States of awareness

Nearly a year to the day after the U.S. Supreme Court found the Patient Protection and Affordable Care Act constitutional, HHS Secretary Kathleen Sebelius launched her department's public awareness and outreach campaign and identified what she sees as its most daunting challenge ahead: Too many Americans still don't know enough about the Affordable Care Act and how it will affect them.

That's why the Obama administration is counting on consumer groups, community health centers, healthcare provider associations and other organizations to educate millions about the law and how to enroll in coverage.

Those efforts are slowly taking shape in the states, where sources say they are mostly still in the planning and early outreach phases of awareness campaigns that will heat up this summer before the open-enrollment period for state health insurance exchanges begins Oct. 1.

Their task is formidable, especially as Sebelius said last week that HHS is hopeful the nonpartisan Congressional Budget Office's estimate of enrolling 7 million enrollees in the exchanges for the first year is a “realistic target.”

Meanwhile, HHS faces an American public that the Kaiser Family Foundation recently reported is still largely in the dark about the landmark 2010 act. In April, Kaiser reported that four in 10 Americans are still unaware the Affordable Care Act is the law of the land, and last month found that unfavorable views of the law outnumber favorable opinions, 43% to 35%, while about 23% of Americans are still undecided about it. The favorable ratings are the lowest since the Kaiser tracking poll was started in April 2010.

“We are now transforming the public discussion from one that was very political to one that is very personal,” says Ron Pollack, executive director of healthcare consumer group Families USA. “And individuals want to know: How will this affect me, how this will affect my family, what will this cost me, what coverage will I have?”

Families USA is not launching an outreach campaign of its own, but is informing Americans about the law with educational materials, hosting media teleconferences, and supporting the work of groups such as Enroll America, the not-for-profit association that will help enroll the uninsured. Pollack serves as chairman of Enroll America's board of directors, which also includes Richard Umbdenstock, president and CEO of the American Hospital Association, and Sister Carol Keehan, president and CEO of the Catholic Health Association.

Enroll America, led by Anne Filipic—a former Obama administration official who also served on the president's 2008 campaign as field director for the Iowa caucuses and general election director for Colorado—launched its campaign in June to spread the word about the law's coverage options. Filipic declined to disclose figures on funds budgeted for the effort. And with Congress denying the administration's recent request for exchange implementation funding, grass-roots organizations are relying on their own resources, help from Enroll America and re-allocated federal dollars to get their messages out.

In August, HHS is expected to award

$54 million in grants for “navigators”—groups and individuals who will help consumers and small businesses with the enrollment process. They are expected to promote awareness about the law through educational activities, provide information that is culturally and linguistically appropriate, and facilitate selection of a qualified health plan. HHS announced the navigator grant funding in April and accepted applications through June 7. The department will announce the awards Aug. 15.

Pollack says Families USA has not applied for a navigator grant, but is working now to set up a support center for navigators and other outreach workers in community health centers, labor unions and faith-based organizations to help them become proficient in helping Americans enroll in coverage. That support center will be in Washington, and Families USA will host periodic webinars about the Affordable Care Act and also set up chat rooms to discuss different aspects of the law, Pollack says.

The group has other activities planned closer to the start of the enrollment process. In September, Families USA expects to host state-specific teleconferences with federal lawmakers who can provide a comprehensive look at what their constituents should expect from changes in the law.

In a separate event, Families USA will feature consumers who have already chosen their health coverage. Pollack says his organization hasn't yet decided if it will invite consumers to fly to Washington for a news conference or tell their stories via teleconference or Skype. The purpose, he says, is to “humanize” the enrollment process so consumers can see how the law will make a difference for them. “We want to make a big and significant start,” Pollack says, “because it provides a foundation for growth much later on.”

In Florida, statewide health advocacy group Florida CHAIN (Community Health Action Information Network) is hopeful it will receive some of the navigator funding HHS will award this summer, says advocacy director Leah Barber-Heinz. Her group is part of a consortium with Florida Covering Kids & Families, the lead organization that applied for a navigator grant. Several lead entities in the state are applying to receive a share of the $5.8 million in navigator funds allocated for the state.

If Florida CHAIN receives some of the money, the group would use it primarily to host 10 five-hour enrollment fairs throughout the state, says Barber-Heinz, who would not specify the amount Florida CHAIN could receive. The group would use August and September to plan their efforts, and then host the fairs in every month of open enrollment for 2014, which begins in October and ends next March.

Barber-Heinz says that with a staff of only six, Florida CHAIN will work closely with Enroll America and other organizations to educate Floridians about the law. One of those is PICO United Florida, a statewide network of 90 congregations that represent more than 60,000 families in low- to moderate-income communities in the state. The group is part of the PICO National Network, a faith-based organization that has more than 1,000 member institutions representing more than a million families in 17 states.

“Because they are churches, they are down deep into the communities. They are able to get into these rural areas,” Barber-Heinz says. “We're trying to start with where they are,” she says, adding that it will be easier for people to learn about the law and its coverage options from people they know well, such as a pastor or teacher.

