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Community Initiatives to Improve Health Insurance Enrollment

Posted: 08 Dec, 2014   Recommendations: 17   Replies: 43

Despite massive government efforts to increase enrollments in health insurance programs through the Affordable Care Act, many people are opting out of insurance, even in states that have implemented the Medicaid expansion. A recent health tracking poll (attached below) by Kaiser Family Foundation shows that many Americans are not signing up for health insurance because they consider insurance programs too expensive. Many uninsured do not know that there are tax credits available to help them get affordable coverage, or struggle with language barriers or a lack of knowledge on how to navigate the health insurance marketplaces. Above all, ACA has become a polarizing political issue, which has had an impact on enrollment.

A key strategy for addressing lower health insurance enrollment rates is closer involvement of community based organizations and advocacy groups with underserved populations. These institutions can provide linguistically and culturally appropriate information, encourage trusted sources like primary care physician to educate the population, and leverage social ties to bring providers and payers together.

GHDonline is pleased to welcome an exciting group of experts to share their knowledge about involving communities in decision-making processes to improve insurance enrollments:

● Dan Burrier, CEO at Common LLC
● Heather Dummer Combs, Project Manager at Milwaukee Enrollment Network
● Michelle Fitzgerald, LMSW, Lead Navigator at Cherry Health, Heart of the City Health Center
● Sovereign Hager, Staff attorney at New Mexico Center for Poverty and Law
● Marcus M. McKinney, DMin, LPC, Vice President of Community Health Equity and Health Policy at St. Francis Hospital and Medical Center
● Carlos Olivares, Executive Director at Yakima Valley Farmworkers Clinic

During our week-long discussion, panelists will address the following questions:

1. How you do engage community members, specifically the ones who fall through the cracks, to enroll in health insurance programs?

2. Are there particular patient populations where your work has had the most impact? If yes, what kind of metrics do you have in place to measure that impact?

3. What are the keys to successful collaboration with the community? How do you ensure that the relationships you build with community are sustainable?

4. One interesting prospect for higher enrollment are Community Based Health Insurance Programs (CBHI), which have been particularly effective in some settings. In your experience, what are the key factors of successful CBHI programs—what role can they play in increasing enrollment?

5. What “do’s” or “don’ts” have you learned from the ACA’s open enrollment period in 2013/14? What are you doing differently this time around?

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve healthcare delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, please take our short (4 question) survey before the discussion begins:

We’re looking forward to a rich discussion next week – please join the conversation and share your questions or comments for our panelists!



Sudip Bhandari Replied at 11:04 AM, 8 Dec 2014

In preparation for next week's discussion, I want to share a few resources that might be of interest.

Attached resources:

Beatriz Manuel Chongo Replied at 1:02 PM, 8 Dec 2014

Thank you very much for your invitation!!!!!

SILAS WAMBULWA Replied at 12:20 PM, 10 Dec 2014

thanks for invitation, we are doing more research to add on to this
discussion, keep up.

Sudip Bhandari Replied at 12:18 PM, 11 Dec 2014

A reminder that our very short Expert Panel survey is open until Monday morning - your responses to these 4 questions will help us evaluate the impact of these types of discussions here at GHDonline and provide us with incredibly helpful feedback. Please take a moment to fill out the survey if you haven't already:

Dan Burrier Replied at 7:34 PM, 14 Dec 2014

Hello all. Dan Burrier here, and I'm honored to be included as one of the panelists in this discussion. By way of introduction, let me include a brief bio here, which includes a link to my LinkedIn profile, and then I'll follow with a few comments which might explain why I'm here and what I might be able to add to the discussion:

A lifelong student of human nature, technology, marketing and things just as they are, Dan has had the good fortune to have been able to apply these learnings in a variety of business settings. From his start-up marcomm shop in Seattle, to BBDO in Los Angeles, where he was Worldwide Creative Director on Apple, to Ogilvy & Mather (NY/LA/Worldwide), where he held posts ranging from Executive Creative Director, Chief Creative Officer of the West, Co-President, OgilvyWest, and Chief Innovation Officer, North America, working on brands ranging from IBM, Motorola and Cisco to Mattel, McKesson and BP.

Now co-CEO of COMMON, Dan applies the power of brand for the common good, working with entrepreneurs and enterprises to accelerate social innovation. Dan is a husband, father, surfer, ultramarathoner, would-be nascent farmer in northern New Mexico and Zen priest.

twitter: @dburrier


So what's a branding guy--an advertising guy--doing in this discussion?

Let's start with the most obvious answer:

1. I've had the good fortune to work with Carlos, one of our fellow panelists, at the Yakima Valley Farmworkers Clinic, as we plotted the way forward for his brand and organization in the face of changing politics, policies and public sentiment. At COMMON, we played our small part in helping the Farmworkers Clinic communicate with their public of the underserved in a region of the country that has seen significant demographic shifts. How, for example, do you attract new Medicaid patients as ACA comes online, to an organization with deep roots serving farmworkers, in a geography that now includes a far more diverse potential patient base, ie, not all farmworkers? Carlos will be far more eloquent and credible as we dive into these topics, but I promise to lend my voice and point of view from the perspective of messaging, marketing and outreach.

