HEALTH INSURANCE EXCHANGES

Spreading the Word

Sally McCarty

EDAC 632

Dr. Bo Chang

December 3, 2012

What are Exchanges?• A major provision of the Affordable Care Act

(“Obamacare”) • Online insurance coverage marketplaces

• Will be operational by January 1, 2014• Enrollment begins October 1, 2013

• Individual Exchanges • For those who don’t have group coverage

• SHOP – Small Business Health Options Program• An Exchange for small employer groups (fewer than 50 or 100

employees, depending on state definition)

What will be sold on the Exchanges?

• Four types of policies will be offered by commercial insurers who apply to be “Qualified Health Plans” (QHPs).

• Bronze • Silver • Gold • Platinum

• Premium Subsidies/tax credits for household incomes between 131% and 400% of the Federal Poverty Level

• Advanced tax credits paid directly to insurer and insurer bills for remainder.

States Have 3 Options• State-based Exchange

• Operated by the state • Minimal federal involvement

• Federal/State partnership Exchange • In conjunction with the federal government • Shared management

• State performs some tasks (e.g., premium rate review) • Federal government performs others, (Medicaid eligibility determination)

• Federally Facilitated Exchange • State defers to federal government • State’s consumers purchase from the Federal Exchange

Funding the State Exchanges• Several types of grants have been available to States:

• Early innovator Grants – for States that decided in 2011 to opt for a State-based Exchange.• Assistance for planning, consultants, IT contractors, etc.

• Planning and Establishment Grants – two levels • Level I - initial planning and research, deciding which option to

choose• Level II – more advanced in process, IT contracts and equipment,

staffing, etc.

• Example: Indiana applied for and received $7.8 million in Level 1 grant funds.

The Dilemma

• “A health exchange’s first task is ensuring that those who are eligible for benefits know about them — right now, research suggests three-quarters have no idea.”

• Sarah Kiff, WashingtonPost.com, November 12, 2012

The Program• Design a community outreach program that states can

use to • Educate consumers about the benefits available

through the Health Insurance Exchange, and • Teach consumers how to access the benefits.

• Adopt the organizational culture/symbolic management perspective • Most appropriate for an endeavor that requires multiple

organizations and cultures (state agencies) to • Work in a coordinated fashion • Toward a common goal to educate the public

• sharing common values• Developing unifying symbols

Program Goals• Assure that consumers who are eligible for coverage

through a state’s Exchange are aware of the Exchange

.• Assure that all consumers who are eligible for coverage

through an Exchange know how to access the Exchange

• Assure that consumers who are eligible for coverage through an Exchange are aware of the subsidies and tax credits for which they may qualify.

Attitudes toward New Health Insurance System “Most were aware of the changes coming in 2014 but knowledge levels were uneven. Some respondents were very knowledgeable about the new system and how it will work, while others were very uninformed. The Spanish-speaking respondents tended to be part of the latter group. In general, there was strong support for the changes but the support was tempered by considerable skepticism on the part of many that high-quality and affordable plans would actually be available.” Discussion of qualitative research from a California Health Benefits Exchange planning document.

The Challenge

Why Organizational Culture/Symbolic Management?

• Success of State Based Exchanges will rely on cooperation among a number of state entities:• Exchange Staff and Board of Directors • Department of Insurance• State Health Department• State Family and Social Services Department, most importantly the

State Medicaid agency

• Most appropriate for an endeavor that requires multiple organizations and cultures (state agencies) to • Work in a coordinated fashion • Work toward a common goal to educate the public

• While sharing common values• And developing unifying symbols

Common Themes found in Literature Review

• Shared values and goals, and participative and less bureaucratic management make an organization more efficient (Tompkins, 2005, p. 360).

• Organizational “symbols,” such as language, rituals, and traditions, can be means means to understanding an organization (Tompkins, 2005, p. 361).

• An organization’s culture affects both the quality of the experience of those involved with an endeavor as well as the quality of the organization’s work product (Pennisi, 2012).

• Transfer of organizational culture to new employees during orientation directly correlates with worker self-efficacy (Simosi, 2012).

Edward Schein’s Symbol Categories• Artifacts:

• visible, such as physical environment, the way meetings are conducted, organizational structure, etc.

• Espoused values • less visible, conscious, such as values that members of the

organization claim to espouse as expressed in various ways, such as strategic goals

• Basic underlying assumptions • not visible, subconscious, taken for granted and create consistency

of behavior (Tompkins, 2005, p. 363-364).

Program InvestigationsEhealthinsurance.com

[Private, commercial enterprise]

Massachusetts Connector

[Government Program]

Values/Organizational Culture (drawn from clues on web site and elsewhere)

• Numbers Driven• State-of-the Art IT system• Profit Oriented• Focus on Customers at

expense of employees

• Team spirit• Human interest• Focus on customers

Artifacts Annual Report is quantitative, using data to illustrate accomplishments.

