Tens of millions of uninsured people will soon have the ability to gain health coverage as the first enrollment period under the Affordable Care Act (ACA) begins on October 1, 2013, with actual coverage starting in January 2014. New marketplaces will be established for the purchase of private insurance, pre-existing coverage exclusions and discriminatory premiums will end, and comprehensive benefits will be included in health plans.
Most significantly for the vast majority of uninsured Americans, the ACA offers unprecedented financial assistance (in the form of a tax credit) to make private health plan premiums more affordable and, in many states, expanded Medicaid coverage.
The ACA represents a truly historic series of improvements – a legislative triumph that eluded many presidents before Barack Obama. As noteworthy as this achievement is, however, substantial coverage expansion will only occur if uninsured families learn about these new opportunities and actually get enrolled in private or public health coverage.
Enroll America was formed in 2011 with that goal of educating consumers about the new law and helping them to enroll in the plan that is right for them. There remains an enormous amount of work to do and challenges to overcome to make sure the ACA lives up to its potential.
First, national surveys and focus groups make clear that the vast majority of uninsured people are simply unaware of the new and significant opportunities that will be available to them through the ACA. Additionally, based on their past frustrations in trying to procure health coverage, uninsured people are understandably skeptical that access to meaningful and affordable insurance will occur.
Second, given the political contentiousness about the ACA, many states headed by the law’s opponents are less than eager to undertake meaningful public education and outreach efforts targeting uninsured people in their states. Indeed, approximately two-thirds of governors across the country have refused so far to set up their own marketplaces, and many have not yet opted into the Medicaid expansion. As a result, the creation of a robust, seamless enrollment infrastructure in all or most of those states is a work in progress.
Third, since many states are not fully participating in outreach efforts, this leaves a greater burden on the Department of Health and Human Services (HHS) to undertake a major, nationwide public education campaign. Although HHS Secretary Sebelius and her colleagues are working effectively to ensure timely implementation of the ACA, there are practical limitations on what HHS can do. Therefore, diverse private-sector health stakeholders will need to step up their own outreach and informational efforts in cooperation with HHS.
The Information and Skepticism Gap: According to a large national survey undertaken by Lake Research Partners for Enroll America, more than three-fourths of uninsured people (78 percent) are unaware of the new health marketplaces that are being established and the financial help that will become available. Among those who are potentially eligible for the Medicaid expansion beginning in 2014, an even larger proportion (83 percent) is unaware of the new health coverage options that are coming.
Ten focus groups conducted in Philadelphia, Miami, San Antonio, and Columbus, Ohio yielded similar results. Even though these focus groups were segmented by demographic groups with the most to gain from the ACA – uninsured Latinos, African Americans, and young adults – virtually none of the focus group participants knew about the new coverage opportunities that will soon be available to them.
Although the overwhelming majority of uninsured Americans feel it is important to have health coverage and would like to obtain it, their previous unsuccessful experiences trying to purchase insurance have been frustrating. Three-quarters of survey respondents who had shopped for health insurance in the existing individual insurance market could not find a plan that was affordable. Almost a comparable portion felt confused by the fine print in the plans. Two-thirds found it difficult to identify a plan that covered their health needs. Yet others were denied the opportunity to purchase coverage because they had a pre-existing health condition.
This information and skepticism gap needs to be fixed to achieve optimal enrollment. Enroll America, working collaboratively with numerous and diverse national and state-based partners as well as HHS, is in the process of building a large national and grassroots campaign to bridge the information and skepticism gap designed to achieve optimal enrollment. Additionally, through its Best Practices Institute, Enroll America is promoting state-by-state adoption of systems that are consumer-friendly and enable everyone seeking coverage to get enrolled.
The Best Practices Institute: During the past two years, the Best Practices Institute has collected information about what has worked and what has failed in securing effective enrollment in Medicaid, the Children’s Health Insurance Program (CHIP), the Medicare Part D prescription drug program, and Massachusetts health reform. It has done the same with other means-tested programs, such as the Supplemental Nutrition Assistance Program (SNAP, also known as food stamps), the Earned Income Tax Credit, the Supplemental Feeding Program for Women, Infants, and Children (WIC), and other programs serving moderate-income families.
Based on that knowledge, the Best Practices Institute continues to promote state-by-state enrollment systems that are most conducive to enabling everyone who wants coverage to get enrolled. These systems require simplified applications, in-person assistance for those who need it, applications available in multiple languages, readily available data technology to easily verify eligibility for Medicaid, CHIP, and tax credits, multiple ways of filing applications (including online), and understandable, simplified comparisons of health plans people can select.
The Best Practices Institute is also helping to empower key institutions so they can play important roles in facilitating enrollment. Institutions like hospitals and community health centers are obvious partners in promoting enrollment at their sites, and the Best Practices Institute is providing and sharing information so that these and other institutions can help to enroll patients as efficiently and effectively as possible.
The Public Education and Outreach Campaign: There are many lessons to draw on in developing an effective public education and outreach campaign. Lessons from the commercial world as well as from political campaigns provide instructive ways of identifying and reaching uninsured Americans. Enroll America is investing significantly in research and analytics so that public education and outreach is undertaken as effectively and efficiently as possible.
As part of this, geographic targeting is crucial. Although Enroll America’s work will have a significant impact nationwide, priority targeting is essential to ensure that available resources are used in the most strategic manner. Census data tell us that more than half of America’s uninsured people reside in just 114 of the nation’s 3,033 counties – less than four percent of all counties in the U.S. As a result, a disproportionate focus of outreach and public education efforts is needed in areas of the country where it will do the most good.
Enroll America intends to use a comprehensive approach to its public education and outreach campaign. It will organize earned media events, place advertisements through various print and electronic media outlets, make effective use of online organizing, promote cooperative public education efforts among a wide variety of national organizations, work with and/or help to create state coalitions that are collaborating in promoting maximum enrollment, and hire field organizers who, in turn, will assemble a strong cadre of outreach volunteers.
Throughout this public education and outreach campaign, Enroll America intends to refine the messages, identify the messengers, and use the mediums that are most likely to reach the diverse people and families needing health coverage. Since most of the uninsured people in the U.S. have modest incomes and many may have had limited educational opportunities, this will no doubt be an enormous challenge and will require creativity and sensitivity about how best to communicate with a very large and diverse segment of the population.
Summation: Although the challenges to securing optimal health coverage enrollment are enormous, so are the opportunities. The ACA provides an unprecedented chance to move our nation much closer to universal health coverage. Working together with many allied organizations and HHS, Enroll America intends to seize this moment to maximize the number of uninsured Americans who enroll in health coverage made available by the ACA.