January 20, 2012

Peter Lee, California Health Benefit Exchange
Toby Douglas, Department of Healthcare Services
Janette Casillas, Managed Risk Medical Insurance Board

Re: Communications Support for the Outreach & Education Campaign Plan AND Assisters Program (HBEX2)

Dear Peter, Toby and Jeanette:

We write today to express our appreciation for the thorough work that went into developing the request for proposals, “Communications Support for the Outreach & Education Campaign Plan AND Assisters Program,” recognizing the challenges and opportunities still ahead. Below we share a number of overall comments, which include areas of concern, omissions and additional considerations.

Those responsible for the outreach and education campaign plan face a very difficult environment, resulting from years of misinformation about the benefits of health reform and the very compressed time frame prior to the opening of enrollment, anticipated for as early as July 2013. Shifting attitudes on health reform will be as difficult as shifting attitudes on tobacco smoking, something on which California state government led the way over the last several decades, beginning with a marketing campaign after the enactment of Proposition 99 in 1988. As California develops its campaign plan, all populations will need some education about the benefits and enrollment processes, but harder to reach populations will need considerable assistance to enroll in appropriate coverage.

Can Just One Vendor Successfully Execute the Duties? Primarily, we are concerned that the RFP combines two distinct activity areas that require very different levels of expertise for one vendor. There are many firms that bring expertise on marketing and outreach, some who may even have the subject area expertise required to develop and implement a communications, outreach and education campaign around health reform. However, the development and consideration of an Assister Program requires a fundamentally different area of experience and engagement, likely outside the scope of the expertise of vendors who demonstrate expertise in the marketing and communications arena. An Assister program will require a vendor with deep subject matter expertise and a thorough understanding of California’s long history developing assister models, both under the Medicare program (SHIP or the HICAP program) and Healthy Families, as well as a knowledge and understanding of the vast network of experienced assisters at the local and community level throughout the state. We would encourage you to consider separating the marketing and outreach components from the Assister Program development in order to ensure that the best and most experienced vendor for each of those jobs is engaged.

Addressing SHOP Enrollees: Throughout the RFP, there is an emphasis on developing plans that will serve individuals and families, which is critical in order to maximize the number of insured Californians. However, equally important in marketing and outreach and assistance, but not thoroughly addressed in the RFP, are the SHOP beneficiaries of the Exchange, including small business employers, employees, and their dependents. Any vendor developing a communications and outreach plan should consider the potential SHOP enrollees. Questions before the vendor will include whether the marketing and outreach for the SHOP program should be different in terms of segments targeted, but also materials developed and communications avenues utilized. Additionally for the Assister Program, the issue of whether to develop a different Assister Program for the SHOP as compared to the individual Exchange should be reviewed and considered.

Health Literacy and Language Access: Recent research by Consumers Union indicates that many consumers have very low levels of knowledge about such basic health insurance terms as “deductibles” and “co-payments.” In addition, California has attempted in the past to be cognizant of the reading comprehension levels of beneficiaries when creating marketing and educational materials within health insurance programs. We believe it is important to incorporate health insurance literacy communications throughout the campaign plans and materials and would like to see language added into the vendor expectations that specifically identifies the importance of health insurance literacy information.

We appreciate the acknowledgment throughout the proposal of the importance of multilingual marketing and assistance campaigns targeted to California’s diverse communities, but we remain concerned that the proposed focus groups are limited to only English and Spanish. We understand that the multi-stage nature of this RFP may allow only a short time-frame to conduct focus groups during the initial stage, limiting the ability to expand beyond English and Spanish before April 2012. However, we would like to see additional confirmation and a clear timeline as part of the RFP process with respect to when focus groups in additional languages will occur. We suggest that they happen no later than July 2012 in order to allow enough lead time to develop the appropriate messaging for multilingual outreach efforts and campaigns in 2013. These efforts are especially important as research has shown that Limited-English-Proficient (LEP) Californians, although less likely to have heard about the Exchange, are more likely to enroll once they learn of its benefits. We are concerned that the absence of targeted marketing campaigns in other languages could leave LEP individuals more susceptible to deceptive marketing practices due to a general lack of information and awareness of the new law.

In addition, we applaud the reference to “threshold languages” throughout the document, however, the RFP is missing a reference definition for threshold languages. We urge the state to use the existing Medi-Cal managed care program definition, as mentioned by many of us in our comments submitted for the IT RFP.

