In Washington, D.C., (population 632,000), the drive to enroll the uninsured into health coverage under President Barack Obama's health care reform law is backed by the city government, federal funding and more than 200 local workers helping people apply for benefits.
In Prince William County, Va., (population 430,000), 30 miles south of the U.S. Capitol, there's pretty much just Frank Principi.
Principi is the executive director of the Greater Prince William Community Health Center in Woodbridge, a nonprofit clinic. The center is home to 14 doctors, nurses and dentists who care for 10,000 low- and middle-income patients a year, and it charges uninsured people on a sliding scale based on income. It's also the only place in the county where those who want to use the health insurance exchanges created by the Affordable Care Act can go for certified, in-person help with their applications.
"People are sick, and people are sick of having to pay large amounts of cash, or forgo paying a bill at all and going into bankruptcy," Principi, 52, said during an interview at the clinic on Wednesday. Principi estimates that about 100 people asked for information on Oct. 1 alone, the day the exchanges opened. Incoming phone calls are up more than 10 percent, he said.
The Obama administration aims to sign up 7 million people for private insurance via the exchanges. This enormous task, challenging under ideal circumstances, is made more difficult by the decisions of many states -- mostly Republican-led and including nearly the entire South -- to resist the law's implementation. As a result, the reach of Obamacare's enrollment drive is expected to vary widely. Fewer uninsured people are expected to get coverage in places like Virginia, which is doing next to nothing to help its residents sign up, than in places like the District of Columbia, which embraced the law's goals. And that's not even factoring in the faulty federal website impeding the project in more than 30 states.
There are about 44,000 uninsured people living in Prince William County, according to Centers for Medicare and Medicaid Services data compiled by Enroll America, a Washington-based organization promoting health insurance coverage. Open enrollment on the exchanges, also called marketplaces, runs until March 31. Principi hopes to sign up 2,500 people by then.
Back in the District of Columbia, more than 1,000 individuals or families applied for coverage on the city's health insurance exchange, DC Health Link, during the first week. The exchange already shifted from the educational phase to the enrollment phase due to intense demand, said Mila Kofman, the executive director of the D.C. Health Benefit Exchange Authority, which oversees DC Health Link.
"We learned that there's this pent-up demand for affordable, quality health coverage," Kofman, 43, said. About 64,000 District residents are uninsured, according to the Henry J. Kaiser Family Foundation.
Washington's 11 percent uninsured rate is lower than the national average. The rate is partially due to the fact that the city already offered coverage to low-income people through its DC Healthcare Alliance. It's also the result of the District's expansion of Medicaid to 200 percent of the federal poverty level, or about $23,000 for a single person. The Medicaid expansion is part of Obamacare, but some states chose not to do it.
The District of Columbia, which is strongly Democratic, opted to build its own health insurance exchange, and the entire apparatus of the District government is behind the project. Sixteen other states also built their own exchanges.
By contrast, Virginia is among the more than 30 states that declined to create their own health insurance marketplace, leaving it to the federal government. Virginia also is one of 25 states that have not expanded Medicaid to more poor residents under Obamacare -- though there's still a slim chance it will next year. The health care reform law calls for Medicaid to be opened to anyone earning up to 133 percent of poverty, which is about $15,300 for a single person this year. But the Supreme Court ruled last year that states may opt out, and about half have.
Currently, adults who don't have children or don't have a disability can't get Medicaid in Virginia, no matter how poor they are. Coverage for parents cuts off at 30 percent of poverty, or about $5,900 for a family of three, and for kids at 133 percent of poverty, or about $26,000 for a family of three.
The Obama administration and allies like Enroll America have targeted some states that aren't going along with Obamacare, like Texas and Florida, with enrollment efforts to boost the number of people covered.
Virginia isn't at the top of their lists, although organizations working as "navigators" -- like the Virginia Poverty Law Center in Richmond and community health centers in other areas -- are doing outreach. Fourteen percent of Virginians, or about 1.1 million, don't have health insurance. The figure is slightly below the 16 percent national rate.
"Political ideology at the state level and the federal level has put in place obstacles or roadblocks to successful and quick enrollment in the marketplace," Principi said.
Principi is immersed in the politics of Obamacare. He's serving his second term on the Prince William Board of County Supervisors and is one of two Democrats on the eight-member panel, which makes county government policy. Fellow Democratic supervisor John Jenkins and U.S. Rep. Gerry Connolly (D) have offices in the complex where the health center is located. The Prince William County Republican Committee is next door.
At the Greater Prince William Community Health Center, Principi employs four staff members to help sign people up for health insurance. He's hiring a fifth.
The health center is holding information sessions and running ads on local TV and radio. Automated telephone calls and text messages are going out to about 8,000 patients that the health center knows don't have insurance, Principi said.
Esthela Santos, 47, came to the health center to fill out an application for coverage Wednesday. She was armed with a pile of documents, and said she wanted to try to sign up even though she knows HealthCare.gov still has technical problems. Santos wants health insurance for herself, her husband and her 21-year-old daughter. Her son, 13, is covered by Medicaid.
"We're just starting with the application. The hard part will be to choose," Santos said.
But that will have to wait until HealthCare.gov is working properly and they can see the actual insurance products and prices. "Right now, all we're doing is filling out the paper applications," said health center employee Neysha Casiano, 27. "Once the site is back up, we'll be manually entering all the data." The health center staff had taken down about 200 applications in the first eight days of enrollment, she said.
Principi believes his patients will brave the extra hassle. "The families that we're helping? They've never had health insurance in their lives," he said. "Getting affordable health insurance for them and their families is a huge, huge relief from the stress, the anxiety, the pressure of not knowing what's going to happen when your child gets sick. These folks are willing to wait."
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