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By JULIE MINDA

An estimated 15.9 million people in the U.S. are eligible for Medicaid or qualify for financial assistance under marketplace plans but remain uninsured, according to analysis by the Henry J. Kaiser Family Foundation.

During the latest open enrollment for health insurance, Catholic Health Initiatives intensified its efforts to reach these insurance holdouts, using grant dollars from the Robert Wood Johnson Foundation. The six-month, $463,000 grant funded a wide variety of CHI outreach initiatives in five states where the system operates.

"These were focused efforts to reach vulnerable and hard-to-reach people," said Diane Jones, vice president of healthy communities for Englewood, Colo.-based CHI. "We were meeting them where they are — schools, churches, town halls, university campuses."

Jacquie Easley McGhee, director of community and diversity services for Mercy Medical Center in Des Moines, second from left, and Tinika Roland, Mercy community outreach coordinator, at far right, staff a health insurance enrollment table Jan. 30 at the "I'll Make Me a World in Iowa" African-American festival in Des Moines.

"We were creating enrollment opportunities in these settings," said Colleen Scanlon, CHI senior vice president and chief advocacy officer.

CHI regions that took part in the grant work used their dollars to bring health insurance education and sign-up help to community gathering spots in geographical areas with high numbers of uninsured people believed to be eligible for coverage. The regions also used the funding to hire and train certified application counselors to help the uninsured navigate the enrollment process.

"It takes time to understand insurance — it's not simple — we were trying to make it as easy as possible" to learn about and enroll in insurance, said Scanlon. CHI estimates that more than 11,000 people enrolled in a health insurance plan as a result of the efforts.

Eligible, but uninsured
According to a January Kaiser Family Foundation analysis, of the 32.3 million uninsured people in the U.S., about 18 percent are adults who qualify for Medicaid, about 10 percent are children eligible for Children's Health Insurance Program coverage, and about 22 percent are adults eligible for subsidized insurance on the health insurance exchanges created by the Affordable Care Act. (The remaining uninsured are ineligible for Medicaid or subsidies. For example, in states that did not expand Medicaid under the ACA, the uninsured include adults with incomes below 100 percent of the federal poverty level, a group ineligible for insurance subsidies on an exchange.)

Jones said many uninsured have not yet enrolled because "there is confusion about insurance, especially about what's covered, what the penalty is for not being covered, and what financial help is available." Also, said Jones, "People lead complex lives" and may not have the time or inclination to sign up for insurance, and are not concerned about the fine. Many uninsured are "young invincibles" who don't think they will get sick, she said.

Scanlon said for many people — especially immigrants — there are language and cultural barriers to learning about and enrolling in insurance.

Annabelle Pike is manager of healthy communities for CHI's KentuckyOne Health of Louisville, Ky. She said, "For a lot of these folks, it's about the hierarchy of needs. Health insurance is not at the top of their priority list. They are just meeting their basic needs."

Targeted outreach
Jones and Scanlon said the grant for the late 2015 to early 2016 open enrollment period enabled participating CHI sites to deepen existing efforts to target and engage with uninsured people.

Lori Grubstein, a program officer with the Robert Wood Johnson Foundation, said CHI won the grant because "of its reach and presence in states and regions with high numbers of uninsured — for example, Texas." The foundation has learned that one effective way to enroll people is through health provider partnerships, she said. CHI sites in Colorado, Iowa, Kentucky, Tennessee and Texas took part in the grant work. Of these states, Tennessee and Texas have opted not to expand Medicaid eligibility.

Visible presence
CHI regions used community assessments to identify populations most in need of enrollment information and help. The regions used zip code tracking to determine exact geographic areas with the highest concentration of uninsured. The regions then worked with community partners or with their own staff to set up information and enrollment booths in hot spots of local activity.

CHI's Mercy Medical Center of Des Moines, Iowa, determined that minority and immigrant populations in Des Moines' urban core could most benefit from this outreach. Jacquie Easley McGhee, director of community and diversity services for the hospital, hired an outreach coordinator from one of the targeted zip codes. Tinika Roland, who formerly was insured by Medicaid, helped create a strategy to reach the target communities. She and community partners staffed enrollment tables at churches, free clinics, a grocery store, a community center, a barber shop and a mall — with most of the locations serving urban Des Moines' minority populations. Certified application counselors had a laptop handy to walk people through enrollment.

The coordinator and her partners also went door to door in neighborhoods with large concentrations of uninsured residents, handing out leaflets with the schedule and location of the enrollment assistance. She also used her personal social media feeds to publicize the outreach efforts. The hospital advertised the enrollment help opportunities on bus shelters and buses in the targeted zip codes.

Near the end of open enrollment, the hospital partnered with the NAACP to set up a booth at Des Moines' premier festival for black people, "I'll Make Me a World in Iowa," which attracts thousands each year.

McGhee said nearly 1,026 people enrolled in Medicaid and about 125 in marketplace plans as a result of all of the outreach. Many were young adults who had never before enrolled in insurance coverage on their own. McGhee said having a coordinator from the targeted communities and trying fresh outreach ideas were key to Mercy Medical's enrollment successes.

Transient groups
Pike is a member of a committee of Louisville's health board that is focused on enrollment efforts. Committee members, many of whom represent family health centers in the city, determined that enhanced outreach would benefit refugees and other immigrants as well as former inmates.

Pike said a collaboration led by KentuckyOne placed navigators at tables in the health centers, community centers and housing developments frequented by immigrants. The navigators helped the decision makers in the immigrant families to understand U.S. insurance requirements and benefits. The navigators also helped those interested to enroll.

Pike said former inmates often remain uninsured because they are unaware that they may qualify for Medicaid, or, if they had Medicaid coverage prior to their incarceration, they may be unaware of the need to reenroll. KentuckyOne worked with the Louisville corrections department to play videos in the jails about insurance enrollment, and to arrange for a "soft handoff" of departing inmates — the jail would help them connect with a navigator to enroll in insurance.

Through all of these efforts, the Kentucky collaborative enrolled 65 people in marketplace plans and 472 in Medicaid.

Pike said working with other organizations in Louisville was essential to reaching these hard-to-reach uninsured populations. "It's important that all the stakeholders that work with these populations are at the table and working on a coordinated effort," she said.