ACA Enrollment as a Continuum
This week, U.S. Secretary of Health and Human Services Kathleen Sebelius is expected to reveal early numbers of how many Americans have applied for and enrolled in health coverage under the Affordable Care Act (ACA). Several states running their own insurance exchanges have also released their own statistics to substantially less media attention and fanfare.
It's understandable that ACA critics and supporters alike are watching these numbers closely. ACA supporters are looking for evidence of success stories and "quick wins" to counter the discouraging troubles facing the federal exchange website. Opponents are hoping to confirm their existing convictions that the ACA will fail and, more broadly, that our federal government cannot deal with large and complex problems such as expanding insurance.
We live in a data-driven world, and we have come to expect data and analysis to support our decisions and views. However, in the case of the ACA, it would behoove all of us, regardless of political and policy stances, to take a longer view. Expanding insurance coverage to 30 million people, who previously had no meaningful access to insurance and limited access to health care, is a monumental undertaking. This is not to excuse the technical and related public relations gaffes committed by the administration, but rather to point out that changes this important do not occur neatly or linearly. The process may not offer immediate and gratifying evidence of its resounding success. We must recall that our unique brand of healthcare and insurance here in the US is immensely complex. The system has not been through a similar upheaval since the creation of Medicare in 1965. That process, which similarly provided new insurance to vast numbers of Americans, took several years to enroll millions of seniors.
Enrolling any individual or household who previously had no insurance into new coverage is not straightforward. Ideally, this process would be as intuitive and user-friendly as ordering new shoes on Zappos or buying electronics on Amazon. Indeed, the administration touted Healthcare.Gov and its enrollment process as just that. But if we pause for a moment, we understand that was never possible. The process of educating a new consumer about a complex insurance product and enrolling them in a plan with government subsidies was never going to be as smooth as one-click shopping and Amazon Prime delivery.
Further, even if enrolling were as simple as online shopping, many Americans face additional barriers to quick and easy enrollment. Individuals with limited English proficiency face the daunting task of understanding highly complex insurance concepts and eligibility requirements without adequate translation and interpretative services. Nearly half of LEP Americans are uninsured, making them about three times as likely to be uninsured than the general population. These individuals will require even more assistance, time and support to gain coverage.
Enrolling in new coverage should be thought of as a process with several stages, rather than a discrete event to be easily captured by the aforementioned enrollment statistics. Individuals and their families are on a continuum of education, understanding and engagement with the ACA. This continuum ranges from those who are not even aware of their new coverage options, to those who know exactly which plan they want and have already calculated their subsidies. In between those extremes are where most of the ACA's target audience lies at the moment.
The ACA created a critically important group of dedicated individuals known as Navigators and Assisters. These are individuals who are trained to take citizens through the enrollment process. However, very rarely do they navigate clients from zero ACA knowledge to enrollment in a single sitting. They often engage with, educate and support individuals over multiple one-on-one sessions, supported by other resources in the community.
Through ZeroDivide's project supporting public libraries in their ACA services, we have observed firsthand the many community touch points that are necessary to successfully enroll individuals under the ACA.
For example, first, a given individual might hear about opportunities under the ACA via a radio advertisement. Then he might explore the exchange website before getting the courage to attend a meeting at his local library. The library could then connect him to a local Navigator who works with him through several sessions to find the right plan and understand the complexity of deductibles and copays.
When enrollment numbers are released and the expected uproar ensues, remember that enrollment is a continuum of education, understanding and engagement. It is not a single event captured by a binary statistic. While the data may look grim in the near term, if you look a bit closer, there is more to the ACA's story. More and more folks will continue to find support from their communities to move along the continuum toward new coverage and meaningful understanding of it.