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There was a bit of bad news for Obamacare in the CBO report that did not say that the law would kill more than two million jobs. Now that that's put to rest, here's the ACA problem the CBO did identify: two million eligible people won't enroll this year, largely because of the botched rollout of the website. But here's the good news for the administration in finding and reaching out to most of them—they know where they are.
Geography could hold the answer, according to a study conducted for The Associated Press. It found the uninsured aren't scattered around the country willy-nilly; half live in just 116 of the nation's 3,143 counties. That means an outreach campaign targeted to select areas can pay off big.

The pattern also holds true for the younger uninsured, the health care overhaul's most coveted demographic. The study found that half the uninsured people ages 19-39 live in 108 counties. Their premiums are needed to offset the cost of insuring older adults, who are more likely to be nursing chronic ailments.

With the website working more smoothly, the Obama administration is using the geography of the uninsured to write a playbook for its closing sign-up campaign. Open enrollment for subsidized private insurance ends March 31 for people who don't have health care through their jobs.

Just to show how well Republican sabotage efforts work, the two metro areas with the most number of eligible people who still haven't signed up are in Texas, Dallas and Houston. Then comes to more Republican state cities: Miami and Atlanta. These states not only aren't publicizing the law, they've enacted any numbers of state laws and regulations to make the job of outreach more difficult.

Originally posted to Joan McCarter on Wed Feb 05, 2014 at 01:24 PM PST.

Also republished by Kos Georgia and Daily Kos.

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Comment Preferences

  •  Tip Jar (40+ / 0-)

    "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

    by Joan McCarter on Wed Feb 05, 2014 at 01:24:24 PM PST

  •  How do we overcome the obstruction? (9+ / 0-)

    This is quite frustrating.

  •  Time to mobilize these areas at the grassroots (9+ / 0-)

    and get people signed up. Maybe some media outreach by the administration can help?

    Shall we go? Yes, let's go.

    by whenwego on Wed Feb 05, 2014 at 01:37:10 PM PST

  •  A map showing which counties (6+ / 0-)

    ..have high levels of unenrollment would be interesting.

    Cogito, ergo Democrata.

    by Ahianne on Wed Feb 05, 2014 at 08:29:17 PM PST

  •  It's truly a revelation... (1+ / 0-)
    Recommended by:
    Victor Ward

    ...that the 3 top areas are in red states.

    I'm not always political, but when I am I vote Democratic. Stay Democratic, my friends. -The Most Interesting Man in the World

    by boran2 on Thu Feb 06, 2014 at 09:21:01 AM PST

    •  Many red states are also rural states. But not all (1+ / 0-)
      Recommended by:

      rural states are red states. We need to look at the percentages of unenrolled population compared to the overall population.

      Working with rural uninsured counties that WANT to enroll their citizens can serve as a case study to influence counties that are not currently invested in moving this forward.

      We need to look at both population centers and also rural counties.

    •  That's maybe what the diary says (1+ / 0-)
      Recommended by:

      but not the embedded link . .. . .

      The research for the AP by the Minnesota health data center found that just 13 counties account for 20 percent of the uninsured. The top county, Los Angeles, has more than 2 million uninsured people, or about 5 percent of the national total.
    •  They aren't. Diary is wrong. (0+ / 0-)

      Those are areas that the Feds are targeting.

      Federal officials are focusing on 25 metro areas, the AP said, including Dallas, Houston, Miami, Atlanta, northern New Jersey, Philadelphia, Detroit, Cleveland and Indianapolis. The feds are less concerned with cities like Los Angeles and New York, where states are running their own health-care exchanges.
      The top uninsured counties are Los Angeles, Harris (Houston), Cook (Chicago), Miami-Dade and Dallas.

      Disclaimer: If the above comment can possibly be construed as snark, it probably is.

      by grubber on Thu Feb 06, 2014 at 10:36:57 AM PST

      [ Parent ]

  •  Houston (3+ / 0-)
    Recommended by:
    dotdash2u, Ahianne, GleninCA

    Houston has a very progressive mayor which should bode well for focusing at the local level.  Not sure that there are funds in her budget, but I would imagine the mayor's office can bring local resources to bear in support.  Will be interesting to watch.

