The video doesn’t give Adrian’s last name, but it shares his story of life without health insurance. “For many years, I was afraid of going to the doctor and finding out what was going on because I wouldn’t have any way to take care of it,” he says.

Framing the Issue: Hospitals are finding effective ways to help the uninsured sign onto public health exchanges

  • Hospitals across the nation are committed to lowering the number of uninsured Americans.
  • Though some big insurers are dropping out or reducing their participation in public health exchanges, experts believe the concept remains strong.
  • Some people who remain uninsured are worried about the high deductibles associated with certain HIX plans and aren't aware of the penalties of going without coverage.
  • Despite worries that high deductibles will lead to nonpayment by some patients, health systems are taking a variety of approaches to actively encourage enrollment.
  • The pace and scope of change will vary by community and by provider.


He was one of nearly 300,000 uninsured individuals touched by Trinity Health, one of the largest Catholic health care delivery systems in the nation, during the initial open-enrollment period for coverage on state and federal health insurance exchanges, sometimes referred to as marketplaces or by the initials HIX.

“Each year, we try to expand upon that number and touch more lives,” says Tina Grant, Trinity Health’s vice president for public policy and state advocacy.

The work to try to ensure that individuals get access to health insurance through a public exchange is going on at health systems across the country, using a variety of approaches. But active community involvement and partnering are common themes found in HIX enrollment strategies at systems like Trinity and others, such as Carolinas Health System and Christus Health.


Tactics to Improve Enrollment

Helping patients to seize the opportunity to gain insurance is a lot of work — and worth the effort, says Abby Lowe McNeil, director of communications and public affairs for Christus Health, an international Catholic system based in Irving, Texas. “It’s part of who we are,” she says. “This is such a great intersection of stability for our health system and providing services that people really need.”

Christus Health has found that the HIX benefits both the patients who need insurance and the health systems that serve them, McNeil says. Christus serves 60 cities in Texas, Arkansas, Louisiana and New Mexico.

A review of Christus patients, newly insured through the exchanges in 2014, found that one-third were new to the Christus system, one-third had been self-pay patients during previous encounters at Christus, and one-third had been covered by another form of insurance during previous visits.

“There was a lot of worry out there about people converting from commercial plans to HIX plans but, even when we factor that in, we are still seeing a healthy financial return from HIX utilization in our system,” she says.

Christus fine-tunes its HIX enrollment strategy each year, learning from the experience gained in previous open-enrollment periods. Its tactics include:

Coalition building. In each market it serves, Christus works with — or, if needed, helps to build — a coalition of other organizations that are working to help people understand their HIX options and enroll in coverage. Partnering organizations range from federally qualified health centers and competing health systems to social service agencies, the national nonprofit Enroll America, insurance brokers and local media outlets. “A lot of our regional operations have existing relationships that really lend themselves to assisting with open enrollment,” McNeil says. “These coalitions keep meeting throughout the year and then ramp up again in late summer and early fall.”

Executive accountability. A regional executive is appointed in each Christus market to take ownership for HIX enrollment for that market. Among other things, each region is expected to have three activities a month, including at least one media placement, designed to encourage people to use enrollment help available in the community, such as eligibility vendors that Christus places at each of its hospitals. Each regional executive is responsible for an enrollment goal. For the 2016 open-enrollment period, the goal was the sum of 30 percent of the potential market for tax credit-eligibles plus 90 percent of the pool of re-enrollees. All individuals who enroll in a given region are counted toward the region’s goal, regardless of how or whether Christus actually interacted with that individual. “We want each region to enroll as many people as possible, but we also want to be realistic about where we set their goals,” McNeil says. In addition to actual enrollment, Christus tracks several metrics in each region, including the number of people touched by the enrollment coalition through physical encounters; distribution of marketing materials or telephone contacts; number of small business interactions; and the average number of hours per week that one-on-one enrollment help is available in the community.

Corporate-level support.The regional efforts are supported by marketing materials developed at the corporate office, including a direct-mail campaign to uninsured individuals who have been treated at a Christus facility and a centralized call center staffed with individuals who can direct callers to enrollment help.

Support grants.The Christus Fund, which invests in community-benefit activities in the system’s various markets, allocated money — $500,000 in each of the first two open-enrollment periods and $250,000 in the third — for grants to agencies working to increase HIX enrollment. “We can make grants to them for either direct-enrollment assistance or marketing or other things, so that we don’t have to own that responsibility entirely in our market,” McNeil says.

