Obamacare's frantic final enrollment drive

With two weeks left in Obamacare's 2014 open enrollment period, insurers, hospitals, insurance exchanges, community health centers and not-for-profit groups across the country are racing to sign up millions of uninsured Americans, with a particular focus on younger people and minorities. At stake heading into the November elections is the public's perception of whether the Patient Protection and Affordable Care Act is working.

Enrollment efforts center on signing up as many younger, healthier Americans as possible, to balance the costs of insuring older and sicker people. But so far, state and federal insurance exchanges have not attracted the so-called young invincibles in sufficient numbers. During their first five months, just 25% of enrollees were between ages 18 and 34—well below the 33% to 40% most experts believe is needed to create a balanced risk pool and keep premiums down in 2015.

Enrollment workers are meeting with resistance because many uninsured people, regardless of age, think premium costs are too high, or are not aware of the generous federal premium subsidies available. Households must decide for themselves what they can afford, said Angela Petsche, enrollment coordinator for the Crescent Community Health Center in Dubuque, Iowa. “Our job is to show them the options,” she said. “We try not to be social workers.”

With the Congressional Budget Office projecting 6 million enrollments by March 31 and the CMS reporting 4.2 million signups through February, that means 1.8 million people will need to sign up for coverage by the end of this month to reach the CBO target. Last week, Avalere Health estimated that 5.4 million signups by March 31 are more likely, based on the 2006 experience of enrolling seniors in Medicare Part D drug coverage. But many big insurers say 15% to 20% of enrollees haven't paid their premiums and thus are not yet covered, which could significantly reduce the final enrollment tally.

The pressure is intense for insurers, hospitals and physicians poised to benefit from millions of newly insured patients, as well as for President Barack Obama and Democrats running in November's congressional elections. Democrats were shaken by last week's special congressional election in Florida, which saw Republicans hold on to a House seat in a swing district, after a campaign that focused heavily on Obamacare.

Democrats are praying for a great March enrollment. “They need some good news to tout when Obamacare comes up on the campaign trail,” said Larry Sabato, director of the University of Virginia's Center for Politics.

But many experts say the final tally may be more important for political appearances than for health policy reality. Theda Skocpol, a government and sociology professor at Harvard University, said it's clear the law is achieving positive results even if it doesn't meet the enrollment goal. “The political debate will have more sound and fury than real significance for assessing whether the Affordable Care Act is succeeding,” she said.

President Obama said Friday that the 4.2 million total so far “is already large enough that I'm confident the program will be stable.”

Younger Americans are the March prize. There is a big push to sign them up through youth culture messaging. Washington state's insurance exchange has run advertisements featuring a hip-hop duo talking to those who have signed up through the exchange. Colorado HealthOP, a startup consumer-governed insurer, will host a “Last Call” event in Denver, offering wheatgrass shots, rather than Jagermeister.

Independence Blue Cross in Pennsylvania is sponsoring a contest asking Philadelphia-area college students to create videos explaining why it's important to get health insurance coverage, with a grand prize of $10,000. Arches Health Plan, a consumer-governed insurer in Salt Lake City, has sponsored sporting events at colleges and visited classrooms. Their pitch: “Take five minutes to find out if you qualify for a $5 premium plan.”

Daniel Hilferty, president and CEO of Independence Blue Cross, boasts that his company's share of 18-to-34-year-old health exchange customers has increased from 27% during the first four months of its operation to 30% in February and March. “Although they're late, they're starting to roll in,” Hilferty said.

Besides young people, other demographic groups with high uninsured rates also are being targeted, particularly Latinos and African-Americans.

In California, despite accounting for more than half of the state's uninsured population, Latinos have made up just 22% of enrollees to date. So Covered California has enlisted legendary activist Dolores Huerta to talk to Spanish-speaking residents through radio and video ads in the last weeks of open enrollment.

Dallas-based hospital chain Tenet Healthcare Corp. also hopes to play a major role in boosting Latino sign-ups. The company has multiple facilities in California, Texas and Florida, states with the largest Spanish-speaking populations. It also operates in 10 of the 13 counties with the largest percentage of uninsured residents nationwide. Tenet has sent out roughly 300,000 letters to uninsured residents advising them about coverage options. It has deployed nearly 400 application counselors staffing a call center and is partnering with 350 community groups on outreach efforts. “There's a business case for it,” said Steve Campanini, Tenet's vice president for corporate communications. “It's also the right thing to do.”

In terms of signing up blacks, a new partnership between the National Medical Association, which represents African-American physicians, and Enroll America, a not-for-profit group, has launched an outreach campaign targeting black churches in 11 states with the largest black populations. Roughly one in five African-Americans lack healthcare coverage, and more than half attend a place of worship at least once a week.

The partnership features black doctors speaking to black church groups. “Having a physician there to provide health education not only could mean greater attendance to our events, but it provides a richer context,” said Etoy Ridgnal, director of African-American Engagement and Faith-Based Initiatives for Enroll America.

Insurers have spent about $10 million a week on TV advertising since early December, when the federal HealthCare.gov website improved its operation, said Elizabeth Wilner, senior vice president for Kantar Media Intelligence. As the deadline nears, more insurers are explicitly referring to the ACA open enrollment period in their ads. By the end of February, nearly half of all advertising dollars were spent on spots specifically referencing the ACA, up from a third in earlier months.

“Those large insurers who shied away from it earlier are now realizing that urging people to sign up by the deadline is probably a pretty helpful message to have in the ads,” Wilner said.

Still, convincing many uninsured Americans to see coverage as necessary and affordable is a tough challenge. Uninsured adults younger than 30 are more likely than older adults to believe they don't need insurance and to report good health, according to research from the Center for Studying Health System Change, now Mathematica Policy Research. That makes younger adults more price-sensitive, said Peter Cunningham, professor of healthcare policy and research at Virginia Commonwealth University, who conducted the research. But even among those under age 30, 75% said they believed they needed insurance.

“It's not 'Do they need health insurance?' or 'Do they want it?'” he said. “The central question is, 'Are they willing and able to pay the price?'”

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