COMMENTARY
Rural Affordable Care Act Outreach and Enrollment: What We Learned During the First Marketplace Open Enrollment Period Linda Kwon, MPH Health Resources and Services Administration, Office of Rural Health Policy, Rockville, Maryland
Disclosures: The Office of Rural Health Policy collected, analyzed, and interpreted data submitted by Rural Health Care Services Outreach Program Affordable Care Act Outreach and Enrollment Supplemental funding grantees. The Health Resources and Services Administration reviewed and commented on this piece prior to submission to The Journal of Rural Health. Acknowledgments: The author would like to acknowledge the following individuals for their contributions to this commentary: Brian S. Olson, Chief Executive Officer (La Red Health Center, Inc., Georgetown, DE); Patricia Hubbard, Project Director, and Cathy Ferron, Evaluator (Lake Country Tribal Health, Inc., Lakeport, CA); and Michael Rust, Chief Operations Officer (ABC for Rural Health, Balsam Lake, WI). For further information, contact: Linda Kwon, MPH, US Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy, 5600 Fishers Lane, 17W17A, Rockville, MD 20857; e-mail: [email protected].
As part of the Patient Protection and Affordable Care Act (Affordable Care Act) of 2010, 2 new opportunities for health care coverage were established for many uninsured individuals beginning on January 1, 2014. The first opportunity was through Medicaid expansion where states had the opportunity to expand Medicaid coverage to individuals with household incomes up to 133% of the federal poverty level. The second opportunity was through the establishment of Health Insurance Marketplaces where individuals could purchase private health plans and potentially qualify for financial assistance in paying for their plans. The Office of Rural Health Policy (ORHP) provided supplemental grant awards to help stimulate Affordable Care Act outreach and education efforts in rural communities that were being served by the Rural Health Care Services Outreach (Outreach) Grant Program. As a result, Outreach grantees enrolled 9,300 rural Americans during the initial Open Enrollment period. Valuable outreach and enrollment lessons were learned from rural communities based on discussions with the Outreach grantees who received the supplemental funding. These lessons will help rural communities prepare for the next Open Enrollment period.
Key words access to care, Affordable Care Act, health services research, insurance, rural health.
doi: 10.1111/jrh.12100
Lessons Learned 1. Individuals within the community who provided consumer assistance were viewed and valued as trusted sources of information. Grantees provided consumer assistancei in a direct and neutral manner that gave their community an opportunity to understand the benefits of the health care law without political rhetoric. Assisters made time to educate each individual and family, which helped change any negative perceptions residents may have had and equipped them with the information
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
needed to make informed decisions. The positive experience consumers had from the one-on-one counseling led them to start referring their family members, friends, and colleagues to these assisters. In Georgetown, Delaware, La Red Health Center (LRHC) provided consumer assistance by hiring 3 full-time certified application counselors (one of whom was funded by the ORHP supplemental funding). Two of them focused on enrollment assistance at both of their practice sites, while the third spent time in the community educating
1
Rural Affordable Care Act Outreach and Enrollment
consumers about new benefits. Federally funded navigators and state-funded marketplace guides were also placed throughout the county to assist in the outreach and enrollment efforts. From the outset, many consumers in Delaware were confused about the Affordable Care Act and “Obamacare”—often thinking these were 2 separate “free” insurance programs. Concerned about the potential for mixed consumer messaging from different enrollment organizations/assisters, LRHC organized a countywide coalition that met periodically to ensure uniform consumer messaging, discuss challenges, and share successes. Consumers benefited from the collective experiences of the coalition members who shared best practices among themselves. LRHC’s assisters benefited from the educational techniques employed by other coalition members, and they became more skilled at using different educational strategies with different consumers. The credibility of LRHC’s marketplace assisters improved as the federal marketplace website, Health Care.gov, was stabilized. Consumer skepticism and anxiety, compounded by HealthCare.gov’s technical problems, posed initial credibility challenges for LRHC’s assisters. As the assisters gained more experience, they became much more adept at anticipating consumer questions, which helped to dissipate some of the frustration. LRHC referred more than 1,500 consumers to their 2 trained outreach and enrollment assistance workers. 2.
Innovative community outreach, education events and strategies helped reach the eligible uninsured. From October 1, 2013, to April 30, 2014, Outreach grantees held more than 1,100 events that reached close to 44,000 rural Americans. Common outreach and education strategies included the use of media, direct mailings, flyers, and presentations. Grantees looked beyond the traditional community settings (eg, clinics, health fairs, churches, and schools) to reach a wider audience. Some conducted outreach events at local high school sporting events because many families attend these events. Others partnered with a local utility company (an informational insert was included in the utility bill) or grocery store to provide outreach.