  •  stupid question (1+ / 0-)
    Recommended by:

    Aren't there federal laws designed to stop states from interfering with interstate trade?  If so, are some R governors breaking those laws?

    Actions speak louder than petitions.

    by melvynny on Thu Feb 06, 2014 at 09:40:57 AM PST

    •  Health Insurances Is Regulated At State Level (0+ / 0-)

      The states have their  own regulatory agencies and licensing requirements

      Men are so necessarily mad, that not to be mad would amount to another form of madness. -Pascal

      by bernardpliers on Thu Feb 06, 2014 at 09:57:14 AM PST

      [ Parent ]

    •  Not exactly (0+ / 0-)

      Congress has the right (under the Constitution) to regulate interstate commerce. But they are not required to do so. The ACA was written to preserve state control over insurance, which is traditionally state-regulated rather than national.
      So no, the R governors are not breaking any laws.

      And the SCOTUS decision on the Medicaid mandate pretty much gave them license to interfere, or at least to refuse to spend a dime of state money to help implement the Federal law.

  •  This way of looking at it makes political sense (2+ / 0-)
    Recommended by:
    blue aardvark, Ahianne

    but does not necessarily make sense health-wise. My county in northern NM is a pleasing cream color, but that is primarily because we have 7 people per square mile in a county the size of an eastern state. We are not going to produce high concentrations of uninsured because we are rural. We should also be looking at percentages. If a high percentage of the population remains uncovered, it destabilizes the entire health care system, which is a huge issue for New Mexico.

    By only looking at concentrations, we abandon many poor rural populations including blacks and hispanics and some indigenous populations who also desperately need care. My guess is that the percentage of uninsured in my county is very high.

    •  But if you're looking at overall national numbers (1+ / 0-)
      Recommended by:

      then focussing on places where you can enroll 5 million people makes more sense than places where you'll have to travel miles and miles to enroll 1.

      Remember also that the Feds kept asking Congress for more money, especially as it became clear that some states were refusing to step up to the plate, and Congress said no way. So they have to use what money they have very efficiently.

      It will be up to local organizations and advocacy groups to do some of the outreach to groups like you're describing. That's where local progressive coalitions can be helpful.

  •  Remember Harvard Medical's study (2+ / 0-)
    Recommended by:
    TheFatLadySings, Ahianne

    Every person denied insurance has an increased risk of death.

    Republican opposition to Obamacare will kill more people than 9/11.

    I'm on a mission! Testing the new site rules.

    by blue aardvark on Thu Feb 06, 2014 at 09:44:33 AM PST

  •  Will some insurance genius please explain (3+ / 0-)
    Recommended by:
    Ahianne, geez53, Cassandra Waites

    why there have to be "enrollment periods" for insurance?

    I mean, I can understand why there are enrollment periods at universities -- it's ultimately because most subjects have to be presented in a certain logical sequence, and usually a student can't join a class at any random time (though online courses are breaking that old rule somewhat). But I cannot imagine any intelligent reason why an insurance policy would need an enrollment period.

    •  Bureaucratic cowboy round up time? (0+ / 0-)

      Cost and logistics of updating huge data bases. Cost of having temp "helpers", everywhere in the system, for a few months instead of all year. Plus it has to be easier to estimate your valuation for Wall Street if you know how many customers you'll have for the rest of the year.

      Can't think of one good way it works for us though, unless you buy in to the lie: "it saves us money, so we trickle the savings down to you".

      Of course, that is just my cynical observation of what actually happens, so maybe we'll get a real "expert" glossy answer/rationalization of how it's supposed to look.

      21st Century America: The distracted, superficial perception of a virtual reality. Gettov Milawn

      by geez53 on Thu Feb 06, 2014 at 10:26:09 AM PST

      [ Parent ]

      •  That's just bad software design (0+ / 0-)

        There is no reason all of that can't be updated continuously.

        My suspicion is that they make significant money from people who do not change their policies every year to seek out the best bargain, and who get hit with jacked-up fees they are locked into for one year. In other words, "enrollment periods" are just another way to fleece people.

      •  I think quite the opposite. (1+ / 0-)
        Recommended by:

        It's likely much cheaper to process a steady trickle of new policies being opened rather than bunching them into one month.

