Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some really amazing people. You will be hearing what health literacy is, why it matters, and how all of us can help improve health understanding.

Today I’m talking with Dr. Don Rubin, who is emeritus professor of Speech Communication, Language and Literacy Education, and Linguistics at the University of Georgia. Among his many projects and responsibilities, Don chairs the Alliance for Health Literacy.

He also works closely with community-based organizations that offer navigator services designed to assist consumers seeking health insurance through the Affordable Care Act insurance exchanges. Welcome, Don.

Don: Thank you, Helen. It’s great speaking with you again.

Helen: You’ve been a guest on Health Literacy Out Loud before. I’m a huge fan of your work. I know you are a long-time champion and activist of working with community-based groups to improve health understanding. I know you’ve done work with Meals on Wheels too. Why are you looking at health insurance now?

Don: First of all, the Affordable Care Act is such a politicized issue, so I need to always start off with the disclaimer that whatever work I’ve done or had the opportunity to do relating to health insurance is something I’ve done apart from any of the other roles that you mentioned when you introduced me.

The reason why health insurance is such a key issue is simply because we in health literacy spend so much time thinking about how to have patients and consumers understand health information, but if they understand health information and then they have no access to the health services, what’s the point of getting all that information across to them?

Helen: It’s really that bridge between understanding or the information itself and taking the action or accessing the services.

Don: That’s part of it. The other part of it is that health insurance is such a complex health issue in and of itself that we need to bring to bear all the tools and resources that we’ve developed as health literacy professionals in order to help Americans understand this thing called health insurance and how they can begin to use it.

Helen: I know health insurance is mind boggling, even the parts I try to deal with. I also know that our audience is international and that many people like you don’t have to deal with insurance, but for everyone, could you just give some high spots about what makes that so hard to understand?

Don: That’s right, Helen. In many parts of the world when you travel overseas, people don’t quite get what the issue is with the American healthcare system because they have universal health coverage, which they may want to supplement in various ways, but everyone has the right to receive the basic healthcare that they need.

In the United States, our health system is organized according to our principles of private sector profitability. It’s another service that we pay, for just like we might pay to get our automobile lubricated at the auto shop.

Helen: What makes it so hard to understand? I know you’re working with insurance navigators. Why do we even need navigators to help us understand all of this?

Don: One of my interests in health literacy in general, Helen, is that all of the written documents and the websites that we work on to make more understandable are vital to being able to inform people about their health services and about healthcare that they need to take advantage of.

For most of us, in order to really make important health decisions, we need a human touch. You mentioned my Meals on Wheels project a minute ago. The Meals on Wheels projects was all about bringing real, live, trusted human beings into people’s households to help them figure out how they ought to interact with their healthcare providers.

The same thing is true in making a huge decision about how you’re going to protect yourself by purchasing health insurance. Although there are some excellent print materials out there, many of which do conform to health literacy best practices, and there are excellent materials on the web, a huge number of people need to sit down, have somebody hold their hand and walk them through the process.

Helen: Don, you’ve been talking about the human touch. Tell us more. How does that happen with the navigators?

Don: It happens one on one. We call that interactive health literacy. I don’t think most people realize just how extensive the human resource is that has been dedicated to helping Americans manage and choose their health insurance options.

Helen: How extensive is it?

Don: If you’ll excuse the militaristic metaphor, it’s an army of health literacy heroes. There are 28,000 navigators that have been enlisted to help work one on one with people in their communities to help those folks make the right decisions for them about all of these complicated health literacy options.

Those 28,000 health literacy heroes actually made one-on-one contact with 10.6 million Americans.

Helen: Oh my goodness! That’s vast.

Don: It’s amazing. It may be part of the largest interpersonal health campaigns that America has ever launched.

Helen: That’s incredible. You’re working with a group of these folks. Is that correct?

Don: That’s right. I’ve worked with a number of navigator groups. The one that I work most closely with is coordinated by an organization called Seedco in four states.

The Seedco navigators come from grassroots organizations of every stripe and variety. They know their communities really well, and they are the best folks around to know how to communicate these complex ideas to the people in those communities.

Helen: Wow! I’m really impressed. What do navigators do that is so terrific?

