If anyone can claim to know how best to implement Obamacare, it might be Kate Bicego.

Kate Bicego, in her Boston office, runs the Massachusetts health insurance helpline. (Sarah Kliff | Washington Post)

What Bicego does do is run the Massachusetts health insurance help line. For six years, she’s been the one making sure the state’s health reform law does what it’s supposed to and cover the uninsured.

“Here we are, many years out from [Massachusetts’] health reform, and people still have problems navigating the system,” says Bicego. “They still need our help.”

Since its health law passed in 2006, Massachusetts has extended health insurance coverage to 98.1 percent of its residents. That has not happened without significant effort. Many of the state’s gains in coverage have depended on the work that Bicego does: Connecting those without insurance, many of whom have never interacted with the system, to the appropriate coverage.

The Massachusetts health insurance hotline is run by Health Care for All Massachusetts, a non-profit that advocated for the 2006 law. State offices answer basic questions: where to get a form, which agency handles which kind of coverage. There is no government agency, however, to explain how to fill out a complex form, or troubleshoot a dispute with a given agency over a coverage determination. That’s where the helpline comes in.

“If you call Medicaid and say ‘I’m pregnant and I want to apply,’ they’ll send you a form,” says Bicego. “We’re the ones that help fill out that form.”

Even six years into Massachusetts health reform, there’s still significant demand for those services: the help line handled 40,000 calls in 2011 alone. The help line team can now fill out an application for Medicaid and other state-subsidized programs in five minutes flat.

The scene when I visited the help line’s offices Thursday: A colleague of Bicego’s, Hannah Frigand, is on hold with the state Medicaid office. She’s working on the case of a woman who previously had insurance through her school, but whose coverage lapsed after she graduated. Now pregnant, she had an urgent need for care but was running into roadblocks getting her application processed quickly.

Massachusetts helpline supervisor Hannah Frigand. (Sarah Kliff | Washington Post)

Bicego has learned a lot in six years of running the Massachusetts helpline. She knows that, if you want to determine how much someone earns (to figure out what subsidies they’re eligible for) you don’t ask directly--people tend to overestimate. Instead, you ask for their hourly wage and weeks worked in the past year.

Issues completely removed from health policy can become significant hurdles. Like the time, two summers ago, when a state agency ran out of paper. Government rules prevented the department from ordering more before the end of the month, so health insurance termination notices ended up going out late, a potential disruption in coverage for some.

Bicego and her colleagues have shared these kinds of insights with the federal government as it gets ready to implement the Affordable Care Act. She also meets with the Massachusetts Medicaid department and the Connector, which administers the rest of the state subsidies, to talk about what isn’t working within the state.

“What we’re able to do is take what we learn here and tell them about our experience,” says Brian Rosman, researcher director for Health Care for All Massachusetts. “The best was when the Medicare person asked what the best way to ask about income was. And she was like, ‘I know exactly how to ask people because I’ve done it 10,000 times.’”

Bicego’s days are busy. The hotline is open from 9 a.m. to 5 p.m. on weekdays, although the inbox tends to already have messages stacked up when staff members arrive.

But she thinks that volume may pale in comparison to what other states might experience, when the federal law expands insurance coverage in 2014. Massachusetts began with an uninsured rate of 10.3 percent; in Texas right now, the same number hovers around 25 percent.

The federal law did include $30 million for consumer assistance programs. But states have mostly used up that money already, before the expansion has even started.

“I think in other states, where you have 25 percent uninsurance rate with people who have never had insurance, and have no idea about terms like premium, copay or deductible, it’s going to be a huge challenge,” she says.

When my half-hour visit to the helpline was ending, Frigand was wrapping up her call with the state Medicaid office. She did reach one person there, but he wasn’t sure if he had the authority to sign off on the expedited application. He transferred Frigand to his supervisor’s voicemail. “We do know he has the authority, but he says he’s not sure,” Frigand says. “It’s frustrating, but we’ll keep on trying.”