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Editor's note: As we approach the beginning of the second open enrollment period under the Affordable Care Act, Walter Zelman describes an effort he led during last year's initial open enrollment period to enroll students in the California State University (CSU) system in coverage. Part 1 below provides background on the CSU system and the enrollment effort, the CSU Health Insurance Education Project, as well as a discussion of what worked well. Part 2, which will appear tomorrow, addresses what worked less well, as well as project results, lessons and policy implications, and next steps.
In addition to Zelman, authors of this post include Wendy Lee, now in a Masters of Public Health Program at Johns Hopkins; Natasha Buransombati, now in a graduate program in Nursing and Public Health at the University of Seattle in Washington; and Carla Bracamonte, now in an MPH program at California State University, Fullerton. As CSU students, Lee and Buransombati served as regional coordinators for HIEP and Bracamonte served as a coordinator, CSU Los Angeles.
The California State University (CSU) system is the largest public university system in the nation, as well as one of the most diverse. The CSU Health Insurance Education Project (HIEP) received a $1.25 million grant to educate students in the CSU system about the Affordable Care Act and health coverage options through California's new marketplace, Covered California. A pre-open enrollment, multi-campus poll found that approximately 25-30 percent of CSU students were uninsured, primarily because they could not afford insurance.
The project placed student educators on CSU's 15 largest campuses. Over a seven-month period they gave approximately 1,500 classroom presentations, and conducted 70 forums and 300 enrollment events. University administrators sent out over 1 million emails to CSU students. Project strategy emphasized a focus on affordability, the need for insurance (accidents happen), and the simplicity of the enrollment process.
A post-enrollment poll conducted on seven of the 15 campuses found that the percent of uninsured students had dropped dramatically from about 25-30 percent to 10 percent. One-third of students reported signing up for Covered California or Medi-Cal, and a similar percentage reported that a family member had done so. Project leadership concluded that enrolling college students is about affordability, not invincibility. They also concluded that those interested in maximizing enrollment of young people should focus on public university systems which, like the CSU, serve low-income, minority student populations. These student populations are easy to access, trust and respect their university messengers, and are comprised of a disproportionate number of uninsured individuals. They also communicate with friends and family such that reaching one reaches many.
By emphasizing the affordability and accessibility of health coverage under the new health law, other states may also benefit from targeted outreach to students in their state university systems.
I. Background: The ACA, Young Adults, Covered California and the California State University system
The Affordable Care Act:
A primary goal of the Affordable Care Act (ACA) is to provide improved access to health care to millions of uninsured individuals and families. At the center of the ACA's increased-access goal are several provisions: a requirement, with a limited number of exceptions, that most US citizens obtain health insurance; the expansion of Medicaid (Medi-Cal in California) to include those earning up to 138 percent of poverty, including childless adults; sliding scale, financial assistance to individuals and families earning between 138-400 percent of federal poverty level (FPL); the establishment of Exchanges, or 'Marketplaces,' in which eligible individuals and families can, and those seeking financial assistance must, purchase their insurance; and new rules allowing young adults to remain on their parents' health insurance policies until the age of 26.
Young Adults
For a variety of reasons, the 18-24 age-group has had the highest rate of uninsured individuals, especially when they do not have access to their parent's insurance plans. They have relatively low rates of employment, and that employment is more likely to be part time and in lower-wage small businesses, where insurance is less likely to be offered. Many are full-time college students. Many, in spite of very low incomes, have not been eligible for Medicaid because they do not have children.
The above-noted changes in the ACA provide considerable opportunity for these young adults, including college students, to now access insurance. In turn, these new opportunities for young adults are critical to the success of the ACA and its potential to reduce the numbers of uninsured Americans. As many analysts have indicated, the enrollment of large numbers of the so-called 'young invincibles' is central to the success of reform. If young adults fail to enroll in adequate numbers, Exchange insurance pools will be disproportionately older, sicker and costlier. The near inevitable result could be a spiral of higher and rising premiums. By contrast, insurance pools that draw large numbers of young and healthy individuals will be larger (more leverage) and less costly, both of which could result, given competitive markets, in lower premiums.
