1. HEALTH INSURANCE
EXCHANGES
Spreading the Word
Sally McCarty
EDAC 632
Dr. Bo Chang
December 3, 2012

2. What are Exchanges?
• A major provision of the Affordable Care Act
(―Obamacare‖)
• Online insurance coverage marketplaces
• Will be operational by January 1, 2014
• Enrollment begins October 1, 2013
• Individual Exchanges
• For those who don’t have group coverage
• SHOP – Small Business Health Options Program
• An Exchange for small employer groups (fewer than 50 or 100
employees, depending on state definition)

3. What will be sold on the Exchanges?
• Four types of policies will be offered by commercial
insurers who apply to be ―Qualified Health Plans‖ (QHPs).
• Bronze
• Silver
• Gold
• Platinum
• Premium Subsidies/tax credits for household incomes between
131% and 400% of the Federal Poverty Level
• Advanced tax credits paid directly to insurer and insurer bills for
remainder.

4. States Have 3 Options
• State-based Exchange
• Operated by the state
• Minimal federal involvement
• Federal/State partnership Exchange
• In conjunction with the federal government
• Shared management
• State performs some tasks (e.g., premium rate review)
• Federal government performs others, (Medicaid eligibility determination)
• Federally Facilitated Exchange
• State defers to federal government
• State’s consumers purchase from the Federal Exchange

5. Funding the State Exchanges
• Several types of grants have been available to States:
• Early innovator Grants – for States that decided in 2011 to opt for a
State-based Exchange.
• Assistance for planning, consultants, IT contractors, etc.
• Planning and Establishment Grants – two levels
• Level I - initial planning and research, deciding which option to
choose
• Level II – more advanced in process, IT contracts and equipment,
staffing, etc.
• Example: Indiana applied for and received $7.8 million in
Level 1 grant funds.

6. The Dilemma
• ―A health exchange’s first task is ensuring
that those who are eligible for benefits
know about them — right now, research
suggests three-quarters have no idea.‖
• Sarah Kiff, WashingtonPost.com,
November 12, 2012

7. The Program
• Design a community outreach program that states can
use to
• Educate consumers about the benefits available
through the Health Insurance Exchange, and
• Teach consumers how to access the benefits.
• Adopt the organizational culture/symbolic management
perspective
• Most appropriate for an endeavor that requires multiple
organizations and cultures (state agencies) to
• Work in a coordinated fashion
• Toward a common goal to educate the public
• sharing common values
• Developing unifying symbols

8. Program Goals
• Assure that consumers who are eligible for coverage
through a state’s Exchange are aware of the Exchange
.
• Assure that all consumers who are eligible for coverage
through an Exchange know how to access the Exchange
• Assure that consumers who are eligible for coverage
through an Exchange are aware of the subsidies and tax
credits for which they may qualify.

9. The Challenge
Attitudes toward New Health Insurance System
―Most were aware of the changes coming in 2014 but
knowledge levels were uneven. Some respondents were
very knowledgeable about the new system and how it will
work, while others were very uninformed. The Spanish-
speaking respondents tended to be part of the latter
group. In general, there was strong support for the
changes but the support was tempered by considerable
skepticism on the part of many that high-quality and
affordable plans would actually be available.‖
Discussion of qualitative research from a California Health
Benefits Exchange planning document.

10. Why Organizational Culture/Symbolic
Management?
• Success of State Based Exchanges will rely on cooperation among
a number of state entities:
• Exchange Staff and Board of Directors
• Department of Insurance
• State Health Department
• State Family and Social Services Department, most importantly the
State Medicaid agency
• Most appropriate for an endeavor that requires multiple
organizations and cultures (state agencies) to
• Work in a coordinated fashion
• Work toward a common goal to educate the public
• While sharing common values
• And developing unifying symbols

11. Common Themes found in Literature
Review
• Shared values and goals, and participative and less bureaucratic
management make an organization more efficient (Tompkins, 2005,
p. 360).
• Organizational ―symbols,‖ such as language, rituals, and traditions,
can be means means to understanding an organization (Tompkins,
2005, p. 361).
• An organization’s culture affects both the quality of the experience
of those involved with an endeavor as well as the quality of the
organization’s work product (Pennisi, 2012).
• Transfer of organizational culture to new employees during
orientation directly correlates with worker self-efficacy (Simosi,
2012).

12. Edward Schein’s Symbol Categories
• Artifacts:
• visible, such as physical environment, the way meetings are
conducted, organizational structure, etc.
• Espoused values
• less visible, conscious, such as values that members of the
organization claim to espouse as expressed in various ways, such
as strategic goals
• Basic underlying assumptions
• not visible, subconscious, taken for granted and create consistency
of behavior (Tompkins, 2005, p. 363-364).

