The holiday season brings many traditions to look forward to, such as spending time with family and exchanging gifts. There are also some less-favored traditions, though, such as the deluge of holiday-themed advertisements. Viewing the same images and hearing the same messages repeatedly can make anyone want to put on their blinders, plug their ears, and tune them out!

When consumer health advocates began planning for the Affordable Care Act’s second open enrollment period, advocates hypothesized that consumers who hadn’t enrolled in the previous open enrollment period may feel the same way that average holiday-shoppers feel – bombarded by the same messages that simply don’t resonate with them, and moreover, cause them to stop listening. To help motivate these consumers to enroll, the advocacy community felt that new messages needed to be created that would tap into the current feelings of the uninsured about having health insurance.

During the summer of 2014, the Robert Wood Johnson Foundation worked with PerryUndem and GMMB to conduct consumer focus groups and a national poll of uninsured individuals to better understand their feelings and attitudes toward having health insurance. Separate focus groups and polling were conducted with Spanish-dominant, uninsured Hispanics as well. Although the participants agreed that having health insurance is important, many of them firmly believed that they could not fit health insurance into their budgets. Overall, they found three messages about health insurance options were the most motivating: 1) there are low-cost health plans, 2) you can get financial help and 3) in-person assistance is available.

Based on their findings, RWJF launched a new website,, which educates consumers about these three aspects of the law and provides communications resources for partners to spread the word. The site provides a roadmap that walks consumers through information about the low-cost plans available through the Marketplace, eligibility information for financial help, and ways to find local, in-person assistance. The site also provides tools to help consumers determine how much financial help they are eligible to receive.

The partner-focused side of includes an outreach toolkit full of creative and innovative communications resources for advocates, enrollment assisters and other enrollment stakeholders. These resources are all available in both English and Spanish. In addition, RWJF has launched a digital and radio advertising campaign in federally-facilitated Marketplace states to help spread the word and encourage consumers to check out their options.

While the ACA has succeeded in enrolling millions of Americans in quality, affordable health coverage, there are still many who remain uninsured, due to perceptions of health insurance being unattainable, unaffordable, or both. Messaging aimed at these consumers should incorporate their current feelings and attitudes toward health insurance in order to be effective. Thanks to the leadership of the Robert Wood Johnson Foundation, we can determine that emphasizing low-cost plans, the availability of financial help to pay for plan costs and in-person assistance to help navigate coverage options, are the messages that will be most effective at addressing attitudinal barriers to enrollment. The wealth of resources available at provides the enrollment community with ways to message ACA enrollment that will make the remaining uninsured stop tuning out and start listening.

With open enrollment in full swing, consumer health advocates are ramping up their outreach to diverse populations that continue to have disproportionately high rates of uninsurance.

 Latinos in particular are more likely to be uninsured, with one in three Latinos lacking coverage nationally. While some states have made great progress in lowering the uninsured rate—states that closed the coverage gap have seen the uninsurance rate among Latinos drop from 36 percent to 23 percent— there is still a lot more work to do to ensure all Latinos can gain access to coverage. 

According to recent research, while most uninsured Latinos recognize the value of having health insurance and are interested in seeking health insurance options, 7.6 million o f an estimated 10.2 million of uninsured Latinos who are eligible for Medicaid or financial help to pay for coverage continue to face barriers to enrolling in coverage:

  • Lack of Awareness: According to a national poll conducted by the Robert Wood Johnson Foundation (RWJF), 81 percent of participants indicated that they do not know enough about the ACA, 78 percent do not know that the ACA provides financial help, and 66 percent do not know free, in-person assistance is available to help people apply for coverage. According to the same RWJF poll, when asked why they do not have insurance, 36 percent of respondents said they cannot afford insurance or they would not qualify. There is lack of awareness among Latinos about the availability of advanced premium tax credits (APTCs) for legal immigrants even if their income is below 100 percent Federal Poverty Level (FPL) and even if they are not eligible for Medicaid or CHIP under the five year bar.
  • Health literacy: Latinos are less likely to understand basic health insurance concepts than white, non-Hispanics. Additionally, some members of the Latino community view health insurance as transactional – something they should pay for as they go.
  • Immigration status: Mixed status families (i.e. families or households comprised of undocumented immigrants and United States residents) fear their undocumented relatives will be deported if they apply for insurance coverage and provide information about their household to the Marketplaces.
  • Language: There is limited access to accurate Spanish-language materials about the enrollment process. Additionally, (the Spanish version of did not launch until December last year, which limited access to information about open enrollment for native Spanish Speakers.

