Sky view image of Iowa homes and city

As part of its Section 1115 Waiver, Iowa included a personal responsibility component called the Healthy Behaviors Program (HBP). The HBP requires individuals who meet income requirements and who do not complete both a wellness exam/dental well visit and a health risk assessment to pay an income-based premium of $5 or $10 a month. Individuals with incomes at or above 101 percent of the federal poverty level (FPL) who fail to pay their premiums are at risk of being dis-enrolled. This process and outcome evaluation includes analysis of administrative claims data, yearly enrollee surveys and interviews with enrollees and clinic staff.

In designing our waiver evaluation, we anticipated that individuals with limited previous experience with the health care system and insurance would struggle with understanding how the program works. Because of this, we designed the first year of the evaluation to focus more on process and implementation, including qualitative data collections with enrollees and clinic staff. We did not anticipate the magnitude of the confusion about the program for both enrollees and clinic staff. As a result, we modified data collections to include more qualitative work and tested all interview and survey instruments extensively to ensure that we had face and content validity.

In considering the most effective approach for communicating our findings, we are targeting two main audiences: the state Medicaid program and researchers. For the state Medicaid program, we strive to find ways to convey the complicated analyses and results in short, digestible formats that are easier to read than our longer technical reports. We also participate in a collaborative review process with the state Medicaid program to ensure that our language is precise and there is limited opportunity for misinterpretation.

Our experience thus far has taught us important lessons about every step of the process. It has been critical for us to communicate with the people implementing the program frequently, so that we could stay on top of program changes and react timely by modifying the evaluation plan. I also recommend testing all the data collection instruments you use to ensure you are getting high quality data that is usable. Cognitive testing is important, especially when the programs are complex and the enrollees have limited experience with the health care system and insurance.

Natoshia presented on a recent webinar for AcademyHealths Medicaid Demonstration Evaluation Learning Collaborative, a group of evaluation researchers examining the policy questions, and study designs, methodologies, data sources and metrics used in Medicaid waiver initiatives.

Natoshia M. Askelson
Author, Presenter

Natoshia M. Askelson, Ph.D., M.P.H.

Assistant Professor - The University of Iowa, College of Public Health

Natoshia M. Askelson is an Assistant Professor in the College of Public Health, Department of Community & Beha... Read Bio

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