        Assume with "continuous" enrollment people really signed up at a flat rate year around (a reasonable first approximation but probably not completely true) but with open enrollment, everyone signed up during a one month period.

        With the "continuous" model, a company would hire, say R customer service reps to deal with new policies and train them once (of course, some ongoing training would be required) and lease just enough office space/phone systems/computer systems to accommodate R customer service reps. Assuming that a customer service rep stays on the job about two years, the annual hiring/training costs would be approximately (ignoring training on new procedures/systems) C×R÷24 for some constant "C" per employee recruiting/training cost.

        With the signups concentrated in a one month period, the company would have to recruit and hire 12×R customer service reps for one month and train all of them as well as acquire/retain office space/phone systems/computer systems to accommodate 12×R customer service reps. Under this scheme, the annual recruiting/training costs would be approximately C×12×R (288 times that of the continuous case).

        As well, it's quite likely that customer satisfaction and the number of issues that get escalated or policies that get screwed up is quite a bit less when your average customer service rep dealing with new polices has been working in that role for twelve months vs. two weeks.

    •  it's because of the free rider problem, I think (2+ / 0-)
      Recommended by:
      Ahianne, Cassandra Waites

      If you could sign up for insurance at any time, then you could skip insurance until you need it.

      (I think "free-rider" is the correct term.)

      An easier way to solve the problem would be to automatically sign up everyone with Medicaid (and add the premium to taxes) unless they had insurance.

      •  Just put in a penalty that decreases (1+ / 0-)
        Recommended by:

        with the amount of time you have had insurance. Of course, if we don't have single payer, the (shrinking) penalty has to be fully transferable so insurance companies don't use it to lock people in.

        •  It already does that (0+ / 0-)

          The penalty is a month-by-month penalty. If you have insurance for six months of the year, you only will pay the penalty for the other six months.

          That still does not solve the problem of people waiting until they are sick to sign up.

          And the penalty is paid to the US government, to offset the costs of providing people with "free" (government-funded) care when they're uninsured.

    •  To help control adverse selection... (1+ / 0-)
      Recommended by:

      ...I believe.

      If one could enroll for health insurance at any time (or upgrade their coverage at any time), many people would intentionally be uninsured or under-insured.

      Then, when they were diagnosed (or were going to be tested via expensive tests) for a disease that is expensive to treat, they would sign up or upgrade for the "best" possible insurance plan (with a high premium, but at that point they would be sure of recovering more than the cost of the premium in terms of more flexibility to access more/better facilities, lower co pays, lower deductibles etc).

      This strategy is, of course, fraught with risks -- esp. the risk of have a critical emergency (such as an accident or a stroke) where the first few hours/days can be very expensive (i.e., before you could arrange for new or upgraded coverage).

      However, this strategy would work well for things like cancer if it were not for enrollment periods (as most people would want to be treated for a cancer discovered the day after open enrollment before the next open enrollment period began).

      Health "insurance" is quite unlike most other forms of insurance. Health insurance pays for treatment provided during the policy period independent of how long ago the condition being treated occurred or was first noticed. Most other forms of insurance (such as homeowners or auto) pay for expenses potentially incurred long after the event/condition that caused the expenses to be incurred. This is why enrollment periods are not needed for most types of insurance.

      If your auto insurance expires at 23:59 Dec 31 and you've not renewed but you have a horrific crash at 23:58 Dec 31, NO expenses occurred during your covered period but your auto insurance will pay for covered expenses years later (which, if a lawsuit is forthcoming, it probably will be). Similarly if your homeowners insurance expires at 23:59 Dec 31 and you've not renewed but a tornado levels your house at 23:58 Dec 31 (hopefully you have a hardened camera with GPS time reference so you can PROVE it didn't happen 90 seconds later!), NO expenses would be incurred during your covered period but your HO insurance will pay, subject to policy limits/terms, for rebuilding your house a year later when you finally get plans approved.

      However, if your health insurance expires at 23:59 Dec 31 and you've not renewed but you have a stroke at 23:58 Dec 31 but don't call 911 until 0:00 Jan 1, your health insurance won't cover ANYTHING as no covered services were provided to you during the covered period. Similarly, if you were uninsured at the time of the stroke but had coverage that started at 0:00 Jan 1, the new insurance would cover everything.

