Targeted ACA enrollment efforts to reach uninsured Latinos
March 31, 2014 marked the end of the first open enrollment period in the Health Insurance Marketplace. It also marked the beginning of National Minority Health Month, an effort by the Office of Minority Health to raise awareness about the disparities that affect racial and ethnic minorities. As the ACA takes full effect, it is critical to understand how the law is impacting minority groups in particular.
Over the last month, the Obama administration made a concerted effort to reach out to Latinos and other minority groups with high rates of uninsurance through targeted marketing efforts on Spanish-language media, town hall gatherings, and celebrity endorsements.
Why the interest in reaching Latinos in particular? Latinos make up the largest group of uninsured adults in the United States. 31% of non-elderly Latinos are uninsured, compared to 21% of African-Americans and 13% of whites (Kaiser Family Foundation, 2013). Not all uninsured Latinos are eligible for coverage under the ACA because of immigration status and other legal restrictions. Nevertheless, the goal is to encourage eligible Latinos to sign up for coverage.
There are a number of barriers this population faces including limited English proficiency, lack of internet or computer access to sign up online, lack of familiarity with the health care system and how it can benefit them, and fears about the legal implications of being from a mixed immigration status family. Given these challenges, levels of Latino enrollment were slow in the early phases of implementation. In contrast to the resource intensive mass media marketing efforts, another approach to boosting Latino enrollment was through the use of navigators.
Role of navigators beyond the open enrollment period
By law, all marketplaces are required to set up two navigator programs, one of which is required to be in a non-profit setting. Navigators are trained according to a standardized federal training curriculum. They perform a number of functions, including distributing information about qualified health plans, providing impartial information about enrollment options, assisting with enrollments, providing referrals to individuals with more complex questions, and ensuring information is provided in a culturally and linguistically appropriate manner to diverse populations (Families USA, 2011).
Navigators were essential in reaching Latinos and hard-to-reach populations during the open enrollment period (Gamboa, 2014). Working out of familiar community organizations which were already trusted sources of information, navigators were highly effective in reaching these populations.
Although the initial enrollment period has ended, the work of navigators continues on. According to the Kaiser Family Foundation, half of all uninsured individuals have been uninsured for more than three years. Chronically uninsured individuals may lack knowledge about the benefits covered by their insurance, the meaning of fundamental concepts of the health insurance system such as copayments and deductibles, or how to find an in-network provider. Having insurance is only the first step in ensuring access to health care services for underserved populations. Navigators can help ensure that people know how to take advantage of their benefits and actually access health care resources, with an emphasis on preventative health care services.
Unfortunately, many states have taken steps to restrict even the most basic functions of navigators, such as providing comparisons of plans offered in the marketplaces (Zomorrodian et al., 2013). 25 states have restricted the role of navigators to solely providing information. While it is important to ensure navigators are offering impartial information to all consumers, delimiting their role strips their ability to help underserved populations effectively navigate the complexities of the healthcare system.
Increasing health care coverage is one of many challenges that navigators can address in the mission to eliminate health disparities among minorities. As we observe Minority Health Month, let us remember the important role that navigators have played in helping Latinos enroll for health insurance and their ongoing work to improve access to health care.
Gamboa, S. (2014, March 31). Hours before deadline, Latinos line up to enroll. NBC News. Retrieved from http://www.nbcnews.com/news/latino/hours-deadline-latinos-line-enroll-n67256.
Families USA. (2011). Navigators need not be licensed as insurance brokers or agents. Retrieved April 7, 2014 from http://familiesusa.org/product/navigators-need-not-be-licensed-insurance-brokers-or-agents.
Kaiser Family Foundation. (2013). The uninsured: A primer. Retrieved April 7, 2014 from http://kaiserfamilyfoundation.files.wordpress.com/2013/10/7451-09-the-uninsured-a-primer-key-facts-about-health-insurance.pdf.