Don: You’ve heard the expression that all politics are local. I have come to the conclusion that all healthcare is local as well, and we need to pass legislation and policies in order to make health services more available to people. Those policies get implemented on a person-to-person, one-on-one basis.

If you are a member of a community organization like a church, Veterans of Foreign Wars or a library, you can invite these folks to your organization to set up their tables to give little outreach talks. They have good training, and they are amazingly expert on the subject. They are extensively trained. You’ll find them very professional. Most people are hungry for this information.

Helen: Don, what do the navigators do that is so terrific in communicating this complicated message?

Don: Everybody agrees that number one is listening. You have to have the patience and empathy to listen to people as they tell their health stories.

These health stories, as you know, are intimately bound up with their life stories, families, employment and aspirations. You can’t help somebody make a choice about health insurance unless you’ve heard their story and find out what their resources and needs are.

Helen: It’s to really put that into someone’s life context. You begin there. What other strategies do they use that work so well?

Don: There are a number of things that we deal with in terms of health literacy. For example, one of the health literacy best practices we know about from document production is not to give a message which is too busy. Don’t try to make too many points at one time.

When our folks go out to make presentations in the communities, we try to teach them to limit to three or four points and not tell everything they know about health literacy. That would be one example. Probably the most interesting one for the listeners right now is the use of metaphors and analogies.

Helen: I love metaphors and analogies. Tell us more.

Don: I know you do.

Helen: The way I frame it, because I teach it sometimes, is comparing something unfamiliar to something familiar. Tell us more.

Don: We spend a lot of time generating and sharing different analogies that people have had work for them. A very basic one that a lot of the navigators have adopted is when people say, “Why do I need health insurance? What’s it all about after all?” is to compare health insurance with car insurance.

The similarities are that you’re not allowed to drive a car. It’s the law. Everybody must have car insurance. If you don’t have it, you can’t drive. You might say, “I’m the safest driver in the world. What do I need car insurance for?” but the point is that it’s the law.

The same thing is true about health insurance. You might say “I’m healthy. I don’t get sick. If I get sick I can take care of myself. What do I need health insurance for?” The answer is pretty much the same. “It’s the law.”

Helen: That’s your metaphor right there.

Don: It’s part of it, yes.

Helen: Is it just like auto insurance?

Don: That’s part of it, yes.

Helen: Is it just like auto insurance or are there ways that they differ?

Don: There are many ways in which they differ. In auto insurance, in pays for repairs when there’s some damage. The same thing is true of health insurance. When we get sick it helps pay for the treatment, but health insurance has the added advantage in that it also pays for preventive care.

Helen: That’s interesting.

Don: Auto insurance does not pay for oil changes. It doesn’t pay to change your fan belt. It doesn’t pay for someone’s test to see if your tire tread is too worn, but health insurance does exactly that.

In fact, that’s really the greatest promise for the Affordable Care Act and for universal health insurance. It’s that we can increase people’s utilization of preventive services so that they don’t need as many healthcare services.

Helen: Don, it’s really interesting how you did that. You used that analogy to say how these concepts are alike and how they differ. That’s great. It sounds like that works really well.

Don: It does work.

Helen: In insurance, there’s a lot to do about money. We have all kinds of new terms such as copays, maximum benefits and all of that. How do the navigators talk about money?

Don: There are metaphors that we’ve developed relating to copays and all of the coinsurance costs. Many newly insured people don’t have the idea that there’s much to worry about once they’ve paid their monthly premiums.

The analogy that we sometimes use is the analogy of a Thanksgiving dinner. Let’s say your rich uncle, let’s call him Uncle Sam, comes along and says, “I want you to have a really nice Thanksgiving dinner, so I’m going to provide you with a turkey at a very low cost.” You shout with glee and say, “Hurray! We got a free turkey!”

Before you can receive the turkey, maybe you need to have a table to put the turkey on. You have to go out to the furniture store and buy a table. That’s similar to what paying your deductible is because you might have to pay $2,000 in deductible expenses before you get to use your health insurance at all.

Helen: You’re explaining all the many intricacies dollar wise that are out there.

Don: That’s right. This is an area where financial literacy and health literacy are totally intertwined. You can’t choose health insurance or utilize health insurance unless you also have a degree of financial literacy.