And move to the less obvious but equally important reason I'm joining in:

2. Community is a conversation. Branding and marketing--when executed powerfully, honestly and well--is a conversation, a dialog, between provider and customer. The dialog must be honest, forthright, devoid of selling and must take all cultural, geographic and demographic cues into consideration. What initiatives will we take? How? And how will they be communicated? What engagement with our communities do we wish? What are the barriers? How do we overcome them?

Because if we can't get people to and through our doors, if we can't listen, if we can't speak in a voice that can be heard, enrollment is an unattainable goal.

Preaching to the choir perhaps. And apologies if so. I'm not a healthcare professional. But I am a professional who cares about health. The health of us all. I'll lend my voice here where it helps, stay out of threads in which I'd be pretending. Use me where best used. I look forward to the conversation this coming week. And thank you, for all that you do!


Marcus McKinney Replied at 7:34 PM, 14 Dec 2014

Thanks for joining the discussion. I began my work at Saint Francis Hospital in Hartford, CT. over 30 years ago, with many roles over the years - as a licensed therapist, chaplain and administrator over community health programs. Some of the lessons I have learned (and keep learning) involve what we might call community health equity "principles". Outreach strategies we use at Saint Francis are continually shaped by these principles. One of these principles involves "meeting people where they are" whenever possible. We have established a health equity team (5 years ago) housed in the Urban League of Greater Hartford (1st Floor) where a natural community flow of traffic occurs. Our team has MD's, nurses, outreach and community health specialists, and partners with the Urban League to do education, screenings, and follow-up alongside insurance assisters and financial counselors. Our outreach events occur most weekends and some evenings IN THE COMMUNITY in agencies/faith-based settings where engagement occurs. Our approach is more a bridging and navigating role between the communities and the health system (and, increasingly, agencies that serve the social determinants of health). The brochure of our main Center is attached. We aim to have an approach that builds trust and a long term relationship with each agency (more on that later) thereby avoiding 'parachuting' into a setting and leaving without ways to build a relationship.

Attached resource:

Michelle Fitzgerald Replied at 8:40 AM, 15 Dec 2014

My name is Michelle Fitzgerald, I hold an MSW from Monmouth University. I am currently a Navigator for a 13 county region in West Michigan so I have been "in the trenches" so to speak assisting individuals and families through the application process as well as acting as an expert for other local agencies that offer application assistance. Though I travel quite extensively I am based out of Cherry Health which is a Federally Qualified Health Center, the health center prior to 2014 focused on offering comprehensive health services to the uninsured, the underinsured, and those who have other barriers to accessing care such as language barriers. This put us into a position to access many key target populations needing to enroll into health insurance through the Health Insurance Marketplace and Medicaid Expansion.

Attached resource:

Sovereign Hager Replied at 11:24 AM, 15 Dec 2014

My name is Sovereign Hager and I am a staff attorney at the New Mexico Center on Law and Poverty. The New Mexico Center on Law and Poverty is dedicated to advancing economic and social justice through education, advocacy and litigation. We work with low-income New Mexicans to improve living conditions, increase opportunities and protect the rights of people living in poverty. My work focuses on expanding access to Medicaid and other healthcare options for New Mexicans. We engage in administrative advocacy, legislative advocacy and litigation to increase enrollment and expand eligibility in health care programs for low income New Mexicans. We also provide extensive training to navigators and other direct service workers on eligibility and overcoming barriers to enrollment in Medicaid. This includes training New Mexico navigators on immigrant family eligibility for Medicaid and exchange coverage and working with tribal leaders and other organizations on healthcare options for Native Americans under the Affordable Care Act.

Michelle Fitzgerald Replied at 11:59 AM, 15 Dec 2014

To expand a bit more on how our agency engages with community members who may slip through the cracks: many of the key strategies have been mentioned by the other panelists, but meeting people where they are is key in many ways. First of all, physically and geographically speaking there must be access to the services provided. We have several health center sites across the city (Grand Rapids, MI) where we offer assistance, including in one of the neighborhoods that houses several homeless shelters. But in addition to our health centers we partner with local libraries, and other business and organizations to provide on-site assistance in places that the community is most familiar and comfortable with. These locations must be on public transit lines to accommodate arrival.
I cannot emphasize enough how important a diverse staff is as well, especially language diversity. Using interpreters is difficult, time consuming, and expensive.If you are working with a population with limited English proficiency it is imperative to have staff that speak their primary language and are involved in their community. Cultural awareness and sensitivity is crucial when dealing with most topics but especially health related topics.
Organizations must also be willing to invest time and resources into these activities. It takes more time and energy to partner with organizations and hold events than it does to operate appointments out of a health center. It takes staff who are willing to work nights and weekends and who can handle the frustration of low turnout. There is no guarantee that people will show up to a Saturday event, even if energy is invested in advertising it. An organization must accept that some events will have low or mediocre turnouts, but they are still necessary because the facilitate engagement with these hard to reach communities.

