Success of the Affordable Care Act could hang on whether about 2
million young and healthy Americans will buy coverage starting Oct. 1,
thereby ensuring the viability of the insurance pools. It’s a steep
climb, made harder by Obamacare foes working to talk them out of it.
By Chelsea B. Sheasley
Christian Science Monitor
PROVIDENCE, R.I. — In Oregon, folk singers croon about the state’s
health insurance exchange in artsy television ads. Connecticut is
passing out “Get covered” sunscreen at the beach, and a Colorado
poster features a young man with a “winner” medal, fists pumped, and
the slogan “When insurance companies compete, the only winner is you.”
The federal government and states in support of the Affordable Care
Act (ACA), better known as Obamacare, are banking on finding a winning
strategy to ensure enough young Americans sign up for the state
insurance exchanges, set to open Oct. 1, to keep rates low as
But people like Kay Lamberti, age 29, a former nursing assistant now
working a temp job in Providence, R.I., aren’t cheering for the health
exchanges just yet. Ms. Lamberti has gone for five years without
health insurance and doesn’t plan on getting it until she gets a
higher paying job.
“It’s not in the budget,” says Lamberti. “I’m pretty healthy at the
moment and I know things could happen, having had worked in the
healthcare field, but I can’t afford it based on that chance.”
Lamberti is representative of the newest challenge facing Obamacare,
after it survived legal challenges from half the states and 40 repeal
attempts by House Republicans: Analysts now are warning that
cash-strapped uninsured Americans ages 18 to 34 may stay away from the
new insurance markets, potentially driving premiums up instead of
Urgency is mounting with the next big deadline coming Oct. 1.
Health-insurance exchanges offering uninsured Americans a range of
choices must be up and running by then. By April 1, 2014, everyone
must be enrolled in a plan. If not enough young adults sign up to
offset the cost of insuring older and ill people, insurance rates will
That wouldn’t necessarily signal the failure of Obamacare — other big,
government programs such as Medicare and Social Security got off to
rocky starts but survived, experts say. Yet the political stakes are
high, with Republicans still pushing for repeal and public skepticism
widespread, and the success of the program next year could hinge on
bands of activists across the country trying to convince young and
healthy Americans that health insurance is something they can’t live
“The fear in the Obama administration is you’re going to get the sick
people signing up and the nonsick not signing up and that would be a
disaster. The insurance pools won’t work,” says Lawrence Jacobs, a
political science professor at the University of Minnesota in
Minneapolis and author of “Health Care Reform and American Politics.”
To ensure that doesn’t happen, the federal government and some states
are expected to spend at least $700 million on marketing and public
outreach about the new exchanges from late summer through the fall —
and much of it will be aimed at this demographic.
“We know that in order for us to be successful, to really make sure
the marketplaces are effective, there’s a smaller subset that needs to
really be at the center of our focus for outreach. And that’s about 2
million to 2-1/2 million young and healthy 18-to-35-year-olds,” said
David Simas, the director of polling for President Obama’s 2012
campaign and a senior adviser to the president, in July on PBS’s
Officials expect that if 7 million uninsured enroll in the
marketplaces this year, 2 million to 2.5 million of those need to be
young adults in order to make the insurance rates work.
The administration has put Mr. Simas in charge of bringing the same
micro-targeting strategies that were so effective in the 2012
presidential campaign to bear on the push for Obamacare enrollment.
Supporters will pinpoint which doors to knock on and advertise on
Spike TV and other networks they’ve identified as popular with the
There are signs it won’t be an easy sell for Millennials. Premiums for
younger, healthier individuals could increase by more than 40 percent
because of changes under the ACA, according to a recent study by
Oliver Wyman, a consulting firm in Milwaukee. Even when federal
tax-credit subsidies are taken into account, prices may still rise for
Millennials, though the new plans would offer much better coverage
than what Millennials have now, the study found. Because the penalty
for skipping insurance is low — $95 or 1 percent of income, whichever
is greater — in 2014, supporters fear young adults will choose
pocketbook economics. Younger individuals “are much less likely to
find it economically rational to purchase coverage,” the authors wrote
in the study.