IB_Insurance_terms_chart.jpg5 Core Strategies to Lower Rate of Uninsured

For Novi, Mich.-based Trinity Health, with 91 hospitals in 21 states, the biggest benefit of the Affordable Care Act has come from Medicaid expansion, says Chief Financial Officer Ben Carter.

In the states that have expanded Medicaid eligibility through the ACA, his system has seen about a 50 percent decline in bad debt and charity care. “Whereas, in states that did not expand, we haven’t seen significant change in bad debt and charity care,” he said.

While more people do have coverage, courtesy of the health insurance exchanges, many of them choose plans with high deductibles, and they turn to Trinity Health for help with their out-of-pocket responsibility.

That said, Trinity Health is committed to lowering the nation’s uninsurance rate by encouraging consumers to enroll through the state and federal exchanges. The system has used five core strategies, says Harpreet Cheema, Trinity Health’s vice president of product development. They include:

Payer partnerships. Trinity Health has worked with payers in various markets to create insurance products designed to be affordable for consumers shopping on the marketplaces. “We identify a high-performance network of our facilities and physicians and work closely with payers to create a premium price that is not only attractive to these [consumers], but that we can sustain over a long period of time,” he says.

Broker relationships. The system partners with brokers — both at the state level and national level — to engage uninsured patients who come to a Trinity Health hospital. If patients are treated at an emergency department or receive charity care for other services, they are referred to a broker who can educate them about coverage options available through the marketplaces.

Community events to provide education and enrollment assistance. “We recognized that we needed to collaborate,” Grant says. “We went to social agencies who have traditionally done this work, and looked for opportunities to create new partnerships with them. We try to get out into schools and into laundromats. We have created our own health fairs, partnered with elected leaders, worked with veterans’ agencies.”

Front-line engagement. Patients who are newly insured through the exchanges often need help understanding their benefits. Trinity Health trained administrative staff members to help patients understand which doctors are in-network, the services covered by their insurance, estimated out-of-pocket responsibility and other information needed to use their coverage wisely.

Marketing. Trinity Health conducted focus group discussions in several of its key markets to understand what uninsured people need and what would motivate them to obtain insurance. Those insights informed the health system’s marketing campaign. “Our ultimate goal is to get the target consumer to engage with brokers to understand and select an insurance product,” Cheema says.

Positioning for success

In the first open-enrollment period, Carolinas Health System worked with payers to make sure individuals shopping in the health insurance marketplace could buy plans that gave them access to its services. But CHS, the largest system serving North and South Carolina, soon found that some newly insured patients were showing up for services, unaware that they had a chosen a plan that didn’t include CHS in its network.

In each subsequent year, the system has continually fine-tuned its marketing to help individuals shop wisely. A sample message from its 2016 open-enrollment campaign: “You don’t buy concert tickets without knowing who’s performing. So why choose health insurance before knowing which doctors and hospitals are part of the plan?”

The goal: to help consumers shop for health coverage in the same way they shop for other goods and services.

“We tried to relate that you really need to understand the plan, understand the providers in your health system and your network before you make a decision,” says Marcey Stone, CHS’ director for market communication and a member of the system’s health information management team.

Other strategies in Carolinas’ arsenal:

Marketing for awareness. In the most recent open-enrollment period, CHS launched its most comprehensive campaign yet, trying to make the confusing process easier for consumers to manage. “The options were changing, the plan designs were changing, premiums were changing,” Stone says. “The concept of a tiered provider network is still relatively new to our market, and we knew that consumers still weren’t spending a whole lot of time doing their research. So, we felt like we had some responsibility to help fill in those gaps.” In addition to mailing letters directly to patients’ homes, CHS used all forms of mass media — billboards, radio, print and digital — to communicate about marketplace enrollment. “We also used bus wraps and bus shelters, and we made a significant effort in community outreach, especially within our faith communities,” she says. “We prepared a team that could go out and talk about our products, about the enrollment process in general and the benefits of health insurance.”

Internal education. CHS knows its 60,000 employees can help to spread the word about the importance of health insurance — and it wants them to be ready to give accurate information when the opportunity arises. “I really can’t say enough about preparing your providers and teammates to have those critical conversations when their neighbor, their mom and dad or their spouse is looking for a health plan on the health insurance marketplaces,” Stone says. “We have spent a lot of time on tool kits and educational materials for our teammates. We offer webinar sessions for them to come and learn about not only our plans, but the landscape in general.” — Lola Butcher is a contributing writer to H&HN. •

Editor’s Note

This is the second of a three-part series on health care coverage options under the Affordable Care Act. The next installment will look at the emergence of narrow networks.