Evaluating Outreach Efforts Targeting Uninsured Minnesotans1
Kristin Dybdal, MPA, senior research fellow, SHADAC
Priyanka Desai, HSRP&A Ph.D student
Kristin Dybdal, MPA, is the lead author of this research study. Priyanka Desai prepared this brief as a class assignment for PubH 8802, Health Policy Applications taught by Lynn Blewett, Ph.D, professor, and Sarah Gollust, Ph.D, assistant professor.
In October 2013, open enrollment began in Federal, State Partnership, and State-based Health Insurance Marketplaces established by the Affordable Care Act (ACA), providing millions of uninsured Americans the opportunity to obtain health insurance coverage. The success of these marketplaces depends on the ability to conduct outreach and enroll the uninsured. Navigator and In-person Assister programs (hereby referred to as Navigator programs) are designed to provide an “in-person resource for Americans who want additional assistance in shopping for and enrolling in the Health Insurance Marketplace.”2 Both the federal government and states have invested significant monetary resources to such programs.
Established in 2008, the Minnesota Community Application Agent (MNCAA) program is an example of a Navigator program designed to enroll vulnerable populations in Minnesota Health Care Programs (MHCP) such as Medicaid and MinnesotaCare. The MNCAA program works with organizations that provide direct assistance to Minnesotans seeking to enroll in MHCP. MNCAA organizations either have a data-sharing agreement with the Minnesota Department of Human Services (DHS) or receive a $25 bonus payment for each successful enrollee. The majority of MNCAA organizations are health care organizations or human service organizations. Other programs and organizations like Community Action Programs, mental health organizations, public schools, local government agencies, and for-profit business also participant in the MCNAA program. All 140 MNCAA organizations receive day-to-day support, technical assistance, and training from the State-created MNCAA Resource Center.
The MNCAA pre-dated the implementation of the ACA and continued into the first year of MNsure, Minnesota’s state-based health insurance marketplace. Lessons learned from the MNCAA program could inform current and future efforts to use Navigator programs to enroll the uninsured in both federal and state-based insurance marketplaces. In 2012, the State Health Access Data Assistance Center (SHADAC) conducted an evaluation of the MNCAA program. The goals of the evaluation were to 1) evaluate the MNCAA program using administrative and payment data as well as key informant interviews, and 2) identify lessons learned about how to partner with organizations to enroll uninsured Minnesotans to inform the creation of Minnesota’s ACA Navigator Program.3
The evaluation period for the MNCAA programs and its 140 member organizations was limited to March 2008 to June 2012 as SHADAC was able to leverage data collection and monitoring activities already performed by DHS. The authors reviewed data on the application status and payment database developed and maintained by the MNCAA Resource Center. Trends in application volume and enrollment were documented to determine program achievements such as whether the program had been effective in enrolling eligible recipients. The authors also examined if factors such as organization type, contract type, or application volume explained program trends.
SHADAC also conducted key informant interviews with three MNCAA Resource Center staff, seven past program directors, and six outreach directors and staff from MNCAA organizations. The authors consulted MNCAA program staff and State Health Access Program leadership at DHS on the identification of key stakeholder groups, the content of interview protocols, and the thematic analysis.
The MNCAA program recruited 66 participating organizations in its first year and more than doubled the number of participating organizations in the second year. However, this growth slowed over time. Key informant interviews indicated that 2009 budget cuts limited the ability of the MNCAA program to recruit new organizations.
Overall, 123 out of 140 participating organizations had submitted applications for enrollees. The top 15 MNCAAS organizations accounted for almost 75% of the total application volume.
The majority of applications came from human service organizations during the first year. However, in 2011 health care organizations submitted 70% of the applications. This shift was partly due to the increasing number of health care organizations in the program. In addition, health care organizations had a financial incentive to enroll individuals in MHCP without additional inducement from the MNCAA program.
By early 2010, budget cuts stopped recruitment of new MNCAA organizations because the program lacked funding to provide additional bonus payments. Data-sharing agreements were an effective recruiting tool in lieu of performance incentives, especially for health care organizations. In 2011 and early 2012, more than 60% of applications came from organizations that had data-sharing agreements.
