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Health law coverage can be tough sell in some states

Group’s experience in Texas underscores resistance, uncertainty

Rachel Perry (left) talked about health care enrollment with Deborah Young, who is self-employed, in Dallas.Ralph Lauer for the Boston Globe/Boston Globe

DALLAS — The young organizers fanned out through a neighborhood of ranch houses on a scorching midsummer morning, eager to educate Texans on the benefits coming their way under President Obama’s health insurance law. Idealistic and motivated, these health care foot soldiers were armed with glossy brochures emblazoned with the slogan: “Get Covered.’’

But a few hours spent with the team, from a nonprofit organization called Enroll America, illustrated the enormous challenges facing the White House and supporters of the health care overhaul in states like Texas.

In this large Republican-leaning state, one in four residents lacks insurance — the highest rate in the country — yet ignorance of the law and its potential benefits is rampant. State political leaders from the governor on down are actively opposing the law’s provisions and want it to fail.


Texas, in other words, remains hostile country before a key element of the law takes effect.

“I’m not interested,” a 37-year-old woman declared, waving an arm at the two college students standing on her porch before shutting her door in their faces.

Later, when the organizers found more people to speak with, they encountered deep confusion and skepticism.

Many Texans erroneously believed elected officials had repealed the law. Young black and Latino men, in particular, wondered if they would be signing up for “real” insurance, disbelieving that coverage could be both affordable and comprehensive.

“Texas is like the worst with health care, so a lot of people, especially people of color, don’t believe that’s going to change,” said Esteria Miller, Enroll America’s regional organizing lead for North Texas.

From the ground level, with time running out, it was difficult to see how these efforts will help Texas meet upcoming deadlines. On Oct. 1, residents are supposed to begin purchasing health insurance on a new government-sponsored website listing options for coverage.


By Jan. 1, they will be required to have obtained insurance or face a tax penalty under one of the most controversial elements of the 2010 law, modeled on Massachusetts’ groundbreaking universal health care requirement.

Governor Rick Perry and the Republican-led Legislature refused to take any part in implementing the online insurance marketplace. That task falls to the federal government, which is also responsible for setting up insurance marketplaces in 26 other states.

Texas has turned down federal Medicaid money included in the law to insure more low-income residents, joining roughly two dozen states that have rejected that provision, as well.

“It would be a challenge in the best of circumstances to get out big change like this, but here it’s much harder because we don't have a uniform team of people statewide working to get as many folks insured as possible,” said Dallas County Judge Clay Jenkins, a Democrat who serves as the county executive and supports the law. Despite the confusion, he added, “We’re committed to making this work.”

Enroll America, a group closely aligned with the president’s former campaign organization, is scrambling to fill some of the information gaps in Texas and other states before the mandate takes effect. The group has enlisted a cadre of Obama campaign veterans and newcomers — more than 130 paid staff and 3,000 volunteers — to organize communities in nine other states where opposition to the law is high, as are the numbers of uninsured: Florida, Arizona, Georgia, Ohio, New Jersey, Pennsylvania, North Carolina, Illinois, and Michigan.


Despite playing a central role in education efforts, Enroll America officials would not divulge how much the effort will cost, other than saying “tens of millions” of dollars are being raised from private foundations, corporations, hospital systems, and individuals.

That ground-level campaign will be reinforced by $41 million worth of national advertising contracts through the federal government. The Obama administration will also spend $67 million on contracts with nonprofits around the country to actually sign people up for insurance — with nearly $11 million going to Texas, more than any other state.

“The state may not be helpful, but it doesn’t matter as much when you’ve got folks on the ground,” said David Simas, a White House advisor overseeing the government’s national marketing of the health law and who directed opinion research for Obama’s reelection.

Texas has 6.1 million residents lacking health insurance; organizers have their sights set on 3.5 million who would be eligible to receive federal subsidies to buy insurance through the marketplace website. Kathleen Sebelius, US secretary of health and human services, has visited Texas twice this summer to promote the law.

On the other side of the public relations battle are Tea Party movement groups determined to hold Republican congressmen to their promise to chip away at the law. At August town halls in Texas and around the country, conservative activists are even pressing the lawmakers to threaten a government shutdown to block funding for the law.


Senator Ted Cruz, a Tea Party Republican from Texas who has introduced a bill to defund the law, is taking his crusade to business leaders throughout his home state during the congressional recess.

