Due to a range of historical, systemic, and socioeconomic determinants, major health inequities persist throughout the United States. Factors like a person’s race and zip code are still powerful predictors of health outcomes.
It’s no surprise that these inequities also exist within health insurance coverage. While passage of the Affordable Care Act, which expanded Medicaid and made insurance more affordable for many people, helped reduce differences along racial lines, gaps remain, according to data released last year by the U.S. Census Bureau. The study found that while the percentage of uninsured among white people was 5.7 percent, it was 9.6 percent for Black people and 17.7 percent for Hispanics. And lack of insurance hosts drastic consequences for these communities. For example, 18% of Black Americans reported problems paying or an inability to pay their medical bills, compared to 12% of white Americans.
Responsibility for closing those gaps rests, in part, with policymakers. But health insurance providers also have to be part of the solution through more effective and inclusive enrollment outreach.
Without a doubt, the mountain of challenges tied to enrollment is steep. Distrust of the medical system and government runs deep in many communities. Due to decades of being neglected or underserved, many people in those communities are reluctant to share personal data with insurance providers. Some don’t have the health literacy or English language proficiency to navigate the enrollment process on their own. Others simply lack information on issues like eligibility and access to benefits.
But reaching all communities must be a priority for insurance providers in this country. The ultimate goal: health equity, the state in which everyone has a fair and just opportunity to attain their highest level of health. Here are five strategies to aid healthcare leaders looking to boost enrollment rates:
1. Demonstrate a cultural humility and curiosity to seek more knowledge and understanding.
In formulating an enrollment outreach strategy that targets hard-to-reach communities, one of the first and most important steps insurance providers can take is to acknowledge what they don’t know about engaging these communities. If this is not acknowledged, these data holes can lead to costly assumptions.
Beyond acknowledging information gaps, insurance providers must demonstrate a genuine interest in those communities and what has hampered enrollment in the past. The answers will form the basis of an effective strategy.
Developing those insights is a significant undertaking. It requires a mix of quantitative and qualitative analysis. That means, for example, collecting and analyzing data on a community’s populations—education levels, races, ethnicities, and languages spoken. It also means establishing a dialogue with people in the community through surveys and interviews to understand their experience with the healthcare system.
Ultimately, demonstrating cultural humility and a commitment to understanding underserved communities will help establish trust with them, an essential ingredient for a successful long-term strategy.
2. Enlist partners with credibility in each community.
In many communities, we have found that messages from outsiders, especially about something as crucial as health, will often be met with skepticism. That’s why partnering with people and organizations with credibility in their community is crucial. Whether a faith-based leader, community organizer, or local bodega owner, some people have built up the trust needed to spur action in a community.
Health insurance providers can build mutually beneficial partnerships with these local leaders. In some communities, for example, a poster urging health insurance enrollment from a state agency may not move anyone. But the same poster featuring a respected partner will have a better chance to captivate and influence community members.
But health insurance providers can’t just take from their partners; they also need to give back. Providers must equip their partners with the resources and training required to make a difference. In our work, we have found that many people rely on trusted partners in the community to navigate the enrollment process. While those partners are often enthusiastic about helping, they need training and capacity building to be as effective as possible in the insurance enrollment process.
3. Develop culturally sensitive and targeted messaging.
Messaging surrounding health insurance enrollment needs to be backed by tailored research and data. Generally, we’ve found some common themes that apply to all communities. Every message, for example, should be simple, concise, and actionable. Dense language and jargon don’t entice anyone.
Beyond that, however, it’s important to account for cultural nuances within and across communities. That means, at a minimum, creating messages in relevant languages—not just in English, Spanish, and Chinese.
The messaging also needs to account for more subtle cultural differences—information that should be collected during the research phase. Sometimes, responses to health messages can differ within the same ethnic groups. For example, in our work promoting COVID-19 vaccines, we observed differences in the engagement strategies that were effective among Latinx communities on the West Coast and in the Southeast.
Another meaningful difference is the messenger. For some communities, messages from a publicly elected official will help drive engagement. These people—small business owners, for example—generally believe in the benefits of government. On the other hand, communities with large immigrant populations may be predisposed to be wary of the government, fearful they could be exposed to legal jeopardy based on their citizenship status.
4. Reach people where they are.
Enrolling in health insurance can be a tedious process. It’s naturally something that many people may consciously or unconsciously avoid, particularly when they are unfamiliar with the process and understand the benefits.
Effective reminders can help overcome that reluctance. Research shows that people often have to be exposed to a message several times before they act. How often generally depends on the significance of the service or product. Given the complexity and importance of enrolling in health insurance, research shows it’s best to err on the side of more frequent points of contact.
That means deploying messages about health insurance benefits and the enrollment process wherever people are, whether at bus stops, laundry mats, schools, churches, community organizations, or across media outlets. Reaching communities via preferred social media and messaging platforms is also key. While text messages can be effective for broader groups, various immigrant communities prefer to receive information via applications such as WhatsApp. Community partners are key to identifying strategies to effectively reach people.
5. Play the long game.
It’s a mistake to view low health insurance enrollment rates in any community as a short-term problem that can be fixed over a brief period. First, that view misrepresents the nature of health insurance, which while fundamental to physical and mental health, is also extremely complex.
Second, it underestimates the time needed to establish the trust required to break through and effectively engage communities often neglected. Achieving sustainable success in this area requires a transformational, long-term commitment to communities—to listen to their concerns and grow with them.
We’ve seen powerful examples of health insurance companies taking this approach to heart. One provider partnered with local organizations to provide regular educational events promoting better health practices. Other providers have partnered with local healthcare providers and community-based organizations to support health-promoting activities. Efforts like these send a clear message that health insurance providers have the best interest of the communities at heart and are not simply promoting a transactional policy.
By effectively engaging communities in the health insurance enrollment process, we optimize the potential of insurance to advance health equity.
Dr. Roy Reese, based in Atlanta, serves as Senior Advisor to Ichor’s Healthcare Practice, leading health equity efforts focused on supporting community engagement and improving public health.
Yaritza Holguin is a Director at Ichor with extensive experience in community outreach and expertise in public health. She is based in New York.
