First published on July 13, 2015 in observance of the COPH’s 30^th anniversary celebration.

Jodi Ray is a bundle of energy when she talks about the project that has become her life’s work, Florida Covering Kids and Families, which is a part of the Lawton and Rhea Chiles Center for Healthy Mothers and Babies.

The founding program director was Mary Figg, a state representative for Hillsborough County.  After a year or two of preliminary maneuvers, the initiative began formally in 1999.  Figg had enlisted Ray, who has a master’s degree in mass communications, the year before to be program coordinator and handle all things media, including assisting her with crafting the successful request for that all-important initial grant.

“My job was to manage a multimedia campaign.  I’ve done a lot of mass communications on this job,” she said.  “In fact, I’d say I do more of that than anything else.”

The project was funded its first seven years by the Robert Wood Johnson Foundation to do outreach enrollment of children eligible for the Children’s Health Insurance Program and Medicaid.  During that time, a staff of two more than doubled to five by 2006, then, when that funding ended, was cut all too literally in half, reduced to a project director, a coordinator and a half-time assistant: essentially, a staff of 2-1/2.  Fortunately, they had a dedicated network behind them.

“We have a state coalition,” Ray said, “a large collaboration of partners from around the state and local coalitions in almost every community in the state.  We came together and said, ‘Our mission is to get uninsured into coverage.’”

The coalition was initially mandated by the RWJF grant, Ray said.  It remains active today and includes some of its original members.  No question, it answered a critical need in 2006, when half the staff was asked to keep up with an exponential work-load increase created three years earlier.

 

Crying on the phone

 

“In 2003,” she explained, “the state ended all outreach efforts for CHIP.  So they literally boxed everything up and sent it to me.  They gave me their contact lists and all of their partnerships and said, ‘Could you please take this on?’  Now granted, there were no financial resources with that at the time.”

“The state also closed enrollment for CHIP in Florida for 18 months.  As a result of that, we lost over 300,000 kids in the Florida KidCare program.  In one month alone, we lost 40,000 kids.

“There was no statewide outreach initiative except us,” she said, “me and my other 1-1/2 people.  The number of calls I got was unbelievable.  People were calling and crying.  It was terrible.”

That situation started Ray on an 18-month crusade, talking to newspaper editorial boards, legislators, community leaders, almost anyone who would listen.

Committed to moving forward, she and the coalition began implementing a plan that was as innovative as it was aggressive:  Sign up as many kids as possible to a waiting list.  When the list reached 120,000, the New York Times took notice and gave the state a boatload of blistering press.  Not long after, the governor issued an executive order to enroll all the kids on the list, and open enrollment returned permanently four months later.

In 2007, a new governor, Charlie Crist, declared the uninsured rate among children appalling.  He brought the state agencies together, Ray said, and told them to figure out how to make it better, and fast.

“One of the things they did was decide to give us some resources,” Ray said.

A state contract and marketing materials soon followed, along with help from state agency staffs on routine but time-consuming matters like mailing.  Growth was back, and with it, ramped-up after-school activities and more engagement with local businesses.

The results since have ranged from impressive to remarkable.  Since the first open enrollment period began on Oct. 1, 2013, the project has gained national media coverage for enrolling about 2.5 million previously uninsured Floridians, twice the expectation.

“We expanded to focus on all the newly eligible uninsured to help them get into whatever coverage options are available,” Ray said, “whether under the Affordable Care Act in the marketplace or Medicaid or CHIP.  One way or another, we were going to help people who didn’t have coverage get health insurance so they could get access to health care services.

“Health care services are important, and having preventive care, all those things.  We talk about all those things being necessary, but you’re not getting in the door unless you have health insurance.  So that’s what we focus on: the first step, getting people in the door.”

That may be the focus, but there’s plenty more to do.

“We also do one-on-one application,” she said.  “We have consumers that actually sit down with us and do enrollment.  We do everything that involves connecting people to health coverage.

“We even do some health literacy.  How do you use health insurance?  How do you make an appointment to see a doctor?  For many of the uninsured, these are not obvious.”

“We work with all the agencies on both the state and federal levels that are involved in implementing health coverage, and we get out there and shake the bushes.”

 

Media and more

 

As much effort as is spent on finding the uninsured, many do find FCKF first, Ray said.