Covered California
The ACA gives states the right to create their own Exchanges or to participate in federal government-created Exchanges. California created its own Exchange, Covered California, directed by a Board of Directors of five individuals appointed by the Governor or legislative leaders. In the wake of the Supreme Court's ruling that the federal government could not require states to participate in the Medicaid expansion, California chose expansion.
In an effort to maximize enrollment, Covered CA created a $37 million grant program, funded by federal dollars, for outreach and education activities. In May of 2013 it announced awards to 48 organizations. The largest award, $1.25 million, went to California State University, Los Angeles (CSULA), one of the 23 campuses in the California State University (CSU) system. CSULA, with the support of the CSU Chancellor's office, proposed to employ a wide variety of outreach tools to educate CSU students about their opportunities and responsibilities under the ACA. The project, known as the CSU Health Insurance Education Project (HIEP) also proposed to reach out, to the extent possible, to the families of those students.
The CSU and its students
The CSU system is the largest and one of the most diverse four-year university education systems in the nation. Its twenty three campuses host almost 450,000 young adults, the great majority of whom come from ethnic minority and lower-income groups. Just over 56 percent of CSU students are female. Thirty-three percent are Latino, almost 17 percent are Asian or Pacific Islanders, just under 5 percent are African American, and 19 percent are white.
Nearly half of CSU students report family incomes under the ACA Medicaid cut-off of 138 percent FPL, about 42 percent of the California's median income. Another 36 percent of students report incomes between 138-400 percent FPL. In sum, over 80 percent of CSU students qualify for free or subsidized health coverage from Medi-Cal or through Covered CA.
As with many young adult populations, CSU students are far more likely to be uninsured than the general population. Unlike the other public university system in California, the University of California, the CSU system does not have a mandate that students already have health insurance prior to enrollment. Given the large numbers of uninsured students and their low-incomes, such a requirement would be wholly unreasonable. Based on polls taken on three university campuses, HIEP estimated that in fall 2013, before the first Covered California open enrollment, 25-30 percent of CSU students were uninsured. That estimate was consistent with the findings of a 2013 California Health Care Foundation poll which found that among 18-20 year old Californians, 21.2 percent were uninsured and among 21-24 year old Californians, 30.3. percent were uninsured
II. The CSU Health Insurance Education Project
Goals & Structure of the Project
Head-quartered at CSULA, HIEP targeted the almost 400,000 students (about 80 percent of CSU-wide enrollment) on the system's largest 15 campuses. The project, based on a peer-to-peer education approach, placed student educators, usually two part-time students, on each campus. To maximize credibility with students, virtually all student educators were enrolled in, or recent graduates of, the campuses on which they worked. Additionally, most were recruited from graduate or undergraduate programs in Health Sciences or Public Health. Campus supervision was provided by faculty from the same departments, who were offered a modest honorarium. All student educators had to undergo two days of training by Covered California, after which they had to pass a test before becoming certified as a Covered California Certified Educator. On most campuses, education efforts commenced in early September 2013 and continued through the close of enrollment on April 15, 2014.
In addition to the staff on each campus, project staff included a part-time Project Director (Chair of the university Department of Public Health), a Project Manager to manage reporting and oversight, two regional coordinators, and a part-time administrative staff person.
Strategy and Tools
At the outset, HIEP leaders identified key strategies and tools. Educators were directed to reach out to and build partnerships with multiple student groups. It was hoped that those groups would be supportive and function as project extenders to various student communities. High priority was placed on outreach to student governments, student health centers, and faculty members who were asked to allow educators into class rooms for brief presentations. The project also identified key outreach opportunities, including new student orientations, health insurance forums, traditional 'tabling' activity, and social media options.
Securing widespread email distribution and access to campus and student organization web pages were also high priorities. But these tasks were primarily assigned to the central operation at CSULA which planned on accessing these outreach options through ongoing contacts with the Office of Chancellor. These options, in other words, would be approached through a top down rather than a bottom up approach.
