Health Insurance Exchanges Suffer Ills Of Geography - NPR (blog)

Navigator Alexandra Dixon at Community Clinic, Inc.

Jenny Gold/NPR

Navigator Alexandra Dixon at Community Clinic, Inc.

Jenny Gold/NPR

Alexandra Dixon threads her way among the people waiting to see a doctor at the Community Clinic, Inc. in Silver Spring, Maryland. She introduces herself with a bright smile and an outstretched hand: "I'm one of the new health care navigators. Have you heard of the Affordable Care Act?"

While some folks mumble, "Um, no I don't think so," Dixon is nonetheless booked up with appointments. She's one of 350 people in Maryland who have been hired and certified to help consumers enroll in the new health insurance options that are offered as part of the health law.

"Sure, I've had a couple of people go, 'Ooooh, Obamacare, I don't want that.'" Dixon says. "But for the most part, people have been really excited and really happy and know what this is."

Dixon sits down with Maria Hernandez, a construction worker who's a legal immigrant and has been uninsured for the past five years. Hernandez says sometimes she gets sick, but without insurance, it's better just to take some medicine and stay home. With Dixon's help, she's started an application for insurance.

Despite Dixon's help, no one at the clinic where she works has actually enrolled on the exchange: The Maryland website freezes almost every time.

But whenever Dixon hits a roadblock, she sets up an appointment for the patient to come back, "because the portal is a lot better this week than it was last week," she says. "I have every expectation that next week it will be working better than this week."

And she has her state behind her: Maryland has embraced the health law. It's one of the 16 states plus the District of Columbia that are running their own exchanges. The rest are being run by the federal government, whose efforts have been stretched thin, according to Caroline Pearson of Avalere Health, a consulting company that's been tracking exchanges.

"The states that are operating their own exchanges just have a lot more funding available to do outreach and enrollment," Pearson says. "The federal government just had limited funding left to do that, and it was spread across a large number of states."

The entire state of Ohio, for example, got just $3 million in grants to do consumer outreach. That's compared to $24 million in Maryland, which has half as many uninsured residents.

That frustrates Lisa Hamler-Fugitt, who runs the Ohio Association of Foodbanks, the state's main consumer outreach group for the exchange.

"We have too few boots on the ground," she says. "We need hundreds if not thousands of individuals to assist us."

Instead, she'll have about 40. Ohio has laws putting additional restrictions on navigators, such as requiring them to go through a longer certification process. Hamler-Fugitt believes that's caused a three-week delay in getting her navigators on the ground.

These early differences between states could hamper the goal of the ACA, which is to get as many people insured as possible, according to Pearson.

"Recent polling shows that only about 12 percent of the uninsured population who could benefit from exchanges understand that they are launching and began on October 1," she says. "So doing a big push out in the community can potentially bring a lot of people into the market, that you're not going to see in a state that isn't as proactive."

But, she adds, this is only the beginning of the enrollment process. Launching a program of this size is always a huge lift, she says.

Consumers have until the end of March to sign up for coverage in 2014.