My name is Kate Worthington. I am currently a research area specialist at the University of Michigan. I earned my BS in Interdisciplinary Health Services from Saint Joseph's University in Philly in 2015. I currently work at the University of Michigan and last year earned my MPH in health behavior and health education. I've also worked on the clinical side and not just in academia as an enrollment specialist and an enrollment assister at a free clinic in Detroit. Essentially, an enrollment assister is a broad umbrella term that we use. Essentially just to describe a group of people who have been trained to help those seeking to enroll in health insurance or to learn more about their health insurance plan and maybe switch insurance plans. Under the umbrella of enrollment assister, there's actually two categories. There's the navigators and the certified application counselors. Essentially the only difference between those two categories is how the position's funded. Navigators are federally funded through grants and are trained through the government that way. Then certified application counselors work at something called certified designated organizations, which are CDOs in short, are organizations like hospitals, clinics that are given permission by the government after applying to train certified application counselors using a CMS program and essentially oversee them. There's only a little difference between the two in terms of funding. But mostly they do the same thing, which is helping people get insurance. I came into the position essentially because after I graduated from undergrad, I wanted to have a community-facing role to help bridge disparities within health care. I applied for a position at a free clinic and they were as I mentioned, a CDO, so a counselor designated organization. They wanted someone who could be their enrollment assister. Essentially just working with patients on helping them navigate the insurance system. Once I applied and got that position, my training is pre-prescribed for certified application counselors. It's an informal training and a formal training. The formal training through the Center for Medicaid and Medicare Services takes about 7-10 hours to complete. They focus mostly on these different modules that take you through just health coverage in general, just the background. What does that look like, topics like privacy and security for your patients, how an assister is supposed to help patients, and how they're not supposed to help patients. Then just go through the basics of the ACA. That's the more formal training, more of the details in the weeds work, then what I considered the informal training was actually working with clients and learning the system. When you're an enrollment assister, depending on what state you're in, you're either going to use the federal websites, so healthcare.gov or some states actually opted to build their own Medicaid websites, and Michigan was one of them. I had to learn the state-based website, and honestly, it's a little tricky to be able to navigate and answer certain questions because of skip patterns. The informal training was just me going into the website and the applications, and learning the best way to answer questions to most accurately represent my clients so that they got their best coverage. Those are the two ways in which I was trained. At the free clinic that I worked at, we had a wide variety of clients, mostly uninsured or underinsured patients. One of the largest categories that I worked with were people who were applying for Medicaid or had consistently been applying to Medicaid and gone through this cycle of acceptance and denial. Let's just say I was working with a patient, for example, who previously had been accepted to have Medicaid as their health insurance. Then a couple months later I received a letter in the mail from the DHS telling them that their health insurance had been terminated. You can imagine that a patient who had just received their health insurance was excited to be able to start going to their primary more regularly and have that financial support when it came to health, would be upset that all of a sudden their insurance was terminated. My role was to have the patient come to me and I would work directly with them to figure out what had happened. Oftentimes, because health care is not just the siloed area, it interacts with a bunch of other things like mailing and housing and those things. Oftentimes, a patient would have been asked by the DHS via mail to provide certain documents. Whether that's their most recent pay stub, whether that's information about whether they moved locations, new contact information. Sometimes the patient wouldn't receive that in time, so they wouldn't receive the letter, so they wouldn't know that they needed to do this thing or give the DHS these documents, and after a certain span of time, the DHS would terminate their Medicaid because they didn't provide those documents. Once they receive a termination letter, you can imagine how frustrating it is like I never received documentation that told me I needed to provide this, so it was this cyclical thing that I was able to work with my patients to have them bring those documents to me, and what I would do is scan them into our system and upload them to their online portal, so, the way that that helped was it removes the necessary trip to the DHS Office for them, and then oftentimes even when they would go to the DHS because it's so busy and such limited hours, they would be asked to use the computers in the front office by themselves and upload it themselves, which not everyone has technology literacy to be able to do that, so that's just one example of some challenges that they faced and how as an enrollment assistant, I was able to provide access to being able to put those documents into the computer so they wouldn't have to worry about that in the future. Then another group of patients I would say that I worked with directly are a group of patients who would fall into this niche area of making too much money to qualify for Medicaid and making too little money to feel comfortable using healthcare.gov to afford health insurance, so they will typically be uninsured. In Michigan and for Medicaid across the board, usually the range for being qualified for Medicaid as a single person there around $16,000 and for four people it's around having $30,000 so if you even made say $35,000 that's not going to be enough to feel comfortable paying for health insurance out of your pocket, but it's also not little enough to afford Medicaid. Some challenges I would face with these participants is when we enroll them, is just health insurance literacy in general, as my job as an enrollment assistant I wanted to make sure they made the right decision for themselves, so a lot of the time it was just education. It was explaining the main components of health insurance rates; deductibles, premiums and co-pays, and not just what they were, but how they interacted with each other was essential, so thinking about healthcare plans when you have a high premium, usually you have a lower deductible and people who select those plans usually are on a medication that they take all the time