Finding the real people and real stories in the ACA rollout

Last fall, we had no idea how the Obamacare rollout was going to go. I had a theory that it would be a somewhat different experience in each state — but I didn’t realize how true that would be.

My fellowship project focused on the idea that the Affordable Care Act would result in somewhat of a patchwork of health care — some state success stories, some failures. I set out uncover those differences. It led me to the Pacific Northwest and the Deep South, to navigators, to frustrated patients and to some obstacles of my own.

One particular challenge — somewhat new to me as a Washington policy reporter — was finding “real” people who signed up for the benefits under the Affordable Care Act. I didn’t want the token Democratic supporter or, just as expected, a Republican opponent. I wanted to find some people who signed up without considering the politics.

And I was trying to avoid being “Chad Henderson’d,” a term my colleagues and I developed in honor of the young man who told many reporters that he signed up for ACA coverage in early October but didn’t actually get through the sign-up process.

I didn’t want these people to lead or rule the stories. Rather, I included them in my stories to provide some on-the-ground perspective, a spot of color to ensure that the policy and political audience in Washington knew that average Americans were involved. It was a little more difficult than I first thought. 

My project took me to several states for just short periods of time, so I wanted to do as much leg work as possible on the phone before I got into town. I cast a very wide net, reaching out to navigator groups that might set me up with enrollees, activist groups in support and opposition to the law, community health centers, and anyone else who came to mind.

Some folks fell through because they ended up not wanting to be interviewed, didn’t actually consider signing up, or their name was also given to other news outlets by activist groups.

But ultimately, in each state I visited, I was able to speak with enrollees.

Here are some of the tricks I learned:

The most fruitful path was working with community health centers. Many of them conducted their own enrollment work and when I contacted them, many were happy to help me get in touch with enrollees. All of them ensured that they were respecting patient confidentiality rules by either contacting a few patients first to see if they’d agree to talk with me and/or asking them to sign HIPAA waivers.

One concern I had was that I would only get patients who backed the law, because most community health centers support the ACA. But, mirroring what the public polls have found, I was always met with a mixed bag. Some patients loved the law because it gave them coverage for the first time in years; others were skeptical of the high cost and said they signed up because they had to, not because they really wanted to.

I was expecting some resistance among consumers who didn’t what their names and personal health information or income in the paper. But well over half of the people I spoke to were willing to put their names and stories in print.

I found that letting the interviewee feel comfortable and in control of the interview really helped him or her open up and tell me his or her story. I typically started my discussion with very open-ended questions about why she or he signed up for coverage (or not), how the sign-up process went, and about their prior interactions with the health system.

The obvious stories in my project were about the most successful and worst state exchanges.

But I also tried to find the off-beat stories that made each state’s Obamacare story unique. By talking with insurance industry sources, I found out that some parts of Mississippi had only one insurance company selling coverage — and that the insurer was going to interesting lengths to enroll people. It led to a well-clicked story following the insurer’s bus around Mississippi as its brokers tried to enroll people.

While off-the-beaten pack stories illuminated quirks of Obamacare, I also tried to compare the experiences of different states to underscore that this national health law led to varied levels of access.

Comparisons work well to illuminate the ACA implementation process. Three of my stories compared the experiences of different states and served as good mechanisms through which to explain that the law wasn’t being implemented in a cookie-cutter way. I compared Texas and New Mexico’s decisions on expanding Medicaid — both have Republican governors but one expanded and one did not. I found a person in Texas who would have qualified for coverage had the state expanded and allowed his voice to tell the story of the people left without coverage. I found a New Mexico resident who got new coverage because of Medicaid and used her voice to tell the story of the newly insured.

I also compared the path of two liberal states — Washington and Oregon — as they set up their health insurance exchanges. One was a success story and the other was a technological disaster. Both stories served up lessons learned and underscored how wildly different the rollout experiences were, even between two sets of leaders with similar politics.