As Allison O’Toole worked at her family’s Minneapolis pharmacy and attended public schools in the 1970s and 1980s, she observed firsthand one of the most homogeneous large cities in America absorb an influx of immigrants from South Asia.
“They have been huge contributors to the community, and they have stayed,” O’Toole says. Some four decades later, she draws from that experience in her role as chief executive officer of MNsure, Minnesota’s state health insurance exchange. Among her duties: encouraging the state’s pockets of Asian and African immigrants to obtain commercial health insurance or enroll in Medicaid.
O’Toole and her counterparts in other states have a formidable challenge: Nonwhite ethnic groups are far less likely to have health insurance than the nation as a whole. According to 2013 federal data, the uninsured rate was 30.3% among Latinos, 18.9% among African-Americans, and 13.8% among Asians. Only 10.8% of whites lacked insurance. The U.S. Department of Health and Human Services estimates that a third of people who would qualify for health insurance through the state and federal exchanges for the 2015–16 enrollment period are African-American or Latino.
One goal of the exchanges is to persuade these groups to obtain insurance despite a barrage of often negative or confusing media coverage about the Affordable Care Act (ACA). The exchanges have to penetrate such background noise and transmit crucial information about premium subsidies and eligibility, often in multiple languages and in culturally appropriate tones that will resonate with each community. And they must do so with fewer resources, as federal funds for outreach have shrunk with each annual enrollment period.
“Overall, Latino enrollment didn’t go at all well [in 2013],” says Gabriel Sanchez, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico. “There was clearly a need for more effort, and for getting a better sense of the enrollment data.”
Take Covered California, the biggest state-based health insurance exchange, which services large concentrations of Latinos. It came under fire for some of its ethnic-group outreach during the first open enrollment, in 2013–14. For example, health insurance brokers and navigators were furnished an informational letter from the federal government to help assure potential enrollees that their data would not be used to track down undocumented relatives — a big concern for many Latino applicants, according to Sanchez. However, that letter was printed on Immigration Customs and Enforcement (ICE) letterhead, potentially cooling many applicants to the idea of seeking coverage.
As state exchanges engage in their third annual enrollment, many have recalibrated their marketing and outreach. Officials in Minnesota and Colorado, for example, have drilled down to demographic data by zip code, to uncover pockets of uninsured people. O’Toole calls such granular analysis “heat maps.”
One hot zone is the Cedar-Riverside neighborhood straddling Minneapolis and St. Paul, home to a large Somali immigrant community, which relies heavily on public transportation, according to O’Toole. At bus stops, MNsure posted signs promoting the exchange and listing nearby locales that offer enrollment services. In addition, O’Toole says that MNsure has earmarked $4 million in outreach grants, to 26 recipients, that will filter to 80 different organizations. Grantees can use the funds for highly targeted efforts, such as publicizing MNsure on foreign-language radio stations that reach Hmong and other Asian immigrant communities.
James Wadleigh, CEO of Access Health CT, Connecticut’s exchange, describes such efforts as “forward-steering while in a skid.” That’s because outreach often has to be adjusted repeatedly during open-enrollment periods.
Among Connecticut’s new approaches to reaching its underinsured African-American and Latino communities: shifting some of the outreach burden from exchange employees to willing community organizations and churches.
“We decided it was better to go where our customers would be going as it related to blacks and Hispanics and educate them on the benefits of enrollment there,” Wadleigh says.
O’Toole concurs: “We know the importance of the relationships that [community groups] have developed over the years. You can’t come in and have people trust us within 10 minutes.”
In California, outreach goes through not only hundreds of community organizations and churches, but also small businesses. According to Covered California’s executive director Peter V. Lee, the state’s enormous Asian population often relies on neighborhood insurance agencies for business-related coverage. Many of those agencies have now been recruited to assist in health care enrollment.
“Community insurance agents are very well networked into the Asian–Pacific Islander groups,” Lee says. He adds that, compared with Latinos, this population is more than twice as likely to use that method to enroll in the exchange. And it seems to have worked: 22.9% of Covered California enrollees eligible for premium subsidies are Asian, even though they would represent only about 20% of that population if all Californians were insured.
For the current enrollment period, Covered California has also intensified its outreach to African-Americans. That’s because although African-Americans represent about 5% of the state’s population that is eligible for premium subsidies, they constitute just 2.4% of the exchange’s total enrollment.
Officials at Covered California are aware of such quirks, thanks in part to an exhaustive report it commissioned from NORC, a research firm affiliated with the University of Chicago. The most recent 193-page tome contains insights such as this one: Latinos are generally more motivated to purchase insurance to avoid tax penalties than are African-Americans, who often want insurance because it offers a sense of security. Perhaps the biggest obstacle cited in the NORC report: Only 47% of people surveyed viewed the ACA positively. And in a separate study from New Mexico, by the research firm Latino Decisions, 75% of Latinos in that state could not name even one specific component of the health care reform law.
The Code Word
Publicizing the ACA to underserved groups means focusing on one word more than any other: Obamacare. Sanchez, who worked with Latino Decisions on research in Colorado, says that Latinos in that state have positive associations with the word — as do African-Americans, according to Kevin Patterson, CEO of Colorado’s state exchange, Connect for Health.
The power of the word “Obamacare” in underserved communities is starkly evident in an anecdote shared by Susan Burks, whose Denver-based firm BurksCommunications does marketing for Connect for Health. At a recent outreach meeting with African-American church ministers in Colorado Springs, information presented about the ACA was drawing mostly blank stares until one of Burks’ employees said, “This is Obamacare, folks.”
After that, “everything changed,” Burks says. “They all started asking, ‘How can we help?’”
Indeed, exchange officials say that the term “Obamacare” has been helpful in reaching Colorado’s sizable Ethiopian population. In Minnesota, according to O’Toole, “Obamacare” opens dialogue with Somali immigrants. Indeed, ample anecdotal evidence from these states suggests that some underserved groups view getting health insurance as something of a duty to President Obama and his call to action.
Contrast that with a recent poll of Kentuckians by the Kaiser Family Foundation. It showed that 49% of Kentucky residents have a negative view of Obamacare, whereas only 28% have a negative view of Kynect, their state exchange whose link to Obamacare often goes unrecognized. (Notably, African-Americans, Latinos, and immigrants make up much smaller percentages of Kentucky’s population than they do in the U.S. as a whole.)
The ultimate effectiveness of ethnically targeted outreach efforts remains to be seen. The exchanges cannot compel applicants to identify themselves by ethnicity, so precise enrollment numbers in many states that operate their own exchanges are not available. However, the most recent healthcare.gov data do show that about 70% of last year’s enrollees self-reported their ethnicity; of that group, one-third self-identified as Latino, African-American, Asian, or multiracial. Outside California, Connecticut seems to have the best data: Wadleigh says that Latino enrollment there has risen by about 30% since targeted outreach was implemented after the first open enrollment.
States that rely on the federal healthcare.gov exchange for enrollment are at an even greater disadvantage, primarily because they receive detailed demographic data only at the end of each enrollment period. That makes it much harder to adjust marketing and outreach efforts quickly.
“States that are running their own thing are having the best success,” Sanchez says. “They have a much better sense if they are doing well.”
This article originally appeared in NEJM Catalyst on January 6, 2016.