This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.
As the February 15 deadline for open enrollment on the ACA marketplaces approaches, surveys tells us that many uninsured people remain unaware or misinformed about whether they qualify for subsidies to help purchase health insurance. Prior to the ACA, many people looked to agents and brokers to understand their options and to help them find an individual plan.
But agents and brokers face obstacles in fully engaging in the marketplaces, as an RWJF/Urban Institute Issue Brief concluded from interviews with insurance professionals after the first open enrollment period. They reported obstacles such as IT issues, poor training, inadequate customer support, and difficulty being paid from state marketplaces. Further, the authors noted, agents and brokers tend to have minimal experience working with a low-income population, and may lack relationships with communities with historically low levels of insurance.
Lafayette Jones and Sandra Miller Jones don’t fit that bill. Using their experience marketing products to African American communities, they have embraced their role in connecting people to insurance through the federal marketplace. In partnership with other licensed agent-navigators, their organization has helped more than 3,000 people and families across North Carolina find health insurance. The following is an edited transcript of our conversation with them.
LDI: How did you decide to become involved in health insurance enrollment and what skills do you bring to the table?
We were already, over the last decade, working with a number of insurance companies and AARP. As a result of our relationship with AARP (and collaborating partners Aetna and Magic Johnson Enterprises), we were doing health fairs in Washington, D.C., New York, Atlanta and other markets targeting African Americans. We designed programs around Medicare enrollment and developed a specialized toolkit that was distributed through churches, barber shops, community centers by “feet on the streets” ambassadors.
When the ACA came along, we began to look at it and wonder how we could be of value. We decided to get familiar with it and we went to [a large insurance company]. Their president asked us to develop a multicultural marketing program, in particular targeting African Americans in North Carolina. Now we provide access to products sold by multiple insurance carriers.
How do your clients find you and access your services?
We fish where the big fish are. We know that we can target certain zip codes, we know that we can find our target audience at churches, at beauty salons, at barber shops and community centers. We understand the culture and how to navigate the culture. We have flyers, posters, print and digital ads, we use gospel radio and all kinds of other tools to reach the target group of people.
There are about 28,000 zip codes in the U.S. You can find 80 percent of African Americans in 2,000 or 3,000 of those zip codes, so a small number of zip codes allow you to be in touch with a high number of African Americans and Latinos.
What is the demographic breakdown of your clients in terms of age, race and gender?
I would estimate that 90% of our clientele is African American. We also work with about 10% Hispanics and Whites. The age groups range from 21 to 64 years old and they are skewed toward that middle range of 35 to 55.
Because we are in the south and there is a significant minority population in rural counties, we have been involved with rural African Americans just as much as urban. There is a significant number of underserved Whites and Latinos on the fringe of African American communities – in continuous neighborhoods nearby – and they often walk into our enrollment centers.
What sort of training process was involved with becoming an insurance agent?
When we became licensed insurance agents in the state of North Carolina, there were lots of product-specific training programs about each of the carriers – Blue Cross Blue Shield, Aetna, Coventry, United Health and others. It was a lot of studying individual company programs, state licensing, and federal government programs.
What is the different between a licensed agent-navigator and the navigators we usually hear about in connection to ACA enrollment?
The federal government has a significant number of navigators on the street. Navigators are valuable for one specific job in one specific period. Navigators are good at finding and helping people to get enrolled, but our experience is that enrollment is just part of the process. For us, enrollment has meant everything from finding the people, making them aware of the benefits and downsides, and also helping them through to finding the right doctor when they enroll.
We have adopted the term agent-navigator because an agent-navigator can do more for the beneficiary and insurer group. Agent-navigators can provide people with professional counseling about plans on a year-round basis instead of just during open enrollment.
Are there enough navigators and agents in the field to meet the new demand?
We know that there is a dearth of African American and Latino insurance agents. There need to be more people in the field like us. We have gone from a small group of five when we started to almost fifty of us now. It’s a conglomeration, a collaboration, an association. A good portion of them don’t actually work for us. We got them because we said, “there are so many people trying to sign up. We need help!”
We don’t have any state grants or federal grants, and it’s certainly a labor of love, but we are also businesspeople. We have to find corporations to support it. When you look at insurance carriers and providers like hospitals, they are just becoming awake to how to serve this population. They know how to serve this population from a professional, medical point of view, but they just don’t have the tools we do and there are very few organizations around like ours.
Could you go more in depth about how you help people post-enrollment?
Many people have been to the emergency room but not to the doctor, and they don’t know the process or expectations when they have their own primary care physicians. There are people who are enrolled who don’t know what step three and four is. Once you get enrolled, you have a doctor – go see your doctor! You can’t sit there and let them tell you what to do. You have to have some dialogue and tell them what needs you have. Many people have not had insurance before and are used to going directly to the emergency rooms.
