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After rocky start with Latinos, Covered California director reflects on lessons learned

Fellowship Story Showcase

After rocky start with Latinos, Covered California director reflects on lessons learned

Picture of Maria Ortiz-Briones

María G. Ortiz-Briones wrote this two-part series for Vida en el Valle as a 2014 California Endowment Health Journalism Fellowship. Other parts of this series include:

In first year, exchange grappled with Latino enrollment challenges

Vida en el Valle
Wednesday, August 27, 2014
Peter Lee, executive director of Covered California, sat down with Vida en el Valle to talk about the health insurance exchange's first-year rollout. Vida en el Valle photo

Covered California didn't hit it off at first with Latinos when it began its enrollment period last fall.

Peter V. Lee, executive director of Covered California, sat down with Vida en el Valle earlier this summer to talk about the health insurance exchange's rollout and the lessons learned from reaching out to the Latino community. 

Q: It's been two months after the open enrollment period ended on April 15. Looking back, the low numbers of Latinos enrolled during the first three months of open enrollment period were worrisome. Were you concerned that Latino enrollment was going to fail at that point?

A: "No, actually we weren't concerned that Latino enrollment was going to fail because we knew that in the first three months of open enrollment, the people that were enrolling were people who had insurance previously. We all expected that there would be fewer Latinos, because Latinos unfortunately are more (likely) to be uninsured.

"So the fact that in the first three months, the overall proportion of Latinos was lower than we want wasn't a huge surprise but still raises the flag to make sure that focusing on and getting Latinos in ... needed to be ... our priority. And we did look at how do we build out a range of strategies, recognizing that many Latinos that were previously uninsured are going to be a harder sell. Because it's not a matter of renewing, it's a matter of communicating a whole new concept, a whole new (idea of) what is this insurance thing about."

Q: What were some of the Latino enrollment efforts that were not working during the first half?

A: "In the first three months, we enrolled about 500,000 people. We believe the vast majority were people that many of them had insurance already and were renewing their insurance. The biggest thing that was different in the first three months for the Latino community versus non-Latinos is the efforts with working with health plans to have their existing insurance converted over and keep insurance including with subsidies really didn't hit the Latino community very large because there were fewer insured. That is one, the biggest.

"The other thing that I think was big is that the Latinos community, in particular Spanish speakers, were more (likely) to want in-person assistance, both from certified insurance agent and certified enrollment counselors. This isn't an issue for the Latino enrollment but for all enrollment. We were ramping up in October, November to actually get people in communities ready to do the enrollment. And that was something that wasn't as robust in December."

Q: When did Covered California realize it was failing badly in getting Latinos to take action?

A: "I take issue with the term. I don't think we were ever failing badly. The issue of the first three months of enrollment, that we had proportionally fewer Latino enrollment, was we think, significantly a product of the fact that in the three months many of those who enrolled were previously insured.

"And we did from Day 1, this is one of the things that we hear very much of a data-oriented organization, so we done surveys including Latinos, Spanish speakers that actually affirms that the outreach and media campaign we launched in October, actually was right in a lot of ways.

"And let me give you an example of that. A year ago no one knew what Covered California was. We were invisible, a totally new organization. So we have to in October, in September, tell the state that Covered California is here. When we developed our advertising, we didn't just say let's develop an advertising campaign and then translate it Spanish. Some of the material we developed, we specifically developed because it was culturally more resonate for the Latino community. Developed first and foremost in Spanish and in fact only in Spanish, other material was in English and Spanish. We then did survey statewide, said what ads did you remember? Which resonated?

"One of the things was really gratifying, is that the ad which we called 'Doors,' which is actually a series of people welcoming Covered California to their home, was 'Bienvenidos,' it was Spanish language, was the ad that had the highest recall among Latino whether or not they were Spanish speakers. And this is a Spanish ad running on Univisión, running on Telemundo; it had high recall among English speaking Latinos, again because of it was cultural relevant. 

"We, from Day 1, we were looking at how to have grassroots outreach anchored in Latino communities, advertising targeting Latino community. The built over time, we absolutely saw, but our enrollment over all build over time, by March when we have huge enrollment of the uninsured, we were seeing well over 30 percent of our enrollment being Latino, which is not far off from the percentage of the population that is subsidy eligible that are Latino."

Q: How did Covered California change strategies? 

A: "A couple of things that we pivoted to, again recognizing what we knew from day one the actually capacity in January encouraging people to get in-person assistant and this play out actually with two or three key messages and capacity. 

"In January, we had thousands of certified enrollment counselors who speak Spanish across the state, thousands of certified agents, insurance agents speaking Spanish across the state. What we did and we heard from focus groups, which we conducted in Spanish and in English, people felt more comfortable sitting across from someone. Also they have worries about confidentiality, many in the Latino community were worried about immigration issues. 

