Ms. Magnificent can stop a moving train before it hits a family of ducks but sometimes asthma gets the best of her, sending this superhero off to the emergency room. She gets a rescue inhaler at the ER and a “super-sized bill.” Marvelous Man saves kittens from trees with his super stretch powers, but when his back acts up from all of the contortions, he doesn’t seek care. He’s a new immigrant who doesn’t think he’s eligible for health insurance.Kid Cartwheel uses her acrobatic prowess to save a turtle from a bus but sprains her wrist in the process. Having just turned 19, she’s no longer covered by the Children’s Health Insurance program. Like many people her age, Kid doesn’t think she needs health coverage. But everyone needs health insurance—even superheroes.This key point and the message that there are people available to help navigate the complex system of health insurance enrollment are takeaways from several short superhero videos and a web resource, created through a partnership among several Detroit area agencies and the University of Michigan, and funded by the National Institute for Health Care Reform.“Health Insurance is very complicated and the Affordable Care Act is very complicated, but we worked as a team to decide on a simple message,” said Minal Patel, the John G. Searle Assistant Professor of Health Behavior and Health Education at the U-M School of Public Health.“Using storytelling, which is an effective way to raise awareness, we created characters who resonated with different sorts of situations most people would experience, such as transitioning off of one plan to another, managing chronic disease and changing your doctor. We embedded particular learning points into all of these stories.”While the Affordable Care Act cut the number of uninsured by more than half since its inception, millions in the United States remain without coverage. “When we looked at the research, it was historically marginalized racial/ethnic communities that continued to remain uninsured,” Patel said. “There was still a disparity between whites and other communities in terms of those actually taking advantage of the ACA and all it had to offer.”Patel, Richard Lichtenstein, co-investigators Barbara Israel and Peter Song, and others from their research team worked with a steering committee that included representatives from health and social service agencies in Detroit.“We worked with a number of groups to try to create the knowledge we would need at the community level to understand the uninsured situation in the Detroit metropolitan area, and what we could do to change that,” said Lichtenstein, professor emeritus of health management and policy.Partners included Latino Family Services, Enroll America (legacy partner), the Michigan Primary Care Association and the Michigan Department of Health and Human Services. The team conducted research at four specific partner sites, Community Health and Social Services Center, Arab Community Center for Economic and Social Services, Mercy Primary Care Center and Covenant Community Care.
The participants in the project were largely Black/African-American, Latino/Hispanic and Arab-American/Middle Eastern descent. The research team asked participants about their knowledge, beliefs, confidence and behavioral intentions with health insurance navigation and care-seeking prior to and six and nine months after engaging with the videos and website."Before there was ever a video series, they liked the focus groups. They liked being asked, 'What do you think?'" said Joslyn Pettway, chief program officer at Covenant Community Care, about her organization's clients. Covenant serves 20,000 Detroit-area patients annually at six sites, each location unique in terms of the profile of those served.Pettway, who is also a graduate of the U-M School of Public Health, said early confusion with healthcare.gov and a delay in getting Michigan's health care exchange up and running, contributed to some frustration."Now we're trying to sell health insurance again and it's like when you go to a restaurant and get bad food. You are reluctant to go back again," she said.Madiha Tariq, deputy director of the ACCESS Community Health & Research Center, said establishing confidence in the system is critical for the Arab-American community she serves. They understand the health care system better than most, the research showed, but they have difficulty, particularly in the current political climate, trusting institutions."Many of our immigrant and refugee clients have sensitivities. They come from war-torn areas and have a mistrust of government," she said. "They are afraid to share personal information."Normally, when we think of superheroes we expect them to save the day. They all still do, but in this case, the champions of the series are the people that help the heroes figure out how to navigate health coverage."I love the characters. I love what they represent, and I love the messages they have, but the navigators were the ones that, to me, make the most impression because now I know who to go to for help, if I had any one of those situations," said Lidia Reyes-Flores, executive director of Latino Family Services.Her organization serves a large number of newly arrived immigrant families who often face confusion regarding legal status and health insurance in the United States, which is explained in Marvelous Man's scenario.Margaret Meyers, medical director at Mercy Primary Care Center, said her organization tries to help people navigate the system but the number of choices in the marketplace is daunting, and people don't understand terms like coinsurance, deductibles and premiums."I think this program's really going to help people as they go to choose insurance to really choose the thing that's going to be best for them," Meyers said. Study participant Tondra Lewis, a Mercy Primary Care Center client, said the videos are entertaining and make learning about the importance of health insurance interesting. For her, the emphasis on preventive care really resonated."To stay alive. To make better choices out of life. To eat better. To have a better heart. Those are the most important parts," Lewis said.The videos are available in Spanish, Arabic and English.