Consumer education materials are easy to read, attractive, and geared toward the average consumer.

Annual report is qualitative, using human interest stories to illustrate accomplishments

Consumer materials are wordy and geared toward a more sophisticated consumer

Program InvestigationLessons Learned

• Each program is doing an excellent job in assuring that those who access its services get the help they need.

• The organizational culture of the Massachusetts Connector is more team-oriented and better suited to my program ( perhaps as a result of running a program that has been heavily scrutinized).

• The Ehealthinsurance consumer materials were more useful, consumer friendly, and better suited to my program (perhaps because of access to better design expertise).

Program Evaluations Lessons Learned – Michelle Rice

• National Advocacy Director – National Hemophilia Foundation

• Two principles that should be incorporated in all message delivery activities. • Choice • Broad appeal

• These are of utmost importance to the chronically ill when delivering the news of Exchanges

Program Evaluations Lessons Learned – Kevin Lucia

• Research Professor, Georgetown Health Policy Institute and Member of the DC Exchange Board of Directors

• Divide the program into two “tiers”• Tier 1 to deliver the “broader” message” that insurance is available,

without details. (The paid media, social media, billboards, posters, etc.) • Tier 2 to deliver the details, once the first message is received (face-to-

face meetings, speakers’ bureau, brochures and other more-detailed print materials).

• Partner with a unifying organization, e.g., Massachusetts Connector partnered with the Boston Red Sox • Uses common cultural values (love of sports, admiration of sports

figures, affiliation with a team, loyalty to that team), and all the symbols affiliated with that entity (logos, mascots, players, etc.) to gain adherence to the primary message.

• Target specific populations

Building the Exchange on Shared Values

• Many of the agencies and groups represented in Exchange operations already share values• Consumer protection and • Access to quality healthcare• Access to affordable health coverage for all, especially vulnerable

citizens,

• Exchange Staff and Board of Directors – Physician and Hospital representatives

• Department of Insurance – Consumer protection activities• State Health Department – Public health responsibilities• State Family and Social Services Department – Aid to vulnerable

citizens• State Medicaid agency – affordable coverage for pregnant woman,

children, the disabled, and the elderly.

Program Design – Tier 1• Tier 1 is designed to deliver a simple message and not

detailed information, e.g., “Get Insured,” or “Insurance is Now Available”

• Media the simple message to target audiences:• “Young invincibles” (healthy young adults who do not tend to purchase

health insurance),• Uninsured individuals and families, particularly women

• Involve the unifying organization partner. • Use social media, paid and free, as well as media outlets

geared toward target audiences – radio stations, billboards, • Posters in doctor’s offices, clinics, emergency rooms, social

service agencies – wherever uninsured are likely to visit

Tier 2 – Elaborate on the Message• Discussion

• Services available through the Exchange, including subsidies and tax credits

• Steer those who could benefit from the Exchange’s services to the navigators or others who can help them

• Media• Strategically-placed articles and stories in media around the

state• More social media, with more information

• Print• Brochures and other print materials in same locations that posters

were placed.

• Billboards• In densely populated and medically underserved areas.

Tier 2 Face to-Face• Convene representatives of social service groups that serve those

with healthcare needs and engage them in spreading the word• Disease group advocacy organizations, • Public health nurses, • County health offices,

• Create a speakers’ bureau drawing from all agencies • Delivering a uniform presentation of the Exchanges services, to a broad

range of organizations, such as:• Local chambers of commerce and other groups representing small

businesses, • Physician organizations, • Service organizations (Optimists, Kiwanis, etc.), • Insurance agents and brokers,

Develop Unifying Mission Statement• The vision of the California Health Benefit Exchange

is to improve the health of all Californians by assuring their access to affordable, high quality care. The mission of the California Health Benefit Exchange is to increase the number of insured Californians, improve health care quality, lower costs, and reduce health disparities through an innovative, competitive marketplace that empowers consumers to choose the health plan and providers that give them the best value.

• California Health Benefit Exchange Mission Statement

Develop a Unifying Symbol or “Brand”

www.getcoveredco.org

www.coveroregon.com

...and Spread the Word that it’s here!

References• Pennisi, Lisa. (2012). Experiencing the Impact of Organizational

structure on planning and visioning tasks. A Journal of Leisure Studies and Recreation Education, 27(1), 46-54.

• Simosi, Maria. (2012). The moderating role of self-efficacy in the organizational culture-training transfer relationship. International Journal of Training and Development, 16(2), 92-106.

• Tompkins, Jonathan R. (2005) Organization Theory and Public Management. Boston, MA: Wadsworth Cengage Learning