‘I just don’t think its possible’: How the uninsured view Obamacare

November 21, 2012

Sondra Carlile, a volunteer at the Baptist Mission Center clinic, checks on uninsured patient Janet Williams, 48, in the clinic's waiting room. (Mei-Chun Jau -- For The Washington Post)

It felt, a bit, like stepping into a scene in "Mad Men": A dimly lit room with three rows of chairs, all hidden behind a two-way mirror. There, experts watched focus groups shuffle in and out in 90-minute intervals. They pointed at logos they did like, logos they didn’t like and tried to explain the difference between the two. 

These focus groups were not under the supervision of Don Draper, but rather Enroll America.  And the nonprofit was trying to figure out how to sell a product that was never available in the 1960s: Universal health insurance.

My story in Wednesday’s paper looks at the how little the public knows about the Affordable Care Act, with those most likely to gain new coverage options least aware of the changes ahead.

Enroll America is one nonprofit trying to change that: It was founded last year with the express goal of maximizing insurance enrollment come 2014. Before that heavy lifting starts, they still need to figure out how to convince people to sign up.

Hence, the focus groups. Enroll America held 10 of them, across the country last week, all with Americans likely to qualify for new coverage options in 2014. I attended two in Philadelphia last week. I found them a hugely interesting window into how Americans think about health insurance, and what that means for the Affordable Care Act.

The knowledge gap was clear from the beginning: None of the 31 participants knew about the health law’s new coverage options, like subsidies for those earning below 400 percent of the poverty line, and Medicaid for the lowest income Americans. It was not, however, a complete knowledge vacuum: When a researcher asked how many people had heard about the mandate to buy insurance, a flash of hands went up.

“Virtually no one who is uninsured understand how health reform will affect their lives,” Ron Pollack, who chairs Enroll America’s board, told me after the focus groups. “While some focus group participants have heard the term Obamacare, literally none of them have an inkling about whether, and how, their lives will be affected.”

This is a huge challenge for the health-care law but it's not necessarily surprising. The health-care law is complex, and the big benefits don't even roll out until 2014. For most Americans, it's hard to see a practical reason to become informed when the benefits don't yet exist. 

Rather, what I found most interesting was the deep skepticism of the health law's benefits as the researchers began to explain them. 

There was certainly a strong desire for health-insurance coverage. “I feel irresponsible,” said Victoria Smuk, a mother of two, who participated in the focus groups. “I feel like I’m less of a person because I don’t even have health insurance.” Smuk had looked for insurance, after she lost her job a year ago, but found it too expensive. The cost for one prescription she takes has shot up from $30 monthly to $120.

Participants roundly agreed that it was a good idea to have health insurance. Yet there was a widespread sense of doubt among the group that the Affordable Care Act’s benefits would extend all the way out to them.

I first noticed this when the focus groups participants were asked to read a description of the health-care law that said Americans "might" qualify for new, affordable insurance options.

When asked to highlight the words they liked, and the ones they didn't, many had circled "might." It conveyed an uncertainty about the law's benefits, suggesting that participants that they might get something -- or they might not get anything at all. “I don’t like the word might at all,” one participant said. “It makes me wonder if it’ll be really expensive,” another added.

One woman who expressed this view the strongest was Marina Sokolovsky, a 26-year-old who has been uninsured since she was 17. Earning about $1,500 each month, she’s near certain to qualify for new benefits. But when she looks out at the insurance system now -- broken, fragmented, and out of her reach -- she just doesn’t think it will work.

“Change is good, and it may be a real change, but if it was doable, it would have been done by now,” she says. “For how complicated things are, it would be a really big shift to find something functional. I just don’t think that’s possible.”

This view seemed to be pretty pervasive throughout the focus groups, where at least a handful had the experience of being denied a government benefit they’d pursued. This law may help other people get insurance, the thinking seemed to go. But somehow, someway, it won’t help me.

Even though the law bans pre-existing conditions, Tim Perot, 30, told me he still thought insurers would find a way to “reject” his coverage. He has let his diabetes and Hepatitis C go largely untreated since he lost his insurance and his job as a cook, two years ago.

He says that he's the kind of guy who tosses out any insurance brochures he might get in the mail. The whole idea of applying for insurance is anxiety inducing and, he admits, a little embarrassing. 

“It’s a lot about pride and embarrassment,” Perot told me when we chatted after the focus groups. “I’ve never had to do any of this. I’ve let my health decline. I’m afraid to reach out for help now.”

These are the obstacles that the health-care law now faces: A public largely unaware of the law and skeptical that our broken health-insurance system can be fixed.

Researchers also used their focus groups to understand what logos and slogans might do best to encourage enrollment. A color scheme with red, white and blue seemed to be a flop -- too reminiscent of a government agency, one participant observed. The name “Get Covered America” got especially high marks.

“I immediately picture the commercial like, ‘Get covered America!’” one participant remarked.

Now, it's up to Enroll America, and groups like it, to deliver on that message.

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Suzy Khimm · November 21, 2012