Politico by Jason Millman and Joanne Kenen –
June 30, 2013:
The Obama administration and its health-law allies are gearing up this summer to slice through three years of confusion and opposition to Obamacare.
They’ve got their work cut out for them.
Obamacare won’t have a shot at success unless millions of people sign up for insurance — the healthy as well as the sick. For that to happen, the White House and its allies will need to make the case that coverage is worth it for the estimated 50 million people who haven’t been able to afford or access insurance. Supporters are planning to spend tens of millions of dollars to persuade people to get covered under new health insurance options and explain how to sign up.
Organizing for Action, spun off from President Barack Obama’s campaign operation, went up with a seven-figure TV ad buy in June, touting the new benefits and promising to offer “the truth” about the law. Enroll America, a nonprofit group with ties to the White House, wants to leverage the grass roots across the country and engage big-name celebrities for the cause.
Here are five of the messaging challenges they face:
Spread the word about the subsidy — without inflating expectations.
Just about everyone knows there’s an individual mandate in the health law — people must have insurance starting in 2014. But another part of the message didn’t get through: Millions of Americans, including some in the middle class, will get help to pay for that coverage. And low-income people won’t have to pay premiums if they qualify for expanded Medicaid.
It’s not entirely clear why the White House hasn’t hit that point harder: One reason may be that it doesn’t want to raise expectations and then crush them. Not everyone gets a subsidy. And subsidy doesn’t mean “free ” — it’s a sliding scale depending on income, location and family size. But some assistance is available up to four times the federal poverty level, or about $93,000 for a family of four.
“It’s very hard to explain the subsidies … so you end up avoiding it,” said Bob Blendon, an expert on health and public opinion at the Harvard School of Public Health. And old hands at health care remember what happened 25 years ago when Congress passed a law to help people with “catastrophic” Medicare expenses — and then had to repeal it when the overly high expectations collided with the cost-benefit realities.
Ethan Rome, executive director of Health Care for America Now, which strongly backs the law, predicts a massive multi-front education campaign that will start breaking through to people. And it will include a “retail” approach, particularly once enrollment opens Oct. 1.
“When you are talking to potential enrollees about the price of the insurance the best conversation you can possibly have is talking to them about their specific situation,” Rome said. Once people begin to get the subsidies and the coverage, he predicted positive word of mouth will encourage more people to sign up.
Reach the hard-to-reach population.
Lots of the people eligible for various government assistance programs don’t actually reach out for them, and that may prove true of the health law, too. A recent Gallup poll found the uninsured knew less about the law than the insured, including the individual mandate.
Many of those who could get Medicaid or subsidized coverage are low-income, and not necessarily English-speaking. They may not see slick ads on English-language TV, and experience shows they may need a lot more than a brochure and a URL to tap into the benefits. They need different messaging and outreach and a lot more hands-on assistance, said Stan Dorn, a Medicaid expert at the Urban Institute.
That’s a conundrum. People can’t be walked through enrollment before it starts in October. But the longer the administration waits to reach this population, the less time they’ll have to break through, said Bruce Siegel, head of America’s Essential Hospitals, whose members treat low-income populations. “Waiting for fall is too late,” he said. Outreach has to be now and it has to target a whole lot of different audiences, from the Spanish-language tweet to a message that can work in a Haitian hair salon in Brooklyn.
Not only that, but the Supreme Court made the law even more confusing for the poor by deciding Medicaid expansion is optional for states. In some states, poor people will get benefits from expanded Medicaid — and in others they’ll get nothing. Even more confounding — the below-the-poverty line Medicaid population can’t tap into the subsidies in the health insurance exchanges, but people who are just few rungs up the income ladder can get that financial help.
“That message is going to be complicated,” HHS Secretary Kathleen Sebelius said last week. “If the governor and legislature choose not to expand Medicaid, there will be a huge gap between what [low-income people] can afford and what is available.”
