Latinos assess Covered California's open enrollment process

Health advocates and supporters in the state spoke with Vida en el Valle about Covered California's performance with Latino enrollment during the health care reform rollout in the state.

Anthony Wright, Executive Director for Health Access California a statewide health care consumer advocacy coalition.

Xavier Morales, Executive Director for Latino Coalition for a Healthy California the only statewide organization with a specific emphasis on Latino health. It was founded in 1992 by health care providers, consumers and advocates to impact Latino health by focusing on policy development, providing enhanced information, and community involvement.

Norma Torres, California State Senator (D-Pomona). Torres introduced a bipartisan legislation to diversify the Covered California board of directors. The bill was signed by the governor and becomes effective Jan. 1, 2015. She was vocal about the poor job done by the state's exchange in enrolling uninsured Latinos during the first months of open enrollment period.

Tana Elizondo, agent and co-owner of Hanford-based Central Valley Life and Health Benefits, Inc. She is one of the thousands insurance agents working with Covered California to do enrollment. Elizondo sits on the SHOP Advisory committee for Covered California.

Q: What are the challenges you can see in enrolling Latinos in the affordable care act?

Wright: “Latinos are more likely to be uninsured, and have many of the same barriers are other uninsured populations: lack of information, lack of connection to somebody who can help, etc. Latinos also face some unique barriers to overcome, including language and also culture-if you haven't been insured before, you may not fully understand its value. There’s also the concern by many families over immigration rules, so even those legally present may be confused, or concerned that signing up may have an impact on family members who are undocumented. There needs to be more publicity to the guidance by President Obama to counter that unfounded concern.”

Morales: “Most of us cannot underestimate the fear that mixed status families face when doing anything that can be perceived as a risk to family unity. The memo from ICE was a first step towards bridging the trust gap, but examples of mixed status families successfully enrolling eligible members will go a long way to decrease fear. When one in six of California’s Latino children lives in a mixed status family, their enrollment becomes the lynchpin for CCA success in the broader Latino community.”

Torres: “It should be recognized that even as Covered California works to improve its Latino outreach, there are still some factors that will hinder its Latino enrollment numbers. First, there are some Latinos, who regardless of how much they are reached out to, will continue to refuse to enroll in Covered California either because they do not see the value in purchasing health insurance or they choose to get their medical care in Mexico or other Latin American countries. Also, some Latinos will need more information to learn how health insurance works. Latinos are the largest uninsured population in California. Many of them have never had an insurance policy. Overcoming the learning curve on how health insurance works will take time.”

Elizondo: “I think the need of accurate information is a necessity, the ease of enrollment is seamless, the negative media spin (depending where the outreach was received) on how things nationally were effected versus what was happening in California was different.”

Q: What grade would you give Covered California when it comes to the first Latino enrollment?

Wright: "We are really in just the first semester, so there’s more work to be done. The initial assessment is B-, which reflects the improvement made, and suggests there's more that can and should be done to ultimately get the A grade that California deserves.”

Morales: “Overall, with the general population, CCA has done an exemplary job of conceptualizing and actualizing a complex solution to a complex challenge. However, when it comes to Latino enrollment, CCA needs to elevate its game. I would assign CCA a C- for the first year of enrollment. Everyone agrees, that there is much room for improvement. The Latino Coalition for a Healthy California is ready to do our part in this larger initiative. We consider ourselves to be a partner of CCA and would like to help them be as successful as possible with California Latinos.”

Torres: "It is difficult to grade an organization that is still evolving. However, I think it is important to provide some kind of evaluation because from the perspective of the consumer, where Covered California is in their organizational development is irrelevant to what they care about-getting access to affordable health care coverage. Therefore, judging from what I’ve heard from consumers and those working in the community to enroll Latinos, I would give Covered California an overall grade of C. This grade probably would have been higher if they had not stumbled out of the gate. During the first three months of the enrollment period they were overlooking simple, yet important details such as not having an application in Spanish, failure to provide adequate and culturally competent translations, and not hiring a sufficient number of Spanish speakers in their call center and in the community. The website and information technology system was unstable and often crashed when consumers or enrollment counselors were trying to submit applications. After getting pressure from me and other lawmakers to fix these problems, Covered California took some action and their Latino enrollment numbers increased. What I think is more important and relevant for Latino consumers to know is that Covered California’s staff has demonstrated their willingness to learn from this experience and make improvements for the next enrollment period.”

Elizondo:“A C+, there is room for improvement. Call waiting time, processing the paper work with carriers, billing, ID cards being issued in a timely manner. Considering all that had to take place in reality the preformed as best as to be expected and with that being considered the overall rating would be a B+.”

Q: In your opinion, how did Covered California perform during the first enrollment period when it comes to Latino enrollment?