Sovereign Hager Replied at 1:29 PM, 15 Dec 2014

At the Center on Law and Poverty, we work closely with navigators and other direct service workers to address barriers to enrollment.
One important effort in increasing easing the enrollment for immigrant families, has been in identifying resources for household members that may not be eligible for coverage and to make sure that navigators have those resources in addition to information necessary to enroll eligible household members. Through training and continued communication with navigators, we've been able to establish a feedback loop where we offer technical assistance and engage in systemic advocacy based on barriers navigators and community organizations identify. Together, we've been able to improve NM's Medicaid enrollment system in various ways. For example, when ineligible family members are asked for immigration status in order to enroll eligible children or other household members in coverage, the household was less likely to enroll the eligible household members. We were able to take this issue to our state agency to improve worker training to reduce this barrier. Other issues we've addressed with our community based partners - backlogs in Medicaid applications, incorrect medicaid eligibility determinations for pregnant women and children in immigrant families, and improved language access.

We also generate informational materials for navigators and community workers to utilize in helping families access coverage. Our comprehensive ACA resource guide for NM is attached.

Attached resource:

Heather Dummer Combs Replied at 1:56 PM, 15 Dec 2014

My name is Heather Dummer Combs and I am Enrollment Project Manager for Milwaukee Health Care Partnership, a role I've held since November 2011. The bulk of my work is managing the Milwaukee Enrollment Network (MKEN), a multi-stakeholder collaboration organized to improve consumer outreach and education, strengthen enrollment support resources, and assist Milwaukee County residents in securing adequate and affordable public or private health insurance. MKEN was formed in July 2013 in preparation for the implementation of health care reform. The network's goals are to facilitate consumer and mobilizer outreach and education, build the capacity and capability of the enrollment assister workforce and infrastructure, support insurance take-up and retention, and measure and monitor coverage and enrollment processes and outcomes.

I have spent her career working for non-profit, community-based organizations, and have extensive experience in organizing, outreach, community education, and public policy advocacy. I received my Bachelor of Arts degree in Politics and Government from Ripon College in Ripon, Wisconsin.

I look forward to participating in this week's discussion!

Attached resource:

Heather Dummer Combs Replied at 6:48 PM, 15 Dec 2014

I'll add a bit more to the conversation. Milwaukee Enrollment Network (MKEN) is made up of over 100 organizations who are engaged in enrollment efforts in the community in some way or another. Membership includes Navigator entities, Certified Application Counselor (CAC) organizations, Agents and Brokers, QHPs, Information and Referral organizations, and others we call "Mobilizers". MKEN's purpose is to reach out and enroll Milwaukeeans in health care coverage, specifically targeting low-income and underserved populations.

As part of our annual work plan, we identify particular target populations and member organizations that service them. As a way to coordinate our community outreach efforts, we have an Outreach & Education workgroup. Representatives from member organizations that focus their efforts on mobilizing or enrolling consumers are involved in the task group. The group meets monthly during Open Enrollment and every other month during the 'off season'.

Since there are so many groups engaged in this effort, as a way to stay abreast of all the outreach and enrollment activities that are happening in the community, MKEN publishes a calendar of events on a monthly basis. See the included link to view December's calendar. This calendar is then widely distributed - posted on MKEN's list serve and website, member organizations distribute it, and release to the media.

One target population we are focusing on this year is the Latino Community. Based on the limited data available to us from last year's Open Enrollment, we determined that this was an area that needed attention. As a result, MKEN has been working to expand our reach in the near south side, where the population is predominately Latino. We are partnering with Centro Hispano, a well established and highly regarded community based organization. They are assisting with various outreach approaches and host enrollment events every Saturday. Other MKEN member organizations have begun to follow suit. Hopefully, these and other efforts will garner positive results.

Attached resource:

Carlos Olivares Replied at 6:56 PM, 15 Dec 2014

My name is Carlos Olivares and I am the Chief Executive Officer of Yakima Valley Farm Workers Clinic. YVFWC provides a broad range of primary care services to the low income population, including migrant and seasonal farm workers and has served 145,000 patients across rural Washington and Oregon.

To the question in hand. Engaging people to enroll for health coverage?

- Communicate early & often - we launched an educational marketing campaign in July, 2013 encouraging folks to contact our outreach team for ACA information. We continued to build upon that platform through Open Enrollment.

- We condensed the information from the State and Federal materials to simplify the information using infographics for non-English-speaking populations.

- Our effort coordinated with internal programs such as WIC (nutrition assistance), Outreach and CHS (Community Health Services Department) to reach as many people as possible within and outside of our clinics. For example, CHS has relationships with all the school districts throughout our areas of operation.

