HOUSTON – The Obama administration is effectively running another national campaign, but this time with the goal not beating Mitt Romney but getting at least six million people to enroll in plans through the Affordable Care Act by the end of this month.
Houston is normally ignored during the presidential election, because it’s in a deeply red state. But now, liberal groups and Obama administration officials are sending staffers and volunteers into churches, community centers, libraries and YMCA’s all across America’s fourth-largest city, determined to find and enroll some of estimated one million uninsured people who live in this area.
Houston is one of 25 major cities nationwide (Atlanta and Miami are among the others) where a huge swath of America’s uninsured live, and Obamacare supporters are concentrating their efforts almost exclusively on ramping up enrollment in these cities over the next two weeks. Houston and surrounding Harris County has about the same number of people as the state of Kentucky (4.3 million) and it’s a much smaller geographic area than an entire state.
But getting people to enroll in insurance may be harder than getting them to vote for you.
“I thought you couldn’t be denied”
Texas is way behind peer states. Even though 300,000 have enrolled in private insurance plans here, the New York Times reports that’s around 54 percent of the administration’s target, compared to 84 percent for California, the other state that had more than six million uninsured before ACA enrollment started.
Liberals here and nationally blame this on Texas Gov. Rick Perry, a vocal Obamacare opponent who refused to set up a state-based exchange or expand Medicaid under the ACA. His administration enacted a provision that requires people who assist the uninsured in enrollment (“navigators” in Obamacare parlance) to undergo background checks and be fingerprinted before they can start the job.
But Houston should be more fertile soil. Obama won Harris County in 2012 and Mayor Annise Parker has heavily promoted the law. The city of Houston has not only hired staffers specifically to help with Obamacare enrollment, but gave Enroll America, a non-profit group staffed by former Obama aides set up to sign up people across the country, an office in the city’s health department. The mayors of San Antonio and Dallas are also big boosters.
And despite Perry’s opposition, people in Houston are being flooded with messages encouraging them to enroll in Obamacare before the March 31 deadline. The law is being covered on local news extensively. Telemundo and Univision stations in Houston have had call-in programs for people to ask questions about the health care law. Many people here told me they heard about the law on the radio. The Centers for Medicare and Medicaid (CMS), which formally runs the ACA, is running TV commercials in big cities around the country, including Houston.
“It was on the news several times this morning,” said Annie Singletary, a retired black woman who was at a YMCA on Sunday with her grandson, referring to Obamacare news.
Singletary said she can’t escape information about the law, even though she’s already on Medicare. Her pastor has brought up the law several times at church, something African-American ministers are doing throughout this area.
“He says ‘this Obamacare is here to help you and anybody who does not have insurance should get it,’” said Singletary.
Still, it’s slow going. After talking to dozens of people here of all ethnic groups and political beliefs, it’s clear the main challenge in Houston is the same as other parts of the country: almost everyone has a bad story about the health care law, or is confused by it.
Some went online in the fall and couldn’t sign up on the broken website and have been reluctant to try again. Others heard horror stories from friends. Many don’t like being required by law to purchase insurance. Another bloc has heard from others that the prices are too high and haven’t bothered to explore healthcare.gov themselves.
“I have an aunt and she didn’t qualify,” said Alfredo Salazar, as he waited for a navigator to help him at an ACA enrollment event at the YMCA. “She was denied. I thought they said you cannot be denied.”
Salazar was referring to one of Obama’s chief selling points for the law: people can’t be denied coverage, as before, because they have illnesses.
Salazar wasn’t exactly sure why his aunt did not get coverage. From his retelling, it was not clear she understood either. And that confusion isn’t helping the law gain support from the public.
“That got me more confused,” he said of his aunt’s experience. That, along with what he had heard about the website, made him decide to wait until Sunday, only two weeks before the end of open enrollment.
“I hope it’s good. I have a bad leg, I haven’t gone to the doctor because I don’t have insurance,” he said.
And many young people here, like in other places, simply aren’t that motivated to get insurance.
“I’m working here, and it took me a while to sign up,” said Jorge Ortiz, who is doing some part-time work for the Houston Area Urban League enrolling people.
