Coming soon: Obamacare, take two

It was a near disaster last year when the Affordable Care Act’s health insurance plan marketplaces opened for business.

The healthcare.gov website for online enrollment crashed on day one. Political opponents rose in a gleeful chorus of “I told you so.” The public was frustrated and confused.

But ultimately, more than 7 million people enrolled in the ACA’s health insurance plans, meeting original predictions.

Now, it’s time for round two. Open enrollment for the ACA’s 2015 marketplace insurance plans starts Nov. 15.

And this time, the organizations promoting enrollment are optimistic it will go a lot more smoothly. The regional coalition of foundations, social service organizations and safety net clinics will try to better coordinate their work and focus on groups — African-Americans, Latinos, the LGBT community, rural residents — that have been hard to reach.

If the Congressional Budget Office’s projections are on track, as they were for the first year’s enrollment, the number of people insured through the ACA’s marketplaces in 2015 will grow to 13 million nationwide.

“When I look ahead, I see a lot of things that will work in our favor,” said Jessica Hembree, a program officer of the Health Care Foundation of Greater Kansas City. The foundation committed about $700,000 toward enrollment outreach in 2013 and will be spending $345,000 this year.

First on Hembree’s list is the new, streamlined version of healthcare.gov. Assuming it’s not plagued with bugs, enrollment should be quicker and simpler than before.

Most people enrolling for the first time will be able to use a shorter version of its online application form. And one of the more irritating limitations of the original website has been fixed: People who make a mistake as they fill in the form now will be able to backtrack to make corrections rather than have to start over from the beginning.

Enrollment organizers also expect favorable word of mouth from people who had coverage this year, and may have received generous federal subsidies of their insurance premiums, to motivate others to sign up.

People who were on the fence before about enrolling now have friends and neighbors who’ve gotten insurance they’re pleased with, Hembree said. “I think the power of the personal experience will really be working for us,” she said.

There are anecdotes about this happening during the first open enrollment period: The Kansas City taxi driver who received assistance enrolling in an insurance plan and was followed a week later by about 15 more people from the same cab company. The owner of a child care center in southeast Missouri who gave workers time off to enroll after learning that an employee had succeeded in gaining coverage.

The steeper tax penalty this time for people who fail to get insurance is also expected to motivate enrollment. Those who went without insurance this year face a penalty of up to $285 for a family or 1 percent of household income, whichever is higher, when filing their 2014 federal tax return. That may not have been enough of an incentive for some people.

But the penalty for going uninsured next year goes up steeply, to $975 per family or 2 percent of income.

“That penalty is a real thing. And you’re getting absolutely nothing in return for that money,” said Nancy Kelley of the Missouri Foundation for Health.

The St. Louis-based foundation is planning to spend about $6.2 million on its Enroll Missouri project this year. That kind of financial commitment has been essential to outreach efforts.

Most of the federal money for enrollment and outreach — about $150 million per year — goes to the nearly 1,200 safety net clinics nationwide. But funding for other grassroot organizations has been relatively small, and it’s declining. Organizations in Kansas and Missouri are receiving $2.3 million this year, a drop from nearly $2.7 million in 2013.

While some states have been enthusiastic about the ACA and have funded additional outreach on their own, the political climate in Kansas and Missouri has been hostile and there’s been no state money. That may have been a factor in the two states’ relatively low ACA enrollment rates.

Nationwide, about 28 percent of people potentially eligible for 2014 marketplace plans signed up for them, according to an estimate by the Kaiser Family Foundation. But in Missouri, 152,000 people selected marketplace plans, just 23.2 percent of those eligible. In Kansas, 57,000 people selected plans, 19.1 percent of those eligible.

“Some states poured a lot of money” into ACA enrollment, Kelley said. “In Missouri, it’s definitely not a secret there were additional barriers.”

Enroll Missouri is designating local organizations around the state as regional “hubs” to coordinate outreach. In Kansas City, the Mid-America Regional Council is coordinating the work.

That’s a change from last year when enrollment efforts often took more of a top-down approach that didn’t always pan out.

Obamacare plan selections in Kansas by ZIP code

 

Obamacare plan selections in Missouri by ZIP code

 

During the first enrollment period, the Health Care Foundation of Greater Kansas City sent out paid canvassers who knocked on 58,000 doors in low-income neighborhoods to spread the word about the ACA’s marketplace, the insurance plans and their premium subsidies.

But what works to get out the vote was a flop with enrollment. The canvassers sent lists, each with about 150 names, to volunteers who made follow-up calls to set them up with someone who would help them enroll.

“I made many of the follow-up calls,” one volunteer told The Star. “Of the 150, we’d get maybe 10 appointments, half of whom might show up. From 150 names, we’d actually enroll zero or one.”

Large enrollment events also didn’t work, organizations discovered. People like to get information first and think about it before signing up for a plan. And many people felt uncomfortable discussing their financial and health information in a public place.

What did work, local organizers found, were efforts to partner with people who already were connected to hard-to-reach communities. The Samuel U. Rodgers Health Center, for example, enrolled people successfully with help from a Vietnamese American organization. The University of Missouri Extension found insurance agents in rural areas to enroll people who wanted to deal with someone they knew.

“We are looking for people in communities who are trusted — churches, community groups, business groups,” Kelley said. “People need to hear the (enrollment) message more than once before they take action. We need to get in the door.”

But outreach alone won’t be enough. Many people, particularly those who’ve never had health insurance before, will need help enrolling.

“In our heads there’s this image of people at home on their laptop, but the reality was people wanted or needed help,” said Hembree. Even with a trained person guiding people through, the enrollment process could take an hour or several hours to complete, she said.

Nearly 100 organizations in the metro area have roughly 500 employees and volunteers who’ve gone through the training required to provide enrollment assistance.

This time around, the Health Care Foundation is working through the United Way’s 2-1-1 referral phone line to direct people to these organizations. The phone line gets about 160,000 calls per year from people seeking help from social service agencies, Hembree said. “It’s a population that is already reaching out, and the United Way is respected.”

The Health Care Foundation conducted focus groups with people who enrolled in plans, or at least tried to, last year. Many had little knowledge of health insurance — one man explained that he didn’t sign up because he already had life insurance. They also had a lot of unclear or politically biased information about the ACA and a great deal of distrust of the healthcare.gov website, Hembree said.

Now that the ACA has been around for a while, Hembree hopes that it has started to cool as a political issue. That would make it easier to get people enrolled in insurance plans.

“I think this will, over time, become a more and more accepted part of how we get insurance,” she said.

This story was originally published October 21, 2014 at 4:43 PM with the headline "Coming soon: Obamacare, take two."