Obamacare challenges: Enrolling 1 million New Jerseyans

By Dan Goldberg/The Star-Ledger 

on September 01, 2013 at 2:02 PM, updated September 01, 2013 at 4:18 PM

Read NJ.com article

If implementing the Affordable Care Act were a race, September would be the home stretch.

In 30 days, about 50 million people across the country — and about 1 million in New Jersey — will be able to sign up for expanded Medicaid or enroll in the health insurance exchange created by the new law, known as “Obamacare.”

Enrolling people is the cornerstone of the new law, its raison d’être. Because sick people will be highly motivated to buy insurance, millions of young, healthy uninsured Americans need to enroll to keep premiums low and the system from collapsing under its own weight, said Joel Cantor, director of the Center for State Health Policy at Rutgers University.

But trying to reach, educate and enroll as many as 1 million New Jerseyans is a logistical nightmare the likes of which no one has ever seen. The target group — the 15 percent of the state’s population without health insurance — lives in every county, speaks more than a dozen languages and may not understand their rights and responsibilities under the new law.

“I’m very worried about this,” said Raymond Castro, senior policy analyst for New Jersey policy perspective, a left-leaning think tank. “We’re all concerned the infrastructure is not there for most of these people. We have a large Hispanic population, we have other language barriers and almost no funds to do the outreach.”

New Jersey received about $5.4 million in federal grant money to help educate and enroll residents. About $2 million went to five organizations across the state to set up a navigator program. Another $3.4 million in federal grants went to 20 health care centers that will hire 69 employees to help people enroll. In addition, volunteer groups like Enroll America, a nonprofit group with ties to the Obama administration, are fanning out across the state to educate people about the new law.

In total, there will be a few hundred trying to reach a few hundred thousand.

Many volunteers and part-time staffers will not receive training until mid-September. Even then, they will receive only 30 hours of online tutelage and be expected to help people navigate an incredibly complex law.

“It’s a huge lift,” said Lynn Blewett a professor at the University of Minnesota, School of Public Health who has looked at enrollment from a national perspective. “Nobody knows how many people are going to show up.”


One of the reasons resources are so scarce is because Gov. Chris Christie chose to have the federal government run the new health exchange — the marketplace that will sell federally subsidized private insurance. Had the governor opted for New Jersey to run its own health exchange, the way New York did, the state would have been eligible for millions more in federal grant money, which could have been used to spread the word.

“I think the negative result in New Jersey is that you do not have the force of people out advertising,” said Ray Hurd when asked if Christie’s decision put the state at a disadvantage. Hurd is the regional administrator for the Boston and New York Regional Offices of the Centers for Medicare and Medicaid Services.

“I would say it has delayed outreach and education to consumers,” he said. “We will see, come October 1, whether the number of navigators and certified application counselors we have are able to meet the demands.”

Estimates are that some 300,000 New Jerseyans will qualify for the expanded Medicaid program, which covers a family of four that earns up to $2,611 per month. As many as 700,000 state residents are eligible to enroll on the federally managed exchange where individuals and families can buy health insurance. The vast majority of these residents will receive federal subsidies to help pay their premiums.

Christie’s decision is not the only reason word about the new law will have trouble getting out. The federal government never thought it would be running so many state exchanges and did not set aside enough money to educate the public.

“We did not expect to be managing 34 federally facilitated exchanges,” Hurd said. “The intent behind the Affordable Care Act is the states would buy into this and then do it themselves. They regulate their own insurance industries, why would you want the federal government to do this for you? So we ended up with a bigger load than anticipated.”

The Christie administration received $8.8 million in federal grant money for researching and planning a health exchange, and $7.6 million of those federal funds remain unspent. Obamacare advocates want that money to be used on advertising the new law and helping people enroll, but the Christie administration will say no more than it is in discussions with the federal government on how it is allowed to use those remaining funds.

Project HOPE, which provides social services in Camden County, received $73,300 of federal grant money to hire two navigators. Executive Director Pat DeShields said they will be in churches, soup kitchens and at community centers as well as knocking on doors, trying to educate people about the new law.

“Our strategy is to sit with them and expose them to the website so we can answer questions,” she said.

The website she refers to is healthcare.gov, which was created earlier this summer. The website is up, but there isn’t much you can do because the prices of these new insurance plans as well as the benefits offered have not yet been announced. And they are not expected to be until mid-September — at the earliest. That makes it impossible for a family to consider its options.


Despite the challenges, federal officials, policy wonks and academics do believe that enrollment efforts will eventually succeed though almost all expect some hiccups in the first few months.

“It’s not going to be a perfect program, it’s not going to reach everybody immediately, but it’s going to grow over time,” said Barbara Scholz, director of advocacy and programs at the FoodBank of Monmouth and Ocean Counties, which received a grant of $137,000.

Oct. 1 is only the start of the enrollment period. Anyone can sign up for the health exchange through March 31, and Hurd expects many will take a few months to consider their options before committing.

That’s fine with the Obama administration, which has set a goal of enrolling 7 million people on the new exchanges by April. No one in New Jersey will set a state-specific target, but if the state were to do its fair share of the 7 million, it would need to enroll about 100,000 people. That doesn’t count the hundreds of thousands of residents who qualify for the expanded Medicaid program.

Each of New Jersey’s 21 counties is responsible for processing applications, but informing the public of the program is a separate matter.

Nicole Brossoie, spokeswoman for the state Department of Human Services, said the state will continue to do what it has always done to advertise Medicaid.

“We will use our social media accounts, stakeholder messages, fliers, fact sheets, newsletters to outreach,” she said. “Our community-based partners work with the uninsured every day. Schools, faith-based groups, health clinics, hospitals, businesses, etc. Our process won’t change; the messaging will.”

The state’s success, or lack thereof, in enrolling people in the expanded Medicaid program, will have a huge impact on New Jersey hospitals, which rely on charity care to treat the uninsured. The greater the number of people who sign up for Medicaid, the less the state could spend supporting hospitals.

“For us, it’s a material issue,” said Barry Ostrowsky, president and CEO of Barnabas Health. “I think new enrollees will be new revenue-paying customers to our organization and, while Medicaid reimbursement is certainly not optimal, it is at least based on services a Medicaid recipient receives, unlike charity care where you get a portion of the pool.”

It could also mean as many as 8,000 new jobs, said Betsy Ryan, president of the New Jersey Hospitals Association, during testimony she gave to the state Assembly in March.

“These jobs will not only be in the health care provider community, where more clinicians will be needed to support the expanded Medicaid population, but also in those industries that support the state’s provider community,” she said.


Enrollment is crucial but it is only a first step. Many uninsured have never had insurance before.

“Making sure they understand the difference between monthly premiums, out-of-pocket costs, their deductible what a provider network means, what in network, out of network services are, what prescriptions drug plans are,” Hurd said. “There are a lot of moving parts.”

In a recent telephone survey of 1,008 adults, more than half of respondents could not accurately identify at least one of the following terms: premium, deductible, and copay, according to the American Institute of CPAs.

“It’s really hard to say whether in April 2014 we will have 400,000 fewer uninsured people,” said Cantor, of Rutgers. “There is a fairly low level of knowledge in the general population of what the options are going to be. There is a concerted effort to educate people, but I think those efforts are late to the game.”

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