Florida CHAIN won't devote all of its attention to educating people about enrollment in the state's insurance marketplace, Barber-Heinz says. The state has more than 4 million uninsured individuals—including 500,000 children—and has not chosen to expand its Medicaid program. As part of its outreach efforts, the organization will seek out those who would have been eligible for the Medicaid expansion.

“There will be many people left behind who are not eligible for tax subsidies for the exchanges and they would have been eligible for the expansion,” Barber-Heinz says. “When we're doing the door-knocking, we want to pull them and make them understand what's happening in Florida,” so that they, too, can lobby for Medicaid expansion.

Her organization plans to invite people to Tallahassee when the legislative session begins in March 2014 to visit lawmakers and tell individual stories to the press. “There was an active campaign last session that we'll continue,” Barber-Heinz says.

In the Lone Star State, community advocacy group Texas Organizing Project also won't give up its fight to expand Medicaid in the state, where one out of four Texans do not have health insurance. TOP, which has about 17,000 dues-paying members, spent April and May reaching out to more than 100,000 people about Gov. Rick Perry's decision to reject the Medicaid expansion, says Ginny Goldman, TOP's executive director. In all, Goldman estimates about 20,000 people engaged in the effort by attending town hall meetings and rallies or sending letters to Perry. This summer, Goldman says her group will amplify those activities.

“We are very, very focused on not letting the governor off the hook,” Goldman says. “That said, millions and millions are eligible for the exchanges,” she says, adding that 1.5 million would have been eligible in the Medicaid expansion while another 2.9 million are eligible to enroll in the state's federally operated exchange.

In Dallas during May and June, TOP representatives knocked on 15,000 doors and spoke with 3,500 people to learn if they were eligible for the healthcare coverage options under the 2010 healthcare reform law. That served as a pilot project to test the best ways to identify those who could benefit from the law's coverage options.

“We asked them about income, family size and their insurance situation,” Goldman says, adding that TOP representatives showed consumers a chart and asked them to point where they fell on the grid. The organization identified 3,100 people as eligible, both for the marketplace and for Medicaid, if the state had expanded its program.

“When it comes to the exchanges, they want to know what it will cover and how much it will cost,” Goldman says. “Now we're partnering with direct-service agencies who will become navigators,” she says, adding, “We will be out in the community driving them to events.”

Like Texas, Wisconsin also chose not to expand its Medicaid program. But as part of the state's recently passed budget, Wisconsin will reduce its Medicaid eligibility to 100% of the federal poverty level—down from its current level of 200%—which means that as of Jan. 1, only individuals who earn below $11,500 a year and a family of four with income of less than $23,550 will be eligible for Medicaid, according to Eric Borgerding, executive vice president of the Wisconsin Hospital Association.

“In addition to the challenge of communicating and enrolling the general population in (exchange) coverage, Wisconsin has an added burden of educating the 90,000 who will be dis-enrolled from Medicaid,” he says, adding that the association is concerned that if the marketplace proves difficult for consumers to access, that could ultimately result in more people without coverage who show up in hospital emergency rooms.

That could lead to the additional challenge of trying to help those people enroll in coverage through the exchanges. Currently, it's a fairly quick process to help patients enroll in Medicaid, Borgerding says. But it's unrealistic to expect that a hospital could hand off a patient seeking enrollment to an insurance agent at, say, 3 o'clock in the morning.

“That's why it's really crucial for us as an organization and our members to do everything we can to aid not only in the establishment of the exchanges, but the outreach and education effort that is going to be undertaken in Wisconsin,” Borgerding says.

In mid-June, the association held two webinars for its members on how the exchanges will work, and Borgerding says about 400 people participated in those programs. It will host similar webinars this month and August, which are expected to include the state's insurance commissioner as well as representatives from the CMS and Wisconsin's health services department. Borgerding says his organization will also establish a member-driven action group on how hospitals of different types and sizes can share best practices.

The WHA is also in the initial process of planning regional meetings with its members and state health department representatives to learn what the department has planned for education and outreach efforts.

Borgerding says the WHA will serve as a facilitator and communicator for its member hospitals, which is similar to the role that the National Association of Community Health Centers will play with its constituents. HHS plans to award about $150 million in grants to community health centers for outreach and enrollment efforts involving the exchanges in July. These facilities—which serve more than 22 million people, of whom about 35% are uninsured, in more than 9,000 communities—not only have the task of spreading the enrollment message, but they will also serve as the source of healthcare for those who don't qualify for either the exchanges or Medicaid.

Claudia Gibson, executive vice president of communications for the NACHC, says the association will rely on help from its existing group of about 66,000 community health center advocates nationwide to help make people aware of the law and its coverage options. “From a national perspective, we want to make sure the information that is disseminated to medically underserved people is clear and culturally appropriate to what's going on,” Gibson says.

The group will also use National Health Center Week—which includes health fairs, screenings and wellness check-ups across the country—as another opportunity to educate people about what they might qualify for under the law. This year, the event is set for Aug. 7-11.

“I'm kind of encouraged by the number of groups—be it social, civic, the government—really focused on getting the information to folks out there in the country,” Gibson says, “and to work toward giving them a better understanding of health reform and its benefits.”

Follow Jessica Zigmond on Twitter: @MHjzigmond