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Wilbert Jones helps local residents sign up for the Affordable Care Act, widely referred to as
Vox's Sarah Kliff has an excellent deep dive into the administration's efforts to sell Obamacare. The biggest barrier wasn't a broken website, it was—and remains—all about the bottom line for new insurance consumers.
Importantly, the success of Obamacare's first enrollment period — as told in interviews with Obama administration officials, advocacy groups, health care experts, and Obamacare shoppers—was not just about fixing a broken website.'s disastrous rollout and ultimate repair mattered, but they didn't explain why people decided to buy insurance.

Behind the scenes, convincing Americans that they could afford insurance was the White House's biggest challenge in making Obamacare work.

The monthly surveys from Kaiser Family Foundation leading up to and throughout the enrollment period consistently showed that cost was a large factor for people and that large portions of the uninsured didn't have enough information about the law, specifically about the subsidies that were available to them to help get insurance. During those months of enrollment in late 2013 and early 2014, PerryUndem, a Democratic polling firm, was working with the White House and surveying the uninsured. They found the same thing—people wanted health insurance, but they weren't going to even shop for it because they couldn't afford it.
"There's one woman we talked to, who I remember very clearly saying, ‘If you don't have money for shoes, you don't go shoe shopping,'" Undem says of the focus groups. "That's when we learned that 69 percent hadn't heard about financial help. If you don't know about financial help, and affordability is the number one concern, that's a huge problem."
That was a far bigger barrier to people signing up than a glitchy website, it turns out. People who had already decided they were going to sign up weren't as deterred by the glitches, and might have grumbled about having the hassle of it all, but it didn't stop them whereas people who were convinced it was going to be too expensive didn't bother. These surveys were running during the enrollment period, giving the administration time to refocus their message. Which they did: "White House and pro-Obamacare groups did two things differently at the end of open enrollment, both aimed at increasing these numbers: they increased the number of events they hosted and overhauled their consumer message to make it all about financial help."

That—and the very human tendency to procrastinate—probably helps to account for the massive sign-ups at the very end of the enrollment period. But the cost factor, as Kliff says in this really very good article that you should read in its entirety, is going to be the primary story in the ongoing success or failure of the new law. Will the 8 million who signed up renew their plans next year, and will the good news about this year's success convince the 20 million still-uninsured to shop this fall? The administration—and Democrats—can't leave that to chance, and still has work to do to sell the law to these folks.

Originally posted to Joan McCarter on Thu Jun 12, 2014 at 08:51 AM PDT.

Also republished by Daily Kos.

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Comment Preferences

  •  Tip Jar (15+ / 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 Thu Jun 12, 2014 at 08:51:12 AM PDT

  •  The biggest obstacle is (1+ / 0-)
    Recommended by:

    the GOP governors who refuse to expand Medicaid.  There are literally close to ten million people who would not have to worry about the cost of healthcare because they would qualify for expanded Medicaid if the GOP governors and state legislatures would just expand it.  Eventually they will be forced to do it because of market forces.

    This is your world These are your people You can live for yourself today Or help build tomorrow for everyone -8.75, -8.00

    by DisNoir36 on Thu Jun 12, 2014 at 11:54:09 AM PDT

  •  There are still issues around affordability (1+ / 0-)
    Recommended by:

    As I've talked with people -- informally urging people to sign up, before the deadline -- here's what I hear:
    1. People without bank accounts do not have an easy way to actually pay premiums, and really wanted a way to have the money taken directly out of their paychecks like employer-based coverage premiums are.
    2. People whose income is uneven -- which is a huge percentage of the workforce, even people on salary but on uneven hours and risks of layoffs -- worry that they can't really estimate their income very accurately, and if at the end of the year they've earned too little (or too much) to qualify for subsidies, they'll have to pay back all the subsidies they've gotten, which they can't afford to do. And many people really have no idea what they earn on an annual basis; if you ask them their income they will say their weekly take-home, not gross.
    3. It was very difficult to make sense out of the different choices in terms of what your out-of-pocket costs would be. I have a law degree and have read countless financial and insurance documents, but I could not figure it out, and still can't really predict when I get some service whether it's covered 100% as "preventative," or has a co-pay or deductible and how much. If you're not used to shopping for insurance, it's a completely opaque foreign language. And the dollar figures for out of pocket -- $2350, or $6350, or whatever -- made people think that the insurance wouldn't kick in at all until they had spent that up front. That's true for some policies but not others.
          For many things, there is evidence that giving people more choices makes it so difficult that people just give up in despair. I'm not excited about hearing that next year there will be two or three times as many options.
    4. For a long time, when you went shopping in the exchanges the only numbers you could get were the unsubsidized rates -- one reason people didn't know that they would be paying a lot less.