      •  Again, my penalty suggestion above (0+ / 0-)

        would handle that.

        •  I don't disagree... (0+ / 0-)

          ...that this is a possible solution.

          However, if people are fiscally rational and can do 8th grade math (sadly, two big assumptions of course), the penalty would have to be very high to be effective.

          The penalty would likely have to be greater than the medical inflation adjusted sum of all annual premiums one had avoided paying had they carried whatever level of insurance they are applying for (in other words, often many tens of thousands of dollars -- all unsubsidized). This is because some people who choose to be uninsured will win the lottery and reach Medicare age with few if any medical expenses -- all of which they will pay out of pocket or stiff the provider on and their premiums would never be in the pool available to pay benefits so the penalty on the remaining "late joiners" would have to cover these as well to keep the motivational value of the penalty properly balanced.

          I question that the penalty is really practical for this reason (most people who would choose to be uninsured probably don't have the necessary $35K lying around to pay the penalty in order to get into the insurance market when they are 30 and start feeling vulnerable).

          I believe such a penalty may be part of (one of many) Republican plans to "fix" the ACA.

          •  Also... (0+ / 0-)

            ...the penalty probably has to be collected up front -- else some free riders would sign up to get their expensive knee surgery due to a sporting accident done and then drop insurance the next year to avoid the premium penalties in the following years. In fact, collecting it over the following years would actually discourage these free riders from remaining in the insurance market after they had gotten what they wanted from it.

          •  No, it wouldn't have to be that high. (0+ / 0-)

            In the current system, there is a de facto penalty for not having insurance and needing medical care: you go to the emergency room, you receive bills you probably can't pay, and your credit is destroyed. So the default of the current system is a stiff penalty.

            Your insurance coverage could ramp up as a function of time. Since insurance companies are perfectly willing (snark intended) to pay out full coverage to people who are enrolled for a year, in the worst case you ought to be fully vested in your policy after 6 months. Up until then, you would pay a sliding penalty that would be at its maximum at the very beginning of coverage, and which would be stiff, but not as bad as the current defacto penalty. After 6 months, you would be fully covered. As long as you stay covered (and this would need to be transferable between policies) you would be fully vested. If you stopped being covered, you would lose your vestment and have to start over.

            I'm just showing that enrollment periods are not actually needed. Personally, I think insurance companies should go to hell and we should have a fully socialized system like the British NHS, which would not need any penalties or insurance at all because it would supported entirely out of tax revenues.

    •  Flip side of individual mandate/no pre-existing (0+ / 0-)

      If you allow people to enroll whenever, you encourage people to wait until they have a problem and then enroll. During healthy months, the cost of the penalty is less than the insurance premiums or the cost of the medical care you don't need. If a woman can wait until she feels a lump in her breast, sign up for insurance, and two weeks later get the mammogram that turns up a tumor, you've just put a major dent in your insurance stats.

      That's why they limit open enrollment. They want people in the pool before they need the benefits.

      There is, BTW, enrollment year-round for people with a change in life situation -- divorce, birth of a new baby, turning 26, losing your job and therefore your health insurance, etc.

  •  How Many Counties Voted For Romney And McCain? (2+ / 0-)
    Recommended by:
    Ahianne, GleninCA

    ......and have plunging life expectancies?

    The picture is slowly coming into focus.  

    Men are so necessarily mad, that not to be mad would amount to another form of madness. -Pascal

    by bernardpliers on Thu Feb 06, 2014 at 09:55:57 AM PST

  •  Rick Perry is... (0+ / 0-)

    the gift that keeps on giving.

  •  Poor use of stats (3+ / 0-)
    Recommended by:
    grubber, Roadbed Guy, WillR

    While I appreciate the point being made, I have to take exception with the revelation that half of the nation's uninsured live in just 116 of our counties.

    Given that 45.3% of the nation's population lives in just the top 116 counties, I really don't think we needed a study to point this out!

    A fool will lose tomorrow reaching back for yesterday.

    by kansasr on Thu Feb 06, 2014 at 10:20:56 AM PST

  •  Sorry, but I have to mention... (0+ / 0-)

    I very much appreciate the information on the geography of uninsured people. It's definitely reassuring to know that some targeted efforts should be able to reach a very high percentage of these uninsured folks.

