Addressing Equity through COVID-19 Response: Communications Approaches in States

Alison Kruzel and Mariah Jones, GMMB

Over the last few months, the COVID-19 crisis has exposed longstanding cracks in our health care system. Not the least of these is the systemic racism and historical health care inequities that have contributed to the significant and disparate impact the virus has had on communities of color. Nationally, data shows that communities of color are at an increased risk of experiencing severe illness and death if infected with COVID-19; face increased challenges accessing COVID-19 testing and treatment; and experience greater financial and health risks associated with COVID-19.[1]

As our country continues to grapple with these realities, we spoke with state health agencies and health insurance marketplaces that have actively identified opportunities to conduct outreach in communities disproportionately impacted by COVID-19. To better understand these efforts, we spoke with DC Health Link (the District of Columbia’s state-based marketplace), the Oregon Health Authority, and beWellnm (New Mexico’s health insurance exchange) about the community-centered outreach they are using to actively enroll and connect consumers to care.

DC Health Link: Removing Barriers to Coverage and Care and Conducting Community-Informed Outreach

With nearly 97 percent insured in the District of Columbia, DC Health Link worked at the onset of the COVID-19 pandemic to remove barriers to medical care and to cover remaining uninsured residents, especially those who would be disproportionately impacted. DC Health Link worked with health plans to waive all deductibles, co-payments and coinsurance for diagnosis, testing, and treatment for COVID-19. DC Health Link insurers agreed to provide telehealth/telemedicine without financial obligations for both COVID-19 and non-COVID-19 care. The marketplace quickly engaged and mobilized a well-established network of community partners and health insurance carriers to develop a COVID-19 strategic plan to reach and enroll uninsured District residents, leading to a policy to open enrollment for all residents through September 15.

To ensure people were able to enroll quickly and easily, the marketplace changed its IT system to open enrollment status, making it as easy as possible to enroll. This rapid response to remove barriers to coverage at the onset of the COVID-19 emergency aligned with DC Health Link’s core mission – to get 100 percent of Washingtonians covered – and has continued to guide their outreach efforts throughout the health crisis.

As the marketplace developed its strategic plan for outreach to communities of color and other communities disproportionately impacted by COVID-19, DC Health Link knew it would be critical to reach consumers through trusted community voices. The marketplace engaged local community leaders and council members; DC Advisory Neighborhood Commissioners; and the Mayor’s Offices on Community Affairs including Asian & Pacific Islander Affairs, African American Affairs, African Affairs, and Latino Affairs – to raise awareness and conduct enrollment outreach through community listservs, tele-town halls, DC Councilmember newsletters and robocalls, and other tactics. The marketplace also partnered with the Department of Employment Services, DC Public Library and the Department of Health Care Finance to spread the word. Additionally, DC Health Link was able to leverage its existing partnerships with local community organizations, faith leaders, public and charter schools, and advocates to share enrollment information across their individual channels. These established relationships opened opportunities for DC Health Link to share messages through paid radio ads featuring popular local DJ personalities, participate in Facebook live and other digital events with trusted community partners, and work with the Leadership Council for Healthy Communities to create pilot health ministries that promote coverage through personal phone calls to congregants.

DC Health Link also collected stories of resiliency from small business customers who overcame operational challenges due to COVID-19. For example, Step Afrika! went from performing on global stages to stepping on the digital stage, while keeping their employees insured in quality health insurance through DC Health Link and maintaining their mission to serve their communities during the pandemic. The DC Chamber of Commerce and The Greater Washington Hispanic Chamber of Commerce also educated residents of color and small businesses about enrollment opportunities through DC Health Link.

