I am going to be interviewed by WBEC Chicago this morning between 850-10am. I will chatting about the experiences of my team and I in assisting the community in enrolling in the ACA. Really nervous but also excited to share some stories, our team’s combined expertise, and raise advocacy on a growing process.
The link is included above in case you’d like to listen in.
Our enrollment assistance team at PrimeCare spends a lot of our time helping immigrants and new residents who are trying to submit a Marketplace application. For every 10 applicants that we see daily, between 4-5 are legally present individuals experiencing difficulties enrolling in health insurance. The Marketplace describes individuals who are eligible for coverage but who do not have US citizenship as “Legally Present Residents”. Since we became Certified Application Counselors and In-Person Counselors we have helped many LPRs. We’ve been slowed down by the Marketplace website that has made it very difficult for our LPR clients who find themselves unable to electronically verify their identity and proceed with the application. We have identified three main ways that the website is unable to complete verification processes:
- Account Creation: The website depends on identity proofing questions in order to verify an applicants’ identity. These questions pull from credit history in order to produce questions unique to the applicant. Many LPRs are unbanked and are unable to be found by a traditional credit search for reasons such as employment history that depends on cash sources of payment, lacking lines of credit in the US, or simply just not enough time in the country. Variations of name placement across immigration documents also impact the ability for someone to be verified.
- Document Verification: If someone is able to get through identity proofing, many have faced a yellow screen letting them know that electronic verification is not possible and to touch base within 24 hours. We have found this to be a permanent feature for our LPRs. We surmise that the website is not equipped to efficient verify an applicant’s citizenship information and gets stuck trying to verify the document information as it connects with the Department of Homeland Security. This usually occurs when an applicant inserts both alien number and document number.
- Eligibility Determination: If someone happens to get through account creation, if an LPR’s income is between 0-100% FPL and do not have legal permanent residency for five years or more, they are disproportionately likely to receive an incorrect eligibility determination. This determination usually points them to Illinois Medicaid, despite the fact that their legal status bars their eligibility.
We’re no different than outreach and enrollment teams across the country that have faced similar Marketplace glitches. Not only were we unable to help our clients who are immigrants through the easier, initial steps (that citizens were able to do) in the Marketplace application, but we also had to share the bad news with them that they should expect to wait additional weeks while we mailed out their documents and waited for verification. By late November, we saw applications for citizens submitted successfully while our LPR clients could not submit application because the electronic identify verification step didn’t work, and the application would literally close out. Our team started calling this “the yellow screen of death” because it meant that the client was completely locked out. Steps to resolve it ranged from starting a new application under a new user name, multiple times, sending paper applications to government offices in Kentucky, to calling the Call Center who hadn’t yet been trained or for whatever reason communicated incorrect information.
Because the neighborhoods we serve have a larger proportion of immigrants compared to other areas, our team felt compelled to figure out what was going on. There is nothing more disheartening than the “yellow screen of death” the sixth time or trying to explain to one of our clients why they were told by Call Center representatives that they needed a Medicaid “denial letter” first before they could proceed with their Marketplace application. We started tracking when and where the glitches occurred and we began piloting combinations of steps that would “trick” the system into accepting the supporting documentation. We took a sample of 75 applications and with the permission of our clients, the applicants, we piloted a combination of steps that took them through the electronic application. This week, we have been successful with 30 applications in 5 days’ time. We are so happy to be able to tell our clients who are immigrants that we can process and successfully submit their application.
We have created a Process Workflow that describes why we are having the success we are. We have done an analysis overlaying application steps and tech-related misfires. We are seeing interesting patterns and we have communicated this to our Government Marketplace counterparts. You’ll find that attached here. As you can see, messy and complex, but so are our clients. We want to share what we are doing that works with other Enrollment Assisters experiencing the same problems. We especially recognize that our clients who are immigrants carry a weightier burden of having to provide additional documentation than our clients who are US citizens. Our clients who are immigrants experience additional steps that both elongate the difficulty of the application and its wait time, but their happiness in selecting a Qualified Health Plan and successfully submitting their own application electronically makes all the difference in our day.
My team has seen many of our original assists from October in the last few weeks. It’s been wonderful to see many of our community members and finally have a game plan for them. It’s been even more wonderful to see them enrolled in health plans. We’ve stuck it out this long together and we’re excited to get them onto the next step of this enrollment journey.