    One thing that I saw in this article that concerns me, however- and it's something I've seen in other Daily Kos articles and on other progressive websites- is the idea that the number of people who remain uninsured is higher than it should be,

    "...largely because of the botched rollout of the website."
    Is that really the case? Have two million people chosen not to obtain insurance under the ACA because of some website issues?

    Admittedly, it's tough to know/prove why two million people are not doing something, but I feel strongly that this is just not the case. I suspect the website issues are only one factor in why two million people have yet to obtain insurance (and further that the website issues are less of a factor each day/week/month since the majority of the problems have been fixed). Worse, laying the primary blame for the large number of uninsured on the website feeds into the right wing's insistence that the ACA is 'broken' and can never work.

    I can posit several other theories about why the number of uninsured remains high:

    - Many of the uninsured are working poor and have limited access to the Internet and/or limited time to research and understand their options under the ACA;

    - The shifting deadline has created confusion;

    - It's human nature that people tend to wait to the last minute to do things (have you been to the post office on April 15?); and

    - The tremendous amount of misinformation deliberately put out by the far right, once legitimized and spread by the all-too-willing media, has led many uninsured to believe ACA is not required, is too expensive, is bad for them, etc., such that they are not signing up even though eligible (this theory really plays into all of the others).

    In the end, I suspect that many if not all of these theories are at play here, including the website issues.

    Again, I appreciate the Diary and the good information provided, but I think it's crucial that we avoid adopting the talking points of the right, however mainstream they have become.

    •  The negative publicity is a huge factor (0+ / 0-)

      I hope history is extremely unkind to the deliberate campaign(s) to persuade people not to sign up. I can't think of any parallel, especially on something that can literally mean life or death to someone.

  •  I don't believe it was the website problems that (2+ / 0-)
    Recommended by:
    Ahianne, Cassandra Waites

    have caused most people to fail to enroll.

    First off, the fact is that going uninsured works for most younger adults.  In any given year, they don't have a serious medical problem.  It was only when I hit my 50s that a majority of my friends started having medical issues.  

    However, for younger people, the issue isn't the odds of whether you'll have a serious medical problem.  The issue is how expensive it will be if you do.  So the odds are low, but the consequences are very high.

    Also, I worked at a tax return place in a shopping mall, and almost all of our customers (it was the first year, so we had no return business) had us prepare prior year's returns which they had never filed, despite almost all of them getting very large refunds for each year.  It taught me how strong the inclination is to put off doing things even if the reward was great to not procrastinate.

    •  One more reason to get rid of enrollment deadlines (0+ / 0-)

      and make the system so simple you can do it online, from a smartphone, in half an hour or less.

      It's possible -- it's just that the insurance industry doesn't really want it to be that transparent, and government is both corrupt and living in the tech stone age.

  •  Not sure if they need outreach. (1+ / 0-)
    Recommended by:

    What they need is a place to sign up. Even now in my very blue state there are difficulties in signing up on the State's health care exchange. At some point people just lose patience.  What they need is ASSISTANCE SIGNING UP, and not "outreach", whatever that is.

    If you hate government, don't run for office in that government.

    by Bensdad on Thu Feb 06, 2014 at 10:50:28 AM PST

    •  They called me this morning. (2+ / 0-)
      Recommended by:
      Bensdad, Ahianne

      I'd tried in October and it was a total fiasco.  Tried again in December using my husband's email and name as primary and sailed right through.  They called because they saw that my original attempt had not yet been finalized and wanted to know if they could help me sign up.

      •  So sad. This incompetence and lack of foresight... (0+ / 0-)

        ....has given the Republicans something they could actually legitimately criticize the law for. These are technical problems but not glitches -- it's a complete system failure that has prevented millions from signing up.

        Outreach won't do, whatever outreach is. You have to give people a way to sign up,

        If you can't sign up in HAWAII, which has only TWO insurers participating, then what?

        If you hate government, don't run for office in that government.

        by Bensdad on Thu Feb 06, 2014 at 11:21:33 AM PST

        [ Parent ]

      •  Great to hear that, shades (0+ / 0-)

        You don't say if you're in a federal-site state or one with its own exchange, but I'm glad to hear there is some follow-up going on with the dropped applications.

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