In Lakeport, California, the Lake County Tribal Health Consortium (LCTH) is a rural federally qualified health center in which the target population are the Native Americans/Tribal individuals and families. LCTH had drop-in as well as regularly scheduled outreach activities that were essential to connecting with families where they congregated. New enrollments and renewals were the focus of these outreach activities that were held
2
Kwon
at Rancherias (small, rural settlements), Tribal Temporary Assistance for Needy Families offices, and LCTH sites both in Lakeport and at the south end of Clear Lake, which is open every 2 weeks. Tribal community members gather on monthly commodities days (days on which there is food distribution) at the Rancherias. As such, staff provided information and educated parents about the need for and availability of health insurance options for themselves and their children. Staff helped start applications in paper form and then made appointments at LCTH on-site offices to complete additional paperwork and obtain verification. LCTH had approximately 15 outreach events that reached about 185 individuals. 3. Leveraging partnerships, both large and small, made an impact on educating and enrolling the eligible uninsured. Despite limited resources, rural communities are rich in relationships. Grantees leveraged these relationships to host joint events or to “piggy back” off of existing events. Other grantees developed referral network systems so that they would primarily educate the uninsured about the Marketplace and then refer those same individuals to a partner organization to get enrolled into a qualified health plan. ABC for Rural Health, located in Balsam Lake, Wisconsin, has a long history of individual and policy advocacy, education, and program partnerships with health care providers, public health and human service agencies, and community-based organizations in northwestern Wisconsin. Outreach and enrollment were natural extensions of ABC for Rural Health’s mission and its statewide HealthWatch Wisconsin network of approximately 100 individual and 40 organizational members. ABC for Rural Health worked to increase its own core competencies regarding the health care law and understand the connections between the new legislation and existing laws—such as the Mental Health Parity and Addictions Equity Act. The organization then incorporated the new information into its existing benefits counseling casework, newsletters, webcasts, and public presentations for an already engaged audience. By simply turning its existing training resources to the Affordable Care Act, ABC for Rural Health was able to produce 133 webcasts that were viewed 4,256 times. Local partnerships enabled ABC for Rural Health to speak to more than 1,100 individuals in northwest Wisconsin alone. For direct enrollment activities, the health benefits counselor resource proved especially valuable. The health department assisted 112 individuals in completing Marketplace applications, one of the medical center partners helped 168 individuals enroll, and another provided
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
Kwon
more than 247 hours of direct application assistance. The supplemental funds to conduct outreach and education supported an additional certified application counselor who was trained and housed by the health department. The counselor went on to enroll 97 individuals through the Marketplace and educate 265 individuals on health insurance options. 4. Recognizing Internet usability and accessibility issues is important. When it comes to using and accessing the Internet, there is a gap between urban and rural communities.1 Outreach grantees reported that many of their residents in rural and frontier areas lacked Internet access in their homes, and that the elderly population was larger compared to urban communities. To help address these challenges, grantees held events in community spaces that already had Internet access such as schools, libraries, hospitals, and clinics.
Rural Affordable Care Act Outreach and Enrollment
individuals in the community was important to help engage individuals and families. Effective outreach and leveraging partnerships were valuable in educating and enrolling the eligible uninsured. And finally, grantees identified ways to improve Internet access for those who did not have immediate access. As the nation prepares for the next Marketplace Open Enrollment period, which begins on November 15, 2014, and continues through February 15, 2015, ORHP hopes that these lessons learned will help inform—and improve—future outreach and education efforts in rural communities across the country.
Note i For the purposes of this supplemental funding, consumer assistance was provided by general educators (individuals who were primarily just educating the community about ACA), certified application counselors, and/or navigators.
Conclusion The Affordable Care Act provides an opportunity to help millions of eligible uninsured Americans obtain health insurance coverage. The outreach and enrollment strategies used by Outreach grantees during the initial Open Enrollment period varied, but 4 common lessons were identified. Consumer assistance provided by trusted
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
Reference 1. Raine L, Reddy P, Bell P. Rural Areas and the Internet. Washington, DC: Pew Research Internet Project. February 17, 2004. Available at: http://www.pewinternet.org/2004/ 02/17/rural-areas-and-the-internet/. Accessed July 31, 2014.