And Senator Mitch McConnell, the Republican leader, is sounding an alarm to Americans about the government-run insurance marketplaces, telling the public that their health and financial information could be compromised because the federal government has missed security testing deadlines.

Opposition by Republicans is having an effect. Nationally, more than half of Americans do not approve of the law, compared with just under 40 percent who do, according to an average compiled by Real Clear Politics, an independent news website.

The Dallas metropolitan area tops the country’s regions with the highest concentration of healthy, young uninsured people, according to a White House analysis of census data. That demographic is key to the success of the law, because young people help drive down the costs. The law prohibits insurers from denying coverage or charging more for preexisting medical conditions.

But local Enroll America organizers were striking out in their efforts to reach these uninsured people on a recent Saturday. Frustrated by the lack of interest as door after door remained closed, they decided to toss their neighborhood maps pinpointing households that were likely to be uninsured. Instead, they drove 6 miles to the north Dallas neighborhood of Hamilton Park, a working-class, predominantly African-American community they hoped would be more receptive to their message.

One of the team members, Rachel Perry, had been trained to resist using the word “Obamacare,” to avoid offending anyone with the mere mention of the president’s name. But the Patient Protection and Affordable Care Act, as the national health reform law is formally known, is a mouthful that often draws quizzical stares. Here, in Hamilton Park, organizers found the use of the shorthand “Obamacare’’ kept doors open.


“Is it F-R-E-E?” asked a man exiting his garage.

Perry, a 20-year-old college senior and field organizer with Enroll America, handed the man a “Get Covered” brochure and told him that signing up for private health insurance starting in October would be as easy as buying a plane ticket online. It would be affordable, too, she promised — but not free. He may even qualify for a federal subsidy, she said, showing him a chart color-coded by income brackets.

“What’s the price? What’s the catch?” asked Mark Booker, 44, an engineer, as he fanned himself with the brochure.

“No catch,” Perry said.

But she acknowledged that she could not answer his bottom-line question: exactly how much the insurance will cost. With little more than one month left before the insurance marketplaces are set to open, the federal government has yet to release the premium rates in Texas.

Perry suggested that Booker sign up for text-message updates about the law. The federal government is also running a 24-hour toll-free hotline to field consumer questions in 150 languages and to eventually help people choose and apply for insurance.

Booker said he knew little about the law, other than “I heard Obamacare was coming, coming and coming, and that you could go to any hospital for free.”

How much consumers will ultimately pay depends on a variety of factors. Americans with annual household incomes up to four times the federal poverty level — $45,960 for an individual or $94,200 for a family for four — will receive subsidies to buy private insurance. Subsidies will average $5,548 per family next year for those eligible who now buy coverage on the individual market, according to a new study by the Kaiser Family Foundation.

Farther down the street, a 51-year-old single mother invited Perry into her air-conditioned dining room.

The woman, Deborah Young, now a self-employed tax preparer, is a former retail manager whose 11-year career ended after she fell off a porch and broke her ankle. She and her 16-year-old son, who was born with a bone cyst in his left leg, lack health insurance. She was offered temporary COBRA insurance, but at $900 a month, she could not afford it.

“It’s scary at times,” Young said. “Everything weighs on you.’’

Perry told her that insurance through the new marketplace would be cheaper than COBRA, especially if she qualifies for a federal subsidy.

“It’s exciting, especially for your son,” Perry said. “Before Obamacare, his bone thing would have been a preexisting condition that he could have been denied insurance for.”

Then Perry made a stronger personal connection. Her identical twin sister, who was born without a left ear, has undergone 21 reconstructive surgeries that has plunged the family in medical debt.

Perry herself was diagnosed with Tourette syndrome at age 7. Without the health law, both Perry and her twin could be denied health insurance, or be charged more.

As Perry spoke, more of Young’s family members piled into the dining room. A nephew, who arrived with his wife to pick up their 1-year-old son, listened with rapt attention. The 33-year-old father of three had been uninsured for six months while he waited for his benefits with Raytheon, a defense contractor, to kick in.

Young was also eager to collect information for her brother, who became disabled after a heart attack, as well as her cousin, who has lupus and diabetes and was recently laid off from a health insurance company.

“Everybody’s heard about Obamacare, but I didn’t know completely what it entails or the procedures for obtaining it,” Young said. “They say it’s affordable, but affordable is a relative term.”

Tracy Jan can be reached at tjan@globe.com. Follow her on Twitter @GlobeTracyJan.