The next phase of DC Health Link’s outreach includes tactics such as utilizing geo-fencing ads to target significantly impacted communities; continuing with earned media and paid media focused in community newspapers read widely in communities of color; hosting Twitter chats, FB live events, and a virtual small business form—POWERUP DC 2020—with sessions for minority and women owned businesses; and integrating enrollment messages across D.C. government agencies. As the District’s contact tracing efforts get up and running, DC Health Link is working on partnering with public health officials to get residents covered. While the marketplace continues to collaborate with partners, it has already seen a 34 percent increase in enrollment this year (June 2020) compared to the same time period as last year (June 2019).

Oregon Health Authority: Adapting Messaging and Transcreating Materials to Reflect Community Needs

As the spread and impact of COVID-19 increased, the Oregon Health Authority (OHA) was hearing from communities that despite its outreach efforts and development of materials in multiple languages, resources and information were not reaching communities that were being disproportionately impacted by the virus. Calling upon their extensive network of nearly 400 organizational partners—representing 52 languages—the agency set out to develop a campaign that was community-informed and responsive to the needs of Oregon’s diverse populations.

OHA recognized that to conduct COVID-19 outreach effectively across diverse and often non-English speaking populations, the perspective of community-based organizations would be invaluable. As they worked to develop a targeted COVID-19 outreach campaign, they conducted 15 informational interviews with organizations that represented diverse communities across the state. In these conversations, organizations shared more about the communication barriers and challenges on the ground to help ensure the campaign’s messaging would be responsive to community needs. For example, the message that had emerged encouraging people to “Stay Home. Save Lives.” was not resonating with everyone, especially in communities that speak languages other than English and among essential workers who did not have the option to stay home. Beyond identifying the appropriate language to use, OHA sought to ensure communities felt respected and valued through its efforts.

These insights also heavily contributed to the creative direction and messaging for the campaign, emphasizing the importance of following COVID-19 guidance to keep communities “safe and strong.” In these conversations, OHA also quickly learned that a major barrier was the lack of culturally competent and responsive materials and resources available for non-English speaking communities. For example, essential workers in these communities did not understand how to protect themselves or their families because original public health guidance did not address preventing spread in multi-generational households. There was also confusion around the severity of the virus. These insights and others informed the creative direction of the Safe + Strong campaign, prioritization of resources on the website, and transcreation of culturally competent materials and messaging in 12 languages.

With the Safe + Strong campaign up and running, OHA continues to partner with community-based organizations to provide support as they spread the word in their communities. This has included the development of Spanish radio PSAs, a messaging toolkit and digital playbook, FAQs, social media graphics, and more. Providing specialized support and materials has filled a gap in capacity for many community-based organizations, and the campaign continues to collect feedback and meet with partners to assess further needs. At the end of June, OHA will hold a partner convening to bring together community organizations, medical directors and health strategists from within the agency to discuss emerging challenges and actions to take.

The Safe + Strong campaign is also being promoted across a multi-channel paid media buy and includes Google ads, digital display ads, paid social, and Spanish radio and TV ads in partnership with Univision. OHA also created a unique Facebook page in Spanish after recognizing that, of their 11,000 followers on the OHA English Facebook page, only 2 percent were Spanish speakers. The “OHA en Español” Facebook page actively shares COVID-19 guidance and resources, reaching more than 140,000 people and collecting nearly 3,000 followers since its creation on April 14. The page continues to grow and has received largely positive feedback from the community, as they continue to see high levels of engagement. The Safe + Strong campaign continues to look for opportunities to expand its reach in disproportionately impacted communities, including partnerships with food banks to distribute materials, and has recently started conducting interviews with organizations to address behavioral health outreach needs in the state.

beWellnm: Promoting Enrollment in Equitable Health Coverage for Tribal Communities

BeWellnm has long-held strong partnerships with Native American tribal communities and has conducted ongoing enrollment outreach across the state. However, as the Native American community has been increasingly and significantly impacted by the COVID-19 pandemic—Native Americans account for 60 percent of coronavirus deaths in New Mexico while only making up 8.8 percent of the population—it has served to further prioritize and enhance outreach and enrollment efforts.[2]

While the Native American community receives no-cost health services through the federal Indian Health Service agency, these benefits are not as inclusive as what is guaranteed through essential health benefits mandated through the Affordable Care Act. The beWellnm outreach and enrollment efforts have centered on demonstrating the added value of having supplemental marketplace or Medicaid coverage to ensure equitable access to care and treatment. To inform the creation of these outreach and enrollment materials, the marketplace collaborated with tribal leaders and its state-wide enrollment network to better understand challenges and opportunities in the community.

