clear patterns of highly collaborative implementation that involved extensive chains of diverse outreach/enrollment actors. These networks – ranging from experienced health advocacy organizations to community members’ recruiting in local churches, schools and barbershops – were able to put into effect comparatively simple systems with clear, shared goals among on-the-ground actors who broke through the implementation complexity, thereby creating new capacity and achieving significant enrollment gains.



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