As a steady rain sets in on Roanoke’s Pride in the Park festival, Robin Davis hunkers under a tent and prepares for the work ahead.
Davis takes brochures about health insurance and the Affordable Care Act from a cardboard box. She places them in giveaway plastic cups and arranges them on a table, bouquets of information to catch the eyes of passers-by.
Soon enough, a woman attending the gay pride festival stops to talk. “I’m really confused, ” she says, about the new federal law that requires everyone to have health insurance.
Davis explains the insurance marketplace, where federally subsidized plans will soon be available for sale, and hands the woman some literature on how to enroll.
“If you get lost in the process, call me, ” she says.
People like Davis are on the front lines of a national effort to educate the public about the Patient Protection and Affordable Care Act, a complex set of rules and regulations perhaps best known as Obamacare.
Funded by federal grants, the so-called navigators and certified application counselors will be helping those who don’t have insurance find ways to get it, as the law prescribes.
They will be at places like Pride in the Park, community meetings, health fairs, lecture halls, churches, libraries and one-on-one enrollment appointments in the coming months.
From day one, the navigators faced a tight deadline: Be ready to help low- to moderate-income people sign up for insurance on the marketplace by Tuesday, when open enrollment begins.
After starting their jobs in late summer, Davis and her colleagues took online training courses and began to cram for opening day. As they worked, opponents of Obamacare continued their efforts to dismantle the program – sowing even more confusion among a public that the navigators hope to inform.
About half of Americans, 51percent, polled by the Kaiser Family Foundation in August said they don’t have enough information about the law to understand how it will affect them, three years after its passage.
Almost as many, 44 percent, were either unsure if the Affordable Care Act remained in effect or believed it had been repealed.
“The biggest challenge we face is misinformation, ” said Davis, the outreach coordinator for New Horizons Healthcare, a nonprofit community health center in Roanoke, who is serving as a certified application counselor.
Davis and her colleagues are tasked with avoiding political minefields while leading their advisees through the steps of online enrollment.
First, someone must determine if he is eligible for reduced-cost insurance – just how reduced depends on where his income falls on a scale of up to four times the federal poverty guideline. Then, after considering copayments and deductibles, he must select one of the private insurance plans offered on the U.S. government-run marketplace that best meets his financial and health needs.
People with decent insurance (the majority of Virginians) will not be directly affected by the law. Those on the other end of the financial spectrum might qualify for Medicaid, the government insurance program for the poor and disabled. But that would depend on whether an expansion of Medicaid, another key provision of the Affordable Care Act, happens in Virginia. That won’t be clear until well after marketplace enrollment begins.
In other words, it could get complicated.
Leaders not on board
With the national launch of the insurance marketplace just two days away, there’s not exactly a buzz in Virginia.
This is the state, after all, where Attorney General Ken Cuccinelli sued unsuccessfully to stop the Affordable Care Act, Gov. Bob McDonnell decided against a state-run marketplace, and the General Assembly remains cool to the idea of a Medicaid expansion.
In fact, Virginia ranks second-to-last in the nation in the per-capita amount it is spending on educating the public about the insurance marketplace.
According to an analysis by Kaiser, a nonpartisan health care institute, Virginia is spending $1.64 per nonelderly, uninsured resident to get the word out. And that money is coming from the federal government.
Only New Jersey spends less, $1.52 per resident. Hawaii was the top-spending state, at $67.54, while the District of Columbia is devoting $101.75 for each of its residents.
“Virginia has failed our people by declining to apply for all the resources available to ensure access to information to help Virginians enroll in the new Health Insurance Marketplace, ” said Sandra Cook, chairwoman of Virginia Organizing, a citizens advocacy group that supports the health care law.
“While other states aggressively sought to fund education and outreach efforts … Virginia’s governor, attorney general and General Assembly fought implementation every step of the way, ” Cook said.
Under the Affordable Care Act, states can create their own insurance marketplaces or use one run by the federal government. Virginia has chosen the latter.
The 16 states, plus the District of Columbia, that have created their own systems have had greater access to funding to promote the programs, a report by Kaiser concluded last week.
That means that states using the federal model might have a harder time reaching all the eligible participants, potentially diminishing the program’s viability.
States with their own marketplaces have come up with catchy names – MNsure in Minnesota, kynect in Kentucky – and splashy websites, social media campaigns and public promotions.
In Virginia, residents looking to sign up will go to the stodgier Health Insurance Marketplace at healthcare.gov. But they won’t get much help from the state.
The Virginia Department of Health “has not been charged with community outreach, ” spokeswoman Michelle Stoll said. Local health districts will refer clients with questions to the community organizations that received navigator grants from the federal government, she said.
The state Department of Social Services is carrying some information about the new law on its website.
In August, the U.S. Department of Health and Human Services awarded $67 million in grants to organizations in all 50 states to serve as navigators.
Nearly $1.8 million went to two Virginia organizations. The Virginia Poverty Law Center has placed navigators at legal aid offices around the state, including in Roanoke and Christiansburg. Richmond-based Advanced Patient Advocacy is establishing navigators at various hospitals, including LewisGale Medical Center in Salem.
New Horizons, the organization for which Davis works, also received an $87,000 grant to fund certified assistance counselors, which are similar to navigators but receive less federally mandated training.
