Healthy Libraries Develop Healthy Communities: Public Libraries and their Tremendous Efforts to Support the Affordable Care Act

Abstract

This article is about the dedication of public library staff and my role as the Consumer Health Coordinator for the National Network of Libraries of Medicine, Middle Atlantic Region (NN/LM MAR) to support outreach efforts for health insurance enrollment under the Patient Protection and Affordable Care Act (ACA). ACA was created in order to ensure that all Americans have access to affordable health care. What we didn’t know is that public libraries across the nation would play such an integral role in the health insurance enrollment process. The National Network of Libraries of Medicine (NN/LM) worked closely with public libraries in order to assist with this new role. As we approach the second enrollment and re-enrollment periods, public libraries are gearing up once again to assist with ACA.

Equal access to health care. A statement that sounds so simple, yet has been a foreign concept to so many Americans. In September 2014, the U.S. Department of Commerce and the U.S. Census Bureau released the “Health Insurance Coverage in the United States: 2013 Current Populations Report. Findings in this report stated that “In 2013, the percentage of people without health insurance coverage for the entire calendar year was 13.4 percent, or 42.0 million”. ¹ That’s why for so many Americans, it was critical that the Patient and Affordable Care Act was signed into law. Yet, despite the statistics showing the great need for health insurance access, many communities were unaware of what ACA was and what it meant for them and their families. On Sunday, June 30, 2013 President Barack Obama released a special video message to American Library Association Conference attendees. In this video announcement President Obama described how libraries would serve as a place for health consumers to learn about the health insurance market place that would begin on October 1, 2013.

Although I was not in attendance at the American Library Association Conference, following this special announcement, I received numerous e-mails and phone calls from library directors and staff from Delaware, New Jersey, New York and Pennsylvania (NN/LM MAR’s 4 State Region). The frenzy of providing tax forms within public library settings was now a blur in comparison to the thought of having to assist community members with health insurance sign ups. Many public library staff knew that this was going to be one of the biggest challenges that they would face and they sought assistance because they also knew that they wanted to be prepared and offer the best service possible.

Public libraries offer a variety of services to their communities that go way beyond the provision of books, magazines and access to computers and the Internet. There are numerous types of community programming, story times, job/career assistance, passport processing, language courses and more. So, it almost seemed natural that yet another task be set before them. The good news for me was that the American Library Association, in anticipation had already formed a partnership with several organizations to assist public libraries with the new task that was set before them and the National Network of Libraries of Medicine (NN/LM) was one of those partners.

In the beginning stages, the questions I received reflected the following:

• What exactly is the Affordable Care Act and how will I a library staff member explain it to members of the general public?

• Why were libraries chosen to take on this task?

• Do we have enough staff to do this efficiently?

• Are there enough computers in our library to offer this type of service?

• What will be done with individuals who are not computer savvy?

These initial questions and more ran through the minds of library staff across the nation and we at the National Network of Libraries of Medicine, Middle Atlantic Region (NN/LM MAR) knew that we would have to at least begin a dialogue and assist our public libraries with how to frame their response to the huge task ahead. Consumer Health Coordinators from all NN/LM regions engaged in conversation via teleconference discussing how to get information out to our public libraries, where the best place to put information on ACA would be, how to address individual needs of states with differences in ACA rollout and simply to figure out what our role was as Regional Medical Libraries and liaisons to public libraries in our various regions. Some of these questions were easier to answer than others. We discussed how MedlinePlus², the National Library of Medicine’s consumer health resource would be a wonderful repository for updated information. There was already a health insurance topic page, so why not add to it. After some discussion the MedlinePlus team was on board and the updates to the health insurance page began, and still continue.

The phone calls and emails grew more frantic and frequent the closer we go to the looming date of October 1, 2013. There were days where I wanted to say to public library staff "I don’t' know more than you, I just have a fancy job title. You know your communities better than I do, you're the expert”. I too had to learn a brand new vocabulary, hunting for resources and was placed in a vulnerable position as I was looked at as an expert and a leader around health information and I had definitely entered unchartered territory. I had to learn, what is this health insurance marketplace everyone is talking about? What is a health insurance exchange, what are health brokers, navigators and certified applicant counselors? I was grateful for the monthly calls with my fellow NN/LM Consumer Health Coordinators leading up to the October 1st open enrollment date where we could brainstorm, strategize and share what we were doing in partnership with our State Libraries and various library systems. There was uncertainty all around, but a sense of comfort in the fact that we were all trying, and doing the best that we could as our roles as outreach liaisons to public libraries in our States. We learned of the OCLC Health Happens in Libraries Program which focused on offering workshops and leading public libraries to resources to “enhance public library capacity to advance health and wellness priorities in the communities they serve.”³