“It’s called procrastination”
The vast majority of Americans who have enrolled in Obamacare did so at home, on their computers, well before the March 31 deadline.
A coalition of pro-ACA groups in Texas and nationally are working on the rest: people who don’t own computers; those, particularly Latinos, who are wary an online government form will expose their own or their relatives’ immigration status; people whose family situations are sufficiently complicated that they have tried to enroll at healthcare.gov but failed; people who truly didn’t know about the health care law until recently; and another bloc described best by Ortiz, who told me, “it’s called procrastination.”
One tactic of the pro-ACA groups (Enroll America, Planned Parenthood, the National Urban League and others) is to put on events, particularly in disproportionate low-income, minority parts of Houston where people can bring in their financial information and get personalized counseling. (Enroll America’s office in Houston includes detailed maps of the city’s uninsured, with zip codes with more than 5,000 people in dark red, and they are trying to have many events in those areas.)
These liberal groups, particularly with only two weeks left in the enrollment process, are largely targeting black and Latino families who truly need health insurance, not the young, healthy men who the White House is focused on to make sure the insurance markets in each state are more balanced by age.
One organizer I talked to specifically mentioned the “Between Two Ferns” video President Obama did last week as an example of the kind of media the people he is trying to enroll don’t watch.
“A lot of people don’t watch TV, a lot of people don’t read the news, a lot of people don’t know what’s going on,” said Ann Lister, one of the field organizers for Enroll America.
She can’t count on the crowds of the Obama campaign. She expected just 20 to attend an enrollment seminar at Good Shepherd, an African-American Baptist church. Another liberal group crowed about an event that 300 people attended, a tiny fraction of the people who are uninsured here.
“I’m triple booked,” Lister said, referring to two other ACA events she was hosting last Saturday. “We are all over the place. That’s how we are going to penetrate Houston.”
And this outreach is labor intensive. The 300-person event, held in downtown Houston, required 25 staffers on hand to help people enroll people. Organizers are already talking about the need to hire more staffers, particularly Spanish speakers, for the next round of Obamacare enrollment, which starts in the fall.
“”The challenge Texas has is there are so many people who need that in-person assistance, who have never had health insurance or who have never made a major purchase online,” said Tiffany Hogue, who is running the state healthcare campaign for Texas Organizing Project.
“Email-set up for marketplace”
Last fall, when President Obama compared buying health insurance to buying an airline ticket on kayak.com, the clunky website undercut that promise.
But he was wrong in two other ways too. Buying health insurance, with the huge set of regulations that comprise Obamacare, is simply more complicated than booking a flight from United. And the president may have forgotten many Americans, particularly elderly and low-income people, don’t purchase airline tickets or anything else online.
Another obstacle: healthcare.gov requires an e-mail address. Each day, enrollment navigators encounter many people who don’t have e-mail addresses, or even a computer at home.
For an event in Houston at Baker Ripley, a neighborhood center that mainly serves Latinos, a staffer was designated just to create Google or Yahoo e-mails for people, with a handwritten-sign “EMAIL SETUP FOR MARKETPLACE,” above her head.
“We were spending 20 minutes working with people, just to set up e-mail accounts, before we even started anything,” one of the Enroll America staffers told me. “So we decided to have somebody there just doing that.”
The best analogy to the Obamacare process is filing your taxes: some people can file online in less than 30 minutes, while some have major challenges that require help from an expert. It just generally takes an hour to enroll someone, the navigators say. The website still goes down on occasion, as I witnessed during one enrollment event in Houston, where frustrated navigators told several people that they can’t finish enrolling them. Some folks don’t like to talk about how much they make. The challenges go on and on.
“We’ve moved away from not talking about the fine”
One component you won’t hear about from the President or LeBron James or any of the celebrities enlisted to tout the plan: the penalty for not getting coverage. (While the rules are complicated, it’s generally $95 for each uninsured adult in a family or 1 percent of their family income, whichever is higher).
And in truth, as Republicans have noted, the administration has created enough loopholes in the mandate that millions can qualify for various exemptions and not pay it.
But on this front, the Obama administration has a smart strategy: let others talk about the sticks while the White House touts the carrots. The media coverage, from Fox News to local newspapers, has been intense around the fine for not having insurance, but most people don’t know about all the exemptions.