I told you about Esperanza a few weeks ago. She was one of my CountyCare patients that for some reason was stuck in a nebulous spot. Her application was yet to be executed and her medical need was way too high for her to stay uninsured. I recap that entry here:
11:55am– A team member comes and grabs me- the tell-tale signs of “uh-oh” are etched on her face. Esperanza is a 36 year old female. She was healthy, she was all smiles when I met her over the summer and helped her enroll. She now carries the weight of her body gingerly, slumped in a chair. Her eyes are sunken, her hands shake. She wears a vibrant head scarf to hide the effects of the brain tumor she has been diagnosed with in the last few months. She applied for CountyCare, the adult medicaid program over the summer, back when we were telling people, “expect to hear back within 75 days.” At 125 days since application date, her application represents a gross anomaly in the application turn around and she wasn’t worried about it until her medical story changed. She was fine. She was okay. She thought she would be enrolled and things change. Life happens.
She breaks down in front of me and I have to bite my cheek so I don’t cry too. I have to will myself to be strong and clear-headed for her but it’s hard. She looks too much like my mother. She tells me how since her diagnosis she has been seeing doctors wherever possible, with whomever will work with her and her friend’s finances. She begs me to help her get insured, to find out what’s going on. I end up escalating her case to our senior management team. She’s one of us now, we need to care for her until the state does on paper.
She and I chat for 20 minutes, but those 20 minutes mean the world. I promise to take on her case myself and I have. As she walks away she says, “I come back here because you and your team, you all have honest faces. You can tell that you mean what you say,” and with that she seals her place in my heart and a constant nag in my gut that promises I won’t be forgetting her all day. I don’t. “Thank you for helping me. I don’t have anything to pay you with and I can’t promise you that I will ever be able to pay it back, but I know that God will.”
Esperanza’s story has changed so much in the last few weeks. Her vision has deteriorated so much that she cannot see basic text- she couldn’t help us locate a confirmation sheet for example. She still wears her vibrant headscarfs. She still keeps the spark of hope alive. She’s always polite, always kind, never pushing. She’s always thankful. She’s quiet but she’s ensured that none of us forget her.
A few days ago, we learned that her application, despite our proof, found itself inexplicably lost and had to be resubmitted Friday. My co-worker J.M. drove over to Esperanza’s home and did the application with her. Her hands shook so much and her vision was so out of focus that it took her several minutes between characters in order to finish her signature. We were calm and collected in front of her and in our exchanges over the phone, but we were furious. Murphy’s Law states: anything that can go wrong, will go wrong, and we genuinely wondered, why Esperanza. Why is the universe messing with her? We pushed and we shoved at DHS. We had to pick up the weight of her story and carry it for her so she could finally be heard. Senior leadership, staff members, doctors alike asked us daily how she was, asked us “when will she be enrolled?”
I’m happy to say that we learned today that Esperanza will be enrolled in CountyCare. She will be able to have the surgery and care she needs. Her doctor is buzzing with an energy to get this woman’s care moving and we’re just so floored it really happened. I called her and she said, “Is this for real? Are you pulling my leg?” Nope, Esperanza, this one’s all yours this time.
Thank you to all of my new readers. I have been floored and humbled by the reactions to this blog. I write because really similarly to Harry Potter’s pensieve, sometimes you need somewhere to temporarily place a memory so you do not feel its weight but can still remember its immediacy and rawness. I write whenever I have time- mostly bus rides home and the last few days have a flurry of last minutes to meet a 1/15 deadline. I write whatever I feel like writing, mostly about the cases that my teammates and I love to remember or are super frustrated by. What follows are some of our favorite moments in the last two days, and what a great two days we have had.
There’s a case that has been circling my mind for months now. I first met Antonio over the summer. He came in unannounced, scared. He entered my office with his work hat, his lunch bag, and a powerful immediacy in his demeanor. Everything about him gave off rays of fear: his posture was slouched and curled in; his hands fisted tight around his body. He wouldn’t look me in the eye. I said, “Antonio, I’m Graciela– how can I help you today?” and the flood gates opened. He told me about not having health insurance for the last ten years. He told me about the pain in his hands and back from long days of work. He told me about how badly he wanted health insurance and at the time, I was stuck. Here was a man asking for my help in July but the Health Insurance Marketplace would not open until October. He and I had a long chat that Friday about his health insurance options. More importantly we dedicated some time to what I call the “game plan”. Antonio cannot read or write. He does not speak English. His memory is poor. He has no cell phone and he self admittedly doesn’t check the mail regularly. His brother has a cell phone but he often misplaces it. He has no computer and he never has used one. He gets to his visits with me via bus.
