A Heroic Effort to Make Health Insurance Education Entertaining
To help uninsured patients grasp the value of health care coverage, a collaborative awareness campaign salutes two kinds of superheroes.
Ms. Magnificent can stop a moving train before it hits a family of ducks. But sometimes asthma gets the best of her, sending the superhero off to the emergency room, where she gets a rescue inhaler and a “super-sized bill.” Ms. Magnificent has no insurance; the costly treatment is just a short-term fix.
Marvelous Man saves kittens from trees with his super-stretch powers. He doesn’t get routine care, however, so his back acts up from all the contortions. He’s also a new immigrant who doesn’t think he’s eligible for health insurance, nor can he afford to pay out-of-pocket.
Kid Cartwheel uses her acrobatic prowess to save a turtle from a bus, spraining her wrist in the process. Having just turned 19, she’s no longer covered by the Children’s Health Insurance Program. Like many people her age, Kid feels invincible and doesn’t think she needs coverage.
But everyone needs health insurance — even superheroes.
That’s the takeaway from several short superhero videos and an online resource created through a partnership among several Detroit area agencies and the University of Michigan.
Funded by the National Institute for Health Care Reform, the Insuring Good Health campaign aims to spread the word that trained individuals are ready and able to help patients navigate the enrollment process.
“Health insurance is very complicated and the Affordable Care Act is very complicated, but we worked as a team to decide on a simple message,” says Minal Patel, Ph.D., MPH, the John G. Searle Assistant Professor of Health Behavior & Health Education at the U-M School of Public Health.
“We created characters who resonated with different sorts of situations most people would experience, such as transitioning off of one plan to another, managing chronic disease, and changing your doctor,” says Patel, also a member of the U-M Institute for Healthcare Policy and Innovation. “We embedded particular learning points into all of these stories.”
Although the Affordable Care Act cut the number of uninsured by more than half since its inception, millions in the United States remain without coverage. When a study evaluating the Insuring Good Health tools began in 2015, metropolitan Detroit had a large population of uninsured residents.
And they share a common thread: “When we looked at the research, it was historically marginalized racial and ethnic communities,” Patel says. “There was still a disparity between whites and other communities in terms of those actually taking advantage of the ACA and all it had to offer.”
Joining forces for good
A strong team of heroes assembled to craft and spread the message.
Patel, Richard Lichtenstein, Ph.D., co-investigators Barbara Israel and Peter Song, and others from their research team worked with a steering committee that included representatives from Detroit health and social service agencies to gather feedback on how to address some of the gaps in health care coverage that impact low-income, historically marginalized communities.
“We worked with a number of groups to try to create the knowledge we would need at the community level to understand the uninsured situation in the Detroit metropolitan area, and what we could do to change that,” says Lichtenstein, professor emeritus of health management and policy at U-M and an IHPI member.
Partners included Latino Family Services, Enroll America, the Michigan Primary Care Association and the Michigan Department of Health and Human Services. Research was conducted at four sites: Community Health and Social Services Center (CHASS), Arab Community Center for Economic and Social Services (ACCESS), Mercy Primary Care Center and Covenant Community Care.
The team used focus groups and surveys to ask residents to help offer feedback at multiple points, including the videos — which are available in Arabic, English and Spanish.
Project participants were largely black, Arab-American/Middle Eastern descent, and Latino. The research team asked about their knowledge, beliefs, confidence and behavioral intentions with health insurance navigation and care-seeking before as well as six and nine months after engaging with the videos and website.
The inclusive and personal approach resonated.
“Before there was ever a video series, they liked the focus groups. They liked being asked, ‘What do you think?’” says Joslyn Pettway, a graduate of the School of Public Health and chief program officer at Covenant Community Care, which serves 20,000 patients annually at six sites.
And the superhero treatment, though entertaining, was meant to educate viewers: “You have to be careful about condescending, but there’s so much information out there that you needed something different,” Pettway says.
Real-life health care heroes
Most people think of superheroes as infallible beings that swoop in to save the day.
In this case, the champions of the video series are the navigators and support staff who help the heroes navigate their health coverage.
“I love the characters,” says Lidia Reyes-Flores, executive director of Latino Family Services. “I love what they represent, and I love the messages they have, but the navigators were the ones that, to me, make the most impression because now I know who to go to for help if I had any one of those situations.”
Flores’ organization serves a large number of newly arrived immigrant families who often face confusion regarding legal status and health insurance — an issue detailed in Marvelous Man’s scenario.
Margaret Meyers, M.D., medical director at Mercy Primary Care Center in Detroit, says her organization tries to help people navigate the system but the number of choices in the marketplace is daunting, and many people don’t understand terms such as coinsurance, deductibles and premiums.
“I think this program’s really going to help people as they go to choose insurance to really choose the thing that’s going to be best for them,” Meyers says.
Prior to the ACA, all Mercy patients were uninsured. Since then, three-quarters are covered under Medicare or Medicaid.
Many of the remaining uninsured patients, primarily low-income and working, would likely relate to Ms. Chill. The superhero’s chronic arthritis goes untreated because the Superhero Bureau where she works doesn’t provide health insurance.
Turning emotions into action
Tondra Lewis, a study participant and Mercy client, was entertained by the animated storyline. But it also helped her learn about the importance of health insurance and preventive care.
Her new objectives? “To stay alive. To make better choices out of life. To eat better. To have a better heart. Those are the most important parts,” says Lewis, who has since convinced her son about the importance of enrolling for coverage. She’s still working on her sister, who paid a tax penalty this year for not signing up.
Like Lewis’ son, most research participants at the nine-month follow-up said they intend to change a health or insurance navigation behavior.
And while they didn’t appeal to everyone, the videos earned a positive reaction from most viewers, who cited one or more learning points related to health insurance. Latino respondents demonstrated the greatest improvement in knowledge, beliefs and confidence with health insurance navigation and care-seeking.
The team began to create the program before parts of the ACA were changed, but Patel believes the website and awareness campaign can endure.
“We named the intervention Insuring Good Health because we want folks to feel confident in engaging with health insurance and health care in general, over their lifetime,” Patel says. “Our team is motivated to continue our work together. There are many complicated aspects of health care navigation that our team wants to make more accessible to everyone.”