“Everyone knows about it,” one administration official told me when I asked about the mandate and why it wasn’t featured in more of Obama’s speeches.
The Obama administration is banking the benefits of the mandate (it is motivating people to get insurance) without having to incur the cost of having the president go around the country and talk about how he is going to tax people.
But, as the deadline approaches, the people between Obama and the uninsured, community leaders, pastors and liberal organizers, have no qualms about talking about the mandate. They say after five months unsuccessfully trying to get some people to buy insurance, that blunt message is the best.
“We have moved away from not talking about it,” said Samantha Gongora of Enroll America in Houston, who said in the early months of open enrollment that the group had shied away from mentioning the mandate. She added, “telling people there will be a fine on March 31 is a motivator.”
“Amazing”
Al Ortiz, the communications director for the Texas Organizing Project, was busy on Sunday. But he wasn’t looking to enroll people – rather, he was looking for people who can’t enroll.
Texas is one of the 25 states that so far have opted against expanding their Medicaid programs under the law. This leaves out an estimated one million Texans who would be eligible for Medicaid otherwise. In this way, Gov. Perry is the biggest and most important Obamacare opponent in the country. (In Kentucky, a state that has expanded Medicaid under the ACA, 222,000 people have enrolled because its new rules cover virtually all low-income people, versus only 94,000 in Texas, even though Texas has six times the population.)
Groups such as TOP hope to find those folks, hand them to reporters and try to shame Gov. Perry and Texas legislators to change their mind. “We are trying to put a face to the one million Texans who don’t qualify,” Ortiz said.
In the midst our conversation, another TOP staffer approached Ortiz and said he found a woman with a story to tell.
The three of us went to talk to Maria Gonzales. But she then explained in Spanish that she had actually been able to enroll in health insurance. I asked her “why did you wait till the last minute to enroll?”
“I don’t know,” she said.
I then asked what she thought of the insurance.
“Amazing,” she said.
She then recited the price, very precisely: $19.64 per month.
“The Gold Card”
Salazar, the man whose aunt had been denied insurance, brought his wife to a YMCA to get help enrolling. In a room where yoga classes usually meet, four of the navigators were set up with their computers, seated far enough apart that if they spoke softly, no one could hear anyone else’s conversation, to preserve privacy.
Salazar, who says he does not work in part because of injuries to his leg and arm, came with dozens of papers that included his family’s tax returns for the last several years.
Then, he and his wife, who works as a maid, sat down and started talking to one of the navigators in Spanish. For about two hours, the navigator walked them through the enrollment process, with Salazar and his wife interjecting at times with information for the navigator to type in. At one point, Salazar got up to get more documents from his car.
“My goodness, this is unbelievable,” he told me, referring to how long the process was taking.
After a third hour, after being moved to a different conference room at the YMCA, Salazar and his wife got up to leave. They looked angry.
The navigator had told them, Salazar said, that their family income of $16,000 for a family of seven (Salazar has five children) would have qualified them for Medicaid if Texas had chosen to expand its program, but they are not eligible under the state’s current guidelines. Salazar and his wife do not make enough money for subsidies, so the cheapest insurance plan would cost them $400 per month.
“I’m shocked,” Salazar said. “I came here with a lot of enthusiasm that I was going to qualify. I’m very shocked.”
He said, for $400 a month, his family would have to choose between paying for food and getting insurance.
So Salazar said he and his wife would instead just stick with the “Gold Card,” a system in Houston in which low-income people get medical service at clinics on a sliding scale based on income. (Recipients used to receive a yellow-colored card to prove they were in the program, but eligibility is now tracked electronically.)
This system provides health care for low-income people, but Salazar and others say they would rather have insurance, as it can take months to see a specialist and you do not get to choose a personal doctor under the “Gold Card” system.
“We will pay the fine,” Salazar said, although he almost certainly will be exempted from it because of his low income. “I hope in the future, they will figure it out.”
“I haven’t gone to the doctor, but I have to deal with this,” he added referring to the pain in his arm. “Now, I have to wait for the Gold Card.”