- Engaging our existing patient base, many of whom were newly eligible for Medicaid, to apply, we provided assistance through the application process.

- Sponsoring health fairs and participating in community events with in-person-assistors present to disperse information and answer questions on the basics of the ACA, in addition to pre-enrolling people, expanded our reach.

- Implementing a multi-disciplined plan of communication for all of our areas, comprised of grass-roots tactics such as t-shirts, branded tote bags for IPA’s to carry their tablets (enrollment on the spot) and distributing branded giveaways, such as stickers and buttons in all clinics, keeps the issue fresh.

- We created traditional marketing campaigns (including radio, direct mail, Out-Of-Home (OOH) advertising).

- Social media campaigns informing on and encouraging enrollment were implemented and proved beneficial.

Marcus McKinney Replied at 8:09 PM, 15 Dec 2014

I also would reinforce the need for diversity in outreach/staff , especially if the larger health system or agency has some work to do on recruiting employees to reflect a diverse community. In this way, the diverse staff serves as a bridge to "translate" cultures that may be quite different. In our case, we knew (and now have experienced) the importance of making our clinics more user friendly because the questions around engagement and insurance found their way into the financial and clinic offices. Some of our key champions to help were our health system financial counselors who had a menu of options including resources in addition to health exchange that people were able to be informed about.

Michelle Fitzgerald Replied at 1:36 PM, 16 Dec 2014

Moving into the second open enrollment period we tried to learn from our experiences in the first. We knew from national and state based data that the Latino/Hispanic population and young people were key targets this time around. We also know from our personal experience that we were much more adept at enrolling people into expanded Medicaid than Marketplace. The population served by the health center itself is primarily Medicaid Expansion eligible, and our naturally aligning community partners were also targeting that population, so we had to be a little more creative with how to target the marketplace eligible.
We targeted these populations by ensuring that all of our materials are in Spanish, dropping of fliers in bodegas and other locales that target the Latino/Hispanic community and started adverting in publications that target all of those groups. We don't track all of these factors but we have seen an increase in the number of Spanish speaking families seeking services, about 19% of our completed applications were with Spanish speaking families.

Rebecca Weintraub, MD Replied at 2:32 PM, 16 Dec 2014

Thanks everyone for sharing work you have done and are currently doing to reach out to underserved populations in a range of settings. I’m pleased to have this opportunity to learn from you.

A couple of questions:

1) What do you do when the target population does not respond to your efforts? Do you have protocols for “next steps”? What are they like?

2) Are there cases where more than one organization is working with the same target population with similar tools and goals? How do you ensure there are no duplication of efforts?

Marcus McKinney Replied at 5:02 PM, 16 Dec 2014

Rebecca - great questions.The process involves, for our approach, identifying groups/agencies/faith-communities where there are "leaders" and often "Wellness" point people within the community group. That person or group often are charged by the agency/etc to develop their group's wellness/health goals. We first have meetings with that group's leaders to basically learn from them any psychological insight they have on what engages their entity. We take careful notes, and ask our team to be teachable (we are especially careful not to assume if one of our team is also familiar with that group (say, a Catholic Church, or YMCA, or Carribbean Club) not assume THIS community group functions like we expect. We try and witness a non-health meeting to see how the group engages each other. Then shape an approach that blends, to the degree possible, the one we learn works for that group. EXAMPLE: A West Indies Pentecostal Church let us know in the learning process their men (The group we aimed to engage for prostate screening) would have strong feeling about not getting the screening. We listened to the Pastor and leaders talk about fiends impacted by cancer and some fears around getting screened, many might have been embarrassing or make men feel vulnerable, but their leaders co-led and set the atmosphere. Were mistakes made? Oh yes! But humor and a style intended for ongoing relationships helped.

Marcus McKinney Replied at 5:13 PM, 16 Dec 2014

The "duplication of efforts" is tricky and I would say we are aiming to have a multi-pronged strategy to offer more options in these days of "enrollment". There was a day (I've hung out in Hartford 30 years from our hospital) when we were quite alone. In areas of town few entered for health engagement. I often partnered then (and still do) with folks who I have come to know from these areas. There is plenty of room for most to offer their resources, sometimes this happens in large, city-organized efforts. But more often the kind of approach we aim for is simply different than what another group might have. Neither are "better" - but the fit is different. Saint Francis designed a "platform" within the Urban League, hiring a team that , from the beginning, included a "Health Liaison" group - taking a lead person from each place we would do outreach and invite them to attend a monthly meeting, with food supplied, at our center - to develop an ongoing - long term relationship with that agency. The discussion would be similar to this blog: asking what motivates? what has worked, what doesn't, how can we (our team) affirm the role that liaison has in their agency and the community to build THEIR impact. Essentially, we felt we need to send a message that we would find perpetual resources to stay as a resource and outreach throughout the year. It's still a work in process, for sure. But has a different feel from our older strategies of "parachuting in" to a site and offering education, screening, and hoping people will act down the road.