I asked if he would please come back and see me the first Friday of October, that I would wait after work hours just for him. I asked him, hoping that the answer would be yes, but as a prior student of mathematics (granted, I am awful at calculus) I knew that probability and chance were not in our corner. He turned and said, “yes, just write it down on my piece of paper.” Antonio left and a lot of time passed. Fast forward to October. It’s Friday and an appointment request announcing Antonio comes up on my screen, and I think, “No way. No way will he come.” After a summer of my first experiences with cancelled appointments, forgetful clients, apathy I thought I knew it all. I thought I had learned that I had no real business getting my hopes up and Antonio walked in, and with it shattered that. He walked in, documents in hand, ready to go; the website was not as ready. We had no way at the time of knowing how long it would be until the website was up and running so he and I did a phone application that day. We were on the phone for over an hour. He was really nervous and scared so my co-worker and I did our best to set him at ease: we giggled about the bad music, we offered him chocolates, got him through it. They told us he would hear something in 6 weeks, and we didn’t like it, but we stomached it. We told him, come back to us as soon as you hear anything.
I’ve discovered a new law of emotional physics in our office. If my team thinks about someone hard enough, that’s the day they walk in to seek our aid. We bump into them on the streets, on the train, in the halls of our office, but somehow, the universe lines up, and you land on our stoop so we can help you. Flash forward to mid-November, six weeks pass and I’m worried. I thought about Antonio often during those weeks, wondering, hoping he would get through and emotional physics works out and Antonio walks in. He has not heard ANYTHING and after a call to the call center, they confirm that they have lost his application. I just about lose it, but its not the right time for my emotions- it’s about Antonio. My co-worker work quickly together- he takes care of lightening the mood and calming Antonio down and I blast through an application but then we get the yellow screen of death. I call this the screen that some of our immigrant applicants get when they apply and the system can’t find them. It’s the end to that application- they’re not going to be able to get through electronically right now.
We met with Antonio 4 more times to try and get his application and nothing we did, nothing the call center tried worked. Finally, Antonio’s life story changed- his income and household size changed. So much time had passed from our original discussion that he now became eligible for Medicaid instead. Fast forward to this week: we are ecstatic to say that we have enrolled Antonio in CountyCare. At this point, Antonio is our friend, and we are relieved to know he will have health insurance. Today I get to give him his confirmation and explain how his insurance will work!!
Many think enrollment assistance is a one time deal, a one stop shop. For some it is. For others, its about multiple touches– calls, visits, applications– to get them through. It’s all about the follow-up. It’s all about the follow-through: “I do exactly what I say I will do.” It’s all about faith. It’s all about turning something scary into something easy. It’s about recognizing and validating humanity. It’s about new friendships. People like Antonio show us why enrollment is and needs to be so much more beyond the application. It’s definitely not for the weak of heart.
People: I am wearing four layers right now. It was -15 with wind chill when I walked in at 8am and the streets are a hot (just kidding) mess. Everything has become an instantaneous ice rink, and yet our patients keep walking in. They’re getting enrolled, they’re navigating the tundra, and they look hella stylish and kind of bulky doing it, but whatever. We’re all bulky. It’s Chicago.
It’s -15 and they care enough to come and see us. I’m letting that one sink in. Who says my community doesn’t want health insurance? They care. I care. We all care. This fact is enough to warm my cold self today. I hope it makes you feel a little warm too. We’re open today when so many places in Chicago are closed, and people are here. There’s a little skip to my step today. Happy Monday.
The last week of enrollments really were a test. My team and I had the same conversation as always– “I really want to get this person enrolled. I really hope the website will let me.” It seems like a matter of chance but in the worst peaks of the website capacity, luck was all we had. We have patients who we have followed through this process since the summer. Individuals who have seen every crash in the website, every coded flaw and have stayed persistent in their faith that they will get health insurance. They are patient, they are understanding. These people are the reason my team was burning last week to enroll. We were running on fumes on extended hours, weekend and night appointments, so hungry to get as many as possible enrolled. We just wanted it so badly.
Every Christmas story has a familiar frame: there’s a hard story to overcome, a test that challenges values and strength, and the miraculous turn that reestablishes belief and hope. My holiday season of enrollments showed this over and over again. I want to speak about this Saturday. I had appointments scheduled back to back all day and everyone showed. As we got closer to the 12/23 deadline, no shows were rare. People were yearning for insurance and they followed through. They heard us loud and clear when we said come prepared. They brought friends, neighbors, little ones. We quickly figured out our supplies kit should include extra chairs, kleenex, coffee, crayons and coloring books, pens, folders, index cards. Towards the end of this first deadline in enrollment, our waiting rooms and offices felt more like small family gatherings. We saw familiar faces, we saw new ones that entered our Primecare family. This Saturday followed was no different. I was about three appointments in when the website starting acting funny– too many people on the site, error messages, and the yellow screen of death that lets you know electronic verification is just not going to happen.
