On a blistering cold Chicago night in November 2013, I met with Lorena, a 25-year-old uninsured Mexican-American bartender whose income fell below $18,000. Lorena belonged to a group that health policy experts refer to as “newly-eligibles,” single able-bodied adults without children living in poverty who now qualify for Medicaid thanks to the Affordable Care Act.
Lorena could have enrolled herself with relative ease. At the time, outreach efforts for the ACA were in full swing. In her home neighborhood of Pilsen, health navigators, insurance brokers, and nonprofit organizations were at soup kitchens, schools, taxi stands, and social service organizations spreading word and enrolling thousands. Our conversation, however, revealed something surprising.
“Do you plan on applying for health insurance through the Affordable Care Act?” I asked sitting across from her at a south loop coffee shop near the bar she worked.
“No,” she bluntly replied.
“Why not?” I asked.
“Mainly because I don’t trust government. I think anything they’re going to be putting out is flawed.”
“What makes you so distrustful?” I asked.
“My friend got these really strong stomach pains and almost fainted so I took her to the county hospital. We were there sitting for hours in the emergency room! The nurses were all hanging out at the desk giggling and laughing and talking to each other drinking their coffee and my friend is bent over like this [Lorena hunches over as she speaks] ready to pass out! I yelled at one of them, “are you gonna take care of her?” They came back to me laughing [telling me], “I’m sorry, we’re actually really professional.”
“What happened to your friend?”
“She was really dehydrated and had a bad urinary tract infection. She spent the night at the hospital which cost her $2300.”
“That experience made you distrustful?”
“Yeah, it’s terrible. When I look at the actual doctors [at the county hospital], they’re very professional and educated but everything else is downhill. With these county clinics, the staff sucks! It’s like they’re hiring just anybody.”
Being Uninsured a Conscious Decision
From November 2013-April 2014, I interviewed 45 uninsured adults like Lorena (between 21 and 35, single, without children, low-income) as part of an ethnographic study of the uninsured in the age of the Affordable Care Act. To my surprise, two-thirds refused to enroll or even inquire about the ACA because of their cynicism in government or the quality of health care provided by Cook County. For people like Lorena, their lack of health insurance did not stem from a lack of outreach or access. Being uninsured was a conscious decision to distance themselves from government and health care agencies.
As outreach efforts continue in Cook County and elsewhere, it is important for health care professionals to remember that the ACA is just one of many arms by which government shapes the lives of the uninsured working poor. For Latinas like Lorena, many of whom have undocumented family members, the ACA is part of the same government body that is deporting family members. For many of my Black respondents, the ACA was seen as part of the same government body whose police force is excessively using deadly force against Black citizens.
Although Medicaid enrollment has exceeded Cook County’s expectations, nearly 600,000 remain uninsured. It’s possible that people like Lorena, with distrust and cynicism toward government and health care, will be the most difficult to enroll.
Lorena’s story highlights the importance of bringing more nuance and strategy to ACA outreach efforts. For cynics of the ACA, simply informing them of their options is not enough to persuade them to enroll. Instead, cynics need to have their opinions validated (no matter how inaccurate or outlandish they might appear) and be empowered to enroll.
Convincing the Skeptics
Two weeks after my interview with Lorena, I observed Abram (a health navigator) put these face-to-face outreach strategies to work during his interaction with Joyce, a 32-year-old cynical and uninsured Black woman. It was family fun night at a Boys and Girls Club in Pilsen. Joyce brought her niece to the event and was sitting at a table eating a sandwich when Abram approached and introduced himself.
“Hi, I’m Abe.”
“Nice to meet you, I’m Joyce.”
“I’m here working for an organization and we’re trying to sign people up for the ACA.”
“Really?” asked Joyce.
“Yes, do you have health insurance now?”
“No.”
Abe pulled out a bright yellow pamphlet and said, “That’s ok. I can assist you with enrolling. In the end, it is completely up to you to make that final decision if you want to enroll in anything at all. I can start you off to see what’s out there. There’s Medicaid, which is completely free public assistance. With the new Medicaid, insurance companies can no longer deny you for pre-existing conditions.”
