Obamacare Enrollment: Lessons From Year One

Navigators and volunteers set up shop in thousands of communities nationwide to get people signed up for health coverage.

Mercy Cabrera, an insurance agent with Sunshine Life and Health Advisors, speaks on the phone as she helps a person with information about an insurance policy under the Affordable Care Act at the store setup in the Westland Mall on November 14, 2013 in Hialeah, Florida.
National Journal
Clara Ritger
March 31, 2014, 1:05 a.m.

If Obama­care en­roll­ment was Pres­id­ent Obama’s “last cam­paign,” Elec­tion Day is Monday.

In a bid to get enough Amer­ic­ans — par­tic­u­larly young, healthy Amer­ic­ans — to en­roll in the Af­ford­able Care Act’s ex­changes, Obama mo­bil­ized much of the same army of or­gan­izers and vo­lun­teers that won him two terms in the White House. Now, with their work largely over, the team is look­ing back, sort­ing their tri­umphs from their fail­ures.

But even as the num­ber of sign-ups crossed 6 mil­lion last week and open en­roll­ment is all but closed, the law’s un­of­fi­cial vo­lun­teer corps is already strategiz­ing for what’s to come: yet an­oth­er long, hard push to get cit­izens to sign up be­fore the next en­roll­ment peri­od.

“We are by no means shut­ting our doors,” said Anne Filipic, a vet­er­an of the Obama White House and the 2012 cam­paign who now runs En­roll Amer­ica, the lead­ing or­gan­iz­a­tion tasked with max­im­iz­ing the num­ber of people sign­ing up for in­sur­ance through the Af­ford­able Care Act.

En­roll Amer­ica tar­geted a hand­ful of states with large un­in­sured pop­u­la­tions and polit­ic­al lead­ers who wer­en’t go­ing to help im­ple­ment Obama­care. Ray Paultre, Flor­ida or­gan­iz­ing dir­ect­or for En­roll Amer­ica, de­scribed the op­er­a­tion like a cam­paign, com­plete with field staff and re­gion­al dir­ect­ors.

“If we could do it all over again, how would we do it dif­fer­ent?” Paultre asked. “I would say we were 80 to 90 per­cent door-to-door con­tact. But it wasn’t so much that door-knock­ing didn’t work, it was that com­mit cards worked so well.”

Vo­lun­teers got con­sumers to fill out “com­mit cards,” pieces of pa­per where a per­son could in­dic­ate wheth­er they were un­in­sured, had in­sur­ance they didn’t like, or knew someone who fell in­to one of those two cat­egor­ies. Then they’d fol­low up to set up an in-per­son ap­point­ment with a nav­ig­at­or — a cer­ti­fied in­sur­ance help­er who could tell con­sumers more about their new in­sur­ance op­tions and guide them through the en­roll­ment pro­cess.

“These are people who have nev­er had in­sur­ance. They don’t un­der­stand premi­ums, co-pay, de­duct­ibles,” said Kar­en Basha Egozi, CEO of the Epi­lepsy Found­a­tion of Flor­ida, which re­ceived a nav­ig­at­or grant to help res­id­ents sign up for health in­sur­ance. “They come in and some of them don’t even have an email, so they can’t sign up on Health­Care.gov.”

In the be­gin­ning, people struggled to get their ap­plic­a­tions through the faulty fed­er­al ex­change site, and some are still work­ing on it, Basha Egozi said.

“A lot of people come back,” Basha Egozi said. “We see people two, three times, es­pe­cially those that star­ted in Oc­to­ber.”

Ba­sic edu­ca­tion about health in­sur­ance re­mains the biggest re­spons­ib­il­ity for Obama­care’s mes­sen­gers.

“We have to con­tin­ue do­ing edu­ca­tion,” said Rachel Alein, en­roll­ment pro­gram dir­ect­or at Fam­il­ies USA. “I think back to Oc­to­ber … a lot of the pub­lic, and spe­cific­ally the un­in­sured, had not heard about a lot of the changes that were com­ing. They maybe had heard of Obama­care, but they didn’t know how it would af­fect them.”

And ex­plain­ing the com­plex sys­tem was hard to do be­fore Health­Care.gov was fixed and people could com­pare their real-life op­tions.

“We struggled with that a lot in ad­vance of the open-en­roll­ment peri­od,” Alein said. “Every­one really wanted to get out and start talk­ing to people about it. There were some reas­ons why it didn’t hap­pen en masse soon­er be­cause we didn’t know what the on­line ap­plic­a­tion looked like and I think it’s hard to do the en­roll­ment without hav­ing the in­form­a­tion in front of people. How soon can you start talk­ing about it when it isn’t real yet?”

It’s one of the reas­ons she is hope­ful about the next en­roll­ment peri­od. Once more in­form­a­tion is avail­able about who signed up, Alein said, or­gan­izers can re­fine whom they reach out to and the mes­sage they bring, based on what worked the first time.

“This was a tre­mend­ous first step,” Alein said. “What we know for next year is that now that everything is work­ing for Health­Care.gov and most states’ web­sites, ad­vert­ising can hap­pen earli­er and it can con­trib­ute to a truly sus­tained pub­lic and private part­ner­ship to get the word out to people about their new cov­er­age op­tions and the avail­ab­il­ity of fin­an­cial help.”

De­vel­op­ing trust was a crit­ic­al com­pon­ent of en­roll­ment ef­forts, Filipic said. En­roll Amer­ica’s vo­lun­teers would work with ex­ist­ing com­munity net­works to reach po­ten­tial en­rollees in a set­ting where they already felt com­fort­able.

“In the past, people couldn’t find health in­sur­ance that met their needs or was af­ford­able to them,” she said. “We found that people come to this pro­cess with a lot of skep­ti­cism, and that it takes in­form­a­tion about fin­an­cial as­sist­ance to show that this time it’s dif­fer­ent.”

Lever­aging ex­ist­ing com­munity or­gan­iz­a­tions also helped set the un­in­sured at ease, es­pe­cially among the Latino pop­u­la­tion which has a high un­in­sured rate, said Juan­ita Main­ster, a nav­ig­at­or at the Epi­lepsy Found­a­tion.

“We get mixed fam­il­ies that do have mem­bers of the fam­ily who are un­doc­u­mented,” Main­ster said. “If you know the com­munity, and the com­munity knows the or­gan­iz­a­tion provid­ing the ser­vice, they tend to feel more con­fid­ent and re­laxed when you tell them they’re not go­ing to get in trouble with any­body.”

Though the work is mostly over — save for those who are get­ting more time to en­roll or who qual­i­fy for Medi­caid — Nov. 15, the vo­lun­teers said, doesn’t feel so far away.

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