Zomorrodian, P., Grace, A., & Rosenbaum, S. (2013). Navigating state exchange laws: An overview of state approaches to navigator regulation. National Association of Community Health Centers. http://www.nachc.com/client/documents/Navigating%20State%20Exchange%20Laws.pdf.
Patrick Tang, MPH
Chronic disease patients spend most of their time away from clinic, and they can often get caught unprepared or puzzled with managing their conditions. Instead of going to the emergency room when that happens, reaching out to a nearby peer can relieve potentially stressful situations and provide answers when healthcare professionals aren’t available.
Organized peer support in the form of one-on-one coaching, group meetings, and telephone calls aren’t available to many people, especially in rural areas. Moreover, when patients struggle with everyday issues regarding their condition, they can’t wait until the next peer support meeting or doctor’s appointment. Now that 58% of the American adult population owns a smartphone, mobile apps are quickly filling this need, improving opportunities for connectivity and responsiveness in peer support.
In the Android and Apple marketplaces, there are thousands of apps to help people manage their chronic diseases. In recent years, the growth of diabetes apps has been especially strong. According to one study, 76% of mobile health app publishers see diabetes as the therapeutic area with the highest business potential for mobile health. Currently, 1.2% of Americans with diabetes that own a smartphone or tablet use apps to manage their conditions. By 2018, the study predicts that that proportion will grow to 7.8%, or 24 million people.
While the majority of diabetes apps help users monitor their glucose and maintain healthy behaviors, some, like HelpAround, take a different approach and are built around peer support. Described as a mobile safety net for people with chronic conditions, HelpAround enables users to find peers around them wherever and whenever they need help or advice. Currently, the app supports communities around diabetes (type 1 and 2), parents of children with diabetes, and food allergies.
HelpAround works by linking “help seekers” with “helpers” in its Diabetes Safety Net. The app identifies the people with the highest likelihood of being able to help, notifies them of the request, and invites them to respond. Using a phone’s GPS, the app can link peers in close proximity to each other when the need arises. The built-in scalability means that user requests aren’t drowned out in a sea of messages. No matter how many people are using the app, only the people most likely to respond will receive requests. Users looking to chat with others that share their conditions can join one of many virtual support groups in the HelpAround community.
Mobile apps like HelpAround can assist healthcare providers build local patient communities that can mutually support each other when providers aren’t available. When patients can help each other before situations turn into emergencies, they are less likely to use urgent care or need hospitalization. Furthermore, healthcare providers can attract new patients, identify dissatisfied or distressed patients, help transition them to at-home care, and lower the risk of hospital readmissions.
Sarah Kowitt, MPH
“I give them a hug. I can see that
if they don’t want to open up,
I give them a big smile and
let them know that I’m here for them.”
Emotional support doesn’t happen right away in a peer support relationship. Although people are happy to receive informational support from someone with lived experience, few are willing, initially, to share their problems and feelings with a complete stranger. Indeed, needs assessments have found that people with chronic conditions rarely indicate a desire for emotional support from peer support services (though it is more desirable in cancer and mental health care). After receiving peer support, however, individuals will extol the value of exchanging emotional support with their peers.
The conversion of clients to realize the benefits of emotional support is an important and complex process that has not been fully explored. The issue is further complicated by the varying cultural norms around the expression of emotional support1.
To examine how emotional support emerges between peer supporters and individuals with diabetes, a qualitative research project was conducted in two distinct cultural settings. Seven Latino peer supporters serving a low-income, Hispanic population in Chicago and nine retired, middle class supporters serving an older, predominately Caucasian population in the United Kingdom (UK) completed semi-structured interviews focusing on their relationships with the people they help.
This blog will share some of the initial findings from the study, including similarities and differences in the emergence of emotional support in two cultural settings, and the implications for peer support programs.