Sovereign Hager Replied at 6:26 PM, 16 Dec 2014

NM Center on Law and Poverty is not a direct service organization, but we do try to evaluate the success of our work and we have looked at changing our approach as we gain a deeper understanding of barriers to enrollment. For example, last year, we completed a survey of navigators and other enrollment workers in NM and identified numerous barriers to enrollment. Many of the barriers were already being addressed in our litigation or other administrative advocacy. However, we did find new areas to work. The report we complied is attached - it includes next steps for the state to address affordability issues, improve reporting and transparency, and customer service related improvements to Medicaid and Exchange enrollment.

There are numerous organizations in NM that seek to improve access to healthcare coverage. There are one coalition of organizations that works on Medicaid issues specifically and another that addresses a broader range of healthcare enrollment and access issues. The coalition meetings are an important way to share information and ensure efforts are not duplicated.

Attached resource:

Heather Dummer Combs Replied at 8:53 PM, 16 Dec 2014

Wisconsin opted to have a partial Medicaid expansion - allowing all adults (including childless individuals) with incomes at or below 100% FPL to enroll in the state's Medicaid program called BadgerCare Plus (BC+). Since a focus of the Milwaukee Enrollment Network (MKEN) is low-income individuals, many MKEN members worked diligently to enroll all newly eligible childless adults in BC+ once eligible, starting in April 2014. A way that we have been able to measure the success of these efforts is through the enrollment numbers, which are released by the state on a monthly basis. As of March 2014, there were 4,225 childless adults enrolled in BC+ in Milwaukee County. According to the report of enrollment numbers for October 2014 (latest available data), 48,621 are now enrolled. That is an increase of over 44,000 newly enrolled individuals, many of whom had not had health insurance in years, if at all.

Prasad Pasam Replied at 9:01 PM, 16 Dec 2014

Team: we have enrolled 65Mn BPL (Below Poverty Line) families as a part of our community Health insurance Scheme.

This mammoth task was achieved by conduct Healthcare camps and issues the health cards at village level. Both local Politicians, Bureaucrats, Insurance Personnel, project implementation agencies were involved to mobilize families and this was done of joy of giving to the families from the Government.

Dr.Prasad Pasam

Sent from BlackBerry® on Airtel

Heather Dummer Combs Replied at 9:08 PM, 16 Dec 2014

Rebecca, happy to try answering your second question.

As I have mentioned before, the Milwaukee Enrollment Network (MKEN) is made up of over 100 organizations that work to support enrollment efforts throughout Milwaukee County. As you can imagine, there are organizations that work with the same target population. MKEN works hard to make sure that all parties are aware of each other and their respective work, encouraging collaboration where and when appropriate. As you can imagine, this only works as well as those organizations are willing to partner with one another.

MKEN's structure helps facilitate this. Leaders of key member organizations make up the Steering Committee. In addition, there is the Outreach & Education workgroup I mentioned in an earlier reply, an Enrollment Assisters workgroup, and Marketing & Communications workgroup, and a Health Systems workgroup. This is provides ample opportunity for communication and collaboration among member organizations.

Aakash Shah Replied at 10:25 PM, 16 Dec 2014

Thank you so much to all of those who have shared their thoughts. All of the comments have been incredibly informative and insightful.

Some have already alluded to lessons learned from national and state-specific data from the first open enrollment. I'd love to hear more about insights gleaned from these data - What worked? What didn't work? And how these findings have informed your efforts during the second enrollment period?

And of course, if folks have reports, memos, or analyses of data from the first open enrollment to share, that'd be great.

Once again, thanks!

Thomas Tsai Replied at 10:51 AM, 17 Dec 2014

Thanks all for participating in this great discussion!

Michelle--in your role as a navigator, what's your sense of individuals' understanding of the subtanstial out-of-pocket savings from Cost-Sharing Reductions (CSR) for those who select silver plans from the ACA Marketplace? There's concern among policymakers that people pay be leaving money on the table in the form of foregone cost-sharing reductions or even passing up on zero-premium bronze plans.

Do you feel people have an understanding of their true out-of-pocket medical expenditures or are they focused primarily on premium costs?

Looking forward to everyone's comments!

Carlos Olivares Replied at 1:31 PM, 17 Dec 2014

Particular patient population:

As an organization, we have a strategic plan where demographic information about the underserved population in our area is collected and analyzed. Based on that information, we then proceed to determine where the gaps for care exist within that population. Equally, we went about understanding where, within our geographic areas, saw the greatest uninsured low income groups and began our enrollment campaign in those communities.

The most challenging population for us to reach and educate about enrollment in the ACA was the migrant population, Their mobility represented a significant challenge and continues to be the focus for our organization in the coming years.

As we move through identifying these populations and because we serve primarily rural and Hispanic communities, we targeted our literature and information to those individuals.