While there are significant barriers to address in outreach to Latino communities, advocates around the country successfully employed essential strategies to reach uninsured Latinos and help them gain access to health care. (Learn more about these strategies and the outcomes they’ve produced by following the links below.):

  • Increasing health literacy and awareness through radio and television: The Colorado Consumer Health Initiative’s Latino Media Project in partnership with Adelante con la Salud (Latino Health Care Engagement Project) worked together to successfully educate Latinos in Colorado about the benefits of the ACA. With the help from Health Care for All Massachusetts (HCFA), they collected success stories about clients who gained coverage, both through expanded access to Medicaid and through financial help. In addition, educational messages about how Latinos benefit from the ACA were also disseminated through radio and television channels in both English and Spanish.
  • Engaging the faith-based community through education and enrollment events: UHCAN Ohio built strong relationships with community and faith based organizations by educating organizations about the ACA and partnering with them in Marketplace outreach, enrollment, and follow-up efforts recruiting some in Medicaid and marketplace outreach, enrollment, and follow-up efforts. Some community and faith groups then hosted enrollment events and others became certified application counselors. With the relationships they’ve already had with the local community, they partnered with church leaders in Latino communities to help them serve as health care resources for their congregations.
  • Training the trainer: The Oregon Latino Health Coalition hosted a conference to train 200 community health workers on how to assist Latino families with enrollment. In Florida, groups like the Epilepsy Foundation of Florida trained Navigators and teaming up with hospitals to reach Latinos.
  • In-person assistance: A personal touch is crucial during successful enrollment. Recent message research has shown that many members of the Latino population value a human interaction to answer questions and allay fears surrounding the enrollment process.
  • Using trusted messengers: the Latino community almost unanimously point to their social circle as their first and most trusted source of information

While it was difficult for advocates to reach and enroll some populations, especially the Latino population, the examples above can provide a roadmap to effectively working with the Latino population. For the second open enrollment period, advocates will need to continue focusing on outreach efforts for the uninsured Latino population, and use the information gained through polling and message research to pivot their efforts toward improving health literacy and adding a personal touch to enrollment assistance. 

These days, when we shop for even the smallest items, we have online reviews to help us find the best deals. But when it comes to the big-ticket item called Medicaid managed care, it's been a lot harder. Consumer advocates and other stakeholders have struggled to locate information on the performance of the multistate companies that are increasingly winning state contracts to manage Medicaid programs. Without this information, it's impossible to get a complete picture of how well a managed care company is likely to serve consumers.

In this season of giving, Community Catalyst has teamed up with the Kaiser Family Foundation to create an online tool that gathers in one place, for the first time, key data on the records of these companies. The Medicaid Managed Care Market Tracker includes quality scores and state-imposed sanctions. The tracker also enables comparisons across states' Medicaid managed care programs, including network access standards and the percent of premiums that go to care versus profits. All of this can help ensure consumers – both individuals and states – are getting their money's worth.

More than half of Medicaid beneficiaries are already in risk-based managed care plans, and states are rapidly expanding managed care to seniors and people with disabilities. In many states, this is tied to closing the coverage gap or demonstration projects for people eligible for both Medicaid and Medicare. Medicaid managed care can improve coordination, quality and efficiency of services. But it can also be risky for consumers, if the companies put profits ahead of people.

The Medicaid Managed Care Market Tracker lets you peer inside the wrapping of these companies.

For example, you can learn that from 2010 through 2013, for-profit UnitedHealth Group plans were sanctioned in seven states for offenses ranging from improperly denying speech therapy services in Florida (fined $1,305,000) to failing to meet standards for children's preventive services and vaccinations in Arizona (fined $200,000). Or that Molina's Texas plan paid the largest state fine during that period: nearly $3 million for problems including blocking access to needed medications, a skimpy provider network and poor handling of consumer complaints.