Over the summer, insurance companies including America’s Health
Insurance Plans and The BlueCross and BlueShield Association sent a
letter to federal health officials warning that they feared low
enrollment among young adults.
Making the pitch
Carmen Mirabal and Megan Hall are positioned at a prime corner of a
farmers’ market in North Providence. Behind them is a banner with
pictures of smiling individuals and the name of the state’s new health
exchange, HealthSource RI, with the slogan “Your Health. Your Way.”
“Have you heard about the state’s new insurance marketplace?” asks Ms.
Mirabal as a couple wanders over.
Mirabel and Ms. Hall are part of a “39 in 3” campaign launched by
HealthSource RI to visit all 39 cities in the state in three months.
The small state is one of just 16 states plus the District of Columbia
running its own exchange. The other states opted to partner with or
have the federal government run their exchanges.
When the ACA first passed in 2010, legislators expected most states
would run their own exchanges. More money was budgeted for marketing
state-run exchanges than the one run by the federal government. But
most Republican governors opted out, leaving participating states to
share far more marketing and outreach dollars.
Rhode Island, for instance, is expected to spend $2.3 million in
federal money to market to the state’s 122,400 uninsured. Oregon will
spend $10.9 million to reach fewer than 600,000 uninsured. Texas and
Florida, states with more than 6 million and 3 million people
uninsured, respectively, received zero marketing dollars because they
did not create their own exchanges.
Seven of the top 10 states with the highest number of uninsured people
are not running their own exchanges and so have received no marketing
money. In those states, advocacy groups are trying to fill the
The largest group is Enroll America, a nonprofit founded by former
Obama administration officials. They’ve recruited more than 3,000
volunteers in the past seven weeks to knock on doors in 10 states that
aren’t doing their own marketing, and have reportedly purchased a
seven-figure media buy.
“We’re meeting [the uninsured] where they are, whether it’s a
barbershop or beauty salon, or a back-to-school program where we can
meet young parents,” says Ashley Allison, the organization’s director
of constituency engagement.
It’s Ms. Allison’s job to reach out to specific constituencies,
including young Americans; women; African-Americans; Hispanics; the
lesbian, gay, bisexual, and transgender community; and some faith
The organization is also taking a page out of the Obama
micro-targeting book. Its data and analytics team crafted a formula
from census data, commercially available consumer databases, and
demographic information to help identify where the uninsured live. So
far, team members say, the tool has been very effective in leading
them to knock on the right doors.
Tax credits and education to woo the wary
Jen Mishory is deputy director of the Young Invincibles, a nonprofit
dedicated to helping young adults get health insurance. Started by
young adults and taken from the insurance industry name for young
people who believe they don’t need health insurance, the group
organizes grass-roots outreach and education.
“One thing we’ve seen, that you see across the board in polls, is that
there’s not this disinterest in health insurance,” she says. “It’s not
that people don’t want coverage. For the most part it’s the inability
for people to afford coverage. There haven’t been that many affordable
options in the past.”
A Kaiser Family Foundation poll in June found that 77 percent of
18-to-25-year-olds and 71 percent of 26-to-30-year-olds say it’s very
important to them personally to have health insurance. When asked if
insurance is worth the money it costs, the answer dropped a tick among
18-to-25-year-olds, and fell six percentage points among
26-to-30-year-olds, the group no longer eligible to remain on their
Ms. Mishory emphasizes the availability of federal tax credits to help
subsidize the cost of insurance as a major new benefit of the ACA. Tax
subsidies will be available for single individuals who make between
100 and 400 percent of the federal poverty level, which is between
$11,490 and $45,960 in 2013 dollars for an individual. People making
below the poverty line may be eligible for Medicaid.
That means that a single 29-year-old nonsmoker making $28,000 a year
can expect a tax-credit subsidy of just over $1,000, but would still
have to pay $182 per month for a mid-level plan, according to a cost
calculator by the Kaiser Family Foundation. If they buy a less
comprehensive plan, they’ll pay $135 a month after the subsidy,
according to the calculator, which is based on Congressional Budget
If that same 29-year-old made $35,000, the cost calculator estimates
they’d qualify for a subsidy of as much as only $52 a year. The
remaining $229 per-month premium for the least comprehensive plan
would come out of pocket.
