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
An Observation on the “Observation Status” Law: It Doesn’t Work
The law, called the NOTICE Act, requires hospitals to notify patients hospitalized for more than 24 hours if they are on observation status. The law won’t go into effect until next August, which is great, because it could be better.
The way the law is written right now, it’s almost like asking a patient under anesthesia to sign a consent form. Within the first 24 hours of being admitted to the hospital for a medical event, many people—especially older people—aren’t able to focus on complicated issues of their status and its consequences.
Being on observation status has significant financial consequences. Observation status is considered outpatient service by Medicare. All care, supplies and procedures are covered under Part B, not Part A, and therefore are subject to Part B's higher deductible and co-pays. On top of that, most hospital pharmacies do not contract for Part D drug payments. Patients who have to take their normal medicines while under observation status will have to submit reimbursement requests to Medicare.
If a patient requires skilled nursing care after being discharged, Medicare will only pay for it following three days of inpatient hospitalization. Being on observation status—an outpatient—doesn't count toward the three-day requirement.
One Woman’s $3,900 Surprise
Jean Arnau, an 84-year-old who spent five days in the hospital with a fractured spine is a perfect example of how observation status poses consequences after discharge. She was in a hospital bed, wore a hospital gown and ID bracelet, ate hospital food and received regular nursing care.
When she was discharged and needed to transfer to a skilled nursing facility for rehabilitation, her family learned that she had never been formally admitted as an inpatient to the hospital at all. Instead, she'd been classified as an outpatient under observation and the nursing facility would charge almost $4000.
What To Do Until There’s a Real Fix
It’s great that the NOTICE Act requires patients receive “accurate, real-time information with respect to their classification, the services and benefits available to them, and the respective cost-sharing requirements they are subject to." It’s just that doing it within 24 hours of admission is too often not fair.
Talk to your clients, and their loved ones, before the need arises. The Center for Medicare Advocacy has put together a thorough packet explaining what your clients can do to protect themselves.
You can help by discussing these things with them:
• Urge them to ask about their status each day they are in the hospital. It can change from day to day.
• Tell them to ask the hospital doctor to reconsider your case or refer it to the hospital committee that decides status.
• Tell them to ask their primary care physician to state whether observation status is justified. If not, ask him or her to call the hospital to explain the medical reasons why you should be admitted as an inpatient.
• If they need rehab or other continuing care but learn that Medicare won't cover a a skilled nursing facility, tell them to ask their doctor if they qualify for similar care at home through Medicare's home health care benefit, or for Medicare-covered care in a rehabilitation hospital.
• After the fact, let them know they can appeal a Medicare decision of non-coverage. All the avenues for appeal are spelled out in the Center for Medicare Advocacy’s packet.
Preparing loved-ones before they are hospitalized isn't a fix to law, but it will empower future patients with a plan and knowledge of their rights. After having these conversations, patients will be more enabled to fight for their rights while Washington hopefully gets around to making much needed improvements to the law.
Phillip Lanier
Health Policy Intern
Health & Disability Advocates
Halloween Marks a Scary Time for Health Care in Illinois
If things don’t change soon, health care could be in for major setbacks in Illinois. The State budget battle is approaching its fifth month and counting. So far, Medicaid payments continue per court order, but other services are beginning to run out of money:
- State payments to 911 call centers throughout the Illinois have been suspended, putting emergency services in jeopardy.
- Illinois has stopped paying medical and dental claims for 150,000 state employees. The long-term cost of delayed care for a group of this size could be far greater than the cost of paying for care and preventative care today.
- The state’s Psychiatric Leadership Capacity Grant, which was $27 million in the State’s FY2015 budget, is no longer being funded, affecting most of the 140 community health centers in Illinois and thousands of people who rely on them for psychiatric care.
It’s Not Too Late to Raise Your Voice!
Contact your State legislators to let them know how concerned you are about the future of health care in Illinois. Tell them that Illinois seniors and children are especially vulnerable. We can’t let cuts affect them.Many program cuts will result in greater costs to the State in the not-so-long run. For example:
- Home care services and home delivered meals to seniors citizens cost a fraction of the $75,000 annual cost of nursing home care. Cuts to these programs will mean more seniors ending up in nursing homes, paid for by Medicaid.
- Cut backs to after-school programs and Department of Children and Family Services support for older children will mean more kids and young adults intersecting with the justice system. Even short-term incarceration can pay for a full year of after-school activities for a child.
- Cut backs to mental health services will only cause an increase in city and country jail populations where the State will not only have to provide mental health services, but food, clothing and shelter.
Phillip Lanier
Health Policy Intern
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
Whose Stethoscope is it? The View's Joy Behar Algorithm
Tweet
Memes Responding to The View's Joy Behar Nurse-Doctor Stethoscope Comment.
Nurses swarmed Facebook and Twitter during their rare combined bathroom/lunch break to support the Miss America contestant and to defend their profession against the incredible remarks.
What better way to support nurses in their rage than to honor their duty to service with a handful of memes. Please enjoy this original collection of The View Joy Behar Nurse Memes, courtesy of The Happy Hospitalist.
"So you insulted 3 million nurses and still have a job?"
"Prepare yourself. Nurses are attacking!"
"What do you mean doctor's stethoscope!"
"One does not simply insult a nurse and get away with it!"
"What if I told you angry nurses are never a Joy to Behar!"
"If you could stop calling it a doctor's stethoscope, that would be great!"
"America is a land of opportunity. All you have to do is not say "doctor's stethoscope!"
Tweet