Outreach worker Angelica Marquez, left, from Community Health Alliance of Pasadena, helps educate Raymond Pinedo on the Affordable Care Act at the Valley Mall in El Monte, Calif. CHAP is expanding by opening a community health center in El Monte. (Bret Hartman/For The Washington Post)

Fliers and tablet computers in hand, a small team of outreach workers from a local nonprofit health clinic blanketed a shopping strip east of Los Angeles, spreading the word about the state’s expanding health insurance landscape under Obamacare.

Stopping passersby on the sidewalk as they ducked in and out of the row of discount stores and easy-credit furniture shops at the Valley Mall, the workers assured them that the changes would put health insurance within the reach of more Californians. The mostly Latino shoppers seemed intrigued, but they also were skeptical. They worried about the penalties imposed on those without insurance. They worried about the cost of policies. And they did not know where and how to sign up.

“It is interesting, but I’m just not sure about it,” Raymond Pinedo, 48, an unemployed construction worker, said after a canvasser tapped his information into her computer to determine which programs might suit him. “How much would I have to pay?”

Bringing people up to speed on the impending changes from the health-care overhaul is critical not only to California, home to 15 percent of the nation’s uninsured, but also to the success or failure of the Affordable Care Act itself.

Under the law, Medicaid is set to cover a broader share of the poor. And Covered California, the insurance marketplace that began enrollment amid intense interest and some technical glitches last week, will offer subsidized coverage for low- and middle-income people in January.

No place has done more to embrace the health-care law than California. In stark contrast to the 26 states that have chosen not to expand Medicaid, excluding millions of poor people from the law’s potential benefits, California is among those extending free health insurance to families whose incomes are as much as $26,951 for a family of three.

Officials here got a head start on the Medicaid expansion by enrolling hundreds of thousands of eligible people into county-run health programs. Many of those enrollees will be transferred to the state’s Medicaid program in January.

California was the first state to construct a health insurance exchange, which includes a broad menu of insurance choices with comprehensive offerings. Last week’s launch of the exchange is being trumpeted with the help of $94 million in outreach money.

“California decided early on to go all in,” said Larry Levitt, senior vice president at the Kaiser Family Foundation. “There has been lots and lots of investment, and a lot of smart people have really been working hard on this. It really set up a best-test-case scenario.”

But if California is making a huge effort to implement the law, it also faces challenges unique to a state with its breathtaking diversity and large pockets of poverty. More than 7 million Californians do not have health insurance, and a large number of them do not speak English as a first language. Nearly a quarter of state residents live in poverty.

In addition, the law itself is complex, with a wide range of purchase options and documents needed for applicants to qualify for insurance subsidies.

From intangible to reality

“It is a complicated and complex set of information for people to absorb,” said Kandis Driscoll, work group director for the nonprofit Insure the Uninsured Project, Santa Monica. “It was so intangible for so long. Many people heard this was coming, but they did not see themselves as being part of it until now.”

The nationwide launch of the health-care exchanges marked a seminal moment for the health law, thrusting the long-running debate about its merits into the lives of individuals.

Interest in California’s exchange has been high, even though many people have questions, according to state officials. More than a half-million unique visitors perused Covered California’s Web site on its first day of operation. It was a far cry from the 5 million Web site hits officials mistakenly touted at first, but they still claimed it as a victory. Another 19,000 people called in to inquire about the exchange.

The exchanges are online marketplaces where people can compare policies side by side and buy health insurance. The sites also allow applicants to determine whether they qualify for government subsidies. Open enrollment started Oct. 1 and runs through March 31. Coverage begins in January, when the law requires almost all Americans to have health insurance or pay a penalty to the government. The penalty starts at $95 in 2014 but increases to at least $695 by 2016.

Covered California officials would not say how many people applied to buy health care through the site, saying they would release those numbers monthly beginning in November.

But the early days of the exchange have brought problems. The state has been slow in awarding grants to train social service workers on the intricacies of the exchange Web site. Also, the heavy traffic forced officials to twice take the system down for maintenance.

Health-care officials said those problems are minor and would not factor in the ultimate fate of the effort. “So there were computer glitches. No one has to enroll right away,” said Mitchell H. Katz, director of Los Angeles County’s Department of Health Services. “If this were the only week you could enroll, that would be a problem.”

Spreading the word

The bigger issue, officials said, is whether people can be educated about the exchange and then see value in enrolling. “The action now is not in Washington. It is not in Sacramento. The action is here in our communities,” said Kim Belshe, a Covered California board member.

So far, it appears that the uninsured know very little about the health-care law. In a recent poll of 2,000 uninsured Californians by the Kaiser Family Foundation, 70 percent of respondents said they did not know enough about the law to understand how it would affect them. Kaiser plans to track the poll participants for two years in an effort to document the impact of the law.

The poll’s findings resonated with the workers at the Valley Mall. “I am hearing a lot of questions,” said Angelica Marquez, an outreach worker with the nonprofit Community Health Alliance of Pasadena. “People know things are changing, but they don’t know how they will be affected.”

Officials launched an advertising campaign with the opening of the exchange to build public understanding. Early on, Covered California’s goals are modest: The exchange hopes to enroll from 500,000 to 700,000 people who are eligible for subsidies by the time open enrollment closes in March.

That would be fewer than a third of the 2.6 million people in the state thought to be eligible for subsidies, which is in line with federal projections that a quarter of eligible people will sign up in the health exchanges during their first year of operation.

“Whether that is acceptable or not is in the eye of the beholder,” the Kaiser Family Foundation’s Levitt said. “It is not unusual for a government program of this size to take time to ramp up.”

Los Angeles County Commissioner Mark Ridley-Thomas said he expects public awareness of the health-care law to increase rapidly now that it is touching more lives. “It’s hard to trump self-interest,” he said. “It’s only a matter of time before people realize that the law benefits them.”

That has been the experience of Devin Leyva. Even though he battles asthma and twice has been hit by cars, leaving him with rickety knees and ankles, Leyva, 27, had long calculated that health insurance was not worth the steep cost — assuming he could find a company to write him a policy. He said he has not had coverage since he was 18.

But with the launch of open enrollment for Covered California, the software designer said the price of insurance for him has fallen by more than half, to about $200 a month. He plans to sign up for coverage shortly.

“I decided that not having health insurance is a gamble,” he said. “It feels like a waste of money when you don’t use it, but you need it when you do.”

Bryan King, 31, a freelance television editor, typically works on short-term contracts that offer no health-care benefits. He has a bare-bones insurance plan that required him to pay out of pocket for many types of care. When he injured his thigh last year, he found himself in physical therapy for knee pain three days a week for six weeks. Each visit cost him $75.

With the exchange coming on line, he learned he could buy a more comprehensive plan for just $30 or $40 a month more than the $168 he is currently paying. He plans to enroll soon.

“The exchange is cool,” King said. “It is a very market-oriented thing. It is like buying something from eBay. You can research it and make an informed decision.”