Wednesday, October 30, 2013

The Mona Lisa of the Marketplace is gone!

After more than one friend, when running into me, was found to greet me with “ So Mrs. Lincoln, how did you like the play?” - not too subtly bringing up my critique of things Open Enrollment, I’ve decided to start each of these open enrollment posts with the following caveat:

I, Christina Zarcadoolas, small town linguist with time on my hands, fully support the ACA and want as many people as possible to find coverage through Open Enrollment.  I am analyzing the messaging and communication through a health literacy and language lens. Sort of the only toolkit I own.  I do this to learn more from those who join the conversation, and to perchance have a small part in improving how we communicate vital issues about health and coverage to everyone.

The smiling face on the home page of is gone. 

Sad, but true, the inviting, smiling face of the Marketplace is gone.

In its place, (no not the Onion 10/22/13’s rendition) ….

She is gone, only to be replaced by 4 icons – a phone, computer, page and people.
(Some of which, by the way, don’t “click” – don’t take you to a phone number, or computer page, or a place to write, or to speak to someone )

So, what do they mean?  They must mean something. Right?

Tuesday, October 29, 2013

I wish I could launch a site that got 14.6 million visits in its first weeks on the market

David Blumenthal, the President of the Commonwealth Fund, said in his blog last week, that received 14.6 million visits by October 11.  

Blumenthal predicted that millions of people will be enrolled before President Obama's term is over.  "...the 15 states that are running their own marketplaces, some with considerable success, will probably have enrolled millions of previously uninsured Americans in Medicaid or private health insurance plans. State-run marketplaces account for half of the nearly 500,000 individuals who have already completed applications. We learned last week that Oregon has already cut the number of its uninsured by 10 percent. In the first five days, California created over 43,000 accounts and recorded nearly 1 million website visits. New York had received 80,000 applications by October 11. Kentucky had created 29,350 accounts by October 10."

     I say to myself..." I should be the developer of such a failure of a website!" 

Don't you think it's worth reconsidering this unmitigated "failure to launch",  the Republic-labeled societal disaster perhaps only rivaled by Johnson's creation of a safety net for all Americans, or "Obama's Iraq" (never was liking Tweets? read AnaMarieCox's (The Guardian) counter to the stupid twitter guy).  

Open enrollment and, even in its tortured debut, has gotten more people to seek out health insurance than CGI or CMS every imagined.  And how do those two behemoths explain their utter lack of imagination, their blindness – in not appreciating, anticipating the state of desperation and desire so many people live with.  (You might find Paul Waldman's piece "Healthcare.gov2: The Contractors Search for More Money" (10/28/13) on The American Prospect insightful about how the federal contracting process was exceptionally ill-suited for the ACA website job.

     14.6 million hits after only 10 days live, and with countless thousands trying but not succeeding in getting through to enroll.  

     It got me to thinking of what that number feels like on the grid.  So here is my homegrown site hit statistics  (my “sources” google and quantcast J ) Note these are international stats.

Google                      196 million per month
Youtube                    181 million per month           
Amazon                     80 million per month 
Ebay                          65+ million per month
Yelp                           65+ million per month
Wikipedia                   52 million per month             29 million per month
Craigslist                   40.8 million per month
Walmart                     24 million per month
Target                       13.5 million per month
Bizrate                      12 million per month
Fandango                 10 million per month
Fedex                       10 million per month
Tripadvisor                 9  million per month
Jcpenny                      8 million per month
Verizon                       5 million per month
Zappos                       4.4 million per month
Simplyrecipes             7 million per month
Staples                       6 million per month
Costco                        5 million per month
NPR                            4.5 million per month
Angie’s list                  4 million per month
Travelzoo                   3.5 million per month
Toysrus                      3 million per month
CDC                           3 million per month
VA                              2.6 million per month
Rush Limbaugh         1.5 million per month

14 million people and rising.  I should only be that lucky. 

Sunday, October 20, 2013's current problems: Hiccup or deadly disruption?

An insightful (anonymous) commenter to my previous post said:
Disruption is fine, but only when oriented toward a useful and healthy goal. Disruption for disruption's sake is not helpful at all (Wanamaker missed that really).
You’re right  - “disruption” for disruption's sake is the mode of current government, and has no place when we’re building ways to get people enrolled in health plans. 

But I’m not ready to say the enrollment system and set out to not work well.  We may differ about this.  But that’s where I stand.  You did get me interrogating just how I approach solutions, tools, technologies that, along their way, create disruption. ( I do realize I'm talking about "disruption" on a pedestrian level here - not as intended by theorists talking about disruption as social change agent/imperative). 

The reality of “disruptive technologies” resonates with me in the following way:
In public health there is a long, long history of identifying problems or “barriers”. Most often we’ve done so by identifying problems/deficits in the population or target community, and in rarer moments, identified problems in the providers or delivery systems.