Joyce raised her eyebrow asking “Really?”
In response, Abe raised both hands in the air to gesture he meant no harm stuttering “I, I, I, don’t want to make any promises because, obviously, we have to see what plan you are eligible for…”
Joyce interrupted, “But that really means a lot to me because I’ve been denied lots of things in the past.”
Abe continued, “I’m going to leave you with my information [hands her his business card]. [Abe pulls out another sheet of paper] This is a list of documents that we are going to need in order to fill out your application, and I can actually sit down with you, with your permission, to go through the entire application. That is something you could do by yourself if you wanted to, or I could sit down with you and assist you.” One week later, Joyce made an appointment with Abe and enrolled.
Like Lorena, Joyce was skeptical that the Affordable Care Act would benefit her. In my interview with Joyce, she shared frustrating stories of seeking medical treatment for health problems only to be told she was ineligible for assistance.
Abram, however, never discounted or diminished Joyce’s skepticism. Nor did he make any promises that he could not keep. Instead, he validated Joyce’s concerns and reminded her that she was the one in control of the interaction, that she could walk away at any time.
Abram did not have to persuade Joyce to trust government or even health care providers. He just had to convince her to trust him, and he was successful by validating her concerns and empowering her.
The Outreach Road Ahead
As the ACA enters its third year, it is now entering a phase where those with the easiest access have enrolled and where many of the remaining uninsured are the hardest to reach. These include many uninsured adults whose negative experiences with government or health agencies have formed the basis of their outlook toward the ACA.
With face-to-face outreach strategies designed to validate and empower the low-income uninsured into enrolling, organizations conducting outreach for the ACA may be able to continue closing the cracks in the Illinois health insurance safety net. As Joyce said in recalling her interaction with Abe, “He didn’t try to sell me. He just say, once we do this it’s strictly up to you just because you talk with us and give us your information doesn’t mean you have to sign up, the ultimate decision is up to you.”
Robert Vargas
Assistant Professor of Sociology
University of Wisconsin-Madison
Robert is currently conducting research on the Affordable Care Act in Chicago, and the publications from his health care research are available at his website www.robvargas.com.
Connecting Navigators to Jobs so They Can Continue Connecting Consumers to Coverage
Navigators are key to health care outreach and enrollment across the country, but in Cook County the number of working Navigators is on the decline as grant funding slows. This is not only bad for individual Navigators unable to find work, but compromises the success of future enrollment cycles. In-person assisters of all stripes — including Navigators, Certified Application Counselors, agents, and brokers — play a crucial role in helping people apply for coverage. An Enroll America study found that people who got in-person help were nearly 60 percent likelier to enroll. To help keep assisters in the community, through the Health Insurance Workforce Pipeline Initiative, Health & Disability Advocates and the Chicago Cook County Workforce Partnership are connecting unemployed Navigators with jobs in the health insurance field — specifically as brokers.
Health & Disability Advocates is leveraging its connections in the health insurance community to bring employees and employers to the table. Meanwhile the Chicago Cook Workforce Partnership contributes Workforce Investment Opportunity Act (WIOA) dollars that pay for job-readiness training, workshops, and on-the-job training that new hires may need once they start their jobs as brokers. Since its formation in early May 2015, the Health Insurance Workforce Pipeline Initiative has hosted Rapid Response Workshops that describe the resources available for unemployed or soon-to-be unemployed enrollment assisters. HDA and CCWP also organized an exclusive job fair where Navigators could meet and interview with employers looking to hire.
Former Navigators are already transitioning into new jobs thanks to this initiative. A group of eight new hires who had previously collaborated as enrollment assisters to connect 51,000 people with Medicaid and marketplace coverage will now be working together as brokers, drawing on their experiences as Navigators. According to Tearalla, a new hire, “As a broker, my Navigator skills are transferable and aligned with my current responsibilities. I will continue to provide outreach, education, and enrollment assistance to newly enrolled consumers and consumers seeking to re-enroll in the Marketplace.”
