TakeAction Minnesota Education Fund CI Report – Final

What has been most instrumenta to your progress?

Directly engaging healthcare consumers. Through door-to-door visits, house meetings and a community story-telling event, we sought the experiences and feedback from people who use MNsure about what works and what doesn’t. These were not policy experts, healthcare professionals or academics but real people who use the system, speaking from personal experience. Their input generated a lot of insight about the developing healthcare exchange. We have made use of this emerging community expertise to propose changes that are already making MNsure more responsive, equitable and effective.

Working collaboratively with navigators. With support from the Bush Foundation, TakeAction staff worked with hundreds of navigators from dozens of navigator organizations. We hosted trainings, convened meetings, scheduled group phone calls and met with them one on one. These conversations made clear that navigators were a vital community resource, uniquely positioned to identify issues on the ground and look beyond the hundreds of individual clients they served to pursue systemic solutions. We helped organize the navigators’ observations and relay their suggestions to MNsure staff, so they could improve the healthcare exchange as it rolled out. Today, navigators are universally recognized as a vital part of the infrastructure for enrollment and consumer education. They have also emerged as an important behind-the-scenes resource for the healthcare exchange, collaborating with MNsure and the Department of Human Services to address the complex experiences and concerns of applicants.

Participation in the state’s Health Care Financing Task Force (HCFTF). In the second half of 2015, TakeAction held a consumer seat on the HCFTF. A learning from the first year of the grant was the need for community collaboration, not just with MNsure but also with DHS and other stakeholders, as few community issues could be resolved solely within MNsure. The task force was a place to engage many key stakeholders at once. But task forces are rarely publicly accountable or accessible. So TakeAction hosted a monthly learning community focused on connecting and supporting people’s organizations to contribute to the task force. We hosted listening sessions so task force members could hear from consumer organizations representing children, immigrants, community clinics and people with high health care needs. We also engaged over 200 consumers by email and shared their stories with the task force. Over and over, we heard people with coverage lament that they couldn’t afford to go to the doctor, or that medical bills threatened their family’s economic security. We recruited ten community members to share their experiences with the task force.

Key lessons learned

One positive lesson was the importance of hearing the actual voices of healthcare consumers, with the support of consumer organizations. In shaping MNsure and expressing concerns about affordability to the task force on healthcare financing, we needed representatives of community organizations, and we also needed the actual individuals from the community to tell their individual stories and lived experiences. Without the organizational leaders to maintain institutional continuity and accountability, decision makers could misinterpret or set aside the experience of healthcare users. Without the healthcare users speaking out themselves, there could be insufficient input to achieve truly responsive policy.

A second (negative) lesson relates to MNsure’s challenges in communicating clearly with the public. We initially approached this project as an opportunity to shape a new public entity, but quickly learned that MNsure could not be addressed in isolation, and that its challenges did not exist in a vacuum. While some of the issues were unique to MNsure, like technological challenges with the website, most of the difficulties applying for public healthcare programs through DHS and the counties are not new. These problems are partly a function of complex policy – there are a lot of hoops to jump through and dots to connect to determine eligibility for health care assistance before and after the ACA. But this complexity has been exacerbated by a long history of poor communication to enrollees. Rather than taking advantage of the opportunity to break with the old problems, MNsure has replicated those problems in a new bureaucracy. This project has helped take steps toward better communication, in part through engagement with DHS. Navigators have frequently alerted MNsure and DHS that consumers were receiving unintelligible notices, but this entrenched issue will require further collaborat

Reflections on the community innovation process

In a sense, TakeAction has been engaged in community innovation since we first started. But your conceptualization has advanced our thinking about what we do and helped us sharpen our tools. It has been helpful to us to differentiate between the processes of increasing understanding, generating ideas and testing solutions. (Too often in community organizing, we run these functions together.) Your emphasis on community innovation fits well with how we work with people, and the importance we place on their lived experience.

Other key elements of Community Innovation

Progress toward an innovation

We have made significant progress toward a collaborative problem-solving culture between the enrollees and managers of our health care programs. First, the navigator feedback infrastructure we helped develop has been institutionalized in some ways. It is a feedback mechanism that draws on the experience of the community and uses it to improve a large public department. Second, in working with community around MNsure, cost and complexity have consistently been identified as ongoing problems, and the task force has both affirmed those problems and begun to propose solutions. The work done under this grant to solicit, channel and explore the opinions and experience of healthcare users was essential to that outcome.

On the other hand, there is a sense in which we are farther from innovative solutions, in that the challenges for public healthcare programs to be responsive to the needs of healthcare users are more apparent than ever. Since the creation of MNsure, these challenges have become more visible (because of greater media attention) and more widespread (because more people have health coverage).

What it will take to reach an innovation?

We presumed from the beginning that this project would develop some solutions that would be readily adopted by MNsure and other entities, and that some would require further action to achieve, whether through legislation or ongoing community engagement beyond the grant term. Both those assumptions are proving true. Public input needs to be further institutionalized into the delivery of public health care programs, including around the clarity of communication between public programs and their enrollees. That is a manageable but very impactful improvement that could be achieved through collaborative organizing in the near term. Community priorities like affordability of health care that have been identified and communicated to stakeholders more likely require a component of legislative action in addition to community solutions.

What’s next?

We plan to continue work on the cost of healthcare and improved communication and responsiveness by public healthcare agencies. In the next two years, we aim to engage consumers to create better understanding of healthcare cost concerns and access priorities. This engagement will include community meetings, surveys and outreach. Out of this engagement, we will develop the leadership skill of grassroots healthcare consumers to engage in ongoing public discussions about healthcare affordability, and join new opportunities to seek solutions at the local and state levels.

If you could do it all over again…

Make time for the people within organizations. Our ability to connect community input and innovations into health care infrastructure really floats or sinks based on individuals within those programs and departments. We sometimes think of a stakeholder as an impenetrable monolith, and in some ways this project confirmed the difficulty of moving big systems. On the other hand, to the extent we were able to bring community-identified problems into focus and develop collaborative solutions, we did it across the table from individuals who work within those organizations. We can get focused on accountability for organizations, and that’s critically important, but the will for collaboration can be built from the inside out between seemingly opposed entities.