EAST LANSING, Mich. » President Barack Obama and the Democrats passed the 2010 health care law to make medical insurance available to more than 30 million people who do not have it. But with recent studies showing that as many as three-fourths of those people are unaware of their new options, health care providers are joining community organizers and insurance companies in an ambitious effort to spread the word in the six months remaining before the health plans become available.
In Michigan, a small army of doctors and nurses, hospital employees, insurance agents and advocates for low-income people is mobilizing for the next phase of this revolution in domestic social policy: finding people who are eligible for health insurance and getting them enrolled.
It will not be an easy task.
The simmering political debate over Obama’s health care law — which includes an expansion of Medicaid, the government program for low-income people, and the creation of "exchanges" to market subsidized private insurance — makes the work of these foot soldiers more difficult, but also more important.
Michigan is, in many ways, a microcosm of what is going on around the country as people race toward the start of "open enrollment" on Oct. 1.
"Confusion, total confusion," said Jan M. Hudson, a consumer advocate, describing state efforts to help more than 1 million Michigan residents get insurance under the law.
Hudson, a founder of Michigan Consumers for Healthcare, a coalition of consumer groups, led a recent conference of more than 200 experts and advocates who banded together on the campus of Michigan State University in East Lansing to try to identify and enroll everyone in the state who might be eligible for coverage.
Amy L. Allen, the director of health care reform at the Michigan Department of Community Health, said that delays and resistance by the state Legislature meant that more of the work must be done by community groups and the private sector. The Republican-controlled Legislature declined to set up a state insurance exchange, and Gov. Rick Snyder, a Republican, has met opposition within his own party to his proposal to expand Medicaid.
Nevertheless, in Michigan, as in many states, advocates for poor people, blacks, Hispanics and people with disabilities are joining health care providers and insurers in a campaign to find the uninsured wherever they live, work, play or pray.
"Getting all these people enrolled will not necessarily be an easy task, but it’s a great opportunity," said Anita M. Fete, who was one of the speakers at the conference and is the director of state assistance at Enroll America, a national nonprofit group set up to maximize enrollment.
The Census Bureau estimates that 1.2 million people in Michigan are uninsured. Most will qualify for subsidized private insurance, or for Medicaid if the state chooses to expand the program.
Nationally, the Congressional Budget Office predicts that 14 million uninsured people will get coverage next year. But that goal is ambitious.
Studies for Enroll America and the Kaiser Family Foundation indicate that three-fourths of uninsured adults are unaware that they will have new insurance options.
Among the people expected to sign up for coverage in the new online markets known as insurance exchanges, 1 in 4 speak a language other than English at home, and 3 out of 4 have a high school diploma or less.
Citing those statistics, Christine P. Barber, a senior policy analyst at Community Catalyst, a consumer organization, said: "There is no time for turf battles. We need to come together to make this work."
In California, the health insurance exchange faces an even more daunting task. It is trying to reach 5 million people who speak 13 different languages and are spread across 163,000 square miles. Nearly half of those in the state who are eligible for insurance subsidies are Hispanic.
The fact that so many people are unaware of their new options has the potential to undermine the entire purpose of the health care law. Congress provided hundreds of billions of dollars for expanded coverage, but it did not fully account for the difficulty or expense of getting people to sign up. Also, Democrats did not anticipate the effects of continued Republican hostility to the law.
"Opponents’ attacks seem to have taken a toll on the public’s expectations, and Americans are now more likely to think the law will make things worse rather than better for their own families," the Kaiser Family Foundation said last month in a summary of its latest poll. "Americans’ awareness of key elements of the law has declined somewhat since passage, when media attention was at its height."
Community organizations, health care providers and insurers, which stand to gain millions of new customers and hundreds of billions of dollars in new revenue, said they were determined to move beyond the bickering of politicians in Washington and in Michigan.
"There are so many moral and pragmatic reasons why hospitals should be engaged in outreach and education," including to reduce the burden of bad debt and charity care, said Tina Weatherwax Grant, a vice president of Trinity Health, a large Catholic health care system based in Livonia, Mich.
Grant said that Trinity would have counselors to help people apply for Medicaid and subsidized private insurance at most of its 47 hospitals. Some sites will also have enrollment kiosks with computers.
Trinity hospitals in the Muskegon area already employ community health workers who knock on doors and buttonhole neighbors at football games and laundromats, offering to help them get insurance. Other health care providers and health plans want to replicate that model.
"It’s a lot like political organizing," Grant said.
The most notable feature of the conference here was the collaboration of diverse groups. They included Blue Cross Blue Shield of Michigan, Easter Seals, the Little River Band of Ottawa Indians, the Grand Rapids African American Health Institute, the state chapter of the American Academy of Pediatrics, Jewish Family Service, and Access, a nonprofit organization that provides health care in Arab and Chaldean communities in the Dearborn area.
Snyder wanted to establish a health insurance exchange, but the state Legislature refused to spend money made available for that purpose by Congress and the Obama administration.
The federal government will run the exchange in Michigan, but the precise division of labor between federal officials and state insurance regulators is not clear.
Snyder has also proposed expanding eligibility for Medicaid, as envisioned in the federal health care law. But he is meeting resistance from conservative Republicans in the state Legislature.
"We have major hurdles in front of us," Allen, the Michigan Department of Community Health official, said. "It’s quite a heavy lift to get spending authority from the state Legislature for anything related to health care reform. But people will still need assistance, still need to know if they are eligible for tax credits and premium subsidies."
Phillip J. Bergquist of the Michigan Primary Care Association said his members, who run community health centers for low-income people, would help patients sign up for coverage when they called to schedule appointments. Many clinics will also take the initiative and call their uninsured patients.
About 100,000 patients of community health centers in Michigan are uninsured and would be eligible for Medicaid if the state expanded the program, Bergquist said. An additional 40,000 to 50,000 will be eligible for income tax credits to help them pay premiums for private insurance, he added.
Jo Murphy, the director of a free counseling service for Medicare beneficiaries in Michigan, has helped thousands of older Americans choose prescription drug plans. But, she said, counseling the uninsured on their options may be a bigger challenge.
"Many of these families have never had coverage," Murphy said. "In many cases, you will be speaking a foreign language. You have to teach them the language before you can explain the options."