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Broad Recommendations
Over the course of our stakeholder interviews, it became clear that the State’s potential transition to an SBM presents the opportunity to more comprehensively center consumer voices and needs. This section focuses on broader recommendations that surfaced throughout the interviews and have implications for the topic-specific recommendations that follow. These recommendations are grounded in the perspective that, to achieve universal access to affordable, quality health care, consumer voices are critical at every step, from design to implementation to evaluation.59
We identify three key recommendations:
1. Increase consumer assistance capacity. 2. Integrate consumer engagement into the process of designing and implementing Maine’s SBM. 3. As a longer-term initiative, re-establish the Maine
Office of Health Equity and empower its staff to coordinate equity efforts across the SBM, the
MaineCare program, and all DHHS Offices. Background
The possible transition to an SBM provides the opportunity to address challenges related to reduced consumer support around enrollment activities. While our stakeholder interviews highlighted existing state efforts to support consumers’ enrollment needs, policies under former Governor LePage and former President Trump—which decreased funding for marketing, outreach, and consumer assistance in the marketplace60—have limited the potential for robust and sustained support for consumers. In this context, foundations have stepped in to provide funding for outreach and enrollment efforts, directing crucial resources to advocacy groups and community-based organizations.i As Maine looks to transition to an SBM, stakeholders stressed that they hope to pivot from functions that could be performed by the State to grassroots organizing and capacity-building among local leaders.
Consumer-facing stakeholders also expressed broad concern that a transition to an SBM may not be responsive to the needs of consumers, particularly historically marginalized Mainers. While state officials have made inroads and hold regular meetings with community organizations and advocacy groups, some stakeholders voiced the perspective that information sharing and collaboration opportunities between community-based groups and state officials can be improved. Another theme that emerged among our interviews was the impressive institutional knowledge, close community, and policy capacity developed among grantees of the Maine Health Access Foundation. The tight-knit nature of this community of organizations was clear throughout our interviews, with community-focused stakeholders referencing conversations we had with previous community organizations -- an indicator of frequent collaboration among such groups. A stakeholder with a national advocacy focus also noted in a conversation that Maine has a particularly robust network of community-focused health policy organizations. Additionally, one stakeholder specifically highlighted that this cohort of advocacy and community-based organizations, which has collaborated since the rollout of the ACA, would likely bring significant value through its policy and consumer-facing experiences with the marketplace. These themes highlight the opportunity to more comprehensively engage this cohort to center consumer voices in the potential SBM transition.
Those providing enrollment support, including navigators, assisters, and call center staff, play an important role in helping consumers with low literacy, limited English proficiency, poor internet access, or who are facing other barriers to enroll in health insurance that meets their needs. While Maine officials should work with consumer groups to make the marketplace as easy to navigate and understand as is possible, many consumers will still likely need or prefer assistance to navigate the marketplace and select a plan. For example, many rural residents rely on navigators for enrollment because they lack access to the internet or can only access it on their phones, making in-person or over-the-phone consumer assistance a lifeline for coverage. Additionally, consumers with limited English proficiency may rely on translation services provided through the call center or other consumer assistance. CMS reduced funding for navigators during 2018 and 2019, which limited funding for enrollment assistance in Maine. In 2019, Western Maine Community Action
i These external sources of support have come to play an integral role in the consumer assistance landscape. For instance, in 2019 alone the Maine Health Access Foundation granted the DHHS Office of MaineCare Services for MaineCare Expansion $450,000 and the Wabanaki Public Health Office $50,000 for ACA MaineCare Direct Outreach and Enrollment and Health Equity Capacity Building. Maine Health Access Foundation. “2019 Annual Report: Responsive Solutions to Improve Health.” https:// mehaf.org/wp-content/uploads/2019-Annual-Report.pdf 18 | BROAD RECOMMENDATIONS
received $100,000 of CMS funding, which was the only federal funding for navigators in Maine that year.61 While Maine officials increased funding for this year, the State should continue to prioritize sustained financial support for consumer assistance programs. Recommendations include the following: • Increase the number of enrollment assisters and call center staff funded by the State. • Prioritize cross-cultural communication skills in hiring and training of staff. • Invest in targeted enrollment outreach to communities facing higher rates of uninsurance, such as
LGBTQ+ individuals.62 • Increase the number of enrollment assisters able to translate material into additional languages. • Create a centralized navigator portal to provide enrollment assisters information about changes to consumers’ health insurance enrollment. • Identify opportunities to train people within historically disempowered communities to serve as enrollment assisters.