These transitioning Navigators will be doing outreach and drawing on their strong connections — including with Navigators — in the communities where they worked for the first two enrollment cycles where they already have strong connections. Said Tearalla, “Networking with existing community stakeholders is ongoing.”
Everyone wins — employers and Navigators alike — when these Navigators transition into new roles as brokers. According to one hiring manager, they were able to hire more former Navigators because money spent for training was covered by WIOA dollars. The hiring manager was also excited that the new hires have great working relationships with groups and community leaders.
New hires are eager to continue enrollment work. They are already reaching out to previous community contacts to spread the word about their new role and the ongoing opportunity to get health insurance. Said one former enrollment assister, Olivia, “I’m excited about the opportunity to continue to enroll folks in the ACA.” It’s a wonderful opportunity for the overall enrollment push in Illinois, too. Having seasoned pros with strong community connections on the front lines of Affordable Care Act outreach like Olivia and Tearalla can help set up a strong foundation for the upcoming enrollment cycle and get even more people connected to health insurance.
This post originally appeared on Enroll America's blog.
Bryce Marable
Health Policy Analyst
Health & Disability Advocates
Chicago needs a plan to sign up its uninsured; here's what to do
Health care coverage has an impact on the economic well-being of lower- and moderate-income people; therefore enrolling the uninsured should be considered a key economic strategy for Chicago and all of Illinois. Unfortunately, this isn't the case.
Sixty-three percent of Illinois' working population eligible for a private path to health coverage under the Affordable Care Act is still uninsured, with large swaths residing in Chicago (see a breakdown of the numbers across Illinois here).
Given those statistics, Mayor Rahm Emanuel needs all hands on deck—from business leaders to health insurance brokers, from community institutions like public libraries to religious leaders—to encourage people to sign up.
Open enrollment for 2016 health insurance coverage starts Nov. 1, so the city is in serious need of a plan. We propose a Commission for Healthy Chicago, similar to the mayor's effort on violence prevention, comprising city staff and community, business, faith and health care leaders to build a cross-sector strategy for outreach and enrollment. Emanuel can improve the economic security of working-poor Chicagoans simply by putting the clout of his office behind such a strategy.
Chicago shouldn't expect the state to lead. In the midst of the state's fiscal disarray, Get Covered Illinois has lost most of its staff and has stated it will rely more heavily on “partners” such as providers, brokers and nonprofits for enrollment support. GCI's limited capacity can't get the job done; nor should the city and state expect nonprofits and health care providers to fill the gap in funding or leadership.
The Task Ahead
With only 37 percent of the estimated 942,000 marketplace-eligible residents having enrolled, Illinois ranks 20th out of the 37 states that operate their marketplaces using the federal HealthCare.gov website.
Here's another way to look at it: Two years into ACA's health insurance efforts, almost two-thirds of Illinois' marketplace population—the lower- to moderate-income people for whom the ACA was created—remain uninsured. Almost half of them are eligible for a tax credit or subsidy to make their plan more affordable.
Overall, about 73 percent of the nearly 600,000 people who are eligible but still uninsured live and work in the Chicago metro area. Within these areas there are significant proportions of the population who do not speak English as their primary language. In nearly half the metro area, at least one-third of the population speaks Spanish or another non-English language. In several of these areas, primarily in Chicago and suburban Cook County, more than 50 percent do not speak English as their first language. Notably, the areas with the highest proportion of non-English speakers are the same areas with the lowest share of eligible population enrolled.
Other states have successfully enrolled low- to moderate-income people in the ACA health insurance marketplace. They have done this through:
• Use of data to target communities with large, underserved marketplace-eligible populations.
• Exploiting numerous local avenues to provide extensive education and outreach, including through events and local media, to directly connect the uninsured with help to enroll in coverage.
• Meaningful collaboration with brokers and the small-business community.
A healthy Chicago economy goes hand in hand with a healthy population that is ready to learn, work and is not burdened by health care costs. Let's not let Chicago and Illinois fall behind when it comes to covering working families.
