In North Carolina, an Obamacare disconnect

North Carolina signed up more enrollees in Obamacare than any other red state. Yet politically, the legislation remains a huge liability for Democrats in the state. That's partly a result of enrollment organizers' attempt to keep insurance sign-ups as separate from the issue's politics as possible.

Jennifer Haberkorn wrote this story for Politico as a 2013 National Health Journalism Fellow, with support from the Dennis A. Hunt Fund for Health Journalism. Earlier stories in her series can be found here.

North Carolinians came out in droves for Obamacare enrollment, signing up at a rate that beat nearly every other red state. But that doesn’t mean they’re going to come out for the law — or the Democratic senator who supported it — at the voting booth in November.

More than any other state, North Carolina may represent the huge disconnect between Obamacare’s success in getting people health insurance and its failure to help the Democratic politicians who voted for the law.

The Tar Heel State signed up more than 357,000 people — one-third of those eligible for the new health insurance exchange. Yet President Barack Obama’s health law remains a major liability for Sen. Kay Hagan, who faces one of the toughest reelection races for any Senate Democrat this year, a true toss-up fight against North Carolina House Speaker Thom Tillis. He misses no chance to tie her to Obama and the Affordable Care Act, forcing her to calibrate both how to defend a law she voted for and how to distance herself from it.

The North Carolina dynamic reflects a national problem for the Obama administration in this midterm election: Despite the solid numbers — 8 million enrolled in Affordable Care Act plans, and 6.7 million signed up for Medicaid — they just can’t move the dial on political support for Obamacare.

The state had the third-highest rate of enrollment among states that decided not to set up their own exchange — only Florida and Maine came out ahead of it.

White House allies mobilized against Republican state leaders who had obstructed the law, organizing volunteers, outreach staff and local advocates to help people sign up. The administration sent more than $3 million to fund enrollment assistance workers known as navigators — more money than it sent to most other states. Clinics and health facilities also worked hard to get their uninsured patients covered. The numbers were strong, even though the Republican state leaders would not expand Medicaid, which could have covered up to a half-million more — a decision that Hagan criticizes.

Many people who enrolled in North Carolina and elsewhere in the country report mixed feelings about their new Obamacare health plans or the costs. The individual mandate, and the threat of a penalty, drove many sign-ups. A polling report by PerryUndem, an opinion research firm that specializes in health care, found that 40 percent of people in one focus group say they might not have signed up without the mandate. But neither an unpopular mandate nor worries about the expense are a political advantage.

One major reason that enrollment is not translating to a political boost — at least not yet — is that the groups that worked to sign people up, such as Enroll America, made a decision to keep insurance coverage as far from politics and “Obamacare” as possible. They kept the conversation focused on the value of health insurance, the ban on denials for pre-existing conditions and the tax subsidies available to make coverage more affordable.

While that helped the administration reach the pivotal 8 million point, many of the newly covered don’t associate their own insurance status with Obamacare — or at least not the political debate around the law, a phenomenon that Mike Perry, a partner at PerryUndem, called a “split personality.”

“You see the disconnect of the personal benefit to them and changing their thinking around the law,” he said of the focus groups he’s done with Obamacare enrollees. They view the two issues on different planes. The insurance, he said, “is a personal thing. It is personally benefiting them and it has nothing to do with the law that they don’t understand.”

That disconnect is haunting Hagan, who doesn’t go out of the way to tout her vote for Obamacare — what Tillis calls “Kay Hagan’s Obamacare Dodge.” She often keeps her comments focused on a piece of it, the failure of state Republicans, including Tillis, to expand Medicaid. Her campaign website doesn’t feature Obamacare, except for provisions that affect women’s health, and even there she doesn’t link them clearly to the president’s health law.

Hagan was not available for an interview during a reporter’s recent visit here. Her campaign spokeswoman downplayed the controversy over Obamacare, and stressed its more popular benefits.

“This is one of many issues in this election,” spokeswoman Sadie Weiner said. “Like all the issues, it is a strong contrast between Kay’s work to make common-sense fixes to the health care law to make it work better, and Tillis, who brags about rejecting health care for 500,000 people and who would take us back to a time when women were charged more than men, seniors paid more for prescriptions and people could be denied care because of a pre-existing condition.”