The “safety net” hospitals and community clinics will try to fill in the considerable awareness gaps when low-income and uninsured patients come in, said Siegel. But how well they do will depend partly on what state they are in, and how much of a buy-in state governments give to Obamacare
Convince young invincibles that they are not.
Everyone’s looking to the young and healthy to buy insurance to keep costs down, but purchasing a health plan will be uncharted waters for many.
“A lot of young people lack basic insurance literacy,” said Jen Mishory, deputy director of Young Invincibles. “They may not have experience with what a co-pay or co-insurance is.”
Obama administration officials in a recent background briefing said they’re hoping 7 million people sign up in the exchanges in the first year, including 2.7 million young adults. They need those young and healthier people to balance out the risks in new insurance pools that are probably going to quickly attract a fair number of older and sicker people. Many young people starting out in the work orce will get subsidies.
The “invincibles” organization, formed during the health law debate, has looked to Massachusetts for insight on what worked when the state passed its universal coverage law seven years ago. It found that protection from financial ruin in the event of a catastrophe and access to preventive care were strong selling points.
Also key for reaching these younger Americans: savvy delivery.
“We know that a large number of young people access information through their mobile phones, so we’re looking at ways to reach young people that way,” said Mishory, adding that text-message campaigns have proved effective for other health outreach efforts.
Advocates also have a secret weapon for this age group: Even if the young invincibles don’t want to shell out money for insurance, their moms might make them.
Appeal to small businesses that think Obamacare will sink them.
So much of the anti-Obamacare arguments have come from, or on behalf of, small business. Less is known, however, about the law’s efforts to help small businesses — and so far the law’s supporters have had a tough time getting that information out.
Small businesses with less than 50 employees get a pass. If they don’t want to cover their workforce, they don’t have to. And some of those who do insure their workers through the Obamacare exchanges can get a tax credit worth up to half the cost.
But that small business tax credit has received little interest, and the Obama administration — overburdened by the task of setting up the law — had to delay by a year a key program that would have given small-business workers more flexibility in picking their own health plans on exchanges, rather than having their employer select one. And some states have seen lackluster interest from insurers.
John Arensmeyer, CEO of the Small Business Majority, a pro-health law advocacy group, is preaching patience.“We need to get this whole new system up and running and start to figure out what’s working and what’s not,” he said.
Local business groups may cut past partisan politics to get the word out.
That’s beginning to happen in Washington, D.C., where the District’s exchange is partnering with the D.C. Chamber of Commerce and Greater Washington Hispanic Chamber of Commerce to educate small-business owners about the ACA.
“Health reform brings new opportunities for business owners throughout the District to gain access to high-quality, affordable health coverage,” Barbara Lang, president and CEO of the D.C. Chamber, said in a Tuesday statement announcing the partnership. “It is incumbent upon organizations like the D.C. Chamber to educate them about these benefits and how they can take advantage of them.”
Know the opposition’s got plans, too.
As Obamacare supporters ramp up their messaging, the opposition has no plans to surrender.
House Republicans are planning their own coordinated messaging strategy to highlight the negatives they see in the health law. Any major insurance hike or talk of employers cutting back because of the health law, the Republicans can hold it up as emblematic of the Obamacare “train wreck” to come.
And then there are the states that won’t lift a finger to help out Obamacare. The administration is investing $54 million in “navigators” to help sign people up for coverage in states not running their own exchanges, but supporters admit that falls well short of what’s necessary to spread the word.
So in huge states like Texas and Florida, which will let the feds run the exchanges, the administration is relying on a mix of grass-roots volunteers and government-paid navigators to pound the pavement over the next few months.
“We got outbeat and outhustled in the initial messaging wars,” acknowledged Jim Manley, a former top Senate Democratic communications strategist now at Quinn Gillespie. “But the idea all along is that the closer we got [to 2014] the more that folks would start paying attention. … The core provisions are kicking in.”