This article originally appeared in Crain's Chicago Business.
Barbara Otto
CEO
Health & Disability Advocates
Illinois Dodges Disaster on Supreme Court's Obamacare Ruling
The following originally appeared on Crain's Chicago Business.
Illinois just dodged a bullet with the outcome of King v. Burwell. If the Supreme Court had ruled against subsidies being challenged in the case, working people and families in the state collectively would have lost more than $49 million a month to help purchase health insurance.
In its decision, the court affirmed the legality of the provision of premium tax credits under the Patient Protection and Affordable Care Act in all states, whether they established their own health insurance marketplace or used the federal marketplace. On average, working poor and middle-class Illinoisans are getting $211 monthly to help pay their health insurance premiums. A different decision would have meant a 169 percent increase in out-of-pocket expense on the average premium.
Recent data by the Kaiser Family Foundation show nearly 73 percent of the remaining uninsured in Illinois eligible for Get Covered Illinois, the state's health insurance marketplace—roughly 597,473 people—live and work in metropolitan Chicago. In the Chicago area, more than 100,000 of the remaining uninsured reside in areas where English is not the predominant spoken language. While concise data are not available of how many of the uninsured are working, American Community Survey data indicate that as many as 62 percent of the uninsured in Illinois are working at least part time and more than likely work for small businesses.
The most recent year for which U.S. Census data on businesses are available, 2012, show 314,199 business establishments in Illinois. However, 94 percent of these companies employ fewer than 50 employees and thus are not required to provide health insurance via the ACA. Cook County alone accounts for 41 percent of the state's total small businesses.
NOW WHAT?
Now that the King v. Burwell decision has put the legality of subsidies to rest, Illinois needs to get busy enrolling the remaining 597,473 uninsured individuals eligible for a path to coverage in the Get Covered Illinois marketplace. Of these uninsured, 283,629 are eligible for a tax credit or subsidy.
It's a matter of economic security for our residents and for Illinois' economic environment. The math tells us that the business community—especially small businesses—needs to be at the heart of efforts to enroll the remaining uninsured. Crain's and Health & Disability Advocates surveyed small businesses last fall and learned that Chicago-area companies still face increasing health care costs; are confused by the requirements of the ACA; and are unlikely to enroll themselves and their employees online. In fact, more than 80 percent of those surveyed said they shop for health insurance for themselves and their employees using health insurance brokers and agents.
Now that federal funding for ACA assisters and navigators is ending, a public-private partnership for enrollment in Get Covered Illinois is critical. We need to double down on engaging health insurance brokers and agents. While the state did an amazing job in enrolling 633,757 adults in Medicaid as part of ACA, Illinois ranked well behind others in marketplace enrollment, coming in 20th out of 37 states that operate marketplaces using HealthCare.gov.
Get Covered Illinois is key to helping Illinois businesses thrive, enabling them to better attract and retain talent. The marketplace also encourages entrepreneurship by ending the reliance of individuals on larger employer-sponsored coverage.
A strong ACA marketplace is a win-win for the business community and the state. We urge Springfield, City Hall and county governments to make enrollment of the remaining uninsured a top priority and engage the business community, health insurance brokers and agents in the process.
Barbara Otto
CEO
Health & Disability Advocates
Erica Salem
Director of Strategic Health Initiatives
Health & Disability Advocates
The Future of Enrollment in Illinois: Where We’ve Been and Where We’re Going
When Get Covered America came to Illinois before the first open enrollment period for the Affordable Care Act in 2013, there was a lot of work to be done. At that time 78% of the uninsured had not heard of the health insurance marketplace and were unaware of the new health coverage options or opportunities for financial help available to them for the first time. The initial awareness gap was daunting, but hundreds of thousands of Illinoisans stood to benefit from the marketplace and needed to know how the Affordable Care Act could help them.