The over 20 years of research in (personal) health literacy was relentlessly focused on how to “cure” the low health literacy of patients.

I’ve found, in my own work, that when you re-frame health literacy in the public area, using a societal lens, it forces you to see health literacy and public understanding and engagement as a social construct, much like risk (Douglas; Wildavsky; Tversky).  So you wind up broadening the lens to look at social and organizational factors that actual can shape our interest in and understanding of, say, health.
  • More and more I find myself doing the following:
  • Identifying a problem that consumers/patients are having with X
  • Asking “how is this problem similar to other problems they are having in their day to day lives?
  • Learning how they deal with this other “daily life” problem
  • Then recalibrating, re-understanding the current problem and try to tackle the X problem I started out with

So, back to your take on the “disruption” currently caused by the somewhat torturous enrollment process.  I’m informally speaking to “aspirants” to enrollment these days, and I am looking forward to two panelists very close to the enrollment process who will speak at the New York Roundtable on Public Health Literacy soon.
   The NYC residents I work with are all to familiar with systems not working properly – from getting your cable fixed, to getting power turned back on after a storm, to figuring out how to get downtown when the subways aren’t running.

·       Many residents come from countries where disruption (and corruption) at every level was the norm.  It can take them a long time to come to expect that when a clinic doctor sends a prescription to the pharmacy, it will be there waiting for them – and with no pills mysteriously missing.  They accept that some things are “rigged” and they can count on others not to be and they adapt.
·      Many (PEW estimates close to 65%) have smart phones; use social media, download new apps, and suffer the same glitches and disruptions with technology that keeps us all wondering just why we are so tethered to these little glass boxes. 

I believe there is some value in adding this analytical perspective – room for looking at what the information commons has already primed us for.  Do you agree? 

For now it seems that people will have to rely more on the Navigators, the Call in Centers.  They will have to persist.  And we worry that some won’t. But people need and want affordable health insurance.  I can hear it in line at the Dunkin’ Donuts here in East Harlem. People are talking about it. 
It’s in play.  It’s not going away.
I don't want to join or be deflected by those who are spending precious time on hand-wring and dart throwing about the glitches, and just fix them?  

The other night I tried to use the and things were going great until, on the 3rd page of personal info, the pull-down menu for what city and state I lived in DIDN’T WORK.  To myself I said, “they gotta’ lot of work to due by January.”

I’m still waiting for them to fix the glitches in the new iPhone iOS7 – some things draining the battery. 

Friday, October 18, 2013

How to critique Open Enrollment without being a critic: that's the bind

We know the motivation of those who are using every dirty trick in the book in a futile attempt to undo the ACA.  This week they're busy highlighting the glitches in the federal portal (many of which arise when an older, underfunded IT platform is asked to do extreme heavy lifting to accommodate thousands of people each day who are enthusiastically trying to get affordable health insurance).  

But I'm not going there. 

There's another group of "critics" that shouldn't get lumped in with the bad guys. 

People like me and my colleagues.  We're trying to figure out how to critique elements of enrollment based on our research with health consumers. 

We believe in the ACA and the powerful change that can come when more people in the US have access to affordable health care. We see things that can  be done to improve consumer engagement and decision-making.  BUT we run the risk of being caste as "friendly fire" - good motivations, but deadly just the same. 

Based on years of research with patients/consumers, studying how they take in and understand information - countless patient participants in the lab telling us, showing us, what they do and don’t understand, and even being gracious enough to tell us how to do our job better - we’re bringing that empirical knowledge to our assessment of current open enrollment practices.

And so we’re commenting on the literacy, health literacy and financial literacy demands (load) of what we see.  Karen Palladino's story today in US News and World Report, “When Buying Insurance on the Exchanges, It Helps to Have Help” reports on some of the areas where we know consumers have historically had difficulties in understanding and making good choices.
       understanding health insurance terms – network, co-pay, generic…
       understanding insurance concepts – deductibles, out of pocket limits…
   health literacy skills – specifically numeracy – working with numbers
  health literacy concept – recognizing the connection between you/your family's health needs and the plan you choose…

We are spot on.
It’s smug and I hate when I find myself saying this to my bright student, but we have years of experience dissecting information and watching people trying to work with this information.  Some of us predicted and now are seeing some problems here in River City. But they're fixable problems. 

We want to point out the needed repairs because we live in a world we're “review and repair” happens every day, and all to the good. 
No successful software or app today is designed without this imperative.  And the tools that win are the product of user centered design.  That’s how your bank’s ATM and your favorite Apps, Facebook, Google Maps and Yelp all made it to the big time.

It takes careful analysis, time and money and input from experts.

So now, anyone have ideas on how to get our best information on users, health choices and health insurance to the toolmakers?