    I'm hoping that as time goes on, people will figure out how the system works. That seems to have happened in Massachusetts. I also hope the Administration will figure out some ways to present the different choices in plain English and diagrams and figures, or examples.  

    •  This is exactly the problem. (2+ / 0-)
      Recommended by:
      Wolf10, Shaylors Provence

      "Choice" is the predatory tactic used to wealth strip.

    •  MediCare for all (1+ / 0-)
      Recommended by:
      rebel ga
      The only way to get the "money" out of the system is to fire the middle men.
      MediCare for every citizen, we should still be pushing for the better solution.

      I would tell you the only word in the English language that has all the vowels in order but, that would be facetious.

      by roninkai on Sat Jun 14, 2014 at 05:23:44 PM PDT

      [ Parent ]

      •  of course, but... (1+ / 0-)
        Recommended by:

        First let's note the irony.  President Obama, who governs as a self-described "80's Republican", had the courage to address lack of health insurance coverage.  And the ACA has a number of excellent features, as far as it goes, such as eliminating "pre-existing conditions".  And it potentially expands Medicaid.  Medicaid is "the food stamps of health care", a shaming program that is designed to force beneficiaries to reveal personal information by using it (you have to be poor to get it), and unlike food stamps, it pays the provider less than other payers (imagine of grocery stores got less money for the food when they accepted food stamps).  But being able to pay anything at all is a huge plus.

        At the end of the day, though, the crux of the ACA is that people are required to buy a product from a for-profit corporation, and fined if they don't do so.  That's how automobile liability insurance works, granted, but that product is far, far cheaper than health insurance.  There are also some national systems in Europe that offer private health insurance as well as public, and have penalties for total lack of coverage, but no other system basically requires a majority of the population to buy for-profit coverage or be fined.  And note that the plans that most Americans will be forced to buy still require large out of pocket payments in many cases.  There will still be medical bankruptcies.  Just not as many.  To the best of my knowledge no other rich nation has citizens going bankrupt for needing medical care.

        Right wingers now oppose a right wing plan because a black Democrat endorses it, but it is a fairly right wing plan (that's the irony).

        So yes,  the ACA is better than the only other realistic alternative, the "Republican plan", which is not even to do nothing, but rather, to attack Medicaid, Medicare, and public health care facilities - the implied objective being to cause more poor and middle class people to die of treatable diseases.  So as a progressive I support the ACA because it's better than the only current alternative.

        But excessive enthusiasm is not called for.

        If pressure to make Medicare universal builds up, by the way, the bipartisan reaction will be to attack Medicare by reducing reimbursements, creating resistance within the medical community.  Multi-million dollar per year CEO's of non-profit hospitals and their administrative executive staff won't be affected, but people who spent years training for a medical career will be.  This will be portrayed by Republicans as "cutting costs" and by Democrats as "attacking greedy doctors".  Watch for this, and watch for certain "progressives" to be fooled by it.  Medicare is efficient right now and should be made universal the way it is but any such effort will be sabotaged by "improvements" to Medicare that attack doctors, nurses, physical therapists and other actual professionals, but ignore actual inefficiencies.

    •  Excellent summary! (1+ / 0-)
      Recommended by:
      Heart of the Rockies

      Each of those very real issues you outlined involving affordability has impacted enrollment.  The only thing I would add to your list is the impact that the media and local, state and national leaders (almost exclusively GOP) had on people who, under the influence of their harmful rhetoric, distortions and outright lies, decided they could not afford " Obamacare", and so never even bothered to check it out, let alone sign up.  We can all remember the "news stories".  The headlines screaming about premiums doubling while coverage decreased.  The fifteen minutes of fame some of these, "victims" of the ACA seemed to cling to.  The politicians who jumped on the stories of their "constituents".  All of these stories were, of course, debunked. But, even when they were, some "media"outlets still gave voice to the false claims, the politicians spreading the lies.  

      To my mind, this is the biggest hurdle in the struggle to sign up those who remain uninsured.  The administration can find ways to help people understand the fact about the ACA and the options available to them.  But, it will be much more difficult to overcome propaganda, especially propaganda that has been designed to target the core belief of the people we are trying to reach: Health insurance is for other people - people with money.  There's no point in even getting your hops up, just so you can be either cheated or disappointed again.

      So, if we want "universal" healthcare, and we aren't prepared to go the easy route (single-payer), then we have to shut down the propaganda.  It doesn't matter what we do to tell people health insurance is affordable under the ACA, if they are having a lifetime of strongly-held beliefs reinforced by the lies of politicians and news sources they should be able to trust...