Many Milestones Through Collaboration
Fortunately, there were a number of stakeholders like Health & Disability Advocates (HDA), the Campaign for Better Health Care (CBHC), Alivio Medical Center and the AIDS Foundation of Chicago, among others, eager and ready for the challenge ahead. This commitment helped achieve many of the goals laid out in the beginning. After two successful open enrollment periods, nearly 350,000 Illinoisans have enrolled in health insurance through the marketplace, and hundreds of thousands more have received coverage through expanded Medicaid and CHIP. Working together towards the same mission, Get Covered America and its partner organizations increased awareness and provided enrollment resources for consumers across the state.
Stepping Back to Move Forward
Because of the great work that has happened on the ground in Illinois, Get Covered America will be stepping back with full confidence in capable partners like HDA, CBHC and many others—such as Family Guidance Centers and Ada S. McKinley—to continue this important work to make health care enrollment a permanent part of communities. It’s clear that the coalition of partners who have come together on this issue have made great strides over the past two years. As the insurance landscape changes and the number of uninsured Illinoisans continues to decrease, Get Covered America wants to make sure that resources are allocated in the smartest and most effective way.
While Get Covered America won’t have an active outreach presence on-the-ground in Illinois moving forward, the organization will continue to support partners in the state with cutting edge data, best practices, tools and resources. Get Covered America will refine and continue to offer digital tools like the Get Covered Connector while also introducing new programs, like training and support for local partners and health insurance literacy resources for the newly insured.
The Enrollment Challenge Ahead
Just released by Get Covered America, the State of Enrollment Report takes a critical look at the lessons learned and what still needs to be done to get Illinois covered. Using on-the-ground knowledge and data analysis, the report identified several key initiatives integral to maximizing the number of Illinoisans who enroll in coverage. This is a great resource for partners on the ground and the foundation for a sustainable coalition for years to come.
The Get Covered America team is thrilled at what has been accomplished in Illinois so far, but there’s still important work to be done. While more Illinoisans have health coverage than ever before, there are still too many who remain uninsured and need the facts about how the Affordable Care Act can help them and their families. On-the-ground partners like CBHC, Family Guidance Centers and Alivio Medical Center will continue this work and make health care enrollment an institutional reality for years to come. And Get Covered America looks forward to supporting their efforts.
David Elin
National Fundraising Director
Enroll America
Faith Leaders Leading the Way on ACA Outreach
CBHC's Faith Caucus is taking a lead role in our efforts to promote enrollment in Illinois' new Health Insurance Marketplace, and a crucial partner in spreading the positive word on health care reform. We are so pleased that the role of our faith leaders in outreach around the Affordable Care Act was important enough to have an AP story!
Faith leaders emerge as key to health law outreachFor the full story, please visit http://www.bnd.com/2013/08/09/2736052/faith-leaders-emerge-as-key-to.html.
CHICAGO — Religion and the nation's new health law haven't exactly been viewed as friendly partners in the public eye, with most of the attention focused on religious employers' objections to covering the cost of birth control.
But under the radar, leaders in some Illinois faith communities are spreading the word about the Affordable Care Act to make sure their uninsured members know about new benefits available starting in 2014 and about the approaching enrollment start date.
Thanks to Rev. Carole Hoke, Rev. Dr. Shirley Fleming, and Aida Giachello of the CBHC Faith Caucus, and to Carla Johnson (@CarlaKJohnson) of the AP for the story.
Health Care Reform Leadership Training for Faith Community and Communities of Color
You can register by clicking this link.
| Day | Date | Time | Location | Room |
| Tuesday | August 28st, 2012 | 1-4 pm | Mercy Hospital | Great Room |
| Tuesday | September 19th, 2012 | 1-4 pm | St. Mary’s Hospital, | 1CD |
| Tuesday | October 16th, 2012 | 1-4 pm | Mercy Hospital | Room 242 |
| Tuesday | November 13th, 2012 | 1-4 pm | Mercy Hospital | Penthouse |
| Tuesday | December 11th, 2012 | 1-4 pm | Mercy Hospital | Penthouse |
Director of Faith Initiatives
Campaign for Better Health Care