Why People Find Obamacare So Confusing

The bewilderment of prospective enrollees in Texas reflects widespread misunderstandings about the law nationally.

DALLAS – A few days before Christmas, Mirna Cervantes bounded through the doors of the Habitat for Humanity office here.

“Am I too late?” she said, rushing toward a fluorescent-lit room where workers sat at long folding tables, pounding away on laptops.

The Habitat building was temporary host to an Affordable Care Act enrollment event held by the Community Council of Greater Dallas, a local nonprofit.

“Some people would rather get help through someone who knows the process,” said Daniel Bouton, who’s a navigator—kind of a professional Affordable Care Act helper—with the Community Council.

In the state with the highest rate of uninsured people, his is a big job. “One consumer I saw hasn’t seen a doctor in 19 years, so he was going to Mexico to get his issues taken care of.” That man, Bouton said, was relieved after navigators helped him sign up for a plan on the federal exchange.

Obamacare scored a small, year-end victory as signups on the exchanges ticked up, with 975,000 people enrolling across the country in the past month alone. But surveys show that many people are still puzzled by the law and wary of the website because of its earlier, shoddy performance. As late as September, six in 10 people told a Washington Post-ABC News poll that they didn’t know what changes the law would bring. In states where the federal government is running the insurance marketplace, such as Texas, only 44 percent of people knew about the existence of the exchanges. In December, 36 percent of people told Consumer Reports that they (wrongly) believe Obamacare allows the government to determine which doctor they’ll see.

In fact, the entire idea of health insurance can be baffling for those who have never had it: A new study from Health Affairs and the Urban Institute reports that just 60 percent of uninsured people understand key concepts related to insurance, such as co-pays, deductibles, premiums, and provider networks.

Scientific polls (and my extremely unscientific conversations with Texans) suggest that despite the administration’s best efforts with bro-friendly ads, Christmas cards, and other get-the-word-out gimmicks, Obamacare remains obscure, scary, and downright befuddling for many.

To demystify the process, many prospective Obamacare consumers are turning to navigators like Bouton.

“I wanted to see someone face-to-face and have my questions answered,” said Cervantes, who is uninsured. “Especially my son, I want him getting routine check-ups and shots, anything he needs."

After talking with Bouton, she had some good news.

“I found out that I do qualify [for the subsidies],” she said. “It’s great to know that it’s a plan that I’ll be able to afford based on what I make.”

The Community Council is one of the local organizations listed on Healthcare.gov as eager to take enrollee questions over the phone and, for the particularly panicked, to make in-person appointments.

Sandra Luz, the Community Council’s lead navigator, said that the group was inundated with two to three times as many calls as usual—sometimes 50 or 60 a day—in the days leading up to December 23, the deadline to enroll in order to start coverage on January 1.

“People were panicking a lot on the 22nd because they were thinking that it was the last day to enroll so they wouldn’t be penalized,” she said. “What I would explain to them was that it was only if they wanted their coverage to start on January 1.”

Luz said many call her after encountering a common Healthcare.gov clog: If consumers don’t enter their names exactly as they appear on their Social Security cards, “the system will stop because it can’t verify the person’s identity,” she said.

Others bring questions about whether their children can remain on the state Children’s Health Insurance Program, or about what happens if they get paid in cash, or what documents they need in order to enroll.

But that’s just the sign-up process. People were also confused about how to use their subsidies (there are three ways), or by which date to make their first payment (states have different deadlines.)

And other visitors were puzzled when they found they fall in the so-called “coverage gap”—the salary span between the point at which Obamacare subsidies kick in and where Medicaid coverage, which Texas has so far opted not to expand, cuts off.

MaGuadalupe Huerta, a single mom who lives in Dallas, said her 14-year-old son helped her navigate Healthcare.gov and select a plan. But when she received her bill in the mail, she realized her chosen insurance policy was beyond unaffordable. She brought it to the enrollment event, where Bouton explained that she didn’t make enough to be eligible for the subsidies, which kick in at 100 percent of the poverty level.

“I thought with Obamacare I’d get better quality and services,” she said through an interpreter. “I guess I don’t qualify.”

At a free clinic in nearby Arlington, patients were similarly stumped when I asked them if they had tried to sign up for Obamacare. (All of them spoke to me on the agreement that I would only use their first names.)

When I asked a man named Keith if he had checked out his options under the ACA, he said he didn’t know what I was referring to.

“The Obamacare law?”

“I’ve heard of that,” he said, “but I haven’t gotten any information about it or anything.”

Through an interpreter, a woman named Maria said she had heard of the ACA but didn’t understand it well. “Can I sign up my whole family or do the kids have to be separate?” she asked. “And will my older kids still qualify for Medicaid?” She said she prefers to speak to a “real person” to sort it all out.

Part of the problem, explains Teresa Coughlin, a senior health policy fellow at the Urban Institute, is that information about Obamacare seems to be less widespread and less clear in states, such as Texas, where the local government doesn’t support the law. Oregon, for example, set up its own exchange and has blasted airwaves and social media sites with ads touting Obamacare. Meanwhile, Texas Gov. Rick Perry has decried the law as a “criminal act.”

Healthcare.gov, though mostly resuscitated from its dead-on-arrival status a few months ago, is still finicky and still part of the problem. Bouton and Luz both said that the site is working much better these days for sign-ups, but many applicants weren’t able to use the site to make their first payment—the final, crucial step. Instead, they had to call the insurance companies to pay for their chosen plans.

Luz said that while the system occasionally gets gummy, it at least now has a feature that allows the navigators to clear out and restart applications that hit a digital snarl.

“If it gets stuck in there, we don’t proceed with that application,” she said. “We just remove back and start over again. It might take us 30 more minutes, but it will get done.”

Another potential hurdle facing the Texas navigators comes in the form of new regulations the state is weighing. If enacted, the rule would require 40 additional hours of state-prescribed training, on top of the 20 hours navigators have already had. The Community Council said the rules would cost them an extra $25,000 a year in unplanned costs, but the state says they’re necessary to ensure accuracy and privacy.

It’s possible that the specifics of the law will become clearer to people in states like Texas as the March 31 open enrollment deadline approaches. But if not, confusion among consumers could make it harder for the insurance marketplace to reach the necessary balance between newly insured sick people and the relatively young, healthy individuals who will subsidize them.

If people like Cervantes, who are healthy and eligible for subsidies, aren’t able to sign up because the process is too opaque and or navigators are too hard to reach, the insurance market may not hit the golden “healthy people” ratio that it needs in order to stabilize.

Part of the problem, of course, was the catastrophic rollout of Healthcare.gov and the Obama Administration's constantly-shifting deadlines. But at the same time, people tend to be more informed about Obamacare in states with state-run exchanges than in those where the federal government has taken the reins because local legislatures or governors have refused. That speaks to how important the politics of individual states have become to the ability of people to get information about healthcare, and to uninsured people getting the medical care they've been waiting for—sometimes for years.