You can also learn that UnitedHealth's Rhode Island plan, which did not face any sanctions, received one of the highest overall quality scores – 85.5 out of 100 – from the National Committee for Quality Assurance. The plans scoring higher were all non-profits.

Other data show some states are paying a high price for having the companies manage their Medicaid programs. For example, in Delaware and Nevada, the companies took nearly 25 percent of taxpayer-supported premiums off the top, spending only 75 percent of premiums on care for state residents. These numbers cry out for closer examination of whether consumers are getting the quality and quantity of care they need.

Here are some more ways to use the new tool:

  • Check out plans operating in your state or planning to bid on business in your state
  • Identify how your state's managed care standards stack up to those in other states and advocate for stronger standards
  • Identify the parent companies of plans in your state and their performance, so you can learn more about their corporate standards
  • Educate policymakers as they consider expanding Medicaid managed care and/or contracting with new plans
  • Highlight promising and problematic plans for media
  • Advocate for more public accountability for the public dollars spent on managed care

To learn more about the tool, please join a webinar hosted by Kaiser Family Foundation on Thursday, December 11 at 12:30 PM EST.

Now if we could only turn this into an app....

As the fight to close the coverage gap continues in 23 states, critics are openly questioning the value of Medicaid and even claiming that it is not better than being uninsured. But recent data unsurprisingly reveals that potential low-income beneficiaries do not quite see it that way.

While we already know that strong empirical evidence confirms Medicaid’s effectiveness at improving access to care, health outcomes, and financial security for its beneficiaries, this recent study provides a fresh perspective that too often gets lost in the politically-charged policy sphere: consumers’ actual experience and perceptions of Medicaid. The study surveyed low-income adults from three southern states who are either Medicaid beneficiaries or would be eligible for Medicaid coverage if their state closed the gap.

According to the study, 80 percent of respondents supported closing the coverage gap and covering more people through the Medicaid program. Between Medicaid and private insurance, the latter had an edge in being able to see the “doctors you want, without having to wait too long.” However, Medicaid ranked higher in enabling beneficiaries to “be able to afford the health care you need,” and on the overall question of “quality of health care” (see Figure 1).

Source: Authors’ analysis of survey data of 2,864 low-income adults (ages 19–64) in Texas, Arkansas, and Kentucky. Health Affairs, October 2014.

When comparing Medicaid with no insurance, more than 90 percent of respondents favored Medicaid across the board in quality, affordability, and being able to access a doctor that respects his/her patients. The study also reveals that despite how much they stand to gain from Medicaid, most low-income people are unaware or misinformed whether or not their state has closed the gap. Thus, while consumers favor improved Medicaid coverage, they are marginalized in the very policy discussions that will impact their health and lives. This discrepancy underscores the critical role that health care reform advocates continue to play in elevating the consumer voice, and particularly the voices of the most vulnerable among us, for improving their access and experience of health care. 

Choosing Wisely

 ·  PostScript

Seeing patients at my local health clinic, I recently had a fairly typical day for many doctors. I saw a child whose parents had been advised to give him a cough-and-cold medicine for his cold, a woman who had been prescribed the antibiotic azithromycin for her viral upper respiratory infection, a high-school teacher who had been prescribed an antibiotic for her pink eye (which wasn't getting better), and a man who had been told he was due for a repeat colonoscopy five years after his previous, completely normal one.

What's wrong with this picture? Cough-and-cold medicines are not recommended for children because they do no good and because they can cause harm to children. Antibiotics like azithromycin are completely ineffective against viral infections and carry a risk of serious side effects. Likewise, antibiotics don't work for pink eye—a condition almost always caused by a virus. That's why my patient hadn't gotten better in the two days she had been using the drops that burned her eyes each time she put them in. And current guidelines, based on research, recommend that patients with a normal colonoscopy can wait 10 years before their next one.

So why was the prior medical care these four patients received so at odds with treatment guidelines? Two patients had been seen in the emergency room, one was treated by a fellow provider in my health center, and one by his prior specialist, a gastroenterologist. Were these other clinicians who had made these inappropriate decisions ignorant of the science? No, I don't think so. They were probably caring doctors and advanced-practice nurses who truly wanted to help their patients.