In our urban areas, we have more population diversity, with our largest groups being Asian, African and Russian, along with Hispanic, Afro-American and Caucasian populations.

Michelle Fitzgerald Replied at 2:34 PM, 17 Dec 2014

Thomas--This is a great question. In my personal experience, and that of my colleagues here at Cherry Health, there is a great deal of education to be done on "actual cost". The average consumer is quite uninformed about what CSRs are and what each piece of insurance means for them. We try to do a lot of education about the CSRs available to folks at the silver level. When someone does qualify for this additional savings we generally start with displaying the silver level plans and explaining what all of the costs are. Then we go on to explain that they may find a lower monthly cost, but their out of pocket costs will rise drastically. Last year the majority of people we assisted DID qualify for CSRs and they enrolled into the cheapest Silver level plan. We did see some people enroll into bronze level plan with a much cheaper premium, even though they did qualify for the CSRs, but most did not. Now, that is for the consumer who sought in person assistance, and we make it a point to try and display options for people in the context of the full cost of health insurance, not just their monthly cost. I would say that people who do not seek assistance are much more likely to choose a plan based on the lowest monthly premium even if they qualified for CSRs.
This year we have seen a slightly higher number of people enroll into a bronze level plan, even though they qualified for CSRs, this is likely due to some of the cost increases for the monthly premiums, it also is more common among young, healthy people as they do not plan to actually use their insurance beyond their wellness visit.
This year I have also seen an increase in the people who are asking questions about total costs, this is mostly among people renewing coverage--perhaps their experience is giving them insight into the actual cost of healthcare.

Michelle Fitzgerald Replied at 2:43 PM, 17 Dec 2014

Aakash Shah--I'm attaching a couple of the reports that we used.

The KFF mapping I found helpful to get geographic information, our health center serves a very large area, and it was hard to tell, beyond how busy we were at each site, how enrollment was going, or whether more outreach was needed in certain areas.

The main thing that we gleaned from the other reports was messaging, what people responded well to and what motivated them to enroll, I won't summarize the reports here because they give quite a bit of detail, but read them through, they do offer some helpful insight.

Attached resources:

Michelle Fitzgerald Replied at 2:55 PM, 17 Dec 2014

And hopefully I'll offer some insight on Rebecca's questions while answering todays focus question, regarding building and maintaining working relationships within the community.
One of the things we did last year, and have continued to develop this year is the Enroll West Michigan Collaborative. This is an open group that is primarily comprised of local organizations that offer in person assistance for Medicaid and/or the Marketplace. This group is committed to collaboration. I think there was a sense of competition last year, and perhaps there still is among insurance companies and health facilities as to who would "acquire" this newly insured population as consumers and as patients. This collaborative has remained committed to keeping the well being of the community and the individual above this competition. We meet monthly during open enrollment to discuss technical issues and work arounds, outreach strategies, capacity, ability to overcome barriers, planning enrollment events etc. This allows us to share our expertise, reach key populations and avoid duplication of services.
Working through partnerships with organizations that aren't offering assistance is a way for us to access populations and maintain relationships in those key communities in a sustainable way. I attend the Latino Community Coalition meeting, it allows me to distribute information about our services and events with multiple organizations, as well as get network with leadership to set up events, or gain insight into what their clients are hearing or experiencing during open enrollment. The local library network is another community partnership that we've been able to easily maintain throughout the year because it is symbiotic, we hold a relevant, informational event that their patrons ask questions about, and we have a useful and neutral space that is closer to communities members' homes than our health centers might be. We document our contact people at each of the organizations that we work with so that we can follow up and maintain these relationships.

Claire Petchler Replied at 7:30 PM, 17 Dec 2014

Hi everyone- thanks for sharing your perspectives on improving insurance enrollment. I am impressed by the depth and breadth of this discussion so far. I am a nurse and I want to ask a question about the role of health care providers in insurance enrollment work. For some individuals, suggestions from their doctors or nurses hold a lot of weight. Have you worked with direct health care providers who could offer suggestions or refer patients to insurance enrollment programs? If yes, what did that collaboration look like?

Carlos Olivares Replied at 12:39 PM, 18 Dec 2014

Keys to successful community collaboration:

Yakima Valley Farm Workers Clinic has developed extensive and collaborative partnerships with a variety of key organizations in the community. For this exercise, we enlisted all of our current partners and conducted informational sessions with them to ensure that they, and their staff, had a clear understanding of the ACA, and outlined our strategy for enrolling people in our community.

They helped us, and participated, in all of our outreach efforts from health fairs to allowing our Outreach Workers and Patient Benefit Coordinators attend meetings with their clients, or their stakeholders, so that we could explain and enroll people in the ACA. Some of our more prominent local partners were the Health Department, local hospitals, food banks and, most important, the schools in our communities.

