By John Reichard, CQ HealthBeat Editor
June 6, 2013 -- Maryland officials convened a summit this week to fire up outreach groups charged with enrolling the uninsured in health coverage this fall, and the daunting size and complexity of the job quickly became apparent.
It was clear from the long meeting of several hundred community, church, social services, and local health officials last week that even in a well-organized, committed state like Maryland, expanding health coverage this fall and winter under the health law is going to be a heavy, heavy lift. The event was held the University of Maryland, Baltimore County campus
Joshua Sharfstein, the state's top health official, got things rolling by declaring to the still somewhat sleepy audience that "this day is an incredibly important day, because we are really here launching the outreach efforts to get more people enrolled and to make health care work better in Maryland."
Sharfstein tried to rouse the crowd by pointing incredulously to a news report that opponents of the health law have spent $400 million on advertising to repeal it. "Four hundred million dollars on paid media to tell people we shouldn't be expanding health care in the United States," he said. "Four hundred million dollars! I want you to stand up if you're on the other side of that ledger. Get up," he said. "This is an incredibly important mission. We are here in Maryland to help people connect to services and opportunities that could literally mean the difference between life and death.
"So I'm going to ask one more time. Please stand up right now," he said. "And I want you to give someone a high five!" Sharfstein finally got most people on their feet, laughing and clapping.
But the moment of levity didn't last long.
The presentations that followed walked audience members through the various provisions of the law (PL 111-148, PL 11-152) and noted the challenges they face in trying to expand coverage to about 700,000 uninsured residents, many of whom have a high school diploma or less.
In many cases they either don't speak English or know insurance terminology such as premiums, deductibles and co-payments, speakers said. And they're less likely to know the ins and outs of "advance refundable premium tax credits," or whether it would be better to take the federal subsidies up front or file for them the following year with their income tax returns.
The lower education levels of many of the uninsured must be accounted for in materials describing the coverage program, said Danielle Davis, who directs Maryland's outreach effort. She added that in many instances, people who are not covered find talking about insurance "intimidating and stressful."
Among the challenges for outreach officials and those they are trying to help is that people without coverage face financial consequences whether or not they take the time to understand the complexities of insurance and how to get it under the health law.
Consumers cannot merely tune out the topic without taking some kind of financial hit, since starting next year they will face a tax penalty if they don't have insurance. If they do sign up they will have out-of-pocket premium costs they do not now pay. That puts pressure on both the uninsured and the people giving them that piece of bad news.
Lynn Quincy, an analyst with Consumers Union, noted another challenge. Middle income people are likely to think that subsidies to buy coverage are not for them, but are just for poor people. Or, they fear they'll get crummy coverage with the subsidies. Neither of those things are true, she said.
Help is On the Way
But the good news in Maryland is that the state has a relatively large amount of money with which to pay people to help consumers sign up for benefits. And navigators in the state will go through far more rigorous training to help people with the law than in other states—120 hours.
Also, the outreach effort blankets Maryland, with the state awarding contracts to six "connector entities" to help people get coverage through the state's marketplace, which is called Maryland Health Connection.
Those six organizations are partnering with many other local groups in their regions, officials said. They are planning a variety of ways to connect with people—linking with hospitals, health centers, churches and schools as well as by sending information home to parents with schoolchildren.
For example, the Howard County connector entity plans to outfit an RV to travel around and provide information about the law, and it has linkages with 125 churches and 15 supermarkets.
There also will be demonstrations on computers in local libraries about how to get educated and enrolled, and visits in Montgomery and Prince George's County to community events and picnics.
Quincy offered encouragement by telling audience members about brochures Consumers Union has carefully designed to educate people about the law. The materials will be customized for each state.
The brochure was tested both in states where people favor the law and in those where they oppose it. She said consumers of differing education and income levels understood the message on the pros and cons of taking tax credits up front as a way of paying less each month for coverage. The pamphlet explains by doing that, consumers risk having to pay more in taxes later if it turns out they got too much in subsidies because their incomes were higher than they anticipated.
Moreover, the consumers they questioned in focus groups said they thought such corrections were fair, she added.
Despite the complexities, consumers viewed the coverage provisions of the law as valuable and a way to protect themselves financially, Quincy said. "Even those with a negative impression of health reform said they would act on tax credit information because it would help their families," she said.
If attendees were discouraged by the challenges speakers described, they didn't express it. And they got encouragement too from Bishop Douglas Miles of Baltimore, who has served as president of the city's Interdenominational Ministerial Alliance.
Miles recalled a Martin Luther King quote in which the civil rights leader said: "Of all the forms of inequality, injustice in health care is the most shocking and inhumane."
Miles suggested that attendees had a chance to combat that inequality, and predicted that because of the overhaul, "nearly 300,000 Marylanders will gain access to quality, affordable health insurance coverage in the coming months, reducing the number of uninsured Marylanders by 50 percent."
What is perhaps most likely to make or break the exchange is whether or not it offers attractive rates. That won't be known until July. The insurer CareFirst caused some consternation by proposing an increase of 25 percent for 2014 in the individual market in Maryland, although Kaiser Permanente proposed only a 4 percent hike.
Sharfstein noted in a brief interview after his remarks that rates proposed by insurers are being reviewed and could be significantly lower in some cases when made final. "There's a multi-step process," he said. "The proposed rates are pretty variable," he said. He added that there will be more plans offered next year in the individual market than there are now.
"At this point really our key message is that they're being reviewed," Sharfstein said concerning the rates. "Everybody should just take their own pulse and see how this all plays out."