Tracking enrollment in four states

Published on
July 14, 2013

The Affordable Care Act was crafted with an ambitious goal of expanding health care coverage to millions of uninsured Americans -- 14 million in the first year alone, according to federal estimates.

But the uninsured won’t enroll if they don’t know about the law’s marketplaces or Medicaid expansion – or if it’s too cumbersome or confusing to sign up for coverage. If web sites crash, phone lines don’t work or applications are longer than a federal tax form, consumers could easily get discouraged. In this way, enrollment will be a significant factor -- perhaps the most important element-- in the law’s early success or failure.

There is no doubt that even if all the infrastructure and technology is correctly implemented, inefficient enrollment procedures could doom the law that’s been dubbed “Obamacare.”

The reason isn’t political – it’s based in actuarial calculations. There needs to be a mix of people in the insurance pools. Young and healthy people (who don’t cost very much to cover) are needed to balance out the more sick individuals (who are expensive to cover). Logic tells us that the very sick will be anxious to sign up for insurance coverage under the law. They’ll go through whatever hoops are necessary to get insurance. Young people might need more convincing.

It’s a challenge that Department of Health and Human Services Secretary Kathleen Sebelius has acknowledged.

“A lot of our efforts will be using creative ways to outreach to sort of the ‘young and healthy’ population who is eligible but may not get up every morning thinking about health insurance,” Sebelius told health care reporters in June.

The problem is compounded by the fact that there is little financial incentive to buy insurance – particularly in the law’s first years. The penalty for not buying coverage in 2014 starts at $95. That’s little compared with even the cheapest insurance premiums. The uninsured are also likely to be Spanish speaking and disproportionately male -- potentially difficult audiences to reach.

Making the enrollment story even more interesting is the fact that consumers could have far different experiences in each state. Some states run by Democratic governors – such as Maryland, Vermont and California – are already showing eagerness to make the enrollment process as smooth as possible. Each of these three states began holding “town hall”-style meetings to explain the law in the early summer.

At the other end of the spectrum, several Republican-led states – such as Texas and Louisiana – have signaled that they’re not going to do anything to help enrollment. In these states, the federal government is running the show on limited financial resources.

The health law’s unique framework and reliance on the states has the potential to create a nation post- 2014 in which access to health care may be even more uneven than it is today – more accessible in some states, but with more barriers in others.

As a 2013 Dennis Hunt Health Journalism grantee, I will track enrollment procedures in four states to find out exactly how the states -- or, in some cases, the federal government -- address the challenge of enrolling the public in the law's health insurance marketplaces and Medicaid expansion. I want to find out how the exchange board or government entity advertises the law, how much outreach there is to minority communities, how smooth the enrollment process is from the consumer's perspective, and how much the exchange entity or Medicaid program works with local partners, such as hospitals.