So why would they make such choices that, in fact, ended up not helping their patients and even putting them at risk for untoward events? Some will say it's because the patients expect the treatments they received. However, multiple studies have shown that most of the time the patient is not expecting the prescription for an antibiotic that that the doctor thinks the patient wants.

Sometimes it's because the doctor wants to do something and mistakenly believes that only a prescription equates to doing something. Other times it may be because the provider is in a hurry and thinks a prescription can replace a conversation and save time. And we must acknowledge that sometimes it is to the financial benefit of the physician to recommend a procedure more frequently than it really is needed. Whatever the reasons, the results show up as the widespread overuse of medical care in the United States, a big problem for several reasons.

First, overtreatment and mistreatment leads to actual harms to patients, sometimes even death. One-third of patients told they needed heart bypass surgery did not need it, according to a study by the Harvard School of Public Health and the RAND Corporation. Nearly 300,000 women have healthy ovaries removed unnecessarily during hysterectomies, subjecting these women to premature cardiovascular disease and osteoporosis as they age, another study found.

And overtreatment wastes money, money that could be spent on expanding health care coverage for millions of people who still lack access to affordable care. And money that could be spent on other important social needs like housing and poverty. In a take-off on the old TV quiz show, “The $64,000 Question,” public health researchers Fuchs and Milstein posed the $640 billion question. They noted that there are individual physicians and health care organizations in the U.S. that deliver high-quality care at roughly 20 percent lower cost than the U.S. average. If the rest of the U.S. health care industry followed their example, we could save $640 billion annually—more than enough to achieve universal coverage.

In 2009, the American Board of Internal Medicine (ABIM) Foundation launched a program providing small grants to advance principles of the Physician Charter, which calls upon physicians to work toward the wise and cost-effective management of limited clinical resources as an ethical commitment to professionalism, and in 2011, members of the progressive physician’s group National Physician’s Alliance (NPA) field-tested proposed "Top 5" lists of things that primary care physicians in family medicine, internal medicine, and pediatrics, should not do and then published our results.

The idea that a group of doctors could come up with a list of five things they shouldn't be doing to patients was a revolutionary notion that grabbed the attention of the lay media, resulting in extensive coverage from the Wall Street Journal to Vogue. The ABIM Foundation was so pleased with the success of this NPA project that they decided to fund and launch a major effort expanding the concept beyond primary care to all medical specialties. The result was the Choosing Wisely campaign that now includes more than 60 medical specialties and has even started to be taken up by health disciplines outside of medicine, such as physical therapy and dentistry.

Winning the hearts and minds of health care providers and the public won't be easy. Powerful forces stoke the engines of overuse—a fee-for-service system that rewards doing more, pharmaceutical companies that want to sell more drugs, hospitals that want to fill beds, and providers who want to do something—all regardless of whether that's really in the best interest of patients.

And winning over patients could also be just as hard. Until patients are better informed about their care, it can be hard not to feel suspicious when your doctor tells you to “wait and see if this symptom clears up on its own” even if that is the best treatment.

That’s why Choosing Wisely has started to create resources to help patients understand when less care can be better, and safer. Consumer Reports has joined the Choosing Wisely campaign and is producing high-quality handouts for patients on each of the items on the "Top 5" lists. Having a trusted group such as Consumer Reports supporting the campaign serves a vital function in blunting any fear that these recommendations in any way represent an effort to ration care. Rationing means denying patients needed and beneficial care; Choosing Wisely focuses on avoiding unneeded, wasteful, and potentially harmful care.

As the health care system continues to change, patients and consumers have the chance to become more involved in decisions about their care. Many consumers resort to the internet to research their care options already. And they need reliable, trusted sources of information. The consumer-friendly resources available through Choosing Wisely are a good place to start.

Consumer advocates can help publicize these important resources for the constituencies they serve to help them learn more about high quality health care. Furthermore, consumer advocates can encourage consumers to bring these resources to their doctor visits, and train them to have open discussions with their providers about when less care is the right choice. Will an antibiotic really help me? Are there risks to getting a scan that I don’t know about? When should my kids get their eyes checked?

And as health care policy continues to change, advocates can help ensure that these recommendations are considered as payment and reimbursement incentives are improved. Consumer advocates must be vigilant, to help ensure that as overtreatment is reduced, the savings that should result are used to improve the value of health care for consumers.

Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant