Connecting Underserved Populations to Health Insurance

Introduction

For many people without health insurance, the cost of obtaining health care services is a significant deterrent to seeking care. Under the Affordable Care Act (ACA), Medicaid expansion in many states will create an opportunity for previously uninsured, childless adults below 133% Federal Poverty Level to receive Medicaid coverage beginning in 2014.[i] For those with higher incomes, health insurance will be available for purchase with the assistance of tax credits and cost sharing subsidies for eligible individuals through the newly created Health Insurance Exchanges, also referred to as health insurance marketplaces.[ii] Connecting underserved, underinsured populations to health insurance coverage is one way that health outreach programs can ensure that eligible individuals and families are not constrained by health care costs. In order to do this, outreach and enrollment workers will need to understand the available insurance options and who in their communities will be eligible. They will need to know what the common barriers are to accessing insurance coverage and how to help families successfully obtain and use health insurance.

Barriers to Health Insurance Enrollment and Retention

Being eligible for insurance coverage will not automatically guarantee enrollment. Understanding the individual mandate and navigating through the enrollment and selection process may be confusing for those who have never had insurance. For instance, many people may not understand how or where to apply, what documentation is required, or how to maintain coverage. Confusion and misinformation about eligibility and cost may create a barrier to enrollment. Further, enrollment can be complicated by lengthy applications, limited assistance in the preferred language of the applicant, or inability of the applicant to produce necessary documentation. For immigrant populations, some individuals may be fearful of applying for insurance for themselves or their children because one or more members of the family do not have legal immigration status and fear deportation. Others who are eligible for public health insurance programs but hope to someday change their immigration status may be reluctant to apply because they incorrectly fear becoming a public charge. For many underserved populations, these barriers are compounded by lack of transportation to locations where individuals and families can receive assistance to apply for insurance coverage. It is common for several of these barriers to be experienced simultaneously. Successfully connecting people to the coverage that is the best fit for them and their families requires addressing these barriers.

Expanding Enrollment and Retention through Outreach

In order to overcome enrollment barriers, it is important to conduct outreach and application assistance through trusted organizations with strong ties to the community. In fact, under the Affordable Care Act, each Health Insurance Exchange is required to establish a navigator program for this very purpose. Each Exchange will be required to award grants to Navigator entities to support outreach and enrollment activities.[iii] There are a number of possible qualifying entities outlined by the ACA including community and consumer-focused nonprofits.[iv] The ACA stipulates that Navigators should have expertise working with specific populations such as low-income individuals and families, people with disabilities, or individuals with Limited English Proficiency. [v]Qualified Navigators will be required to demonstrate either existing relationships or the ability to quickly establish relationships with consumers including uninsured or underinsured populations.[vi] Depending on how the Navigator program is defined and implemented in future months, established organizations already providing outreach and enrollment services that understand local circumstances, language needs and cultural characteristics of the underserved, underinsured populations in their communities may be well positioned to become navigator entities. These trusted organizations have the best opportunity to reach out, provide information and offer assistance to individuals and families. Moving forward it will be essential that all volunteers, staff, and partners providing outreach, enrollment, and renewal assistance are well-trained and prepared regardless of whether or not the organization is a recognized navigator entity. Anyone conducting outreach and enrollment should be aware of the changes in Medicaid eligibility in their state and insurance options available through the Health Insurance Exchanges.

The Importance of Messaging

In addition to establishing teams of trusted, knowledgeable professionals and volunteers, it is important for navigator programs and other community based organizations providing outreach and enrollment services to consider what information should be shared about health insurance options. Effective messaging is created with the priority population’s culture, motivation, barriers, and fears in mind. Understanding these needs and motivations will help organizations share important information in a way that resonates with individuals and families and is likely to produce more meaningful results. Given the changes brought about by the ACA, it will be especially important and necessary to provide accurate, timely information that explains the insurance coverage options. For example, it will be necessary to widely disseminate information about the expansion of Medicaid in participating states in order to inform previously uninsured, ineligible populations that coverage is now available. In addition to offering information about eligibility and availability of insurance options, it is important to provide clear, concrete action steps to the audience. Many of the newly eligible populations will need help with navigating the insurance marketplace including understanding the requirement to obtain insurance, completing an application, and selecting a plan. They will need to understand that there is help available and how to access the needed assistance. Consider including contact information, time assistance is available, locations, and other dates that are important.

Promotion and Education about Available Benefits

Once the outreach and enrollment team is established and clear messaging is created, it is necessary to share the information about available insurance options, eligibility requirements, and application processes in places where underserved, uninsured and underinsured populations live, work, and congregate. Promotion and education activities should happen in places that are convenient to the priority populations, such as labor camps, public housing units, schools, or places of business. Strategic partnerships with school systems can expand opportunities to reach uninsured children and their families. Broad-based outreach that uses traditional media such as newspapers, television, or radio must take language and literacy into consideration. Remember, it is necessary to know the audience and use promotion and education strategies that will work for them given their context.

Ensuring Enrollment, Retention, and Utilization

Making sure accurate, timely information is disseminated is only a part of the process. For many families and individuals, understanding public insurance eligibility, selecting an insurance plan, and using the insurance benefits can be complicated or overwhelming. This can be especially true for those individuals who are unfamiliar with the US health care system or for those that have Limited English Proficiency or low literacy levels. Providing one-on-one assistance through navigators, application assistors, eligibility workers, or trained outreach workers is the best way to ensure that individuals and families get connected to insurance coverage that is the best fit for them. Specifically, assisting families with completing the applications, identifying or gathering necessary documentation, understanding and answering questions, and providing education on the application approval process will be necessary to get people connected to insurance coverage.

Advocacy and follow up will often be required to not only help make sure the applications are properly processed and approved but to also ensure that families understand and are comfortable with their coverage. Just like being eligible does not necessary lead to enrollment, being enrolled in an insurance plan does not necessarily translate into usage. Making sure the newly enrolled understand how to use their benefits is crucial. The ultimate goal of insurance coverage is better access to health care. Outreach and enrollment workers can play a vital role in helping families and individuals actually get the health care they need. They can help those that are enrolled connect to a regular source of care and can check in to help troubleshoot any possible barriers or problems with accessing health care services.

Preparing the Outreach Workforce

The Affordable Care Act provides a unique opportunity for many outreach programs to expand their efforts to get underserved, underinsured populations connected to health insurance. Now is the time to consider the systems, processes, programs, and partnerships that will be needed to effectively meet the challenge of getting newly eligible people in communities around the country connected to health insurance coverage. To help prepare outreach programs, Health Outreach Partners developed a Public Health Insurance Training of Trainers curriculum in 2011. The principle objective of the curriculum is to build a network of outreach personnel equipped with tools, information, and techniques to increase enrollment. The curriculum can be utilized to build leadership among outreach workers, provide a platform to share information, and learn strategies for reaching out to underserved, uninsured and underinsured populations. The curriculum teaches outreach workers the necessary skills for conducting effective eligibility outreach; it also enables outreach staff to widely disseminate this education and information to their peers in public health insurance outreach.

Upcoming Training Event: North West Regional Primary care Association (NWRPCA) Spring Primary Care Conference

Health Outreach Partners will present the Public Health Insurance Outreach Training of Trainers Curriculum at the NWRPCA Spring Primary Care Conference in Anchorage, Alaska on May 18^th, 2013. The training will include an overview of the training of trainers approach and how to effectively use the curriculum to capacitate outreach staff and partnering organizations to conduct public health insurance outreach. Attendees will participate in simulated activities from the curriculum and practice developing a sample agenda for future trainings. For information about the conference, visit NWRPCA’s Spring Conference webpage at http://nwrpca.org/conferences/spring-primary-care-conference.html.