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Rural Affordable Care Act Outreach and Enrollment: What We Learned During the First Marketplace Open Enrollment Period Linda Kwon, MPH Health Resources and Services Administration, Office of Rural Health Policy, Rockville, Maryland
Disclosures: The Office of Rural Health Policy collected, analyzed, and interpreted data submitted by Rural Health Care Services Outreach Program Affordable Care Act Outreach and Enrollment Supplemental funding grantees. The Health Resources and Services Administration reviewed and commented on this piece prior to submission to The Journal of Rural Health. Acknowledgments: The author would like to acknowledge the following individuals for their contributions to this commentary: Brian S. Olson, Chief Executive Officer (La Red Health Center, Inc., Georgetown, DE); Patricia Hubbard, Project Director, and Cathy Ferron, Evaluator (Lake Country Tribal Health, Inc., Lakeport, CA); and Michael Rust, Chief Operations Officer (ABC for Rural Health, Balsam Lake, WI). For further information, contact: Linda Kwon, MPH, US Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy, 5600 Fishers Lane, 17W17A, Rockville, MD 20857; e-mail: [email protected].
As part of the Patient Protection and Affordable Care Act (Affordable Care Act) of 2010, 2 new opportunities for health care coverage were established for many uninsured individuals beginning on January 1, 2014. The first opportunity was through Medicaid expansion where states had the opportunity to expand Medicaid coverage to individuals with household incomes up to 133% of the federal poverty level. The second opportunity was through the establishment of Health Insurance Marketplaces where individuals could purchase private health plans and potentially qualify for financial assistance in paying for their plans. The Office of Rural Health Policy (ORHP) provided supplemental grant awards to help stimulate Affordable Care Act outreach and education efforts in rural communities that were being served by the Rural Health Care Services Outreach (Outreach) Grant Program. As a result, Outreach grantees enrolled 9,300 rural Americans during the initial Open Enrollment period. Valuable outreach and enrollment lessons were learned from rural communities based on discussions with the Outreach grantees who received the supplemental funding. These lessons will help rural communities prepare for the next Open Enrollment period.
Key words access to care, Affordable Care Act, health services research, insurance, rural health.
doi: 10.1111/jrh.12100
Lessons Learned 1. Individuals within the community who provided consumer assistance were viewed and valued as trusted sources of information. Grantees provided consumer assistancei in a direct and neutral manner that gave their community an opportunity to understand the benefits of the health care law without political rhetoric. Assisters made time to educate each individual and family, which helped change any negative perceptions residents may have had and equipped them with the information
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
needed to make informed decisions. The positive experience consumers had from the one-on-one counseling led them to start referring their family members, friends, and colleagues to these assisters. In Georgetown, Delaware, La Red Health Center (LRHC) provided consumer assistance by hiring 3 full-time certified application counselors (one of whom was funded by the ORHP supplemental funding). Two of them focused on enrollment assistance at both of their practice sites, while the third spent time in the community educating
1
Rural Affordable Care Act Outreach and Enrollment
consumers about new benefits. Federally funded navigators and state-funded marketplace guides were also placed throughout the county to assist in the outreach and enrollment efforts. From the outset, many consumers in Delaware were confused about the Affordable Care Act and “Obamacare”—often thinking these were 2 separate “free” insurance programs. Concerned about the potential for mixed consumer messaging from different enrollment organizations/assisters, LRHC organized a countywide coalition that met periodically to ensure uniform consumer messaging, discuss challenges, and share successes. Consumers benefited from the collective experiences of the coalition members who shared best practices among themselves. LRHC’s assisters benefited from the educational techniques employed by other coalition members, and they became more skilled at using different educational strategies with different consumers. The credibility of LRHC’s marketplace assisters improved as the federal marketplace website, Health Care.gov, was stabilized. Consumer skepticism and anxiety, compounded by HealthCare.gov’s technical problems, posed initial credibility challenges for LRHC’s assisters. As the assisters gained more experience, they became much more adept at anticipating consumer questions, which helped to dissipate some of the frustration. LRHC referred more than 1,500 consumers to their 2 trained outreach and enrollment assistance workers. 2.
Innovative community outreach, education events and strategies helped reach the eligible uninsured. From October 1, 2013, to April 30, 2014, Outreach grantees held more than 1,100 events that reached close to 44,000 rural Americans. Common outreach and education strategies included the use of media, direct mailings, flyers, and presentations. Grantees looked beyond the traditional community settings (eg, clinics, health fairs, churches, and schools) to reach a wider audience. Some conducted outreach events at local high school sporting events because many families attend these events. Others partnered with a local utility company (an informational insert was included in the utility bill) or grocery store to provide outreach.