The law’s trade-offs even weigh on its supporters, like Jeremy Reynolds. He volunteered with Enroll America, standing outside grocery stores and Kmarts to encourage people to get covered, and even signed up for his own subsidized policy. But when he used his new coverage to get treatment for a pinched nerve he found it a “hassle.”

The 26-year-old, who splits his time between school and two part-time jobs, is glad to have coverage, knowing it would protect him in a medical crisis. But that pinched nerve led to a $1,100 bill — which he finally got rescinded after repeated rounds of phone calls with his doctor and insurer. And he and his wife are still finding that deductibles and co-pays for specialists are higher than they anticipated.

“I feel like it’s just a hassle, an inconvenience,” he said over a cup of coffee in a Northwest Raleigh specialty coffee shop. “Even though it hasn’t been the best experience, I’m still glad that I have it, especially for my wife … to establish a peace of mind.

Others who signed up are even more skeptical about the benefit. Teresa Mendez, 38, a stay-at-home mother in Carrboro, N.C., got covered to avoid the potential penalty. Now she questions the value of her $135 monthly premium for a single policy. She didn’t get any subsidies and says that no one ever told them they were available to her.

“President Obama said we needed to do it or we would be fined. I did it, perhaps, because of the fine,” she said in Spanish through an interpreter at a clinic in Carrboro, not far from Raleigh. “I feel like it doesn’t help me.”

North Carolina has been trending Republican. Democrats gathered in Charlotte in 2012 to renominate Obama, but the state ended up voting for Republican Mitt Romney — one of only two states in the country to flip from Obama in 2008 to the Republican nominee in 2012. North Carolina elected a Republican governor that year, too, for the first time in two decades.

The Koch brothers-backed Americans for Prosperity and Karl Rove’s Crossroads GPS and its aligned super PAC already have poured millions of dollars into television ads in the Senate race. They attacked Hagan’s vote for the health law and her echo of Obama’s pledge that people could keep their health plans if they liked them, which turned out to be a politically devastating broken promise.

Tillis declined a request for an interview. His campaign manager, Jordan Shaw, said the law is hurting North Carolinians in the pocketbook.

“It’s not just about we got 350,000 sign-ups. I think it requires a larger look at the trickle-down effects on the state’s economy from Obamacare,” Shaw said. “The reality is that in this state, insurance costs are going up, employers are having to pay more to provide insurance, which is resulting in people not only losing their policies but in some cases losing hours at work.”

It’s too early to know whether the Affordable Care Act — which includes access to insurance plans and subsidies for many low- and middle-income Americans — will over the long term bring political gain for Democrats, and if so, how long that might take. So far, 2014 doesn’t appear to be any different than the past two election cycles.

Polls show that throughout the country, Obamacare enrollees often like their coverage but have concerns about whether they can afford it, whether it helps them and whether it gives them adequate access to their doctors.

A PerryUndem focus group found that 31 percent of people who had enrolled nationally said it was too early to rate the coverage; 41 percent were very or somewhat happy with their plans; 16 percent were neither happy nor unhappy; and 11 percent were somewhat or very unhappy.

A Kaiser Family Foundation poll in June found greater happiness with plans. But it also found that nearly half of people with ACA plans say it is difficult to afford monthly premiums, and more than half worried it will become unaffordable in the future. A more recent Commonwealth Fund survey, however, found high satisfaction with plans, including among covered Republicans.

And for some here in North Carolina, newfound coverage is affordable and life-changing.

Teresa Mashburn, a 51-year-old from Goldston, was uninsured for 10 years. The fear of medical bills prevented her from treating crippling knee pain until she signed up for an Obamacare policy that costs her $10.58 per month after subsidies.

Once she had a plan, she got X-rays and tests that showed bursitis in the troublesome knee, which was addressed with cortisone shots, she said.

“I feel like I’ve gotten my life back,” said Mashburn, a patient of Piedmont Health, a group of North Carolina’s federally qualified health centers, which signed her up for a policy but referred her to a specialist for her knee. “Since then, I’ve actually been able to get up and move around and do a lot more than I’ve been doing.”

“I feel like I’m a completely different person,” she added.

But if Obamacare advocates are looking for voters who are shifting Democratic because of their new health coverage, they’re hard to find. Mashburn, for instance, said her Obamacare coverage has transformed her life. But it won’t change her vote. She is already a loyal Democrat.

This story was originally published in POLITICO 

Photo Credit: AP Photos/Getty