Monday September 16th 2019

Nurses take on various roles with insurance exchanges

When it comes to working for people’s access to health care services, nurses have always been there. That strong advocacy continues as nurses around the country lead, promote and participate in efforts to enroll millions of uninsured Americans through health insurance exchanges, also called marketplaces.

Eligible persons who cannot afford insurance or who have been denied coverage can compare and select from insurance options at these exchanges. Some are state run, others, federally run, and still others, a combination. Initial open enrollment in these exchanges began Oct. 1.

The Wisconsin Nurses Association (WNA) Board of Directors created a 45-member task force to help determine the most effective ways nurses can help Wisconsin’s 500,000 residents gain access to coverage via the federal Health Insurance Marketplace. (Wisconsin policymakers rejected developing their own state-run exchange.)

The WNA task force is comprised of nurses from many roles, including staff nurses, administrators and educators, and from the designated 11 Regional Enrollment Networks (RENs) located throughout the state, according to task force Chair and WNA President Lea Acord, PhD, RN.

Task force members divided into working groups that have been gathering comprehensive information – a challenge because there is no one source for that information — and developing strategies around enrollment in four key areas.

“In Wisconsin and across the United States, we can really make a difference in whether the exchanges are implemented well or not,” Acord said. “People trust nurses, and at WNA we feel a strong responsibility to provide accurate information to help people understand their options.”

“Some residents have never had health insurance and may not have a bank account or credit card, which will make it difficult for them to make monthly payments,” she said.

Acord also expressed concern for some 92,000 residents who are set to lose coverage through “Badger Care Plus,” because the governor refused to accept federal dollars to expand the Medicaid program. These people fall into what’s being called the “coverage gap” — meaning their income is too high to receive Medicaid and not enough to be eligible for marketplace premium tax credits. To put it in perspective, people who qualified for Badger Care Plus were making up to 200 percent of poverty, or $47,000 for a family of four with children under 19.

Task force members are targeting educational efforts toward Wisconsin nurses first, by providing them with accurate information on the Affordable Care Act (ACA).  WNA has developed a web-based, nurse-focused presentation that will be shared with nurses in Wisconsin through its website.

Helping in Oklahoma

Every day, Devyn Denton, RN, case manager supervisor and assistant director for Nursing for Ultimate One Home Health in Shawnee, OK, and member of the ANA Board of Directors, has conversations with Oklahoma patients and families about how the federally-run exchange will affect them.

“Many people don’t know how to enroll in the exchange, don’t have access to computers, or can’t figure out what is true and not true,” said Denton, a home health nurse. Armed with a computer and a wireless air card, Denton runs through insurance options and services under the exchange with her patients during home visits. She also asks them to write down any questions they have between visits, so she can address them or reinforce information the next time around.

However like some other nurses, she has faced challenges with the federal website, which have been well-publicized and acknowledged. For example, she has been unable to determine some actual premium costs for her patients who would likely qualify for tax credits.

“I am there to help people with the process,” Denton said. “But right now I’m spending a lot of time undoing the misinformation they’ve heard in commercials [and through other outlets].”

She noted there has been an active, anti-exchange campaign in her state that has been fueling people’s fears about the ACA and enrollment in the exchange. Some of her patients are worried that their health care costs will go up while their health services are decreased. Others think they no longer will be able to get needed physical therapy, medical equipment or their prescription medications, particularly pain meds. And still others are worried that potential employers will gain access to their health data — such as being treated for depression — and they will lose out on jobs.

Denton also has been working closely with religious leaders in her small, hometown community to provide information on enrollment, including how residents can gain free online access through their churches, libraries and schools. Additionally, she sees the need to improve outreach to the large, non-English speaking migrant population who may be eligible for coverage under the exchange.

In Washington State

Meanwhile, as a member of the Advisory Committee to the state-based Washington Health Benefit Exchange and a nurse administrator with Public Health Seattle and King County, Patty Hayes, MN, RN, has been closely involved in developing the exchange. She also has helped design an outreach network and programs to support enrollment in her county.

“In Seattle King County, we took a community-based approach by building a network of organizations and providers who are trusted resources in the community to help enroll uninsured residents,” said Hayes, who also serves on the Washington State Nurses Association’s Legislative and Health Policy Council and brings her expertise on public health and low income populations to the exchange’s Advisory Committee.