I was most fortunate to have supportive leadership and an Executive Director, Renae Barger who was with me every step of the way. From the moment we were contacted by the State Libraries in Delaware, New Jersey and Pennsylvania and by various public library systems Renae sat in on teleconferences, co-designed and led webinars. We sat side by side at local ACA workshops in public libraries hosted by the Allegheny County Library Association in Pennsylvania. We took notes, asked questions, listened to the concerns of other workshop attendees and had what seemed like endless hours of brainstorming sessions on how best to reach public libraries in our region as we knew that it was impossible to conduct in person sessions throughout all four States. For this support, I am grateful because in my moments of uncertainty it gave me strength and encouraged me to do the best that I could in the situation I found myself in. I was not alone, and that was a message that I passed on to public library staff as I provided presentations on the Affordable Care Act and what libraries could do to support health insurance enrollment.

As the National Network of Libraries of Medicine, Middle Atlantic Region (NN/LM MAR) we provided webinars, invited speakers from Centers for Medicare & Medicaid Services (CMS) and other agencies supporting libraries in their ACA outreach efforts. We created a web site, resource guide⁴ and a course designed specifically for public library staff. It was important as the Regional Medical Library that we provided opportunities for educating our region about the Affordable Care Act as well as a forum for dialogue about approaches, best practices and where to locate reliable, current and local resources.

Things became very real for me as on October 1, 2013 I began a series of trainings throughout Eastern Pennsylvania and the State of Delaware for public library staff interested in learning about best practices for health insurance enrollment. October 1, 2013 the very day that open enrollment was scheduled to begin. I’m sure I barely slept the night before as I couldn’t hide behind my computer screen and power point slides as I had done during webinars. In preparation for these in-person trainings and webinars I did exactly what I was encouraging public library staff to do. These were my steps:

• Create a healthcare.gov account

• Sign up to receive updates from healthcare.gov

• Locate the Health Insurance Page for your State

• Sign up to receive updates from the MedlinePlus health insurance topic page

• Contact local agencies using the ‘Find Local Help’ section of the HealthCare.gov site to learn exactly what their services were.

Even after doing all of these things, I felt I was no more prepared or able to assist myself or anyone else in locating health insurance options because the system just wasn't working. I had stayed up in order to attempt to log into HealthCare.gov so that I could walk into my trainings with my head held high and say, “I logged in just this morning and things went smoothly, you’ll be able to help your library users with no problems”. This was not the case. I was frustrated, and thought to myself, how can I encourage others to follow these steps when I did all of the things that I was supposed to do and the web site is not functioning? I'm educated, computer literate, have all of the necessary documents and things should work. But they did not.

So, I used what I had and what I knew. I quickly captured screenshots of the Healthcare.gov site and took snapshots of all of the various ‘error’ messages I received while attempting to sign up for health insurance. I shared these with public library staff who knew that after their day of training they would head back to their libraries to assist with the very thing that I was showing them, was not going so well. I used humor, and gave suggestions and was simply honest. I said things such as “In a perfect world, things would go smoothly, all of our library users who will come in to ask about health insurance sign up and assistance will be computer literate, have all of the necessary documentation, and will not blame you when things don’t work”.

It was my training for the Sussex County Library System, in Southern Delaware that put things into perspective for me. The date was October 3, 2013 and we were 3 days into open enrollment. I knew that the Delaware Division of Libraries had been coordinating with public libraries across the state to have navigators within the libraries and to provide workshops and trainings on the Affordable Care Act as many other libraries across the nation had done. I visited several Federally Qualified Health Centers (FQHC’s) in Southern Delaware in-between training sessions to see how they might assist as they were listed as agencies that could provide local help. It was my hope that they had some secret insight that I hadn’t been provided. However, they only confirmed that there were no training manuals that showed screenshots of the healthcare.gov site as many as I, like many other library staff had wished and hoped for. Copies of the application were hard to come across and the ones that I was able to locate were acquired from these very FQHC's that were serving as navigators and certified applicant counselors.

A major challenge I heard of directly from public library staff was learning to partner with organizations who had hired individuals to serve as certified application counselors and navigators. Public Libraries have partnered with other organizations historically, but not in the same manner. FQHC staff were ready to assist and even attended training sessions with me so that they could introduce themselves and their services directly to the public library staff. This was a major breakthrough and helped to once again build my confidence.