“We get cold calls for everything,” she said.  “I used to wonder sometimes how people find us, but I don’t wonder that anymore.  All you have to do is help somebody.  Then that person gives your number to somebody else.  We get a lot of calls by word of mouth.  We helped someone at some point, and even years later, we get a call from that person’s family member or friend who needs help.”

“The things that consumers come in here and tell you are unbelievable, sometimes heartbreaking.  That’s the other thing that’s really tough,” she said.  “I’ve gotten calls that have made me literally get up and walk around the building a few times because the stories are terrible: the family living in a car; the kid who’s got some kind of horrible heart condition; the mother who had CHIP coverage, but something went wrong with her renewal, it got dropped, it’s Christmastime and she has no money because the asthma medication she had to pick up for her son cost $400.”

While grants provide the funding, the University of South Florida and College of Public Health make it work, Ray said.

“Our work has been very well supported by both the College of Public Health and the University.  I say this out loud every day:  I don’t think anybody doing this work could be in a better place.  I don’t think there’s any way Dr. Petersen could support our work any more than she does.  We get so much support from one end of this university to the other, and we worked with everybody through open enrollment.”

Student Health Services, the libraries, the Morsani College of Medicine and the Marshall Center were regular haunts, as were the St. Petersburg and Sarasota-Manatee campuses.

From the beginning, Ray, who became director upon Figg’s retirement in 2003, has been the media go-to person from the beginning, and that responsibility has grown as exponentially as the project itself.

“We do four press conferences a year.  I spend a ridiculous amount of time talking to reporters.  Just in the first open enrollment period alone, I probably did 80 or 90 interviews with reporters from one end of the country to the other.”

The result was major articles in The New Yorker, the New York Times and the Los Angeles Times, to name a few, as well as pieces widely disseminated by the Associated Press and Reuters, as well as personal visits from two national health secretaries.

“During the first open enrollment period, we had the second-largest grant in the country,” Ray said.  “That, in itself, drew attention, and [U.S. Health and Human Services Secretary Kathleen Sebelius] came here, herself, and awarded the grant.  She came to the college, and that’s how I found out we’d gotten the grant.”

It’s little wonder, then, that what began with two people 17 years ago keeps a dozen in the USF office busy with training, policy work, education, outreach, grant-writing, communications, etc.  It’s an office full of multi-taskers, Ray said.

“We all do all of it,” she said.

Given the complexities of health insurance laws and regulations, not to mention a new set of rules for navigators, just keeping up is a task unto itself.

“We do have to make it a point to stay informed.  We’re constantly on webinars and trainings, reading policies and reading new rules.  We have our hands in a lot of different elements of public health, just because we have to.”

The toughest part of the job, she said, is not being able to help everyone.

“We still have a gap of folks who are not going to qualify for coverage they can afford because the state has not expanded Medicaid coverage,” she said.  “I’d like to see us be able to enroll everyone who has no access to health coverage.  I’d like to see that in less than five years, quite frankly.  I would hate for that to be a five-year goal.”

Ray makes it obvious that what she and her colleagues do at Florida Covering Kids and Families is what keeps her pumped with energy.

“It’s all very exciting,” she said.  “We’re right there at the front end of this, and that, in and of itself, is exhilarating.  I feel good about what we’ve been able to accomplish, so it’s all been worth the time and effort – and the stress and the exhaustion – because it’s paid off.  We’re actually having an impact, and people see it.”

 

Every flight needs a navigator

 

The federal navigator initiative aimed at getting people into the new health insurance marketplace has been a major focus of their work the past two years, as well as a major hallmark of their success.

“The navigators are tied specifically to the federal marketplace.” Ray explained, “Some states are not participating in the federal marketplace, but Florida happens to be one of those states that is.”

The federal program provides outreach enrollment funds.  The first funding opportunities began in 2013, Ray said, and her office applied for USF to get an award that would cover the state.  She and her team did all the grant writing.

“We had already been doing this work on the ground across the state to enroll kids in CHIP and Medicaid,” Ray said, “and many of the partners around the state had come to a consensus that it made perfect sense for us to be the applicant for this grant and take the lead.  So, what we did was look at the model that was already working and find a way to expand on that.”