I got on the phone with the Marketplace hotline for a grand total of 3.5 hours with 3 different clients and I was surprised by the kindness of some; the absolute rudeness of some. Beatriz and I were on the phone for almost 2 hours together- the English speaking agent scoffed off my request for a Spanish speaking agent and promised a short wait time on the Spanish side. I later reasoned she sent us back to central circulation and back to the beginning of the line. Beatriz had walked in as I had already been on the line on hold for 1 hour with Pedro and his wife. I was pretty irate by the time the Marketplace got on the line with him, but almost lost my cool when they told him the website issues were due to volume and that he should try his application later. He looked at me and said, “But doesn’t she know I’m here now?” Pedro and I ended up trying two different applications before deciding we would be in touch as he made attempts over the weekend.
Beatriz and Pedro supported each other through the application process. It was way after the office had closed. They kept each other spirits up; gave each other encouraging words exchanged giggles and laughs over the horrible hotline music. Eventually, after a cup of coffee we all chirped up and things didn’t look so bad: we could all be alone trying to get through a rough patch in the application, but in the comfort of our office, we were together. We were a mismatch family. Sometimes, even health insurance enrollments needs a family of support and I’m grateful we had such beautiful company that day.
We ended up calling it quits after 2 hours on the phone for Beatriz; she was too tired, too emotionally wiped, but I couldn’t sleep. I wasn’t satisfied. I still walked home so unsure that night- how much of an impact was I making with a site that worked like that?? I continued working on her application from home (Bertha granted me status as an approved representative). Picture this: it’s 9PM Sunday night and I finally get through. We had already chatted about plans- she knew down to the T what plan she wanted. She just needed luck on her side and here it was. The exhilaration was too much and I couldn’t help myself– I picked up the phone and called her at 10PM. She answered on the first ring and said, “Oh, thank god. I wanted to call you but didn’t want to be that person.” I let her know that she was enrolled and the relief in her breath was so audible it made my heart lurch. She didn’t have words for me- and she didn’t need them. Her thank you said it all to me. She had expected me to forget; to stop trying: that’s not me. She then told me her belief in serendipty: “I met your team because I was supposed to; sometimes God places specific people your way. I needed help and you did it. I’m going to send everyone I know.” I had met Beatriz a month ago and she had suffered three appointments where the website failed and she hung on with us. Being able to enroll her and finally say “Merry Christmas” and mean, really mean it, was more than I could bear, and I’m not ashamed to say I cried like a baby that night.
Pedro tried the website countless times; he was on the phone, strongly patient and brave and could not get through. He called me on the 24th shy at the call, but I said, “Pedro, please. Shyness is for anyone else but us- you’re family.” I couldn’t get Pedro enrolled electronically. I’m finding that no amount of technology, forms, verification checks help some of our most vulnerable legal permanent residents or unbankable folks (think those with no credit or bank accounts). I was prepared to receive his fury but I was surprised to hear him steal a page from my book, “What’s the game plan here?”
I push the game plan, the what’s next, because you always need a contingency. We plan, the website laughs. Pedro and I figured out a plan and submitted a paper application immediately. I was scared he’d be upset but as we closed out the conversation on the 24th he said, “…and I can come to you with the next step?” “Heck yeah you can–you’re family.” We’re in for the long haul together.
This season of enrollments taught me so much. It is a privilege to do what we do, to hear stories, to impact lives, to get people through one of the hardest steps in recent memory. I was fortunate to see quite a number of Christmas miracles in the last few weeks to reinstate my hope. I also saw some miraculous examples of faith and understanding that remind me of the resilience of my community. These are people that have been waiting for a while and they are not going to be stopped by a website, by snow, by documents, by anything. They will be back, and we will be waiting.
Hope is a funny thing- sometimes you can see it, sometimes you can’t, but lately I can feel it all the time. We’re getting people through to the other side, a side that includes health insurance for the first time for many of them. We’re building a community and a support network in the process, and maybe that’s just my way. It’s personal. It means everything. It’s the utmost privilege and ultimately what makes every day of it worth it.