Thursday, November 07, 2013

More than just a website: state efforts to make the ACA work (and the lack thereof)

We've all read by now that the ACA websites in states that are running their own exchanges (14, plus D.C.) are working much better than the federal site. What most of us may not have fully recognized -- though it's no doubt obvious to health and insurance professionals and people who have run social service programs -- is that establishing, running and marketing a functioning insurance marketplace requires a wholehearted commitment from state government.

Enticing insurers, policing insurers, and, above all, educating and wooing the uininsured public require expertise, commitment, money and accountability. Putting the program across in mostly low-income and low-information populations is a lot like delivering chronic care to those in need: it requires a lot of patient, informed, sensitive one-on-one contact.

Kentucky and California are two states that are going all out to make the Affordable Care Act a success.  The Huffington Post's Jason Cherkis recently did some great reporting in Kentucky, where Governor Steve Besheare, a Democrat,
is using all the powers of his administration to sell Obamacare, marshaling millions of dollars for branding and market research, heartwarming television spots and eye-catching bus ads. A hired army of true believers have held meetings across the state, spreading the word and rebutting misconceptions.
The outreach budget there is limited, and while the state has hired over 600 "Kynectors" to help people navigate the system, it relies largely on volunteers from nonprofits, churches and other groups, whose efforts it has embraced. Here's the experience of one, an attorney with the Kentucky Equal Justice Center:
Stewart expects more road work. Her November schedule looks just like her October schedule, which looked just like her September schedule. She says she is still getting the same volume of requests for presentations. At a recent session before a group of 30 students at a community college in Northern Kentucky, only one had enrolled. All the others, Stewart remembers, thought they weren't eligible.

At every one of her meetings, there are tiny epiphanies -- like the farmer who showed up in his work overalls convinced his rates were going to double, but walked away relieved that he actually qualified for Medicaid. It's enough, Stewart says, to keep her going.

"It seems worth it as soon as you have that moment," she explains. "It seems worth it to come home at 11. It seems worth it to have to find random places to stay. It seems worth it when you have that moment where someone's life is going to change."
Such efforts by nonprofits are also under weigh in states where the federal government is running the exchange -- for example, in Latino neighborhoods in Philadelphia.  But you have to wonder how much of a chasm will open up between states where the state government, the insurance industry, the nonprofit sector and healthcare providers are working in concert and states where they are not.

In California, the public entity established in 2010 to administer the state's health insurance exchange, now called Covered California, is structured to ensure accountability and transparency, as well as a highly public effort to educate and enroll the uninsured.  Here, from a blueprint published in January of this year, is a sampling of planning outreach activity prior to launch (forgive the funky coding; it's pasted pdf):
Stakeholder Consultation
The Board of Covered California has identified as among its core operating values its commitment to be guided in its work by working in partnership with a full range of stakeholdersand earning the public’s trust by being transparent and accountable in how it operates. Stakeholder engagement serves several distinct goals including (1) gathering general and topic-specific input on policy issues, (2) building and sustaining partnerships, (3) fostering better understanding of Covered California, and (4) understanding how Covered California’s policies impact stakeholder partners. Covered California has sought to reflect these values and goals by regularly engaging stakeholders through a variety of activities described below.
Ongoing stakeholder consultation activities 
Public Board meetings: Stakeholders actively participate in monthly public boardmeetings and have an opportunity to comment on each agenda item. All Boardmeetings are webcast with opportunities for phone participants to ask questions ormake comments.
Panel presentations: Covered California invites stakeholders to make presentations tothe Board on policy issues under consideration. Recent stakeholder presentations havefocused on health plan contracting, the Small Employer Health Options Program (SHOP) and strategies to maximize enrollment in health programs.
Sharing reports and comment letters: Covered California staff share stakeholder comment letters and reports with the Board in advance of Board meetings whenever possible. Letters and reports are also posted on the Covered California website.
Email distribution list: Covered California regularly shares program updates with
stakeholders through an email distribution list that includes more than 2,500
individuals. Stakeholders can subscribe to the distribution list through a link on Covered California’s homepage:
•Covered California maintains a stakeholder feedback tab on its website at
•  Covered California frequently issues requests for stakeholder comment on various issues at this tab and includes input forms for these written comments.
•Covered California staff actively consults with the state Medicaid and CHIP agencies as well as other state health program administrators and regulators. Key areas of collaboration include development of joint vendor solicitations and responses to proposed federal regulations, shared stakeholder consultation strategies and forums, and collaborative analysis of implementation including the Covered California’s eligibility and enrollment portal, the California Eligibility, Enrollment and Retention System (CalHEERS).
Tribal consultation: Covered California held its first formal consultation with California’s Indian tribes on July 6, 2012, and will implement an ongoing Tribal consultation policywhich will include the establishment of a Tribal advisory group.
One-on-one stakeholder meetings and presentations: Covered California staff and Board members hold meetings with individual stakeholder groups and make presentations at stakeholder conferences and webinars.
Workgroups and topic-specific input 
Individual and Small Business Workgroups: Workgroups were originally convened in July2011 to advise Covered California on eligibility and enrollment issues. Membership includes consumer advocates, providers, health plans, counties, labor, brokers and small businesses. Recently Covered California has used these groups to provide advice on health plan contracting and SHOP issues and to help develop stakeholder questions on outreach and enrollment and qualified health plan issues.
Ad hoc statewide meetings: Covered California convened meetings around the state onoutreach and enrollment and qualified health plan issues. Sessions were held with consumer advocates, providers, brokers and business representatives. Discussion topics were drawn from a list of questions developed in consultation with the individual and small business workgroups. Summary reports on these sessions are available on Covered California’s website (see marketing and health plan policies) and were shared with staff and contractors to inform policyand strategy development in these areas. 
Topic-specific written stakeholder input: Covered California regularly posts topic-specific questions on the Covered California website for written comment. Comments are subsequently shared with the Board and posted on the website. Covered California staff document changes made to policy recommendations based on stakeholder feedback prior to requesting Board action on the topic. Recent requests for written feedback have included health plan contracting policy recommendations; outreach, marketing and assistance strategies; service center principles and models; and SHOP policy recommendations. (For an example, see consolidated qualified health plan stakeholder comments and summary of changes made to preliminary policy recommendations.)
Topic-specific webinars: Covered California staff regularly host webinars on priority policy issues that are under consideration by the Board. Covered California uses its stakeholder distribution list to invite a broad audience, and Board members frequently participate in webinars. Recent webinar topics have included qualified health plan contracting issues; outreach, marketing and assistance strategies; and service center principles and models. These webinars are posted to the stakeholder portion of Covered California’s website.
The marketing plans, beginning on page 11 of the blueprint, are something to behold. They  include adtesting, market surveys, collateral in 13 languages made available to all interested groups, and a coordinated multimedia campaign.  The Twitter feed @CoveredCalifornia bespeaks the level of on-the-ground outreach:
  1. A 26-year-old making $30,000 per year could qualify for $1,416 annually in financial assistance. Find out if you do:
  2. Stop by! MT : Join us for Health Insurance info at Bothwell Arts Center, Livermore Nov 9 9AM-4PM
  3. Our Facebook community member shared her experience. Call today with your questions.
  4. weekly statistics released. Call volume passes 260,000 since Oct 1.
  5. Learn about your health care options at Cloverdale Library, Nov. 6, 6:30 pm, 401 N. Cloverdale Blvd.,

This is of course self-presentation, and perhaps what you'd expect of a major state initiative. Still, you have to wonder what the absence of such planning and state-organized outreach suggests about ACA prospects in the 36 states that have declined to build and run their own exchanges.

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