and will be on for the rest of their life. Usually they have higher chronic diseases that they have to see specialists for, so their costs of healthcare is going to be a lot higher. For people who select health insurance plans with premiums that are lower and deductibles that are higher, usually this is for people who don't go to the doctor too often, you go for a yearly checkup, sometimes something pops up and you need to go get some antibiotics but you're not going frequently, so I would just simply educate my patients on let's talk about what you spend in a year on your healthcare, let's talk about what you will need and then we'll figure out how to pay for it and what different plans will work best for you and honestly, it's super intimidating because there are a lot of options, and so healthcare.gov and the ACA also provided great financial assistance; premium tax credits and the cost-sharing reduction plan that if you selected a silver plan would take place. All to say, my job essentially was to help them navigate that and to help them with their concerns about whether or not they'd be able to afford health insurance, once we crossed that barrier it was a simple matter of signing them up and filling out the paperwork. One of the largest concerns outside of the cost was being able to keep their physician, because we were a very small clinic, we only had two physicians and nurse practitioner, all who were absolutely lovely and their patients adored them. Because we were such a small clinic and funded in a certain way, we only accepted uninsured patients or Medicaid patients that had a specific plan, within Michigan there were 10 different plans under the Medicaid umbrella that people could select from and this clinic only allowed for one of those plans, which I think they have since expanded. But having to break the news that based on their insurance plan choice they would no longer be able to see their physician. It was a really hard battle to talk about the importance of insurance outweighing the love and care they felt for their current physician, so, I would say that that was definitely one of the largest challenges outside of cost. Because the clinic was niche in terms of the populations that we served, whether it was because of the cyclical nature of Medicaid, being pushed off of Medicaid or brought back onto it, I often had clients coming back in who had been kicked off because they had started a new job, but then they had lost the job and so I had helped them back on it. Patients who honestly just wanted to learn more about Charon's and just love to sit down and chat with me about what they could afford and what insurance would pay for them. I got to know my patients really well and lot of the time too though, I would say that once we did get them on a type of insurance that they enjoyed, some of them would just drop by to check in and say they were doing well. Those were always the repeat clients I really enjoyed seeing. A lot of the challenges that we faced were simply just systematic issues. Sometimes when I had a client who did seasonal work. If they had gone to apply for Medicaid before coming to me and had filled out an application a certain way with their seasonal work, and then realize that they were denied even though they technically qualified. That barrier would appear because the next time we logged in and tried to fill out another application, there would be a long-term review process because the way that they had filled it out previously had showed them not being eligible, but the way I just filled it out, which was the proper way to fill it out, showed that being eligible. A lot of times the barriers and challenges came from having to wait. Like if a patient had to wait a few months to actually have their health insurance turned on. If a patient didn't have access to the internet or didn't have time to come in and drop off their pay stubs to me for me to upload it for them. It was just a variety of factors that kept them from following the timetable that was prescribed by the DHS and made it a little difficult to get them health insurance. We figured out a way to do it for all of our patients and worked with them to make sure they got it. I would call their workers and check in with them and check in on their application as was part of my job and developed good relationships that way with workers at DHS. I would say that those were the main challenges. That's a really good question and one that I think a lot of people are interested in and look at. I think the basic thought process is we know that having access to health insurance in general has been shown to help improve health and better health practices for those who have it. I guess getting communities who are under insured and uninsured to have access to insurance would be essential. We saw it in the observation of the 32 states who expanded Medicaid versus those who didn't. We were able to see that those who fell into a group that hadn't previously had health insurance, but now did started using preventative services more so cancer screenings, visiting and maintaining a primary care provider, and all those things have been shown to improve health over time. I feel like as enrollment assisters, our role in creating that trust in the system enough to get insurance is essential. I think enrollment assisters role within a community provides a greater level of trust because typically enrollment assisters are people who live and work in those communities. Especially certified application counselors because they're the ones who are working at those community odds, or those hospitals, or those clinics that are local. For people who hear someone randomly telling them, hey, you should get health insurance like someone they don't know, that might not be enough for them to get the health insurance. But if it's someone who they trust within their community, whether you define community by race or geographic location or culture, however you define community. When someone in your community is telling you this is important, let me show you why. You're more likely to go ahead and do that thing and take it seriously, which is why I think enrollment assisters are so essential because they're parts of their community and they're someone that people can trust. They're like the community health worker with an insurance twist. Often community health workers are actually enrollment assisters as well. I feel like that's why they're so essential to getting people to enroll in health insurance is because they're part of the community. I think the only thing that I honestly would stress is just how essential they are. I mean, I think the main takeaway from this conversation would be how essential enrollment assisters are in not only getting people to have insurance, but also the right insurance for that person. I think the trust that can be built between someone who lives and works in the community and the community itself allows for a better understanding of how these systems work, and therefore a greater autonomy for individuals to be able to care for their own health. I think enrollment assisters do just that and that's why we should keep funding them and keep giving them the resources they need.