We are a well-respected organization with a 36-year history and strong partnerships in all areas of operation:

- We have bi-lingual/bi-cultural staff.
- Patient/Client Trust– we do not ask for documentation or the resident status of our people.
- We offer a sliding fee scale payment option. We do not turn people away .
- Our network of over 40 locations in Washington and Oregon provides comprehensive services that go beyond medical and dental, such as:

- Behavioral Health;
- Nutrition Assistance;
- Adult Education services/GED Programs;
- Emergency services & homeless prevention;
- Habitat for Humanity/living wage skills development programs;
- Youth education services for health & wellness; and
- HIV/AIDS Clinic.

These multiple touch points support and advance the awareness and knowledge of our organization and the services we provide.

Marie Connelly Replied at 3:40 PM, 18 Dec 2014

Many thanks to all of our panelists and members for their thoughtful contributions this week! It's been an incredibly informative discussion.

We all know that the Affordable Care Act has been a highly politicized topic in the US over the last few years, and I'd be curious to hear from our panel about how that's impacted the work that you do. Has this been a part of the conversations you've had while working to enroll individuals, and how have you addressed myths, concerns, or expectations that individuals or partner groups may have had about enrolling based on this?

Sudip Bhandari Replied at 3:52 PM, 18 Dec 2014

One strategy for enrolling the uninsured, which seems to be working in some settings is the use of targeted text messaging. The Kaiser Family Foundation report I shared at the start of this panel (also attached here) has some interesting data about cell phone usage among low income adults, and the success of personalized texting programs like Text4baby in disseminating information about Medicaid and CHIP. I want to share a few facts from the report that I found really interesting:

- Data suggest that 99 percent of text messages are read, with 91 percent of them read within three minutes.
- Low-income adults and people of color who are cell phone owners are particularly likely to use their phone as their primary way to access the internet.
- A number of the respondents said they applied for Medicaid or CHIP for themselves or an uninsured child after receiving Text4baby’s messages about health coverage.

I'm curious to hear from panelists here about whether you have considered using targeted text messaging or other mobile technology to reach out to the uninsured or underinsured individuals? What were the results like in your case?

Attached resource:

Carlos Olivares Replied at 7:53 PM, 18 Dec 2014

What are the key factors of successful CBHI programs—what role can they play in increasing enrollment?

For the last 10 years, our organizations has been working with health insurance programs in our State allowing us to be an active participant in the implementation and the development of these Community Based Health Insurance programs. I believe they have played a pivotal role in helping us increase our enrollment through the ACA process. We have very good partnerships with these insurance programs and we were able to outline some of the resources to inform our patients about the benefits they bring to the table for the patients they enroll in their systems.

Having them be a part of the development of materials and having them explain to the patients the access they bring for patients to the various hospitals and specialty care, was a tremendous selling point in a motivator for patients to enroll. They became very strong partners from the start and helped us with resources to bring awareness of the benefits associated with the ACA.

Marcus McKinney Replied at 8:20 PM, 18 Dec 2014

About the "politics" - in Connecticut, my sense has been most of our communities, particularly Urban, and on the same political side and same party. In a state that is heavily democratic in affiliation. Regarding the affordable care act - the critique has been on the feeling that there are "poorly communicated complexities" behind some of the choices and the "buzz" abut this has translated to resistance to trust that any option is affordable. As a result - the agencies that play the role of "navigator" and the clinics/health practitioners are often approached to answer health exchange questions. Not all practitioners have answers. So our strategy has included key, highly visible, posters at these points to direct people to assisters. Along with intense outreach in communities that did not see much uptake last year (for us that is in the Latino Communities).

Marcus McKinney Replied at 8:29 PM, 18 Dec 2014

What worked best, from our perspective, for enrollment - has been partnering with reputable agencies/ places of worship / heavily trafficked sites where information AND discussion has allowed dispelling myths, sign-up for follow-up, brokers willing to go the extra mile, and trusted health providers who speak spanish, especially nurses - weekends, evenings making themselves available.

Michelle Fitzgerald Replied at 10:55 AM, 19 Dec 2014

As part of outreach strategy we give educational presentations, we do this to staff of other organizations in the community, and at our enrollment events. Included in our presentations is information to help dispel some of the myths of the ACA. We see a lot of political opinion though in our one on one appointments. With the one on one we try to remain very neutral politically and just give individuals the facts about the law and enrollment. The misconceptions are still rampant. Especially in rural areas this is a major barrier to enrollment. One of the worst examples was during a presentation when an audience member told us we should be reporting undocumented immigrants. Some of the CAC's I know report that they have been heckled during presentations, or when trying to set up events. I was assisting someone, who was very happily signing up for the Medicaid Expansion through the state website tell me all about how "Obamacare" was ruining the country.
I think the most powerful tool we have to combat such political polarization is to tell the success stories. For every person I have spoken to who "hates Obamacare" I have a story I can tell about someone who was diagnosed with cancer and didn't have insurance, and found an affordable plan when 2 years ago they may have been denied for a pre-existing condition, the peace of mind offered to a widow who was trying to get back on her feet and start her own business after her husbands death and found a plan she could afford to pay with her limited income, a couple with chronic diseases who are paying $400 less per month than they did last year because they weren't sure about the marketplace last year but after exploring it this year they liked what the saw. The incredible difference Medicaid expansion is making in the lives of those with the lower levels of income.
Certainly the law does not affect everyone equally, but for those who are benefitting the stories are poignant and reflect how necessary greater access to affordable health coverage was and is.