Consumer Impact
This policy could substantially decrease complexity for consumers by providing them with trusted advice and assistance to enroll. This would likely lead more consumers to enroll, and could advance health equity if assisters can support groups with different language backgrounds, limited internet access, or other barriers such as time scarcity to enroll in coverage. Assisters and call center workers can help consumers find the most affordable plan that offers what they need.
State Feasibility
This policy would likely receive support from stakeholders because it facilitates enrollment by those who may otherwise remain uninsured. Sustained enrollment support could impose increased costs for the State, as it could require hiring of new employees or additional granting to community-based organizations. Recommendation 2: Integrate consumer engagement into the process of designing and implementing Maine’s SBM.
State officials can also consider how to formally embed consumer voices and needs in decision-making processes related to the possible transition to an SBM. For instance, the State could establish a consumer advisory board with representatives from key communities and organizations. The purpose of this structure would be to assure that SBM-related policies are informed by the perspectives of Maine consumers through meaningful collaboration.
DHHS officials could consider leveraging existing infrastructure focused on narrowing disparities and elevating consumer voices, particularly those of historically marginalized health care consumers such as immigrants or the Wabanaki people. One such structure, for instance, is the Permanent Commission on the Status of Racial, Indigenous and Maine Tribal Populations. The Commission—which recently received a one-time $50,000 funding award from the Mills administration63—could receive additional support to act as a channel to embed consumer input and advance equity-focused initiatives. The enabling statute for this Commission outlines a number of roles that this body could engage in to elevate consumer voices and health equity concerns in the potential SBM rollout. For instance, the Commission could hold public hearings and workshops to consider how an SBM could narrow health disparities. The Commission could also carry out relevant research and work with the Governor to advance policy actions promoting health equity. Such activities align with the Commission’s overarching goal to “promote, carry out and coordinate programs designed to improve opportunities for racial and ethnic populations in the State.”64 The State could also look to the existing infrastructure and community of consumer advocates and community-based organizations supported by the Maine Health Access Foundation for opportunities for more robust consumer input.
Consumer Impact
Sustained engagement with consumer-facing stakeholders would benefit consumers by centering their needs and challenges in the potential development of the SBM. Providing consumer groups a forum to voice their concerns and authentically engage in the possible SBM transition can also potentially address coverage barriers and could lead to opportunities for expanded coverage access and increased affordability.
Consumer collaboration could also help officials identify ways to decrease marketplace enrollment complexity by identifying pain points experienced by consumers in the enrollment process. Finally, centering consumer voices—particularly those of marginalized populations—advances health equity by targeting atBROAD RECOMMENDATIONS | 19
tention and resources towards issues impacting populations historically excluded from policymaking spaces.
State Feasibility
This policy would likely be feasible. Many advocacy groups already participate in other state health policy settings, such as Maine Equal Justice on the MaineCare Advisory Committee.65 While this recommendation requires state action to convene and consider how the body informs other processes, it is unlikely to pose significant implementation challenges. Challenges associated with this recommendation are related to broader obstacles around stakeholder and consumer engagement. State officials will need to balance competing needs of different organizations, set expectations for how they incorporate input, and determine which organizations should represent key voices.
Recommendation 3: As a longer-term initiative, re-establish the Maine Office of Health Equity and empower its staff to coordinate equity efforts across the SBM, the MaineCare program, and all DHHS Offices.