In Lakeport, California, the Lake County Tribal Health Consortium (LCTH) is a rural federally qualified health center in which the target population are the Native Americans/Tribal individuals and families. LCTH had drop-in as well as regularly scheduled outreach activities that were essential to connecting with families where they congregated. New enrollments and renewals were the focus of these outreach activities that were held
2
Kwon
at Rancherias (small, rural settlements), Tribal Temporary Assistance for Needy Families offices, and LCTH sites both in Lakeport and at the south end of Clear Lake, which is open every 2 weeks. Tribal community members gather on monthly commodities days (days on which there is food distribution) at the Rancherias. As such, staff provided information and educated parents about the need for and availability of health insurance options for themselves and their children. Staff helped start applications in paper form and then made appointments at LCTH on-site offices to complete additional paperwork and obtain verification. LCTH had approximately 15 outreach events that reached about 185 individuals. 3. Leveraging partnerships, both large and small, made an impact on educating and enrolling the eligible uninsured. Despite limited resources, rural communities are rich in relationships. Grantees leveraged these relationships to host joint events or to “piggy back” off of existing events. Other grantees developed referral network systems so that they would primarily educate the uninsured about the Marketplace and then refer those same individuals to a partner organization to get enrolled into a qualified health plan. ABC for Rural Health, located in Balsam Lake, Wisconsin, has a long history of individual and policy advocacy, education, and program partnerships with health care providers, public health and human service agencies, and community-based organizations in northwestern Wisconsin. Outreach and enrollment were natural extensions of ABC for Rural Health’s mission and its statewide HealthWatch Wisconsin network of approximately 100 individual and 40 organizational members. ABC for Rural Health worked to increase its own core competencies regarding the health care law and understand the connections between the new legislation and existing laws—such as the Mental Health Parity and Addictions Equity Act. The organization then incorporated the new information into its existing benefits counseling casework, newsletters, webcasts, and public presentations for an already engaged audience. By simply turning its existing training resources to the Affordable Care Act, ABC for Rural Health was able to produce 133 webcasts that were viewed 4,256 times. Local partnerships enabled ABC for Rural Health to speak to more than 1,100 individuals in northwest Wisconsin alone. For direct enrollment activities, the health benefits counselor resource proved especially valuable. The health department assisted 112 individuals in completing Marketplace applications, one of the medical center partners helped 168 individuals enroll, and another provided
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
Kwon
more than 247 hours of direct application assistance. The supplemental funds to conduct outreach and education supported an additional certified application counselor who was trained and housed by the health department. The counselor went on to enroll 97 individuals through the Marketplace and educate 265 individuals on health insurance options. 4. Recognizing Internet usability and accessibility issues is important. When it comes to using and accessing the Internet, there is a gap between urban and rural communities.1 Outreach grantees reported that many of their residents in rural and frontier areas lacked Internet access in their homes, and that the elderly population was larger compared to urban communities. To help address these challenges, grantees held events in community spaces that already had Internet access such as schools, libraries, hospitals, and clinics.
Rural Affordable Care Act Outreach and Enrollment
individuals in the community was important to help engage individuals and families. Effective outreach and leveraging partnerships were valuable in educating and enrolling the eligible uninsured. And finally, grantees identified ways to improve Internet access for those who did not have immediate access. As the nation prepares for the next Marketplace Open Enrollment period, which begins on November 15, 2014, and continues through February 15, 2015, ORHP hopes that these lessons learned will help inform—and improve—future outreach and education efforts in rural communities across the country.
Note i For the purposes of this supplemental funding, consumer assistance was provided by general educators (individuals who were primarily just educating the community about ACA), certified application counselors, and/or navigators.
Conclusion The Affordable Care Act provides an opportunity to help millions of eligible uninsured Americans obtain health insurance coverage. The outreach and enrollment strategies used by Outreach grantees during the initial Open Enrollment period varied, but 4 common lessons were identified. Consumer assistance provided by trusted
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 1–3
Reference 1. Raine L, Reddy P, Bell P. Rural Areas and the Internet. Washington, DC: Pew Research Internet Project. February 17, 2004. Available at: http://www.pewinternet.org/2004/ 02/17/rural-areas-and-the-internet/. Accessed July 31, 2014.
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