BeWellnm also collaborated with New Mexico’s Medicaid program to develop COVID-19 outreach materials outlining coverage options available. BeWellnm also partnered with tribal leaders, the National Indian Health Board, NM Human Services Department and the Office of the Superintendent of Insurance which together recommended increased translation (outreach and enrollment materials have been translated in Navajo), attention to simplifying language and an increased use of visuals. BeWellnm will also continue to receive guidance and feedback on its efforts from its previously established Native American Advisory Committee that meets quarterly throughout the year. The marketplace’s established network of more than 400 partnerships across the Native American tribes, pueblos, and nations has proven to be essential in distributing enrollment materials during the COVID-19 crisis. Another invaluable foundation for beWellnm’s COVID-19 outreach efforts has been the state’s enrollment counselor network, which for the past two years has been required to participate in a Native American cultural competency training exam.

As beWellnm continues its COVID-19 outreach efforts, it has conducted several radio and print interviews across the state, utilizing trusted voices from its Board and Native American enrollment team to provide culturally competent perspectives. They also utilize a “beWellnm for Native Americans” Facebook page to share information and host virtual enrollment events, and have partnered on social media with influencers in the Native American community, including Tatanka Means, a public figure in the Navajo tribe. BeWellnm is also working to launch a peer-to-peer text campaign to provide direct outreach and one-on-one enrollment support to Native Americans and is preparing for enrollment flyer distribution at COVID-19 testing centers. The marketplace continues to expand its partner network for future work and explore new outreach opportunities.

Considerations for Communications and Outreach to Address Equity

Across our conversations, several best practices surfaced for marketplaces and agencies to adapt their COVID-19 communications and outreach—and beyond—to ensure those with inequitable access to health coverage are prioritized and supported.

• Establish and maintain meaningful partner relationships, which are critical for robust community outreach. State agencies and marketplaces that invest in building authentic, mutually beneficial partnerships with trusted community organizations are well-positioned to respond quickly in times of crisis and beyond. Not only can these partnerships provide critical insights for message and outreach development, but they can also engage as key messengers to get the word out.

• Embed community perspectives in internal teams to help ensure a culturally competent approach from development to execution. To ensure your communication efforts are responsive to community needs, build a team that reflects diverse perspectives and includes members of the communities you are trying to serve. This is a critical component to success and will help inform your work and better build trust and respect with the people you are trying to reach.

• Develop community-informed messaging and materials to provide more equitable access to resources and coverage. When developing messages and materials, proactively engage community leaders and partners to learn more about communications challenges and barriers, and to help shape culturally competent materials. This will mitigate any miscommunication and prevent cultural missteps, while ensuring relevant information is shared in a way that is accessible to all audiences.

• Continuously explore new outreach tactics and expand partner networks to stay relevant and engaged. Whether you are building from scratch or have a well-established presence, continue to look for opportunities to build inroads and more deeply engage with those in and outside of your network. Stay open to new ideas for outreach. As the landscape continuously changes and evolves, make sure your efforts are doing the same.

[1] Kaiser Family Foundation, “Communities of Color at Higher Risk for Health and Economic Challenges due to COVID-19,” April 7, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/communities-of-color-at-higher-risk-for-health-and-economic-challenges-due-to-covid-19/

[2] APM Research Lab, “The Color of Coronavirus: COVID-19 Deaths By Race and Ethnicity in the U.S.,” June 10, 2020, https://www.apmresearchlab.org/covid/deaths-by-race#indigenous