  •  Ignorance is a double edged sword (1+ / 0-)
    Recommended by:
    "There's one woman we talked to, who I remember very clearly saying, ‘If you don't have money for shoes, you don't go shoe shopping,'" Undem says of the focus groups. "That's when we learned that 69 percent hadn't heard about financial help. If you don't know about financial help, and affordability is the number one concern, that's a huge problem."
    $50 a month is $600 a year. That's a lot of shoes. That's a lot of food. In 20 years that's the difference between whether you qualify for a mortgage or not. The ACA's subsidies are very, very good, but even after them the cost of health insurance has consequences.
  •  Rollllll out the enrolllment! (2+ / 0-)
    Recommended by:
    Kane in CA, Alice Olson

    Apparently, proofreading is a barrier on HuffPo!  :-)

  •  Health care is a societal issue; (3+ / 0-)

    the idea that individuals or companies can deal with this is as absurd as expecting these same to deal with say roads or national defense. It's. gonna. suck.

    HC costs in the US are higher than anywhere else; by quite a margin, too. Health outcomes are about average. Clearly money is being wasted, and it's not being 'wasted' on poor people who need treatment but can't afford to pay.

    It's being wasted on needless tests, profits for private insurers and private providers and the most expensive doctors in the world. It's being wasted on drugs that Congress has decided to make Americans purchase at above-market rates,and it's being wasted on treatment in emergency rooms - when a visit to a doctor a few months earlier ended in less pain, sickness and suffering yet also lower costs.

    Anyone can get sick. All of us.
    It often costs a lot.

    The state is the only entity able to deal with it. That basically means taxes to ensure that the sick get the care they need. For everyone.

    If you disagree with Obamacare, and every other economically developed country, I suggest you come up with a defensible position, in terns of humanity and money.

    I ride the wild horse .

    by BelgianBastard on Sat Jun 14, 2014 at 04:57:45 PM PDT

  •  Very interesting article by Sarah Kliff. (1+ / 0-)
    Recommended by:
    Heart of the Rockies

    I wonder how much of the cost per enrollee was due to the expense of outreach and publicity about the subsidies. For example, the average cost per enrollee in the state exchanges was $1,503, with California's cost per person ($758) the least of any state exchange and the only one under $1,000. In contrast, the cost at was $647 per enrollee. The least expensive states using the federal exchange were Florida, Texas, Georgia, Virginia, and Michigan. The cost per enrollee through the federal exchange in Florida was just $76; in Texas it was $102, and in Michigan $427. This article suggests the reason for the differences is economy of scale. Surprisingly, with twice the population of Florida (which did all it could to discourage people from enrolling), California did not have twice the number of enrollees despite its very active outreach program. 983,775 people in Florida purchased plans by mid-April through while 1,405,102 Californians as of April 15 signed up through Covered California.

    The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

    by ybruti on Sat Jun 14, 2014 at 05:28:14 PM PDT

  •  Take my own son.. (3+ / 0-)

    He's married with one child. His wife has insurance at her work that also covers my grandson.

    He said he couldn't afford Obamacare. I told him he may be eligible for a subsidy so to check it out. I gave him the information and bugged him until he finally looked into it.

    Long story short..He got a premium of $171 a month, but it came with a $99 subsidy, making his final premium $72 a month. He signed up.  

    Living in Texas, it is easy to be uninformed. This state goes out of it's way to spread lies and distortions about the ACA.

    ...the GOP seems perfectly willing to hold their breath until the whole country turns Blue.

    by tommy2tone on Sat Jun 14, 2014 at 06:04:03 PM PDT

  •  One person told me she had to.... (1+ / 0-)
    Recommended by:
    Heart of the Rockies

    get a full time job with benefits so she wouldn't have to pay the penalty for not having insurance.  I tried to tell her about the exemption for people who live in states that didn't take the expansion...........anyway, the conversation slowly denigrated into all out war on Obama.....

    It really is hard to help people who know it all and have all the answers...blah

    "A weed is a plant whose virtues have not yet been discovered." Ralph Waldo Emerson

    by Yo Bubba on Sat Jun 14, 2014 at 06:15:12 PM PDT

  •  In my case, (0+ / 0-)

    the cheapest offerings of the Heritage Unaffordable Couldn't-Care-Less Act were scammy Health Savings Accounts at $190 a month, with sky-high $6500 deductibles or something like that. I don't know if it was the glitch-tastic website or what, but I couldn't even find anything with dental coverage, the primary thing I might reliably and realistically need in the near future. And despite my below-poverty-line income, no subsidies or credits for a single childless male, oh no! Gotta subsidize the aged and the reproductively successful somehow by fighting the War on Young Healthy Loser Dudes, I guess. May as well pay the penalty and continue gambling with my life than be resigned to a life of zero disposable income, zero fun.

    "Elect Republicans, and they will burn the place down. And they will laugh while they do it and have a great time. And then what?" -- Rachel Maddow

    by LumineHall on Sat Jun 14, 2014 at 08:20:39 PM PDT

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