WASHINGTON — It survived a historic Supreme Court fight and a bruising presidential election. Next up for President Obama’s groundbreaking law to expand health insurance coverage: winning over a skeptical and, in much of the country, downright hostile public.
Health care advocates say lessons — and inspiration — can be drawn from the Massachusetts experience, where a multipronged publicity blitz helped the state achieve near-universal coverage more quickly than lawmakers anticipated when they passed the 2006 law.
But much work remains to get Americans to buy into the controversial federal law and educate them on its basic provisions, according to a new poll to be released this month by Enroll America. The forthcoming survey found that 78 percent of people without insurance do not know they could be eligible for subsidized coverage; 83 percent of those likely to be eligible for Medicaid also have not heard about the coming changes.
“It really shows that despite all the energy that has gone into the continuing debate about the Affordable Care Act, the people who would most benefit still don’t know that help is on its way,” said Rachel Klein, executive director of Enroll America, a national coalition of insurers, doctors, hospitals, and others trying to expand public awareness by the time enrollment is scheduled to begin next fall.
While Massachusetts had a mere six months to publicize the law, the Obama administration has until October 2013. But the clock is ticking.
‘Without the Massachusetts experience to guide federal policy makers, we would have no hope.’
“There’s been a lot of time that has been lost, 2½ years wasted when people were sitting on their hands because of the Supreme Court case, the election, and the fear that Congress would repeal the law,” said John McDonough, director of Harvard University’s Center for Public Health Leadership, who helped craft the Massachusetts and federal laws.
In Massachusetts, several major efforts were key to the state’s success in dramatically boosting enrollment. The state was able to use food stamps and welfare records to identify and reach out to low-income uninsured people and automatically enroll them for subsidized insurance without the hassle of new paperwork.
A massive publicity campaign included everything from knocking on doors to reach low-income families in New Bedford to advertising at Fenway Park to reach the so-called “young invincibles,” men in their 20s and 30s who did not see the need for health insurance.
Starting the day after Governor Mitt Romney signed the law, hospitals, physicians, business groups, and insurers gathered in the offices of Partners HealthCare on the 11th floor of the Prudential tower to chart their course. The mission was not only to figure out how best to publicize the law, but also to respond to the torrent of national criticism.
Whenever newspaper op-ed pages ran a column attacking the law, deeming it a disaster and outlining why it would fail, a rapid response team would fire off a letter to the editor or write a competing op-ed defending the law, McDonough said.
“It was in your face. It was aggressive. We left no stone unturned,” he said.
The Obama administration has already tapped the public relations firm Weber Shandwick to assist with marketing and outreach. The same firm designed Massachusetts’ public education campaign, in which the Boston Red Sox played a central role.
The firm launched several public service announcements using players including Tim Wakefield to help convince young, healthy people, especially men, to sign up for insurance. Without a significant enrollment of healthy people in the program, premiums would skyrocket because the law, like the federal version, prohibits discriminating against those with preexisting medical conditions.
But it turned out that millionaire ballplayers were not the most effective people for reaching out to those without insurance, said Tara Murphy, senior vice president at Weber Shandwick.
A new ad focusing on peer testimonials showed the baseball field at Fenway Park to promote the notion of “covering your bases.” Another featured a young actor with a fake broken arm. It turned out he did not have health insurance and decided to sign up during the ad shoot.
Both ads played on the Fenway jumbotron during every home game before sell-out crowds in the team’s championship year in 2007. Announcers broadcast interviews with Senator Edward M.Kennedy and Governor Deval Patrick about the law. State employees manned an information booth at the ballpark and stuffed fliers about the state’s new health insurance exchange — an online marketplace where consumers can more easily choose among competing plans — into the arms of fans.
CVS hung signs in its storefronts promoting the law. Supermarket chains like Shaw’s and Star Market printed similar messages on store receipts. H&R Block provided its uninsured tax clients with information on how to sign up through the exchange.
The state also gave grants to community groups to help individuals fill out their enrollment forms. Health care providers, too, completed forms on behalf of patients. Radio ads in Portuguese and other languages targeted immigrant groups. Churches reached out pew by pew, scouring their congregations for the uninsured.
Within two years after the state passed the country’s first law mandating that people obtain insurance or face a tax penalty, more than 97 percent of residents were insured, the highest rate in the nation. From 2006 to 2008, the proportion of Bay State residents without insurance dropped from 6.4 percent to 2.6 percent. The national rate of uninsured in 2011 was 15.7 percent.
The challenge at the national level of enrolling the tens of millions of uninsured will be much steeper, given the greater public skepticism and political divisions not seen in Massachusetts.
That will make it harder to draw broad support from community and institutional partners like grocery chains and sports franchises, said Jon Kingsdale, former head of the Commonwealth Health Insurance Connector Authority and now a health-care consultant helping other states develop their own insurance exchanges.
McDonough also called upon hospitals, insurers, and drug companies around the country to step up as they did in Massachusetts. Many have signed onto Enroll America’s mission but are not participating in any meaningful way, he said.
“They are in for a dime, and we need them in for a dollar,” McDonough said. “Most of the investments are piddling and not up to the scope of the work that needs to be done. They are overwhelmingly missing in action.”
And politics, too, continues to introduce roadblocks for promoting the law. Earlier this month Republicans on the House Ways and Means Committee subpoenaed Health and Human Services Secretary Kathleen Sebelius, demanding to know how taxpayer money is being used for an “Obamacare” public relations campaign.
Stan Dorn, a senior fellow at the Urban Institute Health Policy Center and coauthor of a paper on the secrets of Massachusetts’ enrollment success, recommended that the federal government begin by using the income tax form to jump-start enrollment. More than 86 percent of all uninsured people file federal income tax returns. Many do so for the earned income tax credit and would likely be eligible for subsidized health coverage under the new law.
“Without the Massachusetts experience to guide federal policy makers, we would have no hope,” Dorn said. “Now we have hope, but we also have huge challenges, and I don’t expect the federal effort to be as successful in enrolling people as Massachusetts was.”