As I continued to provide trainings to library systems throughout our region, in person and online I realized that the approach I had decided upon was the best I could do. It was honest and strategic. We discussed various types of signage that could be prepared beforehand, dedicating a specific number of computers for health insurance sign ups (because the regular work of a library did not stop because another major task had been placed in their laps). We talked about negotiating and effective communication when partnering with other agencies and setting up expectations around customer service and lastly, and most importantly I encouraged library staff to recognize their dedication, and trust that their communities will understand that they were doing the best that they could. I wanted individuals to leave the training sessions not feeling overwhelmed or flustered as they might have upon entering the training room or discouraged as I had when first learning of the role I would have to play. I wanted them to feel as though they had some real solutions and to trust that after brainstorming and thinking of the worst case scenario, to know that they were prepared. Based on evaluations following the numerous webinars and in-person trainings, I’d like to think that we were successful in empowering public library staff in my small part of the nation in knowing that they were talented, caring and dedicated people who would continue to provide the best service possible even with an unknown task, because that is who they are.

It is truly my hope that government officials, board members, and other stakeholders recognize the impact that public libraries have among the individuals and families that they serve within their communities. There is a strength in the ability to provide non-traditional services to their communities. Likewise, I hope that public libraries will begin to share their stories, and tell of the great work that they are doing on a daily basis, around healthcare and insurance roll out, as well as all of the other non-traditional services that they provide. Again, this was more than tax forms. Public Libraries are equal to community, they stand for what makes society good and honest with their dedicated staff, willingness to try new things and implement new programs.

Having health insurance and access to health care is a basic right that every individual residing in the United States should possess. Additionally, the ability to obtain to unbiased and reliable health information in order to make educated decisions regarding health concerns is of equal importance. The Patient Protection and Affordable Care Act afforded me the opportunity to look beyond the obvious and think of ways that public libraries can continue to engage those they serve with the provision of health programming, health and wellness promotion campaigns and begin a continuous dialogue regarding a variety of health and wellness concerns of their communities. Although, playing such a large role in health insurance enrollment was challenging and had moments of frustration it shows the dedication and resilience of public libraries across the nation and their true strength as centers of their communities. ACA has provided an opportunity for public libraries to assist their communities in the process of acquiring health through a variety of mechanisms.

Public Libraries should be recognized for their tremendous efforts and dedication. In my role, I shall continue to work on providing updates and generating ideas on best practices for not only the Affordable Care Act and the continued health insurance enrollment and re-enrollment efforts but for supporting the idea of “Healthy Libraries, Healthy Communities”. I encourage public libraries to share their stories, as no activity is too small to go unrecognized. Web Junction, Health Happens in libraries provides a forum for to enable public libraries to let others know of the work they’ve done through the Health Happens in Libraries-Share Your Story page. Public libraries faced numerous challenges head on, such as the allocation of staff time, lack of computers, and limited staff. There were also issues with Internet connectivity, language barriers, and limited computer literacy of individuals needing to use the HeatlhCare.gov web site. The ability to balance every day work in addition to providing a new high demand commitment of partnering with agencies to assist with health insurance rollout was also challenging. Some libraries prepared themselves for a big rush of individuals and formed partnerships only to have a handful people request information or seek assistance for ACA. Knowing what the need would be for their communities was difficult.

As the Regional Medical Library for the National Network of Libraries of Medicine, Middle Atlantic Region (NN/LM MAR) a series of workshops, were designed specifically to ensure that public libraries were armed with the necessary information tools to successfully assist their users with health insurance enrollment. After discussions with State Library representatives it was hoped that public libraries would build on the momentum of ACA and create opportunities to engage their library users on health literacy topics and how to evaluate the much needed health information we know they are searching for online. What I had hoped for, became a reality as partnerships amongst organizations continue and public libraries begin to offer consumer health outreach at levels that are comfortable to them based on demand, community needs and the availability of library resources.

Libraries have been instrumental in numerous instances helping to enact social change, being places of refuge during disaster and emergency recovery efforts, and assisting their communities with locating good information on health insurance and more is yet another piece to the puzzle. As public library staff gear up for the next round of health insurance enrollment and reenrollment it is my hope that they proceed recognizing that they are pillars in their community and will look to NN/LM as we to prepare to help support the theme of Healthy Libraries developing Healthy Communities.

FIGURE 1.

MedlinePlus health insurance health topic page (http://www.nlm.nih.gov/medlineplus/healthinsurance.html)

FIGURE 2.

Health Happens in Libraries home page (http://www.webjunction.org/explore-topics/ehealth.html)

FIGURE 3.

National Network of Libraries of Medicine, Affordable Care Act Resource Guide (http://guides.nnlm.gov/mar _aca)