Type of support varies over time
Striking consistencies emerged across both projects. The first key finding was that type of support varied over time. Initially, peer supporters were limited to providing information for diabetes self-management; over time, they came to provide substantial emotional support. As one peer supporter in the US stated,
“At the beginning they don’t know you
and just want to talk about their illness.
Over time, the patient feels more comfortable
and that’s when they talk more about their problems.”
This is important because social support theory and many peer support interventions operate under the assumption that social support is most valued when it is matched to participants’ desires2.
Our research suggests that emotional support may be valuable even if clients do not initially express a need for it. Other research has also suggested that overproviding emotional support (but not informational or practical support) is positively associated with improved well-being3. The implication for peer supporters is that their training should help them recognize opportunities to provide emotional support even when it’s not explicitly requested.
The importance of implicit emotional support
Another important finding regarded the distinction between explicit and implicit emotional support. Explicit strategies include discussion of one’s problems and stressors, such as through encouragement, acceptance, reframing, reassurance, and advice whereas implicit support entails “being there” or shared activities without discussion or disclosure of one’s problems1. In both the US and UK sites, emotional support was frequently conveyed implicitly rather than explicitly. For instance, one US peer supporter demonstrated implicit support by saying, “I give them a hug. I can see that if they don’t want to open up, I give them a big smile and let them know that I’m here from you.” Peer supporters from the UK talked about how they organized group-walking trips or played card games with participants.
Few studies have examined the distinctions between explicit and implicit support and most scales operationalize emotional support through verbal exchanges (i.e., explicit support) only4. However, our research suggests that implicit support is a significant part of peer support interactions, and warrants greater attention from researchers. This has implications for training of peer supporters, which should prepare them to provide implicit support, as well as for future research on the development of scales to operationalize all of the dimensions of emotional support.
Cross-cultural differences in barriers to diabetes self-management and the role of the peer supporter
Cross-cultural differences did appear regarding barriers to diabetes self-management. Due to the different settings at the two sites, peer supporters had to respond to different sets of issues. For example, social concerns, such as financial issues, unemployment, or caregiver burden, were more likely to be reported at the US site compared to the UK site. In addition, the peer supporters from the US site were more likely to include family members in their services and provide directive support.
In contrast, the peer supporters at the UK site reported providing nondirective support more often. One peer supporter summarized this sentiment by stating, “The expectation was that you would have an answer for them, which is of course, not the case. We didn’t have answers. We were in the same position as the people who were attending.” This difference in directive vs. non-directive support could be due to several factors—one of which is related to differences in how peer supporters in both projects were compensated. In the US, peer supporters had paid positions and were a bit older than the participants they were helping, whereas in the UK, peer supporters were volunteers. The US peer supporters had more formal roles, which could explain why they would be more likely to provide directive advice.
Our findings suggest that peer supporters gradually provide emotional support through similar strategies across cultures, but that support is tailored to problems facing participants and to cultural factors, including the role of family and style (nondirective, directive) of support. These lessons will be important for future training of peer supporters and the development of scales to operationalize emotional support.
- Uchida, Y., Kitayama, S., Mesquita, B., Reyes, J. A. S., & Morling, B. (2008). Is perceived emotional support beneficial? Well-being and health in independent and interdependent cultures. Personality and Social Psychology Bulletin, 34(6), 741-754.
- Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychol Bull, 98(2), 310-357.
- Siewert, K., Antoniw, K., Kubiak, T., & Weber, H. (2011). The more the better? The relationship between mismatches in social support and subjective well-being in daily life. J Health Psychol, 16(4), 621-631. doi: 10.1177/1359105310385366
- Cyranowski, J. M., Zill, N., Bode, R., Butt, Z., Kelly, M. A., Pilkonis, P. A., . . . Cella, D. (2013). Assessing social support, companionship, and distress: National Institute of Health (NIH) Toolbox Adult Social Relationship Scales. Health Psychol, 32(3), 293-301. doi: 10.1037/a0028586