All state officials we interviewed expressed an interest in partnering more closely with community organizations to reduce inequities regarding health access for historically marginalized communities in Maine. DHHS Offices are taking proactive steps to solicit input from and collaborate with community leaders, especially given the context of the coronavirus pandemic and its disproportionate impact on specific communities. At the same time, officials acknowledged that existing equity activities are siloed, limiting operational efficiency and overall efficacy. Internally, the burden primarily falls on leaders within each Office to foster lasting relationships on behalf of the State, all while juggling multiple priorities. As a result, equity-oriented activities are often ad hoc and/or conducted independently from other Offices within DHHS, even those with closely related responsibilities. Externally, community health groups must maintain relationships with multiple Offices. Officials expressed worries that the State may be responding to communities with greater advocacy resources, rather than targeting the communities with the greatest needs. Overall, this lack of coordination has resulted in potentially duplicative and inconsistent equity efforts, which undermine the State’s ability to 20 | BROAD RECOMMENDATIONS foster trust and ultimately to serve communities. Multiple state leaders also expressed concern at the lack of uniform standards for demographic data across DHHS, a challenge that other states are also grappling with.66 This limits the State’s ability to monitor health access and outcomes across programs, including between OFI and OMS. This is a critical issue if Maine officials wish to capture and monitor community health statistics at a level more specific than the categories used by the federal government (e.g., certain ethnicities, tribes, and LGBTQ+ identities), as inconsistent usage over time could hinder longitudinal analysis.
The shift to the SBM is a chance for DHHS to think more deeply about its operational struc-
ture when it comes to equity, especially given the significant role that assisters and community organizations will play to make the new SBM a success. Prior to the LePage administration, DHHS contained an Office of Health Equity with a mission to “[promote] health and wellness in Maine’s racial and ethnic minority communities.”67 Currently, many of these responsibilities have been carried forward by DHHS’s Manager of Diversity, Equity, and Inclusion. As a longer-term initiative, we recommend that DHHS re-establish this Office but consider expanding its authority and responsibility to (1) coordinate health equity efforts, including data, within DHHS and (2) foster longer-term relationships with community health organizations on behalf of the State.
Such a model would follow existing examples in states like California and Connecticut. California’s Office of Health Equity contains multiple business units engaged with leading the State’s health equity policy and planning, fostering community development and engagement, and providing technical guidance on health research and statistics.68 In a similar model, Connecticut’s Office of Health Equity has worked since 2016 to “ensure that health equity is a cross-cutting principle in all [Department of Health] programs, data collection, and planning efforts,” which includes coordinating efforts with community-based organizations, contractors, and local health officials.69
Many of the access barriers and community disparities relating to the marketplace overlap with those impacting OFI, OMS, and MaineCare program activities, as well as other DHHS programs. If the underlying structure of Maine’s health equity coordination is not eventually addressed, it will limit the SBM’s full poten-
tial to serve Mainers, especially those with historically marginalized identities.
Consumer Impact
A more coordinated approach to equity at DHHS will benefit consumers, especially those who have been historically marginalized or excluded from health systems. It will make it easier for DHHS to develop lasting relationships with community organizations and incorporate their needs across the department, rather than simply on a project or program basis. If DHHS standardizes data collection during this process, it will allow officials to develop, target, and evaluate policies designed to close health disparities or eliminate barriers impacting specific groups.
State Feasibility
Across the country, the national reckoning on anti-Black racism following the murder of George Floyd has led many state governments to begin developing or further enhance their equity capabilities.70,71 There are no easy fixes; racism and other dimensions of oppression are complex and deeply pervasive, and require a long-term commitment to action from all levels of an organization. It is especially important that equity staff are empowered at a level of decision-making to work with Office leaders across DHHS, which will necessitate adequate funding for staff and operations. However, given the current political and cultural moment, state leaders may be more inclined to support health equity efforts, especially in light of the disproportionate impact of COVID-19 on Mainers of color.