The result was a $4.2-million award in 2013 to cover 64 of the state’s 67 counties, the exceptions being Broward, Miami-Dade and Monroe, which submitted their own applications separately.

“The second year,” Ray said, “we went back to those partners again and asked them if they would like to join us for the 2014 application.  They said yes the second time around, so the second time around, we covered all 67 counties in Florida.”

The second award was worth $5.3-million.  Ray’s group had secured million-dollar grants for their Children’s Health Insurance Program enrollments, but those, which  had been their largest to date, are easily dwarfed by the Navigator grants.

Most of the funds are vested in the people who get the job done, Ray said.

“A lot of people.  I’m a big believer that priority number one should be the human resource.  The folks on the ground.  The folks who are out there doing the education, the communication, the one-on-one application assistants, the people who know the processes.  We know from our history of doing this and tons of research that these are the folks who keep people from getting lost along the way through the process.”

In one regard, Ray said, the Navigator’s work has only begun with the enrollment stage.

“They help people navigate the enrollment process and get to the point where they can be enrolled and covered, and they’re also key to helping people appropriately use health insurance,” she said.  “We want folks not just to get in, but we want them to keep their coverage and to use their coverage properly.

“When you’re connecting people to health care coverage for the first time, these are not innately understood concepts.  Insurance is actually a pretty complicated idea, and if you’ve never used it, you really can get overwhelmed.  If you have it and you’re not using it, then the tendency to understand its value can be diminished.  The Navigators and the Florida KidCare application assisters on the ground are essential for that piece of it.  It’s not just about filling out the forms.”

The numbers tell just how busy those people on the ground have been.

“The first year, the projected enrollment for the federal health insurance marketplaces in Florida was around 450,000, give or take,” Ray said.  “We ended up enrolling – with all partners across the state, not just the USF partners – almost a million.  We doubled the projections, basically.

“The second year, the last number I saw was about 1.6 million, but that didn’t include the last month, the limited special enrollment period for people who got hit with the tax penalties.”

As impressive as those figures are, their national rank may be more so, especially given California’s stand as by far the most populous state of the union.

“The first year, every month, we came in second in the country to California,” Ray said.  “This year, our enrollment here in Florida was higher than enrollment in any other state in the country.  It’s a pretty successful initiative in Florida.”

That seems understated, especially considering that it was the work of about 90 Navigators the first enrollment period and around 150 the second round.  Ray was quick to note, however, that Navigators weren’t the only people involved.

“There are more resources that go into managing this than just the enrollment folks,” she said.  “We have IT people involved, we have human resource people involved, we have grant administrators involved.  It’s an undertaking, for sure.  It’s all a team effort.”

 

A niche in the state’s public health

 

The stakes, along with the numbers, will be higher for the third round, since the funding will be for three years.  Ray is undaunted by the change and, in fact, favors it.  For one thing, it will provide greater continuity in enrollment services, she said.

“We won’t have the start-up delays that come with a grant ending,” she explained, “and then waiting for another grant to come in.”

Given the early success but also knowing the nature of the funding world, Ray is cautiously optimistic about future Navigator grants.

“We’re keeping our fingers crossed,” she said.  “I feel like we’ve done a good job.  I think our outcomes have been really high.  Our partners at the federal level seem very pleased with the work that we’re doing.

“Florida certainly has been a shining star all the way through this.  Not because I was optimistic, but because I believed we were doing the right thing and that we knew what we were doing, I’m not surprised.  Because we didn’t go into this making up a plan of action.  We went into it with a sense of how it can be done, what the best practices were.  We had learned our lessons along the way.  We didn’t have to reinvent the wheel to do this.  All our collaborative partners made a big difference, too.

“I feel pretty good going into years three through five.  It’s going to be harder going into these years, because we’ve enrolled so many of the low-hanging fruit, so we really have to hone in on who we’re missing and whatever we need to do to make sure we’re not leaving people behind.

“This is our niche for the state of Florida in public health.  Whether it’s obesity or diabetes or getting cancer screenings, it’s very difficult for people to do anything about those things we talk about in public health if they don’t have health insurance.  So, I think we’re doing something valuable in contributing that first step to addressing some of these important public health issues that are so important.”

 

Story by David Brothers, College of Public Health.  Graphics courtesy of Florida Covering Kids and Families, CSPAN and Jodi Ray.