13. Program Investigations
Ehealthinsurance.com Massachusetts
Connector
[Private, commercial
enterprise] [Government Program]
Values/ • Numbers Driven • Team spirit
Organizational • State-of-the Art IT system • Human interest
Culture • Profit Oriented • Focus on customers
(drawn from
• Focus on Customers at
clues on web site
and elsewhere) expense of employees
Artifacts Annual Report is quantitative, Annual report is
using data to illustrate qualitative, using human
accomplishments. interest stories to illustrate
accomplishments
Consumer education materials
are easy to read, attractive, and Consumer materials are
geared toward the average wordy and geared toward
consumer. a more sophisticated
consumer

14. Program Investigation
Lessons Learned
• Each program is doing an excellent job in assuring that
those who access its services get the help they need.
• The organizational culture of the Massachusetts
Connector is more team-oriented and better suited to my
program ( perhaps as a result of running a program that
has been heavily scrutinized).
• The Ehealthinsurance consumer materials were more
useful, consumer friendly, and better suited to my program
(perhaps because of access to better design expertise).

15. Program Evaluations
Lessons Learned – Michelle Rice
• National Advocacy Director – National Hemophilia
Foundation
• Two principles that should be incorporated in all message
delivery activities.
• Choice
• Broad appeal
• These are of utmost importance to the chronically ill when
delivering the news of Exchanges

16. Program Evaluations
Lessons Learned – Kevin Lucia
• Research Professor, Georgetown Health Policy Institute and
Member of the DC Exchange Board of Directors
• Divide the program into two ―tiers‖
• Tier 1 to deliver the ―broader‖ message‖ that insurance is available,
without details. (The paid media, social media, billboards, posters, etc.)
• Tier 2 to deliver the details, once the first message is received (face-to-
face meetings, speakers’ bureau, brochures and other more-detailed
print materials).
• Partner with a unifying organization, e.g., Massachusetts
Connector partnered with the Boston Red Sox
• Uses common cultural values (love of sports, admiration of sports
figures, affiliation with a team, loyalty to that team), and all the symbols
affiliated with that entity (logos, mascots, players, etc.) to gain
adherence to the primary message.
• Target specific populations

17. Building the Exchange on Shared Values
• Many of the agencies and groups represented in Exchange
operations already share values
• Consumer protection and
• Access to quality healthcare
• Access to affordable health coverage for all, especially vulnerable
citizens,
• Exchange Staff and Board of Directors – Physician and Hospital
representatives
• Department of Insurance – Consumer protection activities
• State Health Department – Public health responsibilities
• State Family and Social Services Department – Aid to vulnerable
citizens
• State Medicaid agency – affordable coverage for pregnant woman,
children, the disabled, and the elderly.

18. Program Design – Tier 1
• Tier 1 is designed to deliver a simple message and not
detailed information, e.g., ―Get Insured,‖ or ―Insurance is
Now Available‖
• Media the simple message to target audiences:
• ―Young invincibles‖ (healthy young adults who do not tend to purchase
health insurance),
• Uninsured individuals and families, particularly women
• Involve the unifying organization partner.
• Use social media, paid and free, as well as media outlets
geared toward target audiences – radio stations,
billboards,
• Posters in doctor’s offices, clinics, emergency rooms,
social service agencies – wherever uninsured are likely to
visit

19. Tier 2 – Elaborate on the Message
• Discussion
• Services available through the Exchange, including subsidies and
tax credits
• Steer those who could benefit from the Exchange’s services to the
navigators or others who can help them
• Media
• Strategically-placed articles and stories in media around the
state
• More social media, with more information
• Print
• Brochures and other print materials in same locations that posters
were placed.
• Billboards
• In densely populated and medically underserved areas.

20. Tier 2 Face to-Face
• Convene representatives of social service groups that serve those
with healthcare needs and engage them in spreading the word
• Disease group advocacy organizations,
• Public health nurses,
• County health offices,
• Create a speakers’ bureau drawing from all agencies
• Delivering a uniform presentation of the Exchanges services, to a broad
range of organizations, such as:
• Local chambers of commerce and other groups representing small
businesses,
• Physician organizations,
• Service organizations (Optimists, Kiwanis, etc.),
• Insurance agents and brokers,

21. Develop Unifying Mission Statement
• The vision of the California Health Benefit Exchange
is to improve the health of all Californians by assuring
their access to affordable, high quality care. The
mission of the California Health Benefit Exchange is
to increase the number of insured Californians,
improve health care quality, lower costs, and reduce
health disparities through an innovative, competitive
marketplace that empowers consumers to choose the
health plan and providers that give them the best
value.
• California Health Benefit Exchange Mission Statement

22. Develop a Unifying Symbol or ―Brand‖
www.getcoveredco.org
www.coveroregon.com

23. ...and Spread the Word that it’s here!

24. References
• Pennisi, Lisa. (2012). Experiencing the Impact of Organizational
structure on planning and visioning tasks. A Journal of Leisure
Studies and Recreation Education, 27(1), 46-54.
• Simosi, Maria. (2012). The moderating role of self-efficacy in the
organizational culture-training transfer relationship. International
Journal of Training and Development, 16(2), 92-106.
• Tompkins, Jonathan R. (2005) Organization Theory and Public
Management. Boston, MA: Wadsworth Cengage Learning