When grouped with rent, groceries, smartphone costs, student loans,
and other bills young adults often pay, that $229 premium may not fit
in the budget.
Additionally, young adults are much less likely to be familiar with
health insurance to begin with. Young adults make up the highest
percentage of the uninsured, and an August Gallup poll found that
18-to-34-year-olds were the least familiar with the ACA out of all
adults; more than 1 in 3 say they are not too familiar or not at all
familiar with the law.
“We don’t teach health insurance literacy in high school,” Mishory
says. “It’s also a challenge to make sure … [young adults
understand] things like what is a premium, what is a deductible.”
Young Invincibles plans on training more than 1,000 community groups
on education and outreach strategies and has developed an app to send
reminders of key registration dates.
‘Young people know a bad deal’
Evan Feinberg, 29, is president of Generation Opportunity, a
libertarian youth organization developing its own grass-roots campaign
to send a different message about Obamacare.
“We’re encouraging young people not to sign up for the exchanges
because it’s a bad deal,” Mr. Feinberg says. “Fortunately that message
resonates because people know a bad deal when they see it.”
In particular, Feinberg notes that he can find 100 plans for himself
with less-than-$100-a-month premiums on ehealthinsurance.com, a
private online health insurance exchange. Critics say many of those
plans don’t offer coverage as robust as what’s required under the ACA,
but Feinberg says they cover what he needs.
Feinberg says his organization, which has 1.5 million Facebook fans,
will be mobilizing on college campuses and sending field coordinators
to target young professionals. (The group isn’t saying how large its
effort will be.)
In August, FreedomWorks and Young Americans for Liberty teamed up to
announce a “Burn your Obamacare card” campaign: young adults who have
made videos of themselves burning a symbolic Obamacare card, made to
look like a Vietnam draft card, while saying why they oppose
“I’m burning my Obamacare card because I’m too busy paying student
loans to pay for somebody else’s health insurance,” one of the video
‘Affordable for me’
Some Millennials, especially those with what insurance companies call
preexisting conditions, are thrilled about Obamacare. Lori Leonti, 27,
a waitress at a P.F. Chang’s in Providence, made a beeline for the
HealthSource RI table at the farmers’ market. She earns between $350
and $650 a week as a waitress, but spends $600 a month on
antidepressant and anxiety prescriptions. She expects to receive tax
credits and a plan that will include the cost of prescriptions.
“I’m very excited. I’m struggling with the bills now,” Ms. Leonti
says. Leonti and her mom came to the farmers’ market specifically to
visit the health exchange booth after hearing about the event on the
John McColley, 25, from Tampa, Fla., in the past has applied for
health insurance from BlueCross BlueShield Florida and Humana, but was
denied after disclosing he’s previously sought treatment for
Mr. McColley, who is financially independent, makes $18,000 a year as
a kindergarten teacher’s assistant as he finishes a degree to become a
teacher. On the Kaiser cost calculator, he learns he may qualify for
subsidies that would enable him to pay about $65 a month for
insurance. “I live off a strict budget and that’s completely
affordable for me,” he says. “That’s awesome.”
Doom for Obamacare?
While reaching 18-to-35-year-olds is crucial for the initial rollout
of the law, the consequences if young adults opt out of the exchanges
likely won’t pave the path to GOP dreams of repeal, some analysts say.
“I see no chance that the law is going to be repealed,” Professor
Jacobs of the University of Minnesota says, pointing to a bumpy
rollout in early years for now-popular Medicaid, Medicare, and Social
Security before implementation kinks were ironed out.
Proponents of the law also point out that they have until March 31,
2014, when enrollment ends, to recruit young people, and premiums
wouldn’t rise until next year if too many young people opt out.
“You can think of it like World War I trench warfare,” says Jacobs.
“This is going to be a sustained grind. Opponents are very determined,
but they are up against very large federal agencies. You have a vast
number of people with enormous resources [in support of the law] and
they will not stop.”