Uninsured will see differing levels of help for Obamacare in Maryland, Virginia, D.C.

August 9, 2013

Maryland consumers who want to buy health insurance under Obamacare in the fall will be able to read glossy fact sheets that spell out the law in simple language. Or talk to one of 325 specially trained workers who will explain the intricacies and help them enroll. Or get information via Facebook, Twitter and YouTube.

In Virginia, it’s a different story. People can seek assistance from about two dozen special guides. Or they can go to their state legislators, who might refer them to phone numbers and Web sites operated by the federal government.

The two states have taken vastly different paths although they have comparable numbers of uninsured: at least 844,000 in Virginia and an estimated 800,000 in Maryland.

“Virginia’s approach is totally opposite from Maryland,” said Cindi Jones, who is overseeing Virginia’s implementation of the health-care law.

For people without health insurance in the Washington region and elsewhere, the help they get figuring out the complicated law known as “Obamacare” will depend on where they live, a testament to the uneven way President Obama’s signature legislation is being implemented around the country.


See how the states have sided on some of the key provisions of the Affordable Care Act. (Katie Park and Rebecca Rolfe;/Kaiser Family Foundation)

A key test comes Oct. 1, when insurance marketplaces open for enrollment. These marketplaces will be Web sites where people can compare and shop for health insurance coverage effective in January. People will also be able to find out if they qualify for subsidies to reduce their costs or whether they’re eligible for Medicaid, the state-federal program for the poor.

But two months before these systems must be in place, striking gaps in resources and readiness suggest that people will have widely varying experiences in trying to purchase health insurance. And those differences are likely to affect the law’s success, which hinges on millions of uninsured Americans, especially healthy ones, signing up for coverage.

State differences

In states such as Maryland, which embraced the law and is building its own marketplace, health officials are getting access to millions of federal dollars to identify the uninsured, bombard them with information and then provide human helpers to guide them through their options. But in places such as Virginia, which rejected the law and even mounted an unsuccessful lawsuit challenging it, the enthusiasm to spread the word and the resources to do so will be much more limited.

In a news conference Friday, Obama noted that Republicans have made it their “holy grail” to prevent people from getting health care under the law. He also acknowledged that “there are going to be some glitches” implementing the Affordable Care Act.

“No doubt about it,” he said. “There are going to be things where we say, ‘You know what? We should have thought of that earlier,’ or ‘This would work a little bit better’ or ‘This needs an adjustment.’ ”

Health and Human Services Secretary Kathleen Sebelius acknowledged in a recent interview that efforts to help consumers have been uneven. “Certainly, it is much more robust in some areas than others,” she said. “Having consumers be able to get information easy to read, easy to understand, answer questions, pull together their financial information and then get ready, may be more challenging in states where there isn’t a really robust outreach effort.” “There’s a really huge difference in the amount of funds for consumer assistance, outreach and enrollment,” said Sarah Dash, research faculty at Georgetown University’s Center for Health Insurance Reform, who is tracking implementation of the law.

Under the health law, states that built their own marketplaces could tap into limitless federal funding. But facing political opposition, only 16 states, including Maryland, and the District of Columbia took on the task.

Because limited funds had been set aside for the states that refused, such as Virginia, the federal government has had to cobble together other resources. As a result, only $54 million is available for community groups in 34 states to train and hire the special workforce known as “navigators” to help with education, outreach and enrollment.

Adding to confusion in the Washington region: Virginia is not implementing a key provision of the law that allows more people with low-to-moderate incomes to be covered under Medicaid. Both Maryland and the District are doing so. That means a greater share of Virginia’s uninsured will need help figuring out what to do.

“We’re going to be struggling to get our message out, and that will be very different from what Maryland and D.C. are putting out,” said Cyndy Dailey, an executive at Northern Virginia Family Service, a nonprofit working on outreach with other community groups.

Getting people signed up

Starting next year, all Americans over 18 must carry health insurance or face a fine. The penalty starts at $95 or 1 percent of income for the first year, and rises to $695 or more annually for an individual in 2016.

By law, plans offered on the new insurance marketplaces will cover a wider range of benefits than most individual plans do today, including prescription drugs and maternity and newborn care.

Insurance companies will be barred from denying applicants because of pre-existing conditions, such as cancer and diabetes.

In Maryland, where uninsured residents make up about 14 percent of the population, the state is mobilizing a small army to help, training about 5,000 people, said Rebecca Pearce, executive director of the Maryland Health Benefit Exchange. They include health and social service workers, insurance brokers, “navigators” and others.

The state’s call center, which opened Monday, will handle basic questions. Its staff will be fluent in Spanish; an interpreter service line can handle 200 other languages. The Maryland Health Connection Web site also has fact sheets and videos.

“The onus is on us to make sure the experience, once you get here, is right,” Pearce said.

Maryland received more than $157 million in federal grants. The state kicked in an additional $8 million. Out of the total, it is devoting $24 million to hire 175 navigators and an additional 150 helpers.