"Third issue they were worried about, this is new, they were not very familiar with health insurance. They were worried that if they went and ask for help, they get charged. And there were people out there saying pay me $100 and I'll help you get health insurance. We did a major shift of our radio and TV to say, 'Get help, confidentially, free in your community.'

"That messaging, it's confidential, it reinforced our work getting out the message, immigration status, you need to talk to us about immigration status to see if you are eligible. But we don't use that information for anything but determine your eligibility. In your community, we develop fliers to say that if you are in El Segundo, here are people who speak Spanish in your neighborhood you can go speak to. Radio spot find help near me, our CoveredCA.com, find help near you, put in your zip code.

"The third issue is free. Reinforce the assistance you can get in person was free."

Q: What would you say was the best strategy to enroll Latinos? 

A: "The best strategy, is really a strategy that is multifaceted. The thing I think was mostly right was to say we need a strategy that is complementary, in Spanish paid media, on radio, in TV. We have a huge amount of effort in being in Spanish language media that we are going to keep doing. But it needs to complement having community base outreach.

"We have grants to dozens of organizations anchored in Latino communities doing outreach and education in street fairs, going to reach out to Latino students at Cal State… When we did our community base grants, we did grants to Latino groups, but we also did other groups grants to groups that were not specifically Latino, but because they could reach Latino community. For instance we had a major grant to Cal State, there are a lot of Latinos students in Cal State. Fresno State University, have their students go from 33 percent of uninsured to 7 percent uninsured. 

"A lot of them were Latinos, so we are going to keep on having a strategy that is broad in terms of paid media, but that is also anchored in communities. And in many ways we did not do by any means a perfect outreach but neither anyone around the nation did. But one of the striking things we found, is there is a lot of reason different people don't have health insurance. Some we can't address, the issues of insurance coverage for the undocumented. 

"Covered California is the only place people eligible for subsidies can get subsidies. We are also working in very close partnership with Medical; if you are eligible for medical we want you to get medical. But for us we are about this very specific 2.6 million people eligible for subsidies, of them about 37 percent that we now know is Latino.

"A year ago, we thought it was 46 percent, but that number was wrong. We thought we were further off target that what we are. Of subsidy eligible (portion) our enrollment was about 31 percent. Thirty one percent, 37 percent, is not perfect but is not that bad. But we as state can feel very proud that community organizers, community clinics, faith-based organizations across the state did a pretty good job."

Q: Who would you said did the most Latino enrollment? 

A: "The thing we saw is there were literally hundreds of organizations that helped enrolled people. There were thousands of groups. This is one where truly does takes a village, it takes everyone stepping forward. We certified enrollment counselors, and the people who went to those enrollment counselors were more up to be Latino, which meant certified enrollment counselors were really important.

"But because there is more insurance agent out there, more people who are Latino, actually enrolled through insurance agents than through certified counselors. So is not that we are saying use one versus the other, we got to use both. And similarly, we saw a lot of Latinos did enroll directly online without in-person help. 

"So, we think is so important to provide in-person to where is needed, but we also want to make sure that people can enroll online, people can enroll by calling our service center and having phone support. Rather than thinking about the best strategic, we believe we need to place our bets in a range of places, which we did, and a lot of them are paying off."

Q: When we look at the Latino numbers during the first three months versus the last month in March, we see a huge difference in Latinos numbers. Where you relieved the intensive campaign finally pay off?

A: "Yes and no. We put more resources in to community organizing in the last three months in particular areas that were lower enrollment, areas that had more Latino population. We did focus on encouraging in-person enrollment more, but we still have in the month of March, a lot of people were enrolling online. The reality when we look back and learn from this is, regardless of being Latino, or African American, or Asian, people that previously were not insured, were more up to wait to the end. They took longer time to be educated and this is particularly true in Latino community.

"It reinforces that we need to talk to people again, and again, and again. In fact, the main message for us as we get ready for next open enrollment is never going to be a single touch. And this is particular true for people that previously didn't have insurance. And we hear this on focus groups. I sat behind the glass, behind the two way mirrors and watch this groups, and watch the sessions of both Spanish speakers and English-speaker Latinos and a number said, 'What have I done? I go across the border to get my drugs at 'farmacia.' Insurance? I can't afford it, I am not going to get insurance.'

"So to help people understand that insurance is not affordable, that's not a one phone call issue, or seeing one ad in Univisión, or securing one radio spot. It's hearing it in your church, hearing again at your school, it's talking about it with your family, and we need to be out there, in multiple ways to reinforce the message again and again. 

"And also, this is what's I think is the exiting opportunity going forward. Over 30 percent of those who got health insurance through subsidies in Covered California are Latino, the most important thing that is going to matter next year, is those people who got insured talking to their friends and families. Saying 'Oh, it is affordable. It means I was able to get the preventive care that I've been putting it off, I can get a doctor who speak Spanish in the neighborhood.'

