LAWRENCE — The decision to get health insurance came to Wilson Santana as he was leaving church. There, a woman handed him a flier about an enrollment event, and he promised to attend. For months, Santana had been among the 3.6 percent of Massachusetts residents without coverage.
One day this month, he entered a vast gymnasium at the YWCA of Greater Lawrence and found rows of laptops on folding tables and workers eager to sign him up. They are among an army of helpers deployed in community centers and health clinics across the state, charged with a singular mission: lower what is already the nation’s lowest rate of uninsured people.
A decade after enacting the law that became the model for the federal Affordable Care Act, Massachusetts continues to leave a steady 3 to 4 percent of its citizens uncovered year after year. The state’s pursuit of this elusive population could provide a template for other states where the rate of uninsured people has fallen into the single digits. But the Massachusetts enrollment blitz raises an intriguing question: How low can the rate go?
“I think we need to have that honest conversation. Is having 3 percent uninsured OK?” said Marylou Sudders, Massachusetts secretary of health and human services. She called for an analysis of whether the marketing and outreach will be worth the cost.
Many of those involved are convinced the campaign will work. “We are going to get closer to and closer to no uninsured in the state of Massachusetts,” said Kathryn Segel, senior consumer education and enrollment manager at the advocacy group Health Care for All.
New data have pinpointed the neighborhoods where most uninsured people live and found they are more likely to be male, single, low-income, and Hispanic. So the state is advertising in dozens of small, ethnic media outlets and targeting certain communities.
Enrollment workers are focusing on places such as Lawrence, an old mill city near the New Hampshire border, where three-quarters of the population is Hispanic and one in 10 residents lacks health insurance.
And they’re looking for men such as the 43-year-old Santana, a Dominican immigrant who manages a tire store where health insurance is not offered. At the YWCA, it took Santana just 20 minutes to find out he qualified for subsidized coverage with Neighborhood Health Plan and to enroll his son in MassHealth, the state’s Medicaid program for low-income adults and children.
“It’s easy,” he said. Many people he knows are afraid to enroll, fearing it will be time-consuming and costly, he said.
Most people without insurance in Massachusetts fall into one of three categories.
Some are unauthorized immigrants who don’t qualify for state and federal health insurance, although many can obtain limited coverage.
Some choose not to buy insurance, preferring to pay the penalty at tax time — although that calculus may change as the federal penalty doubles for 2016.
The largest group is people who have lost their job or their coverage and haven’t found a replacement.
The estimate that 3.6 percent of Massachusetts residents are uninsured, from a state survey conducted last spring and summer, is merely a moment’s snapshot.
When asked whether they had been without insurance at any point over the previous 12 months, a full 8 percent answered yes. Only 1.5 percent had been uninsured throughout the previous 12 months.
“Very few people are uninsured for the whole year,” said Sharon K. Long, senior fellow at the Urban Institute and an author of the report on the survey. “Most of it is people who are moving in and out of coverage.”
The effects of these gaps in coverage — whether that results in people avoiding needed care or paying out of their own pockets — have not been well studied, Long said.
This fluidity of jobs and incomes is unlikely to change, said Joshua Archambault, senior fellow at the Pioneer Institute, a Boston public policy group with a free-market, limited-government philosophy. Archambault supports the goal of enrolling people who want insurance but questions the extent of the state’s marketing. “The return on investment is inevitably going to be terrible,” he said.
It’s difficult to tease out the cost of the effort to reach the uninsured, said Jason Lefferts, spokesman for the Massachusetts Health Connector, the agency serving people who don’t get coverage through an employer.
The Connector’s total cost for advertising, outreach, and related materials is $3.7 million (about 40 percent from the federal government), but that money pays for interactions with existing clients as well as uninsured people. Of that, $1.6 million in state money goes toward “navigators,” the in-person guides for insurance seekers.
They include Angelo Nogueira Sanca, who has worked for years as a navigator at the Boston Public Health Commission. This year, he was sent back to his home neighborhood of East Boston, where some tracts have more than 20 percent uninsured.
He handed out leaflets at a subway station and visited laundromats, hair salons, and other small businesses to spread the word. “People were very receptive,” he said.
A recent survey by the Connector hints at possible success. Of the 28,000 newly enrolled in November and December, 12 percent had never had insurance before. A significant number live in targeted areas with high rates of uninsured people.
Nationwide, about 9 percent of people lack health insurance, down from 16 percent when the Affordable Care Act was enacted.
In Massachusetts, just over half of people without insurance named cost as the reason. But many of them probably qualify for free or nearly free coverage under MassHealth, and most others are eligible for federal and state subsidies that significantly lower premiums in private insurance.
The hunt for uninsured people comes as the Connector emerges from its rocky transition to a new computer system required by the Affordable Care Act. Connector officials acknowledge that some people went without insurance because they gave up in frustration with the Connector software.
Even if Massachusetts abandoned efforts to whittle the number of uninsured people, the state would still have to spend money on marketing just to maintain the current rate, said Ashley Hague, the Connector’s deputy executive director. Although the numbers remain steady, she noted, different individuals become uninsured each year and new people need to learn the ropes.
Dr. Benjamin Sommers, assistant professor of health policy and economics at the Harvard T.H. Chan School of Public Health, said the enrollment campaign is not a fool’s errand.
“People who have health insurance have better access to health care,” Sommers said. “They feel better about their health, and they’re better able to deal with the financial issues associated with getting sick.”Felice J. Freyer can be reached at firstname.lastname@example.org. Follow her on Twitter @felicejfreyer.