LOS ANGELES — As states gear up for Round 2 of Affordable Care Act enrollment next month, they have their sights set on people like Miles Alva.
Alva, 28, works part time at a video store and is about to graduate from California State University at Northridge. Getting insured is about the last thing on his mind.
“It’s not a priority,” the television and cinema arts student said. “I am not interested in paying for health insurance right now.”
The second round of enrollment under the nation’s health-care law promises to be tougher than the first. Many of those eager to get covered already did, including those with health conditions that had prevented them from getting insurance in the past.
About 30 million to 40 million people remain uninsured in the United States, according to various surveys.
“When you look at those who remain uninsured, they are in many ways harder to reach,” said Anne Filipic, president of Enroll America, a nonprofit group that signs up consumers for new health coverage. “This is really about doubling down and reaching those folks who didn’t get the message the first time.”
During the inaugural round, computer glitches and other missteps delayed sign-ups and created a political backlash. Yet more than 7.3 million people purchased health plans through new insurance marketplaces, and nearly 8 million low-income people enrolled in Medicaid. The massive effort helped to bring the nation’s uninsured rate down to its lowest level since 2008.
This time, states and the federal government aim to renew the people they signed up last year, as well as add about 6 million uninsured residents to the exchanges and 4 million to the Medicaid rolls, according to estimates from the Congressional Budget Office.
And there is a time crunch — the second round of open enrollment lasts only three months, about half the time as before.
Health and Human Services Secretary Sylvia Mathews Burwell said last week that the government is facing “deadlines every day” so it will be ready for the Nov. 15 start date. Officials are testing the site to ensure it can handle the demand, she said.
Health officials and advocates plan to adjust their pitch. Last time, they persuaded many to sign up by extolling the benefits of insurance. This time, they plan to focus more on the financial assistance available to consumers and the penalty for not having coverage. In Year 2, those without insurance face a fine of $325 per person or 2 percent of income, whichever is larger.
“People dismissed the penalty a little bit last year,” said Michael Marchand, director of communications for the Washington Health Benefit Exchange, which enrolled 164,000 in health plans last year. This year, higher fines could prompt an “awakening” and change people’s minds, he said.
But for many, whether to enroll in a plan has nothing to do with the penalty. In fact, a large portion of uninsured people were unaware of it, polls show. What troubles them is the price.
Alva, for example, makes about $10 an hour at his video job, working 25 to 30 hours a week during school — not enough, he said, to afford insurance. He has heard about the penalty but does not know how much it is for him. “I guess I will deal with that when it comes,” he said.
Barb Hill, 54, who lives outside Chicago, supports Obamacare but chose not to sign up last year. Even with a subsidy, she said, insurance would have cost her $200 each month. “I really don’t go to the doctor that much, so I didn’t know if it was worth spending that,” said Hill, an X-ray technician at a private health-care office.
Among consumers still uninsured as of June, nearly 60 percent said they couldn’t afford coverage, according to a recent analysis by the Urban Institute.
But many consumers were not aware they might be eligible for subsidies. “A lot of people don’t know what the costs are,” said Sharon Long, senior fellow at the Urban Institute. “They just assume it is going to be high, or they are afraid it is going to be high.”
Long said the states and federal government need to do a better job of educating potential consumers about their options.
That’s what Sheila Chilson and her team at Moses Lake Community Health Center in Washington are trying to do — teach patients how insurance works and help them figure out how to afford it. “We have a year’s experience under our belt, but we are preparing ourselves for the same level of volume and potential frustration,” she said.
Although uninsured residents are scattered throughout the United States, nearly half live in the South and many are concentrated in the two dozen states that chose not to expand their Medicaid programs, according to the Urban Institute analysis. The health law expanded Medicaid to more low-income adults, but a Supreme Court ruling made that provision optional for states.
As a result, nearly 5 million uninsured adults fall into a “coverage gap” — they make too much to qualify for the existing Medicaid program but too little to get financial help purchasing a plan through the marketplaces, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation).
Greg Morris, 46, is one of about 300,000 Missouri residents in that gap. Morris, a single father, lives in Osage County and works part time at a miniature-golf course. “The only option I have is to pay more than I can afford,” he said.
Nationwide, among the most difficult populations to reach are Latinos. About 6 million people in the United States, many of them Latino, are uninsured and ineligible for coverage because they are undocumented, according to the Kaiser Family Foundation. But even among eligible Latinos, enrollment has been impaired by a fear of calling attention to undocumented family members, a lack of timely Spanish-language information and a shortage of bilingual enrollment workers.
Nevertheless, the percentage of uninsured Latinos across the nation decreased from 36 percent to 23 percent by June 2014, according a September report from the Commonwealth Fund. Coverage gains were greatest in the states that expanded Medicaid eligibility.
Advocates found that in-person help worked best, as did partnerships with trusted groups, advertising on buses serving Latino neighborhoods and the use of health counselors, called promotoras.
“Latinos really like personal contact, they don’t like to make decisions about health care over the Internet,” said Commonwealth report author Michelle Doty.
Nationwide, more than 600,000 Asian Americans, Native Hawaiians and Pacific Islanders enrolled in coverage, primarily through community groups, but about 1.3 million remain uninsured, according to the Asian & Pacific Islander American Health Forum.
To reach them, the marketplaces need to invest more in outreach and education, through libraries, ethnic grocery stores and faith-based institutions, said Bonnie Kwon, a program manager at the forum. “If they are coming from a country that has a completely different system, they don’t understand co-pays, they don’t understand deductibles,” she said.
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.