As Year 3 of Affordable Care Act (ACA) enrollment quickly approaches, we can look to experienced assisters to figure out how to best plan for a successful year. During the first two years of open enrollment, Illinois had a large cadre of in-person assisters: hundreds of federally funded navigators, state-funded In Person Counselors (IPCs), and Certified Application Counselors were spread out across the state from Moline to Chicago and Waukegan to East St. Louis. These assisters were located in diverse communities from Polish, Latino, and Chinese urban immigrant enclaves to communities of young invincibles in college towns to farming communities mid-state. Over the past two years they reached many hard-to-serve populations, such as limited English speakers and homeless populations that may never have gotten coverage without in-person assistance.
Yet, even with their different backgrounds and experiences, the enrollment specialists we interviewed this summer about “best practices” in outreach and enrollment all had similar things to say. When it comes to a successful outreach plan , three strategies were key: Partnerships, Meeting People Where They Are, and Building Trust.
Partnerships of all kinds – with the state, with other community-based organizations, and with other enrollment entities – made all the difference to Illinois enrollment assisters in their ability to increase their impact.
Martin Logo of the Project of the Quad Cities said that their collaboration with Get Covered Illinois helped them provide staff trainings and logistical support to enrollment assisters. In addition, the Project of the Quad Cities worked with local job training sites that provide literacy services, job skills, and counseling to unemployed and low-income individuals. The partnership included staffing information tables at events, weekly presentations, and one-on-one enrollment sessions. The Project of the Quad Cities was invited to speak during various job information classes and reached a large number of uninsured, unemployed residents who previously had minimal information about the ACA.
Bill Green of United Way of Metropolitan Chicago stressed the importance of working with existing organizations that have a wealth of knowledge about their local community and its needs that assisters do not always recognize. For example, an agency in Chicago’s Chinatown knew that many community members commute via bus to work every morning. Assisters working with the organization decided to go to the bus stop in the early mornings to hand out flyers and make enrollment appointments. Without input from the local organization, the assisters would not have known how to reach the population in effective ways.
In another example of collaboration, navigators working within the Chicago Northwest and Southwest Consortium formed a tight collaborative of over 25 partnering enrollment organizations in highly uninsured neighborhoods in Chicago. Representatives from all enrollment organizations hold bi-weekly meetings, share their best practices and challenges, and work together toward a common goal of cultivating community enrollment opportunities. This consortium is also working together to develop and pilot a sustainable model for enrollment assistance.
Graciela Guzman, a Navigator with PrimeCare Community Health, described the enormous power of the consortium. Guzman notes that the highest number of enrollments in Chicago came out of this region because of the enrollment organizations’ high-level of coordination and resource sharing. The consortium model benefits assisters as well, giving them a place to share their frustrations and successes with others in their same positions. It also allows a forum for ongoing training, including specialized training beyond what the state can provide.
HelpHub, a technical assistance center for enrollment specialists in Illinois, and the Shriver Center provided ongoing trainings for the Chicago Northwest and Southwest Consortium. These trainings were offered at quarterly meetings on subjects such as Medicaid redeterminations and renewals, the TANF/SNAP online system integration with Medicaid, and immigrant eligibility trouble-shooting.
Building a consortium of small, regional groups of assisters can be helpful because members of the individual groups know their particular neighborhoods or communities well or can address specific needs together like outreach to new immigrants.
Meeting People Where They Are
To be effective, assisters must go to the people. As Bill Green stated, “You have to go inside the community itself.” According to Green, the most effective enrollment events by far were ones that “piggybacked on existing community events. Creating our own events didn’t work very well.”
Every interviewee mentioned the ongoing necessity of expanding enrollment assistance and health literacy by providing language access in multiple languages. A large proportion of the uninsured do not speak English, and it is important to be able to educate them about their healthcare options in languages that they can understand. For example, Martin Logo said that his organization gave educational presentations at community meetings in English, French, and four different African languages. Graciela Guzman says that a third of her clients self-reported having difficulty reading and writing in their native languages or in English, and 90% needed email accounts created because they did not previously have one and were not familiar with computers.
Megan Davy, of Peer Services in Evanston, had a particularly adventurous take on meeting people where they are. Davy knew from a long career in advertising that “word of mouth is the best advertising.” She took to the streets, walking into every business and speaking to every owner about his/her employees’ health insurance coverage. She spoke to many employees who were unaware of their need for health insurance, and even more who were unsure of how to get it. By doing this, Davy reached a large population of young invincibles. Moreover, by getting out into the neighborhood and especially meeting people where they are most often (such as at work), Peer Services was successful in getting more people educated and enrolled.
The best practice cited by our interviewees most often was a simple concept but one that takes time to develop. Janice Parker, a Navigator at Navicore Solutions summed it up well: “It’s not just as easy as ‘You want healthcare? Enroll!’ It’s also a matter of trust.” In most cases, this refers to the trust of community members, who aren’t inclined to put their lives in the hands of just anybody.
It takes time to invest in the relationship building. One way to build trust more quickly is for the state, medical centers, or contracted organizations to make a concerted effort to hire from the communities they serve so that they have culturally competent, linguistically expert, trusted partners from the beginning. Sometimes, building trust is as simple as speaking and distributing educational materials in the native language of a client. Graciela Guzman professed that there is “so much trust involved… They believe in your ability to get you through the process. I don’t take that lightly.” Janice Parker stressed the importance of integrating family members into the enrollment process in order to build trust. The individualistic nature of enrollment may alienate some clients, but Navigators have the unique ability to transform it into a much kinder process.
Interviewees spoke about the deep ties they developed with clients. The emotional impact of the job is huge, and assisters’ effect on the lives of their clients is tangible. Megan Davy went on to explain: “Every day, somebody hugged me and said thank you. People share their [specific individual] information. To help somebody feel safe – what’s more important than their health?” It takes skill and trust to reassure someone about privacy concerns and give them individualized assistance in the same manner that financial counselors, insurance brokers, and credit managers do.
Final Thoughts About the Upcoming Open Enrollment Period
Faced with reductions of Get Covered Illinois staff and a much smaller funded network of in-person help across the state, the coming year will bring challenges in Illinois. As Bill Green puts it, year three is certainly a “make or break year.” Many organizations will no longer have the dedicated full-time staff to work on outreach and enrollment. In the face of these upcoming challenges, building partnerships, building trust and going to where the people are will be more important than ever.
It will also now mean that consumers may turn more to Certified Application Counselors (CACs) at health centers for help enrolling. In turn, CACs may have to do more outreach at health fairs or homeless shelters in the community and other places where uninsured populations who may have been “missed” the first and second time around can be found. Fortunately, the Illinois Primary Healthcare Association, which represents community health centers around the state was chosen as one of the sites around the country to participate in the inaugural Get Covered Academy Endowment, focused on outreach training this year. We are excited about this new partnership and the learnings they can share with the rest of the enrollment community.
As Graciela Guzman puts it. “We’ve enrolled individuals more likely and wanting to enroll in the process. We’re going to have to start thinking outside of the box to reach consumers that may not have heard the message yet or are hesitant about the process.”
From what we’ve seen of these incredibly talented, passionate assisters, they will do just that to enroll the remaining uninsured in Illinois.
This blog post was co-authored by Anna Kanter, intern, and Stephanie Altman, Assistant Director of Health Care Justice at the Sargent Shriver National Center on Poverty Law.
The Shriver Center’s health team trains extensively on ACA implementation in Illinois and runs HelpHub, an online technical assistance center for enrollment specialists in Illinois.