Interagency Jurisdiction: We request that other state agencies and offices be incorporated via this RFP into vendors’ proposed scope of work. Specific references to the Department of Healthcare Services and the Managed Risk Medical Insurance Board are critical, as are those to the Department of Managed Healthcare and the Department of Insurance; absent is the Office of the Patient Advocate (OPA). OPA will play an important role in providing consumer assistance, yet in the RFP it is not included as a Project Partner or resource. OPA should be an essential collaborator to the development of the Assister Program, much the same as other Project Sponsors, playing an important role in providing consumer assistance, but also as a liaison to some of the communitybased organizations that are locally based, who are well positioned to participate in any Assister Program that is developed.

Considering Target Populations: A population that should be specifically identified in the RFP and included in the scope of the work for marketing, outreach and education, as well as the Assister Program, are people who may be auto-enrolled (for example, those covered by FamilyPact, as well as eligible parents of Healthy Families children or family members of Access for Infants and Mothers (AIM) enrollees). Those who may be auto-enrolled (or auto-converted, as was done in Massachusetts for beneficiaries of the uncompensated care pool) should be specifically addressed in the RFP and vendor plan, as they likely require a different focus than some of the other outreach and assistance populations to ensure the activities are targeted and able to support a more streamlined enrollment process. Another important segment of the population that should be accounted for in targeted marketing and outreach is the group of people who experience life transitions (for example, divorce or job loss), particularly since potential private and public entity partners may be uniquely positioned to reach these populations (e.g. DMV, state courts, EDD, etc.).

The currently uninsured in California are a diverse group, but certain characteristics are common within the group, as are characteristics of those who might change coverage when the Exchange products become available. As such, we would like to see a vendor plan that considers or incorporates separate strategies for outreach and communications and the Assister Program that distinguish work targeted at easy- and hard-to-reach populations. A full evaluation of metrics for success should not just consider the number of individuals reached; rather, different measurements should be incorporated to ensure that those easy to enroll are not prioritized at the expense of hardto- reach populations.

Additional Considerations: In the listing of program coverage expertise required of the Assister Program, the RFP should require expertise and understanding of the private insurance market, as well as the cost-sharing and advanced premium tax credits (APTC) – in particular, Assisters should deeply understand how the advanced premium tax credit reconciliation process will work, as this will have significant financial repercussions for individuals eligible for APTC whose circumstances later change.

We also see a number of areas where the vendor will not be developing policy, but rather implementing it, which would require that a simultaneous consideration of the policy issues occurs on a similar time frame as the plans are developed – a good example of this is on branding, whereby the marketing team will have the expertise to determine how to develop one overall brand for all health coverage programs, but not be the experts to determine the policy on whether one overall brand is the right way to go for California – we want to ensure that the policy discussions within the state are happening at the same time and allow for sufficient stakeholder input. In our experience working with numerous issue advocacy campaigns, vendors need to understand (and believe in) the policy objective in order to be effective at developing marketing strategies.

The RFP identifies a fairly vague stakeholder process, requiring the vendor to work with and support the Project Sponsors with stakeholder engagement. The groups signed below are anxious to see the plan that will outline the process for stakeholder engagement. Given the short time frames articulated in this RFP and the importance of stakeholder engagement that will be needed during March and April 2012, we are concerned that you have yet to publicly release a plan that outlines the activities around stakeholder engagement and/ or identify a key staff contact/s for stakeholders to engage with.

In addition, we recognize that the RFP contemplates the vendor responsibility to develop a compensation plan for Assisters. We believe that there should be an additional request for the vendor to consider whether this compensation scheme should be similar to limitations or definitions of Assister consideration outside the Exchange. We are concerned about the implications of having different compensation mechanisms inside and outside the Exchange and how that might impact steering and adverse selection.

Representatives of the undersigned organizations would like to request a meeting with the staff of your agencies to discuss our above comments in further detail. We look forward to hearing from you soon to schedule a time to meet.

Thank you in advance.

Sincerely,

On behalf of:
Julie Silas &
Betsy Imholz
Consumers Union

Ronald Coleman
California Immigrant Policy Center

Vanessa Cajina & Elizabeth Landsberg
Western Center on Law and Poverty

Byron Gross
National Health Law Program

Beth Capell & Anthony Wright
Health Access

Gary Passmore
Congress of California Seniors

Cary Sanders
California Pan Ethnic Health Network

Mari Lopez
California Partnership

Carla Saporta
Greenlining Institute

Jamila Iris Edwards
Children’s Defense Fund – California

Mike Odeh
Children Now

Sarah Flocks
California Labor Federation

Mike Russo
CalPIRG

Fatima Morales
Community Health Councils

cc:
Thien Lam, HBEX
Dennis Gilliam, HBEX
David Panush, HBEX
Len Finocchio, DHCS
Ernesto Sanchez, MRMIB