Helen: I assume that goes way beyond a metaphor.

Don: It goes way beyond a metaphor. It’s very real. Just as an example, we can go through all of the trouble of helping people enroll in health insurance and have them understand how health insurance works by using the best health literacy practices, but in the end it means nothing unless you can pay for it.

The evidence is that somewhere around 15% of the people who enrolled in health insurance never paid their first premium. That means that of these 8 million people that we are so proud to have enrolled in health insurance for the first time, perhaps as many as 1 million of them don’t currently have health insurance because they haven’t been able to pay their first premium.

This is a really interesting issue for those of us who want to be involved in health communication. We have to help people learn to think beyond just the enrollment process.

Helen: That’s really interesting. It goes all the way from that knowledge that this even exists, to understanding the concept of figuring out how to use it and what that would mean in your life, and then how to use it in an ongoing way. That navigators have done this with over 10 million people is astounding.

Don: Navigators have had conversations about enrollment with over 10 million people. Navigators have had a little bit more limited involvement in what happens after enrollment, which is at least as important.

We hope to increase the community resources that help people keep their eyes on the health services prize. Enrollment is just Step 1. After that, it’s, “How are you going to this to actually improve your health?”

Helen: Thank you for making that very clear. The other part I was thinking is that this must be exhausting to be that person communicating the message over and over. Are navigators the only ones doing this kind of work?

Don: There is a whole support system. Infrastructure is provided by organizations like Seedco with additional training and other kinds of resources that are available to navigators.

The Centers for Medicaid Studies and other organizations like Enroll America have evolved to help give navigators some of the technical information they need and also some of the communication skills that we’ve been talking about in our conversation right now.

Helen: What about the practitioners and office staff. Are we all in this together or is this its own field?

Don: We are totally in this together. First of all, there have been some issues with practitioners being uncertain with which types of  insurances they accept and don’t accept.

There are some very sad stories, Helen, about people who have saved their money and worked very hard to enroll in a health insurance policy. They’ve done all their homework and did everything right. Then in the end, the practitioner they go to visit says to them, “I’m not sure we can really help you if you have this particular insurance policy.”

There does need to be better coordination between providers and the Affordable Care Act administration.

Helen: Don, you’re talking about all that’s in place and that we move forward and we are making progress. I know that this is a gigantic job. What’s on your wish list for what’s ahead?

Don: Helen, I appreciate the fact that you mention we are making progress because clearly we are. Despite all of the difficulties that Affordable Care Act had getting started and all of the complexities involved in implementing it, we are surely making progress. There’s no question about that.

In the upcoming days and years, there are really four areas that I think health communicators need to give some thought to and help lend their talents.

One is the need for ongoing financial literacy coaching. Along with health information and using plain language to help people understand health conditions, we need to use our talents to help people understand how to budget for their healthcare needs.

Second is that we need to contribute to a culture of regular healthcare utilization so that people don’t think you only go to a doctor when you’re acutely ill, but that everybody has a right to seek and receive medical attention.

The third point is to get out the word about all of these wonderful preventive services that are mandated now because of the Affordable Care Act. For example, women have the right now to have an annual well-health checkup. It’s an amazing gift that the Affordable Care Act has given to the American people.

Then there is the point that we are so focused on helping people enroll in health insurance. The issue we’ve been talking about is what happens after enrollment. How can we help people learn to use their new health insurance to actually access their healthcare service that they need? That’s a job that people in health literacy are really well equipped to help out with.

Helen: Thank you for making that so clear about the work ahead. The listeners of Health Literacy Out Loud all care about health communication, and you’ve given us a good outline of moving this forward.

As far as people learning more, I do want to let listeners know that we will have a link to a lot of different resources on the Health Literacy Out Loud website.

Don, I want to thank you, those navigators, and everybody who’s helping us to move forward from information to access to utilization of health services. You indeed are all health literacy heroes. Thanks for being a guest on Health Literacy Out Loud.

Don: Thanks so much, Helen, and thanks to all of the health literacy heroes out there listening.

Helen: As we just heard, health communication and health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly enewsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find them at Stitcher Radio, iTunes and the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.