Instead of trumpeting the rollout of the nation's biggest health reform in almost half a century, the front pages of the largest newspapers Tuesday blared headlines about the first government shutdown in less than two decades. For Obamacare advocates, this was a missed opportunity for the administration to tell people they could now buy insurance, thanks to a law that still confuses most of the public. "It rains on their parade," says Keith Nahigian, who helped design the Medicare Part D prescription-drug enrollment campaign in 2005-06 and now runs a communications-strategy firm. "This is the [first] day of a crowning achievement of a major legislative accomplishment. And you only have one launch."
But the population that will determine the law's success is not necessarily the same one tracking congressional shutdown machinations. For uninsured, poor, or self-employed Americans outside of Washington, Beltway-level interest in the House speaker's latest tactic or the president's latest posture may pose no real opportunity cost. As of August, more than four in 10 Americans weren't even sure if Obamacare was the law, according to a Kaiser Family Foundation health tracking poll. For those people, outreach is not all about national headlines and cable-news commentary.
The administration's challenge is formidable. It needs to tailor its approach to reach the people whom the Affordable Care Act actually targets. The law will subsidize insurance in the online marketplaces for Americans earning between 100 and 400 percent of the federal poverty level, and it will expand Medicaid eligibility in 24 states and D.C. Nearly three-quarters of the uninsured didn't know in mid-September that the exchanges were weeks away from launching, according to Kaiser polling. The majority of uninsured Americans are in low-income, working families. The highest concentrations are in Florida, New Mexico, Nevada, and Texas. People of color are more likely to be uninsured; 32 percent of the non-elderly uninsured population is Hispanic, according to separate Kaiser research. Two million rely on Spanish, according to an administration presentation obtained by BuzzFeed this summer.
"By and large, people get their news from their local news station and the network," says Stephanie Cutter, former deputy campaign manager to President Obama and now a partner at consulting firm Precision Strategies. And the law did receive a lot of coverage in local media markets on opening day, she points out. The administration has vowed to "turn up the volume" in these spaces with celebrity endorsements and ad buys. "Word of mouth is important. Facebook is important. Most of these people are probably on the Internet," Cutter says.
According to the Pew Research Center, 79 percent of uninsured Americans are. But that leaves 21 percent who aren't connected. To reach them, the administration is leaning on in-person "assisters" and "navigators," who are paid to help people understand and sign up for insurance under the law — as well as on volunteer "Champions for Coverage," organizations and businesses that pledge to the Health and Human Services Department that they will help sign up Americans for insurance through the exchanges. Community health centers also received $150 million in grants to support enrollment. Rural populations pose a particular outreach challenge, HHS Secretary Kathleen Sebelius said at the National Rural Assembly in June.
These in-person contacts will take time to establish, and the law's advocates are playing up the long view. "From a media standpoint, day one is a signpost day," says Ron Pollack, executive director of the consumer group Families USA, which has paired its outreach efforts with Enroll America, the nonprofit leading efforts to get people signed up for coverage. But "there still are a very substantial number of people who are unaware of how the Affordable Care Act can help them. So I think what will happen in an accelerated way is that, increasingly, people will see others who they can identify with who are getting help under the Affordable Care Act, and that is going to be the best way people get educated about how this will affect their lives."
A clinic run by Unity Health Care in Washington was bustling on the morning of Oct. 1. A government-trained enrollment assister, 24-year-old Jorhan Santana, had briefed three people in the waiting room (one had Medicaid; the others were not quite ready to sign up on the exchanges yet). At his training, he says, instructors had warned that "not everybody would come in for the first day."
But interest — perhaps even driven by the shutdown caused by a disagreement over Obamacare — was strong. The volume of traffic to HHS servers caused glitches, and the White House reported that 4.7 million people had visited HealthCare.gov, the site of the marketplaces, on the first day. (As of press time, the administration had yet to release opening-day enrollment numbers.) "This isn't Election Day," says Anne Filipic, head of Enroll America. "This isn't a one-day effort. This is a process." And the systematic, nationwide health care overhaul likely won't be stopped by shutdown machinations in Washington.