In a similar 'top down' strategy, project leaders in Los Angeles tried to ease the organizational burdens on campus-based student educators. Efforts that could be undertaken on a statewide basis - e.g., creation of presentations, access to CSU and high-level university officials with access to mass-email capacity - would be directed out of Los Angeles. It was also anticipated that, being based at CSULA, the project might get special support from its administration, allowing it to try outreach options on one campus and then, if successful, apply them on others.
Finally, project leaders emphasized that student educators should think 'wholesale, not retail.' Educators were instructed to focus on opportunities to reach hundreds or thousands of students with basic information, rather than provide extensive one-on-one advising. Trying to reach hundreds of thousands of students would not allow for extensive one-on-one advising. Tabling activities that did not attract large numbers would be discontinued. 'Office hours,' during which students came in to have individual questions answered, were strongly discouraged. HIEP's efforts - by contract and preference - would be educators, not certified enrollers. Project leaders believed, correctly as it turned out, that had educators also been enrollers they would have been far more likely to spend time in long one-on-one discussions (closer to student comfort zones) rather than reaching out to larger numbers.
To maximize the value of these strategies and tools, HIEP ran staff training sessions in Northern and Southern California, with each student receiving a handbook and tips on applying the various project tools. These sessions were in addition to the Covered California training. Weekly conference calls with student educators provided leadership the opportunity to address new challenges and adjust priorities. Two recent graduates were employed as full-time regional coordinators, with the goal of maintaining ongoing, two-way communication between the central office and student educators.
The project also established its own web page, located on the CSU web site. The site offered student-oriented explanations of the ACA and Covered California, a link to the Covered California premium estimator, a message from the CSU Chancellor, several presentations including a webinar in English and Spanish, advice on enrollment options, and other information relevant to a college student audience.
In an effort to define messaging and strategy, HIEP conducted a student poll on three CSU campuses (Los Angeles, Fresno, and San Jose). The poll, conducted in September 2013, sought to gauge student opinions about health insurance issues and help HIEP leaders establish baseline data and develop strategy for the education campaign (See Note 1).
The most striking findings identified relationships between income, insurance status, and affordability of insurance. Seventy-nine percent of uninsured students reported that they were uninsured because they could not afford insurance. Just 9 percent of the uninsured reported that they did not want or need coverage, suggesting, as has been noted by others, that the challenge of enrolling college students is one of affordability, not invincibility. Seventy-three percent of students indicated they believed they should have access to insurance to obtain care when they needed it.
The relationship between income and insurance status was also evident in the finding that lower income students (whether independent of or dependent on parents) were far more likely to be uninsured (See Figure 1). And about 65 percent of respondents reported that the most they could pay for insurance per month was '$100 or less.'
FIGURE 1
The poll also revealed that 60 percent of polled students knew 'nothing' or 'very little' about the ACA, and that Latinos (as expected) were far more likely than members of other ethnic groups to be uninsured. Latino students comprised just over 40 percent of the sample, but almost 60 percent of those reporting themselves as uninsured.
Age-wise, students 22 and older were far more likely, and students 18-19 far less likely, to be uninsured than the general population. Evaluating this and other data, HIEP leaders assumed that the most likely cause of this finding was dependency status, with older independent students being more likely to be uninsured than younger, dependent students who might still have access to their parent's policies. While older students might be more likely to be in the work force, most were probably working part-time, in lower-wage jobs where access to employer-sponsored coverage is less common. (The CSU system does not have data on insurance or employment status of students.) Strategically, this finding suggested a project focus on upper-division (juniors and seniors) rather than lower-division (freshman and sophomores) students.
Informed with student opinion, analysis from other sources, and their own experiences with CSU students, HIEP leaders crafted a messaging strategy focused on the need for insurance, the new affordability of insurance, and the simplicity of enrollment (at least for most tech-savvy college students). Messages, sometimes humorous, relating to the need for insurance emphasized accidents, the unexpected, and the high cost of emergency rooms, all reminders that even the strongest and healthiest might need insurance.
