Oba­macare’s fran­tic fi­nal en­roll­ment drive

Modern Healthcare - - NEWS - By Paul Demko, Vir­gil Dick­son and Me­lanie Evans

With two weeks left in Oba­macare’s 2014 open en­roll­ment pe­riod, in­sur­ers, hos­pi­tals, in­sur­ance ex­changes, com­mu­nity health cen­ters and not­for-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 premi- um 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 hiphop 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-yearold 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 doc- tors 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?’”

April Cald­well, 19, suc­cess­fully en­rolls at a Get Cov­ered Amer­ica health­care en­roll­ment event at the Allen Met­ro­pol­i­tan CME church in Chicago.

A Salt Lake City-based health plan urges cov­er­age in its ad cam­paigns.

The In­de­pen­dence Blue Cross Ex­press pro­gram of­fers mo­bile health­care cov­er­age en­roll­ment in Philadel­phia.

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