State officials have set up an extensive network for deploying these guides, with six geographical regions, each headed by one lead group, or “connector.” Each connector is teaming up with local partners. They include health clinics, immigrant-service organizations and consumer-focused nonprofit groups, all of whom are training and hiring staff members or volunteers to provide in-person guidance — especially to hard-to-reach populations — and to provide space for them to work.

For example, the Montgomery County Health Department will be trying to find and sign up the nearly 222,000 uninsured residents of Montgomery and Prince George’s counties, the largest concentration in the state.

Maryland’s navigators will receive 90 hours of training — more than the 20 hours of initial training planned for navigators in Virginia and other states under the federal government’s direction.

People can sign up for insurance through March. Maryland officials hope to enroll 180,000 people for private insurance in the first year. An additional 100,000 low-income individuals are likely to qualify for expanded coverage under Medicaid. Adults earning up to about $15,856 a year, or a family of four earning up to $32,500, will qualify.

The District is also running its own marketplace, known as DC Health Link. Only 42,000 people, or 7 percent of the population, is uninsured. But officials are hoping that an additional 150,000 people who already have insurance will buy a plan on the exchange; some may be eligible for a subsidy.

The District has received about $100 million in federal grants to build its systems, hire navigators and conduct outreach. Officials are setting up education seminars for small-business owners and holding “summits” with community leaders to enlist their help.

By comparison, Virginia received about $6 million in federal funds because it declined to set up its own insurance exchange, defaulting to the federal government. The governor and Republican legislators said there were too many unanswered questions — about how much a state-run marketplace would cost, how well the federal version will work and whether the private sector might fill the niche.

Gov. Robert F. McDonnell, often mentioned last year as a GOP vice presidential contender, was also not eager to take any action that might be seen as a tacit endorsement of Obamacare, according to people knowledgeable about the health-care discussions in Richmond who spoke on the condition of anonymity to discuss a sensitive matter.

As a result, Virginia didn’t receive millions in federal funds, including money for education and outreach. Nor is the state budgeting money for consumer assistance. Instead, the federal Health and Human Services Department is giving $1.4 million to community groups in Virginia to hire navigators. The state’s federally funded community health centers also received $2.5 million in grants to help with outreach.

Consumer advocates say the navigator money will be enough to hire about 20 full-time guides. Navigators working one-on-one with applicants can probably enroll about 20 people a week.

Jones, Virginia’s director of health-care reform, said she expects private groups will pitch in to get the message out. But, she acknowledged, “Virginians are going to be confused.”

Challenge of enrollment

Private organizations say they are scrambling in the absence of state action. And they question whether there is enough money and time to reach consumers. Enroll America, a nonprofit group that is helping the uninsured get coverage, is not including Virginia in the 10 states where it is conducting door-to-door campaigns.

“No one is able to predict how efficient the enrollment process will be,” said Kathy May, director of Virginia Consumer Voices for Healthcare, a nonprofit group working on enrollment.

Of the estimated 500,000 Virginians who will be eligible to access health insurance through the new system, more than 81,000 people are likely to qualify for tax subsidies in Northern Virginia, according to the nonprofit Northern Virginia Family Service.

Signing up people for coverage is even more challenging in Northern Virginia. Residents there will be hearing the same TV and radio messages about expanded Medicaid options as those in Maryland and the District.

But Virginians won’t have that option because the state is not broadening Medicaid. Community groups estimate that about 441,000 uninsured Virginians would have qualified. In states that refuse to expand Medicaid, residents whose incomes are above the poverty line (about $11,500 for an individual) will still have access to tax credits for purchasing private insurance in the marketplace. But those below the poverty level will not receive help obtaining coverage.

“It does really complicate enrollment and outreach,” said Jill Hanken of the Virginia Poverty Law Center.

Maryland has also spent millions to make the consumer’s Web experience as smooth as possible. The state is building an integrated system that is supposed to minimize data transfer between one eligibility system and another. Doing so reduces delays and prevents people from slipping through the cracks, experts said.

One of the companies working on the system, Fort Lauderdale, Fla.-based EngagePoint, moved seven senior executives to Linthicum, Md., to work on the project round-the-clock. Even so, the task is enormously complex.

Testing that should be done sequentially, for example, is instead being done all at the same time.

“It’s insanity,” said Pradeep Goel, EngagePoint’s chief executive.

In Virginia, consumers are relying on the federal government’s massive data hub to “ping” or query back to the state’s Medicaid eligibility system. Transferring data back and forth could be a challenge, experts said.

Maryland has also developed an outreach tool kit online and on CDs for community organizations. Fact sheets feature the marketplace’s logo, a four-leaf-like shape that is supposed to signal to consumers that there is “no wrong door” on the Web site, said outreach director Danielle Davis. Even the name — the Maryland Health Connection — is deliberately chosen to be in lowercase letters in the logo.

The idea, Davis said, is for consumers to find the marketplace “a welcoming and unintimidating source of information.”

Sandhya Somashekhar, Laura Vozzella and Alice Crites contributed to this report.

Lena H. Sun is a national reporter for The Washington Post, focusing on health.
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