Overall, 65% of applicants were successfully enrolled in MHCP between 2008 and 2011. Approximately 79% of the successful applications were enrolled in Minnesota’s Medical Assistance Program; however, only 13% of these individuals were new to the MHCP program.
Resource constraints at the state and county level caused lengthy waiting periods for processing MNCAA applications. Eligible MNCAA organizations received bonus payments only after applicants were successfully enrolled. Between 2008 and 2011, the average time between submitted an application and receiving a bonus payment was 18 weeks.
The MNCAA organizations valued the support provided by the MNCAA Resource Center. Organizations used the Center on a daily basis to obtain case status updates and other information about the application process.
MNCAA organizations that received the $25 bonus payments stated that the payment did not adequately cover the cost of providing enrollment support. Organizations relied on other sources funding such as the federal government, foundations, and other health care providers to maintain services.
SHADAC’s evaluation found that the MNCAA program was successful in enrolling uninsured Minnesotans in health insurance programs and developing a group of community-based organizations that could provide direct assistance to individuals applying for MHCP. While these accomplishments are significant, the evaluation also found that the MNCAA program might not be effective in targeting populations that had not previously accessed MHCP. Several important lessons learned emerged from the evaluation.
First, states should leverage existing expertise in outreach and insuring individuals in public health care programs. Experienced organizations could take a similar role to the MNCCA Resource Center and serve a resource for less experienced organizations.
In addition, state and county officials should consider ways to streamline the process to obtain case updates and data-sharing agreements. The accomplishments of the MNCAA program can partially be attributed to the ability of workers to access to applicant case information in a timely manner through the MNCAA Resource Center. Data sharing agreements were highly valued by participating health care organizations. Creating an infrastructure for real-time access to state eligibility and enrollment information will bolster the success of Navigator programs.
Finally, states must be willing to invest substantial human resources and financial incentives to sustain Navigator programs. MNCAA organizations stated that the $25 bonus payment was insufficient to cover the costs of provide direct, in-person services to MHCP applicants. Health care organizations participating in MNCAA had an incentive to enroll Minnesotans in public health care programs without bonus payments. However, the enrollees from these organizations often had previous experience with MHCP. Recruiting a diverse set of organizations that will be able enroll hard-to-reach populations will require more staff time to support Navigator programs as well better financial incentives.
Several of the lessons learned from the MNCAA program have already been used to improve strategies for enrolling individuals in Minnesota’s state-based health insurance marketplace. Navigator programs represent an importance resource for health insurance marketplaces looking to bolster enrollment as well as applicants needing assistance in the enrollment process.
The lessons learned from the MNCAA evaluation can be used to inform Navigator programs in other health insurance marketplaces, especially those seeking to enroll hard-to-reach populations.
1Research brief is a summary of the research article: Dybdal, Kristin, Lynn A. Blewett, Jessie Kemmick Pintor, and Kelli Johnson. Dybdal, Kristin, et al. “Putting Out the Welcome Mat—Targeting Outreach Efforts Under the Affordable Care Act: Evidence From the Minnesota Community Application Agent Program.” Journal of Public Health Management and Practice 21.1 (2015): 51-58.
2U.S. Department of Health & Human Services News Release. New resources available to help consumers navigate the Health Insurance Marketplace (2013). 15 Aug 2013. Web. 24 March 2015. http://www.hhs.gov/news/press/2013pres/08/20130815a.html.
3The evaluation, “Evaluation of the Minnesota Community Application Agent (MNCAA) Program: A State Health Access Program Analysis for the Minnesota Department of Human Services,” Aug 2012, was funded by the DHS through a grant from the U.S. Health Resources and Services Administration’s (HRSA) State Health Access Program.
HPM Research Brief is a summary of recent research by faculty and staff in the Division of Health Policy and Management, School of Public Health, University of Minnesota. Our efforts help to influence policy and improve health outcomes across the globe. Visit our website at sph.umn.edu/hpm.