Can Neighborhood Outreach Boost Obamacare Enrollment?

Bridgette Richardson Hempstead knows almost nothing about football, but she recently found herself standing on the sidelines of the Seattle Seahawks' CenturyLink Field, with microphone in hand and a large TV camera projecting her image on a Jumbotron to 70,000 excited fans as she belted the national anthem. She said some on the field were crying.

"It was pretty incredible. They said they had never ever had anyone sing the anthem like that and have a reaction from the community like that," Hempstead says. "Too bad they lost."

Passions run high in electrically charged communities united in a single cause. That cause might be beating the Cowboys—or, in Hempstead's day job, making sure that women of color have access to appropriate health care. A breast-cancer survivor and head of the trusted health advocacy group Cierra Sisters, Hempstead gives assurance and advice to those who are afraid to go to the doctor or flummoxed by the world of health insurance.

Hempstead is just one of the roughly two dozen community leaders that make up Daphne Pie's insurance-enrollment army. Pie is the manager of access and outreach at the public health department for Seattle and King County. Others in her army include organizers from the Open Arms Perinatal Doula Program—which is deeply rooted in Seattle's Latina and Somali communities; the Gay City health project; and the Asian Counseling and Referral Service.

The County Council adopted an "equity and social justice" strategic plan four years ago that directs all its municipal departments to target the areas of greatest inequity in whatever they are doing. For a transit agency, that means expanding bus services to poor neighborhoods. For the health department, it means digging into the county's insurance-enrollment statistics to ferret out the populations that are under-covered.

But while the county's bureaucrats can identify the types of residents who lag behind, they can't always reach out to them on their own. "We need to have strong community organizations that can actually move their agenda, have a voice, and really kind of drive the change," says Matias Valenzuela, King County's Equity and Social Justice Manager. (Yes, that's an actual title.)

So for every niche population that shows higher-than-average uninsured rates, Pie and Venezuela have identified a trusted leader within that community to carry their message: You can have health insurance for free or at very low cost. There is no mention of political lightning rods like "Obamacare" or Medicaid. The community leaders are free to highlight their groups' unique concerns about health coverage in order to pique interest. For Latina women, it might be natural childbirth. For the gay, lesbian, and transgender community, it might be HIV treatment or even the unresolved question of whether insurance companies should cover sex-change hormone therapy.

Pie and her staff sit in the background at events organized by these leaders, laptops, and portable printers poised, ready to enroll attendees who need technical assistance. "You have to reach the uninsured where they live. We can't expect these people to always come to us," Pie says.

Most enrollees need help. It's a complicated process. The King County bureaucrats are the experts on that front, but they do not see themselves as the spokespeople for the communities they target. They want those groups to speak for themselves. Their faith in civic, church, and ethnic leaders to convey their message comes with dollar signs. Last year, King County received $1.6 million in federal grants to enroll its uninsured population. It gave $1.3 million of that money to its community partners.

County executives are aware that the highly structured cultural rituals of some of their target groups require a carefully tailored outreach. When health officials approach the Purepecha American Indian tribe about health coverage, for instance, they know they must address the men first, who will then invite the women to join in if they like the message. The Purepecha's native language also cannot be written down, so Purepecha leaders have worked with the county to come up with written enrollment manuals that mostly use pictures.

Pie's rhetoric echoes that of a civil-rights activist rather than a regulatory specialist. "Do you feel like health care reform is an equity issue? Absolutely, it has to be an equity issue," she recently told health care journalists at a conference on Obamacare enrollment. "I believe it's our responsibility to reduce disparities. Period."

Nothing irritates Pie more than public-private partnerships that dissolve as soon as the money runs out, as it inevitably does. She is already planning for what King County can do when the federal government scales back its funding for Obamacare enrollment as the number of covered people in the region grows. Uninsured people will still need to be identified and covered. Pie believes that serious partnerships with the community leaders who will accomplish that goal require a long-term commitment from her staff that can't be dependent on onetime government grants.

King County's partners know Pie personally. Her enrollment expertise is in evidence at every local health fair and community gathering in a diverse county. They can find her every first Friday of the month at regular forums where public health officials update and train community leaders on the latest developments on Medicaid or Washington's Basic Health plan.

First Friday Forums are also the hub of King County's enrollment operation. This is where Pie and her staff solve problems and ask questions about who is being left out. If a homeless advocate says some pharmacies are charging young people on Medicaid for birth control, Pie makes sure the state's provider corrects that problem. When the state's buggy enrollment website was directing enrollees to contact the overwhelmed statewide call center, Pie asked the state to allow her staff to override error messages so they could complete enrollments in one sitting. "They did it. They approved it. My staff knows how to clear it. That technical barrier, we take it away," she says.

With a solid reputation as problem solvers, King County health officials have become embedded in broader nongovernment efforts to provide health care to a whole series of disparate populations. Cierra Sisters offers mammograms and diabetes screenings and blood pressure readings, essential for women of color. Gay City offers HIV and sexually transmitted disease screenings, necessary for gay men. At events sponsored by those community leaders, Pie and her crew have been there to help attendees sign up for insurance in a place where they feel comfortable and willing to ask questions.

"To enroll them in a safe place, a place where there's other health activities that are going on, was very powerful and empowering to the community," Hempstead says.

When health care becomes a synchronized effort between government and community alike, it transcends politics and familial affiliations. Everyone is on the same team. The goal is to get people covered. And also to beat the Cowboys.