"We are going to be doing a lot of work between now and next open enrollment, not just getting ready for new marketing, but to make sure the people that have insurance use their insurance, understand the benefits of it, because the worth of mouth, is really going to be so important. From our perspective, is so important to remember, in the end, what we Covered California is about, it isn't about health insurance, is about getting people the health care they need.

"So we have hundreds of thousands of Latino Californians that have health insurance. Then renewing next year, it's going to be because not only they got a subsidy to make it more affordable, but they got preventive care. They got a doctor in their neighborhood they can go and visit, etc.

"We are spending a lot of effort now, making sure that people that got insured get the care they need. So when it comes next fall, and they are sitting around at the dinner table talking to their friends and families saying 'I got this Covered California health insurance, and now I got the preventive care exam and it was free' or 'My office visit, it was like $10 because of how much money I made, I got help to lower the cost of my office visit.' " 

Q: Did Covered California expect Latino enrollment to be as challenging as it was? 

A: "We did. University of California did estimates on how many people might enrolled. They actually said it was going to be harder to enroll people that are non-English speakers, its going to be harder to enroll people who didn't have health insurance. So part of making more investments, in both our original plan and in the second half of open enrollment, was because culturally, educationally, it's a bigger lift. 

"The Latino community is more apt to be uninsured, more apt to not have insurance previously. So it's a bigger lift to educate people about why insurance matter, why is a good thing for you. So again, our investments that we made, and will make in the next open enrollment, which will be weighted for the Latino community are based on it's a harder community because people haven't had health insurance before so we need to get the message out." 

Q: From July 2013 through April 15, Covered California spent $25.16 million in marketing, to target both Spanish-speaking and English-speaking Latinos. By the end of the open enrollment period, we have 305,106 Latinos enrolled. That is more or less $82.5 per person. Would you say that it is a good return of the money spent? 

A: "We are still doing analysis of what we uses as quote on 'cost per acquisition,' which is that dollar spent is the marketing dollar, but we also have to spend. That doesn't count the money we spend on people answering phones at the service center, many do speak Spanish, it doesn't count the cost of developing our website, but really it cost more than that to enroll people. But we always said that the cost of getting people to enroll is absolutely critical to do because we are changing history.

"We are changing a culture to move from a culture of coping without insurance to a culture of having coverage and in doing that it's going to cost. We had estimates that it would cost anywhere from $80 to $150 from the marketing side to get people in the door. In many ways, that $82 on the marketing side, we think that is a value and a great investment and we could do as well in our next round of open enrollment, I think we are doing well for Latinos and well for the state of California." 

Q: What was the biggest Latino enrollment barrier Covered California faced? 

A: "I think the biggest barrier is the fact that such a substantial portion of the Latinos community did not previously have insurance. For many that are in the individual market, which is where this is they have been denied coverage, some people get in and out of getting insurance coverage from a job to being uninsured but buying it themselves. We believe, the surveys we'll back us up, a significant percentage in the Latino community just never had insurance. And so it is culturally a different thing to educate people about.

"That is why I said about moving into educating a culture of coverage, instead of a culture of coping. So many Latino communities had lived with that culture of coping. Again, 'I will go across the border to the farmacia to get my drugs for my chronic illness for next year because that is the cheapest way to do it. I will go to a community clinic and pay for a visit, as opposed to say what is the value of insurance?' That's the biggest challenge and we are trying to address that through education, through material and through actually really changing the culture."

Q: What are the lessons learn from the last open enrollment period when it comes to Latino enrollment?

A: "A couple of things. The biggest one that I've mention a couple of times is there is not silver bullet. There is not a single solution to make sure enrollment is to work. It starts with having health insurance products that are affordable, and one of the things that I feel good about, many of the insurance product we offer, whether in L.A. or Fresno, specifically did work in their health plans to make sure they have a good network of Spanish-speaking doctors and nurses. 

"The starting thing we did, I think we did right. Let's get the right product, but then we have to do marketing and outreach that addresses a whole range of strategies. So rather than say we need one, it's a one-shot strategy, it's doing pay media, in Spanish-speaking media. It's news, or things that get news coverage that is specific to Latino community, it's doing community outreach in communities where people can work together.

Q: What grade would you give yourself when it comes to latino enrollment?

A: "I wouldn't do it in a letter grade, but I give us a satisfactory. We did OK. In some areas we did really well; we showed that we can adjust and learned as we go. We also learned that it takes a lot of contacts. So I think we did a good job. Overall, a pretty good job in terms of enrollment, learning, adjusting, and building really important relationships with organizations throughout the latino community, that is a good foundation for the future."

Q: Covered California exceeded the base projection for Latino enrollment of 265,000. Are you happy with the end result?