‘Obstruction and harassment’
In a windowless office at Legal Aid Society Roanoke Valley, Patrick Kelly’s desk has the uncluttered look of someone brand new to his job.
Next to one of the two computers is a certificate dated Sept. 11 from the federal government, attesting that Kelly has completed the 20 hours of training, followed by an exam, that is required of every Obamacare navigator.
As an attorney and an amateur actor, Kelly has no reservations about immersing himself in a dense subject, mastering the details and presenting them to the public.
“I’ve got a little evangelist in me, I suppose, ” he said recently.
Although “the apparatus is admittedly complex, ” he says of a law that has spawned thousands of pages of regulations, Kelly believes that many people will be able to go online and enroll on their own. He’s ready to help the others.
“I remain in awe of the task that is before me, ” Kelly said, “but it feels manageable.”
As Kelly and other navigators settle in to their jobs, the political debate over Obamacare continues to swirl around them.
Some Republicans in Congress are trying to defund the program, and opposition groups around the country are encouraging people to opt out of the Affordable Care Act’s requirement that nearly everyone have health insurance. Those who don’t abide by the so-called “individual mandate” must pay a tax penalty.
Generation Opportunity has launched a campaign aimed at dissuading young people – whose general good health makes them a needed demographic to help pay for the costs of an older, sicker population – from buying into a “bad deal” that will lead to high premiums.
One video produced by the group shows a distressed young woman on a doctor’s examining table, her feet in stirrups, as a sinister-looking Uncle Sam character hovers over her, a speculum in hand.
“Don’t let government play doctor, ” the video admonishes. “Opt out of Obamacare.”
In his Roanoke office, Kelly is well aware of the opposition, but he has no plans to engage it.
“Ours is not a political job, ” he said. “There are other places where grievances can be taken. That’s what our political system is about.”
As a navigator, “I’m not making decisions for anyone, ” he said. “I’m not recommending anything for anyone. That is not my mandate. My mandate is to help people understand their options in a nonbiased way.”
So far, outreach groups in Virginia have not been subjected to the kind of obstruction that is happening in other states, said Ron Pollack, who is monitoring the situation as executive director of Families U.S.A., a nonprofit organization that supports the health care law.
In some states, groups that received navigator grants have gotten letters signed by Republican members of the House Energy and Commerce Committee, asking for extensive documentation of their work so far.
And legislatures in at least 13 states have passed laws aimed at limiting the work of navigators, according to a report last week by Health Care for America Now. The laws include residency rules, extra fees, background checks, additional training requirements and prohibitions against navigators discussing with consumers the benefits offered by different insurance plans.
Pollack said his organization is aware of at least four groups that have returned their navigator grant money to the government, deciding that it’s not worth the trouble.
“Clearly, this is intended as obstruction and harassment of these groups, ” he said.
While conceding there has been an impact, Pollack dismissed the efforts as part of the “increasing desperation” among Obamacare opponents.
“The clock is ticking, ” he said. “The opponents of the Affordable Care Act know that as more and more people get enrolled and start getting significant help, it’s going to be virtually impossible to repeal the Affordable Care Act.
“Once people can see how it affects them in a positive way, it’s going to be hard to take that away.”
Other groups helping
The rain shows no signs of letting up, but Robin Davis is getting a steady stream of people at her information booth at Pride in the Park.
Carolyn Edelstein stops by to pick up a brochure about the insurance marketplace for her unemployed and uninsured daughter.
She’s grateful that the information is being provided to the community, but she wonders why it isn’t happening in more places.
“It should be at every doctor’s office. It should be at the mall, ” Edelstein says. “It should be everywhere.”
With limited government funds, some of the outreach efforts will fall to community organizations. St. Paul United Methodist Church in northwest Roanoke, for example, held a community meeting and is planning sign-up sessions.
Health care providers are also getting involved. Carilion Clinic has designated staffers to help its patients understand what their insurance options are, which includes an explanation of what’s available through the Affordable Care Act, spokesman Eric Earnhart said.
Carilion is also applying to become a certified application counselor organization, which entails signing people up on the marketplace.
In the most recent fiscal year, the estimated cost of charity care provided by Carilion was $67 million. Much of that involved the treatment of low-income and uninsured patients in the emergency room, and having more of those people covered by Medicaid or subsidized insurance would help Carilion’s bottom line.
Davis used to work for the health care giant as a software trainer. She decided to switch jobs when she saw an ad for a community outreach position related to the Affordable Care Act, described as the most sweeping social legislation since Medicare and Medicaid were enacted 48 years ago.
“This is historic, ” she said, “and I wanted to be a part of it.”
The Sept. 21 Pride in the Park was her first major community outreach, and Davis worried just a bit about the topic’s complexity – and its controversial nature.
But she encounters no pushback on this day, except for a Bible-waving protester who quotes scriptures to the gay and lesbian festivalgoers, urging them to repent.
At one point, the wide-eyed man in a dark suit approaches Davis’s booth. “Do you support this?” he asks. “This homosexuality?”
Davis ignores the man, and he moves on.
Relieved, she turns to the next person who is there to learn more about the Affordable Care Act. She still has work to do.