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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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State Health Exchanges, a Skeptical Public, and the Role of Health Care Professionals

Imagine the following scenario: it’s October 2013, you’re a health care professional, and Sara Smith, a 45-year-old woman with diabetes, arrives in your clinic for the first time in more than 4 years. You ask her why it’s been so long since her last visit.

Diana Mason, PhD, RN

“My husband lost his job right after I last saw you, and we can’t afford the health insurance that my job provides,” she replies.

“Why don’t you contact the state health exchange for coverage?” you ask.

She looks baffled. “What’s that?”

Sara has 2 related issues that need to be addressed, her diabetes and her access to care for her disorder. Do you know enough about the federal and state health exchanges to help her get coverage? Or do you simply move on to discuss her diabetes?

Health Exchanges

By January 2014, the Affordable Care Act will extend health insurance coverage to an estimated 8 million to 12 million uninsured Americans through health exchanges, increasing to 24 million to 28 million by 2019. Health exchanges can be viewed as health insurance marketplaces for individuals and small businesses (fewer than 50-100 employees, depending on the state). Subsidies will be available for people whose annual income is less than 400% of the poverty level. The lower the income, the higher the subsidy. Exchanges will also refer eligible people to the Medicaid program.

People who do not purchase health insurance will be subject to an annual penalty of $95 or up to 1% of personal income, whichever is higher, in 2014. The penalty increases in subsequent years. The Obama administration recently announced new rules that would permit exchanges to exempt people from the penalty if they meet select hardship criteria, such as being homeless or qualifying for Medicaid in a state that has decided not to expand its Medicaid coverage as permitted under the Affordable Care Act.

States were allowed to choose whether to form their own exchanges. Those that decline to do so will default to a federally run exchange. As of February 16, 2013, 17 states and the District of Columbia declared that they will develop their own health exchanges, 8 states are partnering on a state-federal exchange, and 25 states are defaulting to the federal exchange.

Regardless of who runs the exchanges, they’re expected to provide enrollees with user-friendly, comparative information on various kinds of health plans, including cost and quality; someone who can answer questions; a common application for enrollment in a regular or subsidized plan; and help with completing the application. Most will include graded insurance options, from bronze to platinum, with the prices set accordingly.

The exchanges must be in place and offer open enrollment by October 1 of this year so that coverage can begin by January 2014. Although there is concern that some insurance companies may decide it’s too unprofitable for them to participate in the exchanges, the most pressing challenge for most of the exchanges will be meeting their enrollment goals.

And that’s where health care professionals come in. Primary care practices, community health centers, and emergency rooms provide crucial opportunities for uninsured patients to learn about getting covered at a low cost—and, in some cases, for free. As trusted sources, physicians and nurses—and all health care professionals—hold the keys to raising awareness about the exchanges.

An Uninformed, Skeptical Public

At the 2013 AcademyHealth National Health Policy Conference in Washington, DC, in February, Alison Betty, a partner with GMMB, a Washington-based communications firm, reported on focus groups and statewide surveys of more than 2000 low-income residents of Alabama, Maryland, and Michigan to ascertain their attitudes toward the health exchanges and Medicaid. She reported that people were skeptical about the exchanges but mostly didn’t know about them. Funded by the Robert Wood Johnson Foundation, the study found that once the exchanges were explained, most of the participants thought them to be a “good idea” and were interested in using them. They didn’t like being mandated to buy insurance; however, they valued being able to have coverage, and the vast majority said the mandate would motivate them to seek coverage.

These and other findings from this study were used to frame the messages most likely to be effective with those who need insurance. Using straightforward language works best. Health care professionals can adapt these to their own encounters with patients. For example, they might

  • Describe the exchange to a patient as “a tool to help you find insurance that is right for you and your family.”

  • Discuss “searching and comparing” health plans rather than referring to “shopping for insurance.”

  • Explain that insurance will be “low cost or free” rather than “affordable.”

  • Emphasize that the exchange exists to provide information, answer questions, and enroll people in a health insurance plan that is best for their needs.


The exchanges are required to have information about coverage options and enroll people online, in person, by phone, and in print. Significant outreach to uninsured individuals and small businesses is expected to begin during the summer. Guides on engaging patients and communities in learning about the exchanges have already been developed for health centers.

People who participated in the GMMB survey identified the women in their family as the most trusted source of information, followed by physicians and nurses, Betty reported. Informational materials and training programs will soon be available for those who will play an active role in helping uninsured people use the exchange available in their state. Health professionals can adapt these materials or craft their own verbal and written messages, perhaps a flyer or palm card with the contact information for the exchange their state is using.

For example, if I were putting together such information for patients, I’d use the following, adapted from the GMMB evidence-based message about health exchanges:

Individuals and families who need good, affordable health insurance will be able to get it through a new online marketplace called [Exchange name].

On [Exchange name], you can shop for health insurance and find a plan that fits your budget. You may even qualify for a low-cost or free plan.

[State or Exchange name] will offer an easy-to-use website where you can search and compare plans, a hotline you can call to talk with someone about your options, and places where you can sign up in your community.

You’ll be able to find health insurance for you and your family, without the hassle.

Here’s the website and phone number to get help with enrolling: [the state is expected to have this information by late summer].

The Affordable Care Act promises to ameliorate the tragedy of 48 million Americans being uninsured and without access to vital health care services. Health care professionals are in an important position to help the nation fulfill this promise. It could only take a minute to let the Sara Smiths of the nation know how to get better access to services that can improve their health and save their lives.

About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
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