As the new Affordable Care marketplaces get under way in each state, how many Americans without health insurance will learn about their new options – including the generous subsidies available to help people with low or moderate incomes afford premiums for health insurance plans? Public confusion has been widespread, but outreach experiences suggest that providing accurate information – especially face-to-face – makes people more positive toward the health reform law and increases their willingness to sign up.

In the words of outreach specialist Libby Cummings of the Community Health Center in Portland, Maine, “When we have a chance to explain it to people, it’s been very positive. People are excited about it and want to have health insurance. People see it as an opportunity to get coverage that was never open to them before.”

Confusion is Rampant

A lot of Americans don’t know much about how the Affordable Care Act works.

• Media coverage mostly features political maneuvering – and some months ago, the Kaiser Family Fund’s health reform tracking poll found that 44% of Americans thought the Affordable Care Act was repealed or ruled unconstitutional, or were otherwise uncertain whether it is still the law.
• Just over half of Americans say they don’t know how health reform will affect them. Those who have the most to gain are most likely to say they don’t have sufficient information. More than six of ten uninsured people say they lack information, as do 64% of Hispanics, 62% of young adults, and 60% of people in families making less than $40,000 a year.
• Supporters of the Affordable Care Act claim to understand it better than opponents. According to a Washington Post poll, only 30% of the law’s opponents say they understand how reform operates, compared to 69% of opponents who say they don’t. More supporters of the law (45%) said they understand reform – yet fully 53% of supporters say they do not understand.
• The Kaiser poll found that only 15% of the public and 12% of the uninsured knew that the marketplaces would open on October 1, 2013. People know more if they live in states where officials are setting up their own health reform marketplaces.
• When reporters discuss the new marketplaces, they stress the prices for insurance plans without highlighting the premium subsidies that about 90% of the people who use the marketplaces will receive. Polls by Kaiser and the Pew Research Center show that only about half of the uninsured know that Affordable Care promises them financial aid to buy insurance.

Massachusetts Shows That Outreach Matters

In 2006, Massachusetts adopted reforms similar to those featured in the Affordable Care Act – including an online marketplace to buy insurance, financial aid based on a sliding scale, and a requirement for state residents to have coverage. The state used many ways to explain the system and help people sign up. Advertising was a part of the strategy, but outreach also included person-to-person contact. Many uninsured people in the state got care at community health centers and had little experience buying and using private insurance. Active help from staff allowed many uninsured Massachusetts people to buy coverage at very low cost.Amid confusion and conflict, health reform is most likely to succeed when staffers and volunteers directly explain the new choices and help uninsured people sign up.

Six years after Massachusetts began its program, researchers have found:

• Intensive outreach is critical because low-income uninsured people need extra help. Many move frequently, some are homeless, and a large percentage lack Internet access to view the marketplace site or do not have the skills they need to navigate the site and make choices. Some of the uninsured cannot read or do not speak English well or at all.
• Readily available help boosts the rate of health insurance coverage. Information needs to be conveniently available right in people’s neighborhoods and community health centers.
• Assistance has to remain available – so people can get help more than once. Notices about coverage can be difficult to understand and sometimes new documents must be submitted. As years go by, people still need and want help to renew insurance or obtain it for the first time.

Explaining Affordable Care Person to Person

Under the Affordable Care Act now, as in Massachusetts some years ago, “navigators” in community health clinics will help uninsured people obtain coverage. Associations and community groups are also deploying volunteers and staff to tell people about the program.

A few months before marketplaces opened on October 1, the Maine People’s Resource Center tried an experiment. They did a state-wide poll and also surveyed eight towns in central Maine. Canvassers had doorstep conversations with nearly 8,000 people in those towns, including over 700 who had no insurance, nearly 1,300 young people, and over 2,000 seniors. After these conversations, the community organization did a second wave of polling, both state-wide and in the canvassed towns.

The results show that face-to-face explanations matter. Across the state, there was no significant change in views or knowledge about the Affordable Care Act. But in the towns where door to door canvassing happened, people were more likely to know about key parts of health reform – the insurance marketplace, the ability of young people to stay on their parents’ plans until age 26, and the free preventive health services the law requires. More people in the targeted towns believed that the marketplace would be good for themselves or others. They had more information about benefits and more often agreed that the law is a “good thing.”

In short, amid public confusion and conflicts, health reform is most likely to succeed when staffers and volunteers directly explain the new choices and help uninsured people sign up.

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This brief draws upon research and data in Julia Paradise, Sara Rosenbaum, Peter Shin, Jessica Sharac, Carmen Alvarez, Julia Zur, and Leighton Ku, “Providing Outreach and Enrollment Assistance: Lessons Learned from Community Health Centers in Massachusetts,” Kaiser Family Foundation, September 2013.