Health insurance campaigns face new obstacles with a tighter budget

By Tara Kulash, St. Louis Post-Dispatch

McClatchy-Tribune Information Services

July 20 --Learning from the stumbles and success of the first open enrollment period for insurance, Illinois and Missouri campaigns are taking different approaches to not only gain new customers this fall but also to keep their previous ones.

Every state has a unique strategy, given its population and political stance. Missouri and Illinois are no exception. The Show-Me state has a smaller, more rural population and a history of opposing the Affordable Care Act. For this reason, the nonprofit organization Missouri Foundation for Health took on the responsibility of creating an enrollment campaign without the state's help.

And in the Land of Lincoln, where Barack Obama got his start in politics, the state has embraced the president's signature health care law and runs its own campaign, while partnering with the federal government for its online marketplace.

Factoring in the support and bigger population in Illinois, it might make sense that Illinois spent more on its marketing than a nonprofit organization in Missouri with a limited budget.

They do share one thing, though: FleishmanHillard.

Both states hired the St. Louis-based marketing and public relations firm for the first enrollment period, which lasted from October 2013 through spring. Missouri Foundation for Health spent $1.8 million on its contract, while Illinois spent $33 million .

The campaign, Get Covered Illinois, has been under fire recently as a result of an Associated Press report alleging the state overspent on its contract.

After several Freedom of Information Act requests, the AP found Illinois spent nearly four times more than New York and nearly twice as much as California per enrollee on television ads. More than 90 people from FleishmanHillard and subcontractors also billed Illinois $270 an hour. The AP report found that Colorado spent $120 per hour.

Despite the criticism -- and an Illinois representative's call for investigation -- Illinois will stay with FleishmanHillard for the next enrollment period, this time at $25 million .

'We think that we ran a very good, successful, strong campaign, so we're continuing to work with them in year two,' said Jennifer Koehler, executive director of Get Covered Illinois.

And while the Missouri foundation's campaign, Cover Missouri, has accepted bids from five companies for this year, FleishmanHillard is among them and under consideration for renewal. The campaign will announce its contract in August.

Ryan Barker, vice president for health policy at the Missouri Foundation for Health, said the Illinois criticisms will not affect his organization's future partnerships with the firm in St. Louis.

'We're going to judge it on our work with them,' he said. 'It's apples to oranges. This is a private organization doing this coalition work because the state has not engaged, so it's just totally different.'

Yet the Missouri campaign seemed to keep pace with Illinois' sign-ups, at least proportionally.

With more than 800,000 uninsured in the state, Cover Missouri set a goal of 200,000 marketplace enrollments during the first period. At the end of open enrollment, 152,335 people selected plans. That's more than 75 percent of the campaign's goal.

Illinois began with an uninsured population of about 1.8 million. The AP reports Get Covered Illinois had an internal goal of 337,000 sign-ups. The state reached 217,000, or around two-thirds of that goal.

But Mike Claffey, a spokesman for Get Covered Illinois, maintains that 337,000 was an estimate from 2011 that was never an official goal.

Still, on highly contrasting budgets, the two states saw similar results.

Dr. Michael Mackert, an associate professor of advertising at the University of Texas at Austin, said the product depends on how you work with the budget you're given.

'You can of course spend a ton of money on a bad message, or a little bit of money on a really good message,' said Mackert, whose research focus is on health literacy.

One of the biggest challenges, he said, is selling to 'young invincibles' who believe they don't need insurance, as well as those who struggle with understanding how health insurance works.

'Those are both very hard groups of people to engage ... especially with a 15-second TV spot,' he said.

In line with Mackert's thinking, Barker said Cover Missouri actually plans to spend less on its marketing this year -- down from $1.8 million to $500,000 . The majority of that will go toward technical assistance, such as social media and keeping the website updated, he said.

One of the biggest lessons learned from the first enrollment period, he said, is that health insurance is a confusing language, and consumers had better luck signing up if they talked to a navigator, or an in-person assistant.

'It's difficult for (enrollees) to even get to a point to pick a plan in the marketplace when they don't understand how insurance works,' Barker said.

So Cover Missouri is setting aside another $500,000 for Health Literacy Missouri, a group that will work with consumers and providers about how to effectively communicate about health insurance.

Barker said there will also be more focus on in-person assistance to reach patients in need of coverage. Last year's budget to train and hire counselors was $5 million . This year, Barker said, Cover Missouri will grant $4.5 million . The number of organizations that receive grants to hire counselors will remain about the same, though, which he said was about 17 last year.

The Illinois campaign will also put more focus on in-person assistance.

'The navigators on the ground, that's where the enrollment happens,' Koehler said. 'And communities want to hear from trusted voices they know and recognize. ... That's where the ground game is.'

Last year the state doled out $28 million to organizations for 1,200 navigators. This year it will be $25 million , but as Koehler pointed out, the enrollment period is shorter, from November to February.

Get Covered Illinois will also continue its focus on media outreach.

'(Navigators) need help and support with public awareness through advertising, marketing, digital strategies, etc.,' Koehler said. 'So we think both of those strategies will really complement each other.'

Jose Munoz, chief marketing officer for Get Covered Illinois, said the media campaign is still being fleshed out, but he plans to be even more creative than last year.

He cited the partnerships with celebrities and the Onion, a satirical news site, as successful in reaching the so-called young invincibles.

'We want to continue to use the stuff that works, but we also want to make sure we're just as creative this year in our application,' he said.

Another challenge will be to successfully target Latinos. Nationally, that effort was a dud last year. Less than 8 percent of enrollees identified themselves as Latino in the federally run marketplaces.

Part of the problem was the late introduction of the Spanish-language insurance portal. That website didn't launch until early December, more than two months after the English-language site began operating.

Barker also thinks part of the issue is trust. Many immigrants, who make up a large portion of Latinos, are cautious with anyone associated with the government. So Cover Missouri plans to partner with organizations that are trusted among Latinos.

Munoz, at Get Covered Illinois, said he thinks the first year was a success for the most part, 'because we know from looking at health insurance literacy levels, the Latinos are going to take a multiyear effort to get them enrolling at the same level.'

But he echoed the idea that using organizations trusted by Latinos would help.

Still, Mackert, at the University of Texas at Austin, makes one point.

'Broadly, around any culturally targeted messaging, something that the audience hates the most is feeling like they're targeted,' he said.

No matter the culture, he said, people are people, and they don't want to be targeted for being an ethnic minority. It rubs them the wrong way.

'Start with fundamental human truths,' he said. 'And target with certain media.'

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This report was prepared in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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