One young man who we coached didn’t pay his premium one month because he wasn’t sick. What that meant to us was that he didn’t understand what insurance was. We coached him to understand that you need to pay insurance every month because you get benefits every month, whether or not you use them.
For people who miss the income cutoff and live in states that did not choose to expand Medicaid, those people are absolutely lost because there is nothing for them. Some of their children are in children’s health insurance programs and Medicaid, but there is no funding for the parents. If the parents don’t have any insurance, and they haven’t had any insurance before, they don’t expect to get insurance and use it.
What other perceptions or understandings health insurance are out there that you have discovered through your work?
There are many people who are confused about what’s going on. They’re trapped between the Republicans’ and the Democrats’ constant fighting: “You should have health insurance” and “No, you should not have health insurance.” These people don’t know what to think. Their decision is often driven by political forces that have nothing to do with their health care.
We have another group of what we call “absolute converts.” These are the people who have heard about insurance and the Affordable Care Act. They want to know about it, but it’s kind of like when the ATMs came out in the world. Everyone looked at it and wondered what it was. And we weren’t quite sure if we were going to put our money in it, but you would press a button and money would come out. Well, ATMs are commonplace now and everyone uses them. Such is the same with health insurance and enrolling for health insurance.
There is also a group of people who have been told through videos and radio that, “all you have to do is just go to your laptop or computer and sign up. It’s like booking a ticket.” Well, maybe it’s like booking a ticket for those who fly. But for those who have never been on a plane, or don’t have a laptop or access to a computer, it is very new to them. We have talked to a number of our clients, many of whom are sophisticated people, who have gone online and been absolutely thrown.
What is your perspective on the technical and administrative problems during the first period of open enrollment last year?
The system has gotten better – no doubt about it. What we had last year and this year is vastly improved. The process of purchasing affordable health insurance is continuing to improve… because the geeks are here now! We are finding ways to create shortcuts where we can knock out some of the barriers to sign-ups.
The insurance companies – Aetna, Coventry, United Healthcare, Blue Cross Blue Shield – are benefitting too because they have never had such a huge number of people sign up. Can you imagine six to seven million people signing up for health insurance in a ninety day period with 14,000 points of data on each person? There are just so many systems that actually melted down. Even the federal government system melted down where they couldn’t take phone calls – on top of the original problems with the original website. So you had slowdowns and breakdowns with sign-ups.
Another problem that they had is that a large portion of the population is unbankable, where they don’t have a credit card or debit card. All they know is cash or postal money orders. The big boys didn’t know that. These are not PayPal people – they don’t know what PayPal is. They are flying below the radar, unbanked.
Then you have a group of people who want to get in on the deal but they can’t because they haven’t filed their taxes. They have never filed their taxes. Some of them are now beginning to file their taxes because they see the benefit of it. For the first time there is a program where if you have an income between x and y, you can actually get a really great benefit.
There are people that we have signed up with five or six children and we’ll get them a $1500/month subsidy for the husband and wife (the children are usually all on Medicaid and CHIP) to take care of their family’s insurance needs. It’s a really good thing. Their out-of-pocket is $5, $25, $50. It’s very minimal – or what we call minimal. A $5 payment per month for many of our clients is still a hardship.
What has improved this year with the ACA rollout and what still needs work?
First of all, the website works. That’s a big deal. In the Healthcare.gov call centers, the people are actually really good. I’ve talked to hundreds of them. The quality varies, but nine out of ten times they’re good. They’re friendly, they’re courteous, they want to help people. What the administration has done on the front end has worked.
Their marketing is weak. There are millions of people who they aren’t touching because they are underutilizing tools – and I don’t mean just navigators. They are spending a ton of money with navigators, which is fine, but there are other things they can do to develop a comprehensive program. When you are in this battle to spread the word, you need seasoned marketers with experience in this category. There is a group of people like us who can be an enormous help to the federal and state governments.
What client stories can you share that are particularly memorable?
I spoke to a woman yesterday. We’d been trying to get the daughter, who is 19, on her mother’s policy for three months. We have been working on this since day one but could not get through the administrative hurdles until now. We helped her do that and she was so pleased that her daughter would have health insurance too.
Another story comes to mind. A husband and wife came to Goodwill and sat down. She said that she was there to get insurance. He had his mouth stuck out and said that he didn’t want any of that Obamacare. She said to him, “Tell you what, buddy. We’re not going to have any more children here because I’m just not going to go through that process unless we have insurance and get comfortable. So we can sit here and get enrolled, or… guess what!”
What keeps you going in this work?
I’m getting ready to turn 71 and I’m working on this because I love it. I love going out into the field, talking with folks and feeling the joy. We’ve recently moved our offices to a black church with a brand new family enrichment center. Health is where it is. It’s the future.
Imran Cronk 