HealthCare.gov enrollment efforts target young, minorities

The race to enroll uninsured Americans in health plans has started again—but with only half as much time as the first open enrollment and a harder-to-convince pool of potential customers.

Community groups, hospitals, insurers and brokers have three months to persuade millions of uninsured Americans to buy individual coverage sold on and off the exchanges created by the Patient Protection and Affordable Care Act. Most are eligible for federal premium subsidies available to households with incomes from 100% to 400% of the federal poverty level.

Enrollment organizations are focusing on particular demographic groups where signups lagged during the first open enrollment. Hispanics and young adults, in particular, are being targeted, because they represent a disproportionate share of the roughly 32 million remaining uninsured Americans.

More than 7 million consumers bought and paid for individual insurance in 2014, during an open enrollment that lasted six months. Last week the Obama administration estimated that exchange plan enrollment for 2015 would total 9 million to 9.9 million. Administration officials and outside experts say projected signups will be lower than previously thought because of the difficulty of signing up the remaining uninsured, the need to re-enroll 2014 customers, and slower-than-expected moves by smaller businesses to shift their workers onto the exchanges.

“Much of the low-hanging fruit has already been plucked, and new enrollees will be harder to find,” said Tim Jost, a Washington and Lee University law professor and expert on the ACA.

Nevertheless, a Kaiser Family Foundation tracking poll last month found that 59% of uninsured people who were surveyed said they plan to buy coverage in the next few months. If that comes to pass, that would mean 18 million of the nation's 32 million uninsured would be potentially eligible for expanded coverage under the reform law. Many of the rest are undocumented immigrants who do not qualify for subsidies or Medicaid.

Enrollment groups are concentrating their efforts on demographic groups that are disproportionately uninsured. Roughly one-third of Hispanics remain uninsured, according to Gallup. By comparison, 13.8% of African-Americans lack coverage and less than 10% of whites are uninsured.

Among adults ages 26 to 34, the uninsured rate was 23.7%, according to Gallup data released last month; for people ages 18 to 25, the rate was 18.7%, a percentage that has fallen thanks to the healthcare reform law's provision allowing children up to age 26 to remain on their parents' plan. For all other adults under the age of 65, the uninsured rate was 13.4%.

Outreach workers also are redoubling efforts in the South, where nearly half of all uninsured people now reside, according to the Kaiser Family Foundation. Those efforts will be complicated by the fact that many of those states have not opted to expand Medicaid, leaving no affordable coverage options for low-income individuals and families. In addition, political antipathy toward Obamacare in those states may increase the difficulty of signing people up.

For Hispanics, the main barriers to enrollment are language and distrust of the government related to the deportation of undocumented immigrants, experts say. The language barrier was exacerbated in the first open enrollment because the Spanish-language version of HealthCare.gov didn't launch until more than two months after the exchanges opened.

This time, a button on the website labeled “Espanol” offers immediate translation into Spanish.

But a broad lack of public awareness and the complexity of shopping for insurance are further barriers to expanding coverage, say leaders of public and private enrollment efforts. As of October, about 90% of uninsured adults were unaware of open enrollment and the exchanges, though more than half said they planned to buy coverage, according to polls by the Kaiser Family Foundation and Gallup.

“A lot of people just don't understand it,” said Ellie Middleton, who oversees a team of certified application counselors at Geisinger Health System, based in Danville, Pa. Many don't know how to buy health plans, or that they could face a stiff tax penalty if they fail to do so, she said. Roughly one-third of uninsured adults did not know about the tax penalty, the Gallup poll found.

About one-third of uninsured adults as of June would have qualified for federal premium tax credits, Urban Institute estimates show.

Many of the remaining uninsured had incomes below 100% of the federal poverty line, which makes them ineligible to receive subsidies. And in the 23 states that have not expanded Medicaid, about 4 million uninsured Americans do not qualify for Medicaid either.

Health plans and health systems are again mounting extensive campaigns to reach the uninsured. “There is still a strong need for basic information and education on health coverage through the exchanges,” said Alex Kepnes, a spokesman for Humana, which is working with retail pharmacy giant CVS Health and community groups such as the YMCA to promote enrollment. Tenet Healthcare Corp., the national hospital operator based in Dallas, will deploy more than 350 counselors certified to help the uninsured enroll in plans; Tenet will stage more than 300 events in coming months to promote enrollment.

Lack of knowledge about insurance especially complicates enrollment efforts among Hispanics. A survey of uninsured Hispanic adults by the Robert Wood Johnson Foundation found that 91% of respondents indicated that they had limited knowledge about how to acquire coverage. Norberto Gonzalez, program coordinator with MHP Salud, has seen this while working in outreach efforts in Texas' Rio Grande Valley.

“We discovered that many applicants were not well informed about the Affordable Care Act,” Gonzalez said. “We learned not to give up.”

Access Health CT, Connecticut's insurance exchange, is focusing its outreach on 10 cities where the bulk of the state's uninsured population is concentrated. Roughly half of the state's African-American and Hispanic residents, who are disproportionately represented among the state's uninsured population, live in those metro areas.

The exchange is using cable TV buys to more precisely target potential customers in those cities. The Connecticut exchange also plans to run ads on Spanish-language TV stations and in black newspapers, said Jason Madrak, Access Health CT's chief marketing officer.

While 286,000 Connecticut residents enrolled in private coverage or Medicaid for 2014, there still are about 200,000 uninsured residents. Access Health CT hopes its more targeted outreach efforts will lead to an additional 70,000 individuals signing up for private plans.

Many outreach organizers say they are seeking to precisely target their resources where enrollment efforts will make the most difference. Christus Health, based in Irving, Texas, analyzed its market and patient data to create maps showing where the most uninsured and subsidy-eligible people live. The analysis will help tailor Christus' direct mailing to uninsured households in January and help identify which community groups the system will solicit as partners to promote enrollment. Christus will seek to enroll 100,000 in health plans this year, or 30% of those eligible in their markets.

But not all hospitals and insurers are spending a lot of effort on enrollment, based on their own cost-benefit assessment. Some say they are simply notifying uninsured patients about the exchanges. That's true for Excela Health, which owns three hospitals in and around Greensburg, Pa. Other providers and insurers see little benefit in trying to convince consumers who are reluctant or unwilling to buy insurance.

North Shore-Long Island Jewish Health System, based in Great Neck, N.Y., launched a health plan a year ago to compete for customers on the New York exchange. The health plan, CareConnect, has 15,000 members and ambitious plans for growth. But the uninsured aren't the primary target of its marketing efforts during the next three months.

Alan Murray, the health plan's CEO, said his organization's marketing will target consumers who already are shopping for health plans. Many who have decided not to enroll have done so based on personal reasons and their specific financial and other circumstances, and advertising and outreach likely won't convince them to reconsider. “That may take longer than one page in the newspaper or a 30-second commercial,” Murray said.

Among younger uninsured people, the calculus of whether or not to buy coverage may come down to cost. A survey by Deloitte Consulting of young adults ages 19 to 34 found that 66% of respondents indicated that they did not buy coverage during the first open enrollment because it was too expensive.

But such perceptions often are based on incomplete information. Just 55% of young adults said they were aware that federal subsidies were available to help pay for coverage. That may have led individuals to wrongly conclude that they couldn't afford insurance, said Paul Lambdin, a director with Deloitte Consulting.

Follow Melanie Evans on Twitter: @MHmevans

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