Michelle Fitzgerald Replied at 11:08 AM, 19 Dec 2014

Regarding partnerships with medical staff, I think this is an untapped resource. As a health center we have worked diligently to have all of our staff on the lookout for the uninsured. We have developed policies and procedures for how to refer uninsured patients and what to say to them etc. We have seen mixed results on the follow through. Its not always the priority, which is understandable, we have very busy health centers and there may be more pressing matters.
However, I think that one of the most powerful referrals is from someone's trusted medical providers. If your Doctor tells you to do something, you are likely to listen. I'm not sure how feasible it is to do direct referrals from outside agencies, but we leave our referral cards in various offices.

Maggie Sullivan Replied at 12:04 PM, 19 Dec 2014

I appreciate the breadth of experience, professional and geographically, represented on this panel. I am one of the, assumedly, many healthcare providers who knows next-to-nothing about improving insurance enrollment. It seems like such a specialized field with many legal ins and outs, that it seems daunting to broach. I think my hesitation is also compounded by practicing in Massachusetts where I feel like I have the luxury of treating patients, with very little thought as to their health insurance status. That said, I have great concern about our undocumented patients and their lack of access insurance as described in the ACA. I'm glad to see that many panelists have spoken about taking care of our immigrant, Latino and/or Spanish-speaking patients; but what is to be done about quelling fears within mixed immigration status families? How do you enroll some family members and not others? While the majority of people in this country are eligible for insurance and just need to be made aware of it, how are we going to take care of our community members who are not eligible? The irony is not lost on me that many of these individuals are farmworkers, like the folks Carlos's organization serves, and they put some of the healthiest foods we consume on the table.

Michelle Fitzgerald Replied at 1:44 PM, 19 Dec 2014

Maggie, I would agree with you that the ACA is complex, and understanding eligibility takes a lot of knowledge of the nuances and intricacies of the law, especially when we are dealing with a complex eligibility scenario. If you, as a medical professional, want to be involved I would recommend finding a trusted agency that you can refer uninsured individuals to for assistance with understanding what they may qualify for. That way you can be part of the conversation, and encourage enrollment, but don't have to get overly involved in all the details of eligibility.
As for the other piece, we serve many families with mixed immigration statuses. Last year ICE did make a statement saying (to paraphrase) that there would be no legal repercussions for undocumented individuals who are applying for relatives who qualify for the ACA. We make sure that our staff understands these issues and is comfortable discussing them with the families we serve to help alleviate fears. Its actually very easy to enroll some family members and not others, it is one of the first questions asked, "who are you applying for?" Now, because of the nature of the application you may have to provide name and DOB for an individual, even if you are not applying, but you do NOT have to provide social security number or immigration status for anyone who is not applying.

Heather Dummer Combs Replied at 6:14 PM, 19 Dec 2014

Sudip, thanks for raising your question about whether anyone has used texting as an outreach method. In Milwaukee we have just begun to explore this option.

Our local 211 agency (an information and referral call center) started this fall collecting mobile phone numbers from callers and have begun sending text messages to them specifically about enrollment opportunities (Marketplace Open Enrollment, state's Medicaid program, etc.). Before responding, I reached out to my colleague at IMPACT 211 to see how things are going but was unable to connect with him. I'd be happy to share the results once we have something to report.

Also, one of the hospital health systems in our area is also exploring texting patients. We will see if they decide to take this approach and whether 211's results weigh their decision.

Carlos Olivares Replied at 8:18 PM, 19 Dec 2014

Lessons Learned:

Federal and State entities assumed that people were willing and able to enroll online with no assistance, which we discovered was not the case. As the ACA continues, online enrollment may become more common, but our populations, many of whom count English as a second language, preferred to work with an In-Person-Assistor.

Most of our population is located in rural, agricultural areas where migrant and seasonal farm worker communicate about ACA enrollment via word-of-mouth, which is consistent with how other communication works in our rural sites.

It is vital to educate people, particularly from other cultures, on the importance of insurance – why it’s necessary and how to use it. As part of the education process, we need to work on communicating the value of primary and preventive care versus ER visits.

Stock paper applications in case the web site is down and be prepared to help people understand the importance and method of their site access (Log-in, password, insurance cards, etc.).

We learned that our patients preferred to complete applications in person at our locations as opposed to over-the-phone (hi-touch experience).

Sudip Bhandari Replied at 9:00 AM, 22 Dec 2014

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