The message of affordability led to an emphasis on new access to Medi-Cal and examples of the substantial subsidies available through Covered California, especially for very low-income individuals and families. The affordability focus also suggested an emphasis on Covered California's Bronze plan, which offered, by far, the lowest premiums. Project leaders recognized that Silver plans offered the best value, particularly low-income students, including as they do subsidies for out-of-pocket costs as well as premiums.
The high deductibles at the Bronze level were also of concern. But the affordability challenge appeared so great that project leaders concluded that an emphasis on the lowest possible cost might be the 'foot in the door' that compelled students to consider insurance. It was also thought that even with its very high deductible it was an acceptable option for healthy students, especially given their access to many free health services at student health centers (See Note 2).
Finally, a focus on the simplicity of enrollment was employed. Project leaders were concerned that the perceived complexities of enrollment, combined with the need to learn about a complex insurance system, might stifle interest. However, as over 70 percent of CSU students applied for financial aid, most had already collected the income and tax-related data they would need for the Covered CA application. Messaging could remind students, 'This is no more complicated than FAFSA' (Free Application for Student Aid), that they could learn much of what they needed to online, and that assistance would be available on-campus and by phone.
HIEP messaging, it should be noted, did not emphasize the penalties for not enrolling. Those penalties would be part of presentations, but HIEP leaders were concerned that an emphasis on penalties would undermine the positive message that obtaining insurance was something students should do, rather than something they had to do. It was also assumed that the modest penalties the ACA imposed during the first-year of implementation would be too small to compel enrollment.
III. What Worked Well
Above all, flexibility was key. Campuses have different cultures; student educators had different skill sets; some faculty supervisors proved more available than others; some student health centers took more leadership than others. Students and HIEP leadership had to make continuing adjustments on system-wide and campus-by-campus strategies. Fortunately, project reporting structures and high quality performance from LA-based statewide student coordinators enabled timely adjustments to changing circumstances, successes, and failures. These structures maximized input from student educators. They also enabled HIEP leaders to both define and maintain priorities for the group as a whole while recognizing and encouraging variation in strategies and activities on a campus by campus basis.
Tracking and reporting were key to successfully working with remote teams. Statewide coordinators employed the PPP management framework on their weekly calls to track Progress, Plans and Problems on each campus. That framework helped keep teams on task and highlight challenges that needed to be addressed. In addition, student educators completed regular activity reporting so that each presentation, forum, meeting, and activity was reported in a way that facilitated the aggregate reporting of activities and audiences to Covered CA through their Grant Program Administrative System (GPAS). Finally, team emails were managed through an online management system which insured that all outbound team communication was centralized and consistent, and which also allowed for tracking to ensure that all team members received the messages.
Class Presentations
The exception to the flexibility rule was class presentations. On all campuses these became the bread and butter of the education effort. Based on polling data indicating that older students were more likely to be uninsured, emphasis was placed on upper-division classes. Faculty members were contacted by supportive deans and HIEP faculty supervisors, but mostly by student educators themselves. Requests almost always referenced the support of the Chancellor's office and that HIEP was a CSU-supported project.
When reached, the great majority of faculty members granted student educators five minutes, usually at the start of class. A standard five-minute presentation was prepared, explaining the ACA and Covered California and emphasizing the affordability of the new insurance options. Specific examples of students and their costs were outlined and highlighted on the basic project handout. Questions were taken. At the end of each presentation, names and emails of students wishing to receive supplementary information were collected.
One challenge in these presentations was to familiarize students not just with the ACA and Covered California but with health insurance itself. Many students knew little about insurance; many, it was assumed, had never had it, or at least never purchased it themselves.
Overall, approximately 1,500 such presentations were delivered to audiences averaging 40 students. Most importantly, presenters found that five minutes was adequate to communicate the main themes. Greater understanding would have to come with more contact. Most student presenters also reported that classes of 40-50, as opposed to larger lectures, were the preferred size. Larger lectures left too many students in distant seating, inattentive, and often talking with friends, disrupting the connection between presenter and audience.
Campus Forums
Early in the open enrollment period HIEP undertook a coordinated effort to host forums on all campuses. Campuses conducted seventy forums, attracting over 3,000 students, with each forum led by project educators who presented the same twenty-minute presentation. Again, affordability was emphasized. But as compared to the five-minute class presentation, the twenty-minute presentation focused more on what students would need to know and do in order to enroll.
While the first forum on each campus often drew small numbers, later forums produced significantly larger turnouts. Perhaps more important, the promotion of the forums provided an opportunity for HIEP educators to distribute thousands of announcements, raising the visibility of the effort well beyond those who attended. Also critical was the support of university administrators, most of who responded positively to the request - coordinated by the Los Angeles leadership - to issue campus-wide emails inviting students to the forums. These education forums were a tangible 'ask' of campus organizations and administrators to effectively organize the support of the campus community.
Exposure in the media
Finally, the project used the forums as a media event, producing considerable coverage across the state in print and television media. One result was the recognition that student educators, rather than faculty leadership, were the project's best spokespersons. After a very modest level of media training, and relying on the guidance offered in Covered CA's media guides, the student educators proved articulate, genuine, and knowledgeable, continually impressing and engaging reporters who produced nothing but positive stories throughout the process.
Student Health Centers and Educational Opportunities Programs
The participation and support of many student health centers (SHCs) was also extremely valuable. A natural home for the project, several SHCs agreed to house and help supervise student educators. Some SHCs invited student educators to table alongside them at large events (some of the project's only effective tabling efforts). Many used their email lists to alert student clients about the need for insurance, its affordability, and how to access it. Many SHC's were also willing to distribute project information to students seeking services, many of whom were uninsured.
Educational Opportunity Programs (EOP), established on each CSU campus to provide special assistance to very low-income students, also emerged as invaluable partners. Once contacted by student educators or by the project's LA office, most EOP administrators aggressively sought to educate their clients, hosting mini-forums for those students and emphasizing the new Medi-Cal rules and sizable subsidies available through Covered California.
Enrollment Events
As the close of open enrollment approached (it was extended twice), the project launched a coordinated effort to assist students with completing the Covered California application. As student educators were not Certified Enrollment Counselors, they could not assist others in filling out applications. To meet this need the project central office assisted in contacting and recruiting Covered CA-certified organizations and individuals, including insurance agents, and inviting them to assist with student enrollments. Each campus scheduled their events at a series of consistent dates and times.
The process of promoting the enrollment events included tabling activities, aggressive distribution of flyers, purchase of advertisements in several campus newspapers, and mass emails from university administrators. Overall, 300 enrollment events were held, attracting at least 7,000 students and family members.
Local Campus Faculty Supervision
Some student educators proved more independent than others. But with a few exceptions, all benefited to at some degree from faculty advisers, almost all of whom came from the student educator's own department. Among other things, faculty members were able to use their unique campus access - to colleagues, to deans, to administrators, and even to University Presidents - to get doors opened, mass emails sent, and meetings scheduled that students did not have the clout or connections to arrange.
Emphasis on Affordability
As the project matured, the need to emphasize affordability grew more apparent. While Covered California, for good reason, highlighted the Silver level and recommended HIEP do the same, the project pressed the Bronze numbers. In the experience of student educators, the Silver-level numbers listed in the project's first brochure, while indicating greatly discounted insurance premiums for low-income students, were not low enough to command student attention. After consultation with Covered California, HIEP altered its basic handout, replacing the Silver with the Bronze numbers.
Feedback from student educators was universally positive. The Bronze numbers were more striking to students and even to some reporters. Examples were clear and dramatic. Insurance could be attained by many for free or less than the cost of 'two movie tickets.' Many families could enroll for much less than 'a monthly cell phone bill.'