Currently there are an estimated 180,000 uninsured King County residents who are eligible for affordable coverage through the expansion of Medicaid and through the Washington Healhplanfinder.

In King County alone, more than 500 in-person assisters have been trained to help in enrollment, with more than 200 community outreach events scheduled. Further, four major outreach events with media participation have been held in that county, where the largest percentage of uninsured resides.

Hayes also offered an example of the power of the ACA. She noted that one self-employed family is currently paying $1,200 a month for insurance. With subsidies under the exchange, the cost will be reduced to $300 a month – which she said was a great surprise to the family. Because of the ACA, family members also will receive preventive services without co-pays.

As of mid-October, nearly 25,000 residents statewide enrolled in the health insurance program, and an additional 37,000 residents completed online applications, according to the Washington Health Benefit Exchange.

In South Dakota, Nebraska

South Dakota Nurses Association (SDNA) Treasurer Deb Fischer-Clemens, MHA, BSN, RN, has been spreading the word about how South Dakotans can enroll in the federally run exchange through her role as senior vice president for policy for a large health system and as a member of the SDNA Government Relations Committee.

“I’ve been doing a lot of presentations to nurses and other staff [who are part of our health care system] and out in the community,” Fischer-Clemens said. “Nurses want to know how to respond to their patients’ questions about the exchange and enrollment, and they should be raising the issue with patients.”

Fischer-Clemens also has helped develop and disseminate materials on the exchange to health care staff and other stakeholders. She noted that large contingents of volunteers won’t be coming to South Dakota to help enroll residents. So beyond the trained navigators and certified application counselors who can talk about the specifics of insurance products, it’s critical that nurses get educated on and involved in enrollment efforts.

“It’s about social justice,” Fischer-Clemens said. “Health care is a basic human right. And who should be helping people gain this right but nurses?”

In Nebraska, Melissa Florell, MSN, RN, has been researching specific plans being offered in her state, such as Blue Cross, as well as working to promote the value of the exchange. Nebraska lawmakers also opted out of running a state-based exchange, so residents must enroll through the federal exchange.

“It looks like there are good options for families,” said Florell, who recently transitioned from a volunteer member on the Nebraska Nurses Association’s (NNA) Commission on Advocacy and Representation to serving as NNA’s director of State Affairs.

One issue she has discovered, however, involves determining the actual cost of the plans, because of challenges in accessing specific information on the exchange website.

In her new role, Florell hopes to develop resources that NNA nurses can use to assist their patients in enrolling in the exchange, as well as partner with other groups to reach those who are the hardest to reach — rural residents, many of whom also lack access to the Internet.

“Rural Americans also tend to be under-insured and are often self-employed, which means they are exactly the people that would most benefit from the exchange,” Florell said.

Spreading the word in California, nationally

Alice Benjamin, MSN, RN, ACNS-BC, PCCN, secretary of the ANA\California Board of Directors and AARP volunteer educator, routinely speaks at schools, churches and community events about the Affordable Care Act (ACA), and increasingly, the importance of the insurance health exchange.

“Often at these community events, I’m the only health care professional in the room,” Benjamin said. So she’s constantly reading the room to see if people are understanding what other speakers are saying, and interjecting at times to present information in a more understandable way.

“I really believe I’m making an impact by helping consumers understand issues around the law, including the exchanges, and I’d like to see more nurses involved,” she said. “As nurses, our holistic approach and ability to meet people where they are [in terms of learning] can really help.”

Benjamin is scheduled to address nurses and other health care professionals at her workplace, Cedars-Sinai Medical Center in Los Angeles. She also has planned a train-the-trainer program for members of the Council of Black Nurses, the Los Angeles chapter of the National Black Nurses Association, on broad aspects of the ACA. She hopes to follow up with another program that focuses on more specifics of health reform, including enrollment in the exchanges.

As for California statistics, the number of uninsured people in the state totals roughly 7.3 million. By Oct. 12, there were nearly 1.6 million “unique visits” to the Covered California website, California’s state-run exchange, and more than 100,000 calls to its service center.

— Susan Trossman is the senior reporter for The American Nurse.

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