Wright: “The Affordable Care Act provides a historic opportunity to address a longstanding problem-one that is disproportionately felt in the Latino community, where too many of our friends and neighbors are uninsured, and thus live sicker, die younger, and are one emergency away from financial ruin. The ACA provided new coverage options, through Medi-Cal and Covered California that now provide access to care and peace of mind to hundreds of thousands of Latinos in California. But the problem is so big and the barriers still significant enough that after the first enrollment period, there are still many more hundreds of thousands of Latinos that are eligible for coverage but unenrolled. Covered California started in October with many key elements lacking, from glitches in the Spanish-language website, to not having a Spanish language paper application until the holidays, to not having enough enrollment counselors trained. But there were improvements made throughout the first enrollment period, and Covered California seemed to hit their Latino enrollment goals-even as they exceeded their goals in other categories.”

Morales: “Covered California had a very steep learning curve when it came not only to creating an infrastructure for general enrollment, but especially with Latinos and other hard to reach populations. Their strategy to contract with community organizations who had the closest relationships with the target Latino populations was genius. The challenges, however, revolved around understanding the fragile nature of mixed status families and also how many touches it would take to inform, educate, and enroll members of a community that have traditionally not had opportunities for health care insurance. There is much area for improvement as we start gearing up for the second enrollment period.”

Torres: “When it comes to signing up Latinos, Covered California’s performance during the first enrollment period did not start off well but improved toward the end. Initially, Covered California was not doing enough outreach to Latinos even though they make up 60 percent of the state’s uninsured population. This became evident in November when the first set of detailed enrollment numbers was released. Those numbers showed only 10,600 Latinos had signed up and only 4,500 were Spanish speakers. This was significantly less than the number of enrollees from other groups. At that point it became clear that Covered California’s Latino outreach plan was not working. My office began investigating and we discovered that their Latino outreach plan was flawed. They did not have Latino cultural experts in positions of power overseeing the work. Simple tasks vital to Latino enrollment like making an application available in Spanish and putting bilingual enrollment counselors in the community were not getting done. There were also errors in translations and problems with the website and information technology system. That is when I and other Latino lawmakers put pressure on Covered California to revise their outreach plan. They began working on changes in January. They also hired more culturally competent staff. As a result, their Latino enrollment numbers significantly improved in the final month and they are continuing to work on improvements.”

Elizondo: “I believe the literature prepared and circulated was sufficient. I am not sure if the tracking within Covered CA enrollment was indicated by surname only as the fields that were populated to elected ethnicity was voluntarily. In total, 252,000 of the exchange’s 1.2 million enrollees identified as Latino, close to Covered California’s goal of 265,000. So I would think the projected target was reached. (Note: 252,000 represent Latino enrollment by the end of March).”

Q: What can Covered California improve to make sure Latinos continue to enroll or renew their health plans in Covered California?

Wright: “Covered California should and is embarking on a series of improvements in their operations that should make it easier for all Californians to enroll and renew: this includes everything from an improved website to reducing the waiting times at the call center. There were several enrollment strategies and efforts that were very successful, the issue now is to bring them to scale, given California’s immense size. We know that Latino populations are less connected online, and more likely to prefer in-person assistance, so we need to have more community enrollment counselors, especially those who speak Spanish and other languages. We need to improve and expand the Spanish-language materials for Covered California.”

Morales: “Those in charge of setting the strategic direction and monitoring the operations of Covered California need to be able to decode what is going on in the target audiences. Not everything translates culturally, generationally, or linguistically. It is important for CCA leadership to include very diverse staff who can apply different social, cultural, and economic lenses to the initiative. Assume that many of those who need to sign up have never had health insurance. ‘No denials for preexisting conditions,’ doesn’t mean as much if one has never had health coverage before. Health insurance is complicated. It can be hard for someone who has never had insurance to understand the acronyms and concepts that are barely understandable to those of us who have had insurance. We need to have more success stories than nightmares. CCA staff and their contractors should approach their work like employees who are seeking a good reference would. It is the shortcomings that get press. The successes need to be elevated and shared broadly.”

Torres: “My staff and I have been meeting periodically with Covered California to get updates on their progress. They have learned through trial and error what works and what doesn’t work when trying to enroll Latinos. At this point they should continue getting feedback and suggestions from those who worked closely with the Latino community during the first enrollment period. Some of this work has started and Covered California is making improvements to enroll more Latinos. For example, they have indicated that they plan to put more bilingual enrollment counselors out in the community. They have also indicated that they are building partnerships with businesses that reach Latino and Spanish-speaking consumers. They have hired a communications and marketing director with a Hispanic background. He is making it a priority to improve Covered California’s outreach plan to Latinos.”

Elizondo: “Continue the discussion, continue with outreach and education, continue with the same efforts in their marketing campaign.”

This is the sidebar of the last of a two-part series on the Affordable Care Act rollout in California and Latino enrollment. This article was originally published in Vida en el Valle.