Employed in this fashion, the Bronze numbers were used to at least get a 'foot in the door.' The added benefits of Silver were explained, but the lower Bronze price seemed necessary to begin the conversation. Also, as many students are, in fact, young and healthy, would have difficulty paying even significantly subsidized premiums, and have access to many free health services through their campus' student health center, the Bronze level, catastrophic-type coverage may be a reasonable, even only, choice for many.
An Absence of Politics
The ACA, of course, remained highly controversial. The obvious strategy was to avoid that controversy and the politics that accompanied it. Accordingly, student educators were advised to stick to the law and its implications for students. The ACA was the law. Many students would be required to purchase insurance. Many would be newly eligible for free insurance; others would have access to very low-cost insurance. Undoubtedly, all of the student educators thought the ACA a positive step. But their personal views were never part of the presentation. To the surprise of all, as far as project efforts were concerned, the controversy surrounding the ACA was both minimal and irrelevant.
Word of Mouth
Project leadership learned very quickly what strategies and tools were and were not effective. But it was impossible to assess the extent to which students reached by the project were then relaying what they'd learned to others, especially family members. A few evening enrollment events were scheduled for parents. Flyers encouraged students to talk with their parents. The project even printed large signs looking like notes from students' parents, intending to insert a little humor into the process ('Did you get that insurance yet? Love, Mom,' and 'Stuff Happens, Did you get that insurance? Love, Dad'). But there was no way to gauge the effectiveness of these efforts.
Only when a post-enrollment poll was taken did it become clear that there was considerable passage of information by word of mouth. Almost half of student respondents to a post-enrollment poll reported that they talked to family members about insurance. Only about 30 percent reported that they did not talk to anyone. Even more striking was that one third of students polled knew that a family member had signed up for insurance. (Twenty-five percent reported they did not know if a family member had enrolled, so well more than one-third of family members may, in fact, have done so).
Role of the CSU Chancellor
Above all, the project benefitted from the strong and outspoken support from CSU Chancellor Timothy White. That support opened almost any door in the Chancellor's Office and the various universities. This access was critical to reaching individuals with system-wide knowledge and leverage who could make things happen at system levels. It also provided official sanction-including the all-important use of the CSU logo-and instant credibility to student educators.
Early on, Chancellor White issued a public statement endorsing the effort. He communicated that support directly to the presidents of the 23 CSU campuses. He designated the Vice-Presidents of Student Affairs as project contact persons on each campus 'to assist in the system-wide outreach and communications effort.' He participated in a press event with student leaders from several Southern California schools.
Most importantly, the Chancellor's support shielded the project from any suggestion of political motivation. The project was never about Democrats and Republicans; it was only about getting affordable health care to students who needed it and serving the best interest of the CSU community.
A Covered California Education Campaign
Finally, the project benefited enormously, from the educational effort undertaken by Covered California. That effort included major amounts of paid and earned media, as well as social media efforts. Major 'kick-offs' on key dates attracted widespread attention. Some aspects of the campaign seemed more effective than others, but the overall impact was a dramatic increase in the visibility and saliency of Covered California, the ACA, and the choices that would be required of many, including CSU students.
Note 1. The project intended to select one high-income school (San Jose), one low-income (Fresno), and one middle-income (Long Beach). However, time ran short with approvals at Long Beach, and Cal State Los Angeles was substituted. This selection meant that the poll sample overrepresented low-income schools likely to have higher numbers of uninsured individuals. For this reason, although two of the schools had uninsured rates of over 30 percent, we used 25 percent as an estimate of the number of individuals uninsured in September 2013. Estimates of reductions in the numbers of the uninsured are based on that 25 percent figure and the numbers from a seven-campus poll taken after open enrollment that more accurately reflected the demographics of the CSU system.
Note 2. There is some anecdotal evidence and poll results from one campus that suggests more students ultimately chose Silver rather than Bronze plans. The greater value of Silver plans for low-income individuals was clearly apparent during the online enrollment process. Still, HIEP leaders thought an emphasis on the lowest possible cost might be required to get students to the enrollment process.
Don't miss the insightful policy recommendations and thought-provoking research findings published in Health Affairs.
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