A: “Yes and no. The projections of what we might enroll were not our projections. That was University of California’s. We exceeded them. We feel great about exceeding projections. But we feel good about having over 300,000 Latinos with subsidies through Covered California. But we know that there are hundreds of thousands that didn’t sign up.

“We are a pessimist organization, we don’t want to look at the glass half empty, but rather we know we still have work to do. So we do feel good that we have hundreds of thousands of Spanish-speaking Latinos that are enrolled, absolutely. We feel good that across the state 1.2 million Californians now have insurance coverage through Covered California. We feel good about that. 

“But we also know there are millions of Californians without health insurance. Many are eligible for Medi-Cal, many are eligible for Covered California. We need to say our lessons learned to get back out there to get everyone through the door.”

Q: Open enrollment is just around the corner, what would you do differently this time to make sure Latinos are enrolling or renewing their health plans? 

A: “First, remind us not just that open enrollment is right around the corner but that we are still enrolling people today. It’s so important to remind everyone that we are in what is call special enrollment period and every day a Californian, Latino California might lose their job where they have insurance from, they are now eligible to come in and get subsidize coverage through Covered California or get married, have a kid, move, those are good reason you can actually enroll to have guarantee health insurance that has financial support through Covered California.

“So I want you to know that open enrollment in November is coming up right around the corner, but Covered California is open for business today. And what we are doing today, is making sure we are reaching out in Spanish, in English, with community groups, anchored in communities across the state, and we are going to keep doing that. When we are coming to next open enrollment period, that two big things that I know, are first to the importance of worth of mouth, you know la familia, people talk to your family, they listen to the family.

“Not only are they staying with Covered California and renewing their coverage but talking to their friends and family. And second, we are going to be doing advertising again. Anchoring that advertising thought in one of the things we did in the second half of open enrollment, which is to have people telling their own stories about having health insurance.

“A couple things change in our first round of open enrollment, and the second three months. The biggest one, going from November and December, we didn’t have insurance. We were selling the terms, we had the doors open. In January and February, we had people who could tell their story, so our advertising in the second half of open enrollment is what we call ‘Tengo Plan’ or ‘I am in,’ which is people who have the experience of having a plan because of Covered California, telling their story in their own words, what it meant to them and their families.

“We are gong to do that again and we know that was very effective. It was effective to have fabulous to have spoke people like Dolores Huerta saying ‘It’s the right thing to do, it’s important.’

“But more important instead of having spokepeople, is having people anchoring in their own communities saying ‘tengo un plan. It gives me a piece of mind. I am in. I have health insurance and this is what it means to me.’ So we are going that and again it is going to be people from East L.A. telling how to get coverage, people from Fresno, people in Bakersfield telling their experience, and we are going to be building on our outreach work.

“We are going to be expanding our navigators program, selecting more grantees which are community groups to do outreach, education, an enrollment to help people in the local community. We are thrill that people can enroll on their own online. That’s great, and many Latinos are doing that, many are doing it in Spanish. But we want to make sure that people who have questions, they can get an answers by phone, we expanded the number of people who speak Spanish, but also resources in the community. So we are going to be focusing on building out how communities can work together and make resources available in every community in the state." 

Q: Do we have a base projection number for 2015?

A: “We do. We enrolled ballpark 1.2 million Californians in the first open enrollment period. Our goal is to end the second open enrollment period with 1.7 million Californians insured. So we hope to grow by about 500,000. Now what does that mean? Our hope would be that close to 40 percent of those to be Latino. Thirty seven percent subsidy-eligible Californians are Latino.

“We want to have that many of our folks that we sign up for subsidies to be Latino. What does that mean? That means, 150,000, 200,000 newly insured Latinos we hope would come through the doors because of our work. In addition, hundreds of thousands Latinos would get Medi-Cal. Its about getting people coverage and that is something we are committed to do.” 

Q: Anything else you would like to add? 

A: “We in California, in many ways are an example for the rest of the nation. We need to look at not just at how we did, where can we learn, where can we adjust, but also what can we learn from others, what can we teach others. How do we do compared to Texas, how do we do compared to Florida, other states that have large Latino population. My senses overall, we did pretty good, we did better than them. 

“But that doesn’t mean we don’t get to learn from them. If they have a particular strategies, we continue to look at how do we improve and that is the main thing. We are a learning organization that is about getting California coverage which means do, evaluate, revise, do it again, do it again. So we are going to go through second open enrollment having learned lessons like reinforce confidentiality, reinforce the issue that immigration status is something we need to know about but is not used for anything else. Reinforce information about you can get help in your community while at the same time making it as easy as possible for people to go online and doing online themselves.

“We are going to keep analyzing data and work with community partners to make it work. This is an issue we are committed to and we’ve working on for months and years to come.”

This article was originally published in Vida en el Valle.