The Journal of Extension -

October 2012 // Volume 50 // Number 5 // Commentary // v50-5comm1

Commentaries conform to JOE submission standards and provide an opportunity for Extension professionals to exchange perspectives and ideas.

Responding to Health Care Reform: Mobilizing Extension

The 2010 Affordable Care Act provides an opportunity for Extension. Research shows that most Americans do not understand the law's provisions and are not comfortable making health insurance purchase decisions. By January 2014, nearly 30 million Americans will be making enrollment decisions; an estimated 180 million will be reenrolling in health plans. We have a teachable moment to both educate and measure the impact of that education. At issue is the question of the extent to which we in Extension are willing and able to mobilize to address the opportunity.

Bonnie Braun
Professor and Extension Family Policy Specialist
Faculty Scholar, Horowitz Center for Health Literacy
University of Maryland School of Public Health and Extension
College Park, Maryland


With passage of the 2010 Affordable Care Act (ACA) and the Supreme Court decision to uphold the law, our nation again tackled an issue affecting the well-being of our people—population health and access to and cost of care. Health affects the ability to perform well in school, on-the-job, and as a productive, contributing member of society.

Monthly polls by the Kaiser Family Foundation find that most Americans remain confused about the law's 10 titles, key provisions, and impact on their lives (Kaiser Family Foundation, 2012). And while websites from the Foundation <> and the government <> provide information, people need help in understanding the provisions. And they need that help from a reliable source they can trust.

Response—Public Issues Education

Extension, with its network of educators across the nation, is well-positioned to provide that education. We have a history of doing public issues education as a neutral party. Our own Journal of Extension(JOE) contains articles that demonstrate this capacity. Morton (2002), Goard & Dresbach, (2003) and Gerrior, et al. (2009) are examples.

In Maryland, in 2010, we held a statewide forum with local facilitators at sites connected through Web technology to explore the ACA. Our focus was the ACA's impact on rural Maryland. Extension partnered with the University of Maryland School of Public Health, Hershel S. Horowitz Center for Health Literacy, Rural Maryland Council, and Maryland Rural Health Association to conduct the workshop as part of a core health messaging project funded by a USDA Rural Health and Safety Grant. Ninety-six people attended. Our post-pre evaluation determined that understanding of the law increased, with that understanding still holding 6 months later. The data serve as an indicator that Extension public issues education can make a difference. For a report of the findings go to: <>.

Maryland is not alone in responding to health reform. Wisconsin Extension is doing programming and has a website: <>. Likely still others are actively engaged in related public issues programming.

Response—Preventive Care Education

The ACA makes preventive care a priority of the nation for the first time in our history. Prevention education is central to Extension education in food and nutrition, safety, pesticide management, and other programs. Extension can leverage the emphasis on prevention into programming opportunities to capture attention and interest in existing or new programming.

For example, in August 2012 most of the women's health provisions took effect. New private health plans are now required to cover a number of preventive health services. A premise of this provision is that women will now be able to make many preventive health decisions—not the government or the insurance companies. That premise is an opportunity for Extension. We can educate women about the provision, what's covered, and when they can begin to take advantage of the provision.

Response—Health Insurance Literacy

Another ACA provision draws a great deal of attention—that of health insurance. Research shows that health insurance plans are complicated and difficult to understand and that the process of choosing is overwhelming (Quincy, 2012). This applies both to those who have health insurance and those who will be purchasing insurance.

In November 2011, Consumers Union, the American Institutes for Research (AIR), and the University of Maryland held a Call-to-Action Roundtable that included three representatives from Extension (Consumers Union, 2012). The group produced the logic for, and a working definition of, the concept of health insurance literacy:

Health insurance literacy measures the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health plans, select the best plan for their own (or their family's) financial and health circumstances, and use the plan once enrolled.

Currently AIR is doing the formative research to develop and test a measure of health insurance literacy. Such a measure can be used by Extension as a pre- and post-test for impact assessment of health insurance education and by researchers to monitor change over time which could affect public policy.

Through timely education, Extension can help to increase the knowledge, ability, and confidence of health insurance consumers—including that of our own faculty and staff! With research colleagues, we can measure the impact of our programming using the standardized assessment of health insurance literacy and use for compiling impact across our system.

Timely action is imperative. We must develop and test curriculum and communication channels prior to the fall of 2013, when the window opens for enrollment. Maryland Extension is moving to be ready. We received some Extension funding to establish a development team and a Council of Stakeholders to guide a timely response. Already on the Council are professionals from national, state, and county positions with expertise in financial and health literacy and health reform policy. You are welcome to join us.

To date, several states in the Northeast region are exploring how we might program together. Some interest has been expressed in creating a system-wide response.


Following passage of welfare reform in the late 1990s, the land-grant system mobilized to address the need for understanding the law; educate state and local community members, policy makers, and students; and conduct research (Braun & Benning, 2001). We again have an opportunity to work together to fill a demand for understanding, learning, and establishing a body of knowledge related to health reform and specifically health insurance literacy. Not only will our response help people respond knowledgeably, but also it will position Extension and the land-grant system as a leader in addressing this compelling public policy issue.

How are you responding? Are you willing join in a collective response? What say ye?


This article is dedicated to Jean W. Bauer, Ph.D., Extension Family Economist, who worked with me to help the land-grant system respond knowledgeably to welfare reform. Jean died in August 2012 leaving behind an award winning legacy of public policy education and research.


Braun, B., & Benning, L. K. (2001). Welfare reform 4 years later: The Mobilization of the land-grant system. Journal of Extension [On-line], 39(3) Article 3COM1. Available at:

Braun, B., McCoy, T., & Dugall, M. (2012). A statewide health care reform forum: Health care, rural communities and you. Retrieved from:

Consumers Union. (February 2012). Measuring health insurance literacy: A call to action. A Report from the Health Insurance Literacy Expert Roundtable. Retrieved from:

Goard, L. M., & Dresbach, S. H. (2003). Community health as community partnerships. Journal of Extension [On-line], 41(3) Article 3IAW3. Available at:

Gerrior, S., Beckstrom, L., Braun, B., Chipman, H., Drescher, A., Drake, L., Fungwe, T., & Young, D. (2009). Assessing Extension's involvement in health and wellness public policy education. Journal of Extension [On-line], 47(5) Article 5FEA5. Available at:

Kaiser health tracking poll. (2012). Kaiser Family Foundation. Retrieved from:

Morton, L. W. (2002). Building local knowledge for developing health policy through key informant interviews. Journal of Extension [On-line], 40(2) Article 1FEA7. Available at:

Quincy, L. (January, 2012). What's behind the door: Consumers' difficulties selecting health plans. Consumer's Union Health Policy Brief. Retrieved from:

Simmons, A., & Skopec, L. (July 31, 2012). 47 million women will have guaranteed access to women's preventive services with zero cost-sharing under the Affordable Care Act. Department of Health and Human Services. Retrieved from: