After the disastrous rollout of the healthcare exchanges last October, Kathleen Sebelius has hit the road to pump up enrollment-and it just might be working.
JERSEY CITY, NJ
After a disastrous start, the effort to enroll 7 million people on healthcare exchanges under the Affordable Care Act hit its stride in January. With time running short, however, the move is under way to redefine success through the stories of ordinary Americans. It’s a classic campaign strategy, and one that new polling shows just may convince voters that a law they still don’t like probably should not be repealed.
Through piles of snow on February 4, 2014, the press turned out. During the presidential interview, Fox News’ Bill O’Reilly had pressed President Barack Obama on why Health and Human Services (HHS) Secretary Kathleen Sebelius was still around1 after the epic fail otherwise known as the launch of HealthCare. gov, which half of US states are using to enroll consumers on the federal exchange under the Affordable Care Act (ACA).2
“Why didn't you fire Sebelius?” O'Reilly asked.3
The president did not so much answer O’Reilly’s question as ignore it, choosing instead to focus on the 3 million who had enrolled for health coverage on the exchanges to that point.1 (The most recent total is 4 million through February 27, 2014.4) The chattering classes have been asking O’Reilly’s question since the website’s catastrophic launch, especially with estimates of repair costs ranging from $600 million to $1 billion.5,6 A piece in The National Journal on Sebelius’s staying power offered reasons from the then—Kansas governor’s key 2008 endorsement of Obama to their shared love of basketball.7
Frequently overlooked is an obvious, more practical reason: To have any shot of meeting the original goal of signing up 7 million people by March 31, 2014, when the first open enrollment ends, someone had to go out and sell this thing. And from the start, the person with that assignment has been Sebelius.
Two days after the Super Bowl, and 8 weeks before that deadline, Sebelius arrived at City Hall in Jersey City for a stop on what might be the toughest campaign of her life. This effort looks every bit the push to the finish that it is; some in the trenches admit as much. There are campaign stops, targeted groups, talking points, ground troops, and no shortage of barbs at those who have fought Obamacare every step of the way. There’s also money, amid fresh speculation in The Washington Examiner that Sebelius has not stopped raising funds for Enroll America,8 the group created to sign up the uninsured from what was left of Obama’s last campaign for president.
But as the deadline nears, it seems Sebelius has decided that the 7 million target she had touted as late as September 20139 was in fact someone else’s creation—the Congressional Budget Office’s, to be precise. So, Sebelius has simply moved the goalpost to, well, maybe…nowhere.
“First of all, the 7 million was not the administration. That was a CBO, Congressional Budget Office prediction when the bill was first signed,” Sebelius said in a February 25, 2014, interview with HuffPost Live host Marc Lamont Hill. “I’m not quite sure where they even got their numbers. Their numbers are all over the board, and the vice president [Joe Biden] has looked and said it may be closer to 5 to 6.”10
Sebelius’ answer was no accident. The American Journal of Accountable Care had asked HHS for the most recent enrollment numbers and how they compared with projections. The day before the HuffPost appearance, an HHS response floated this same claim that the administration never made projections, only the CBO did.
The appearance with Hill was the clearest evidence yet that Sebelius seeks to redefine what victory will look like come March 31. Her Jersey City stop was among the last that focused on the numbers game instead of individual triumphs, what campaigns call “people like me.” When HuffPost’s Hill, whose interview could hardly be called aggressive, kept pressing Sebelius for a revised goal, she said only, “Everyone who is covered is a success story.”10
A Campaign Like No Other
So why send out a battered secretary to promote Obamacare? Numbers matter in campaigns, and Sebelius’s are stellar. She can lay claim to something even the president cannot: Kathleen Sebelius has faced the voters 8 times in her life, and she has never lost.11 In her first race for Kansas governor in 2002, the prochoice Democrat garnered 52.9% of the vote in a red state, with America in war mode. She won reelection in 2006 with 57.8%.12 Her past year belies the fact that Sebelius was once considered one of her party’s brightest stars.
In Jersey City, Sebelius’s skills as a retail politician were on full display as she warmed up to local officials and took questions from reporters. “Mayors are the hardest working elected officials in the country,” she said, in a nod to her host, 36-year-old Steve Fulop. “They’re really where the rubber meets the road.”13 Her theme in Jersey City: with 2 months to go, enrollment is climbing, and there’s still time to sign up.
When a Cabinet officer serves a chief executive at any level, whether that leader is the president, a governor, or a big-city mayor, the rules of carrying a major policy portfolio are never spoken, yet they are crystal clear: the ball is yours to carry until just before the goal line. When success is assured, the boss carries it across. With the ACA rollout, early missteps—even Obama called them “fumbles” in his Super Bowl interview1—meant that Sebelius’s task would be the equivalent of scoring after a 30-yard sack on first down. In theory, enrolling 7 million people might still be possible. It would also be really, really hard.
Sebelius’s road show was in full swing before enrollment opened October 1, 2013, but her quest screeched to a halt from self-inflicted wounds: the software meltdowns, the president’s broken promise of “If you like your plan you can keep your plan,” except when you can’t.1 Her low point came on October 30, 2013, when she told the House Energy and Commerce Committee, “You deserve better. I apologize. I’m accountable to you for fixing these problems.”14
By January 2014, she was back on the road, trying to make up for lost time. The Friday before the Jersey City stop, Sebelius had been in St. Louis, Missouri,15 telling taxpayers there that they were losing $5 million a day by refusing to expand Medicaid under the ACA. But she also brought out Nathaniel Carroll, a 28-year-old father and law student, who found coverage for $43 a month.15 On February 7, 2014, came New Orleans, where Sebelius kept her focus off the big picture and squarely on the stories of consumers paying stunningly low out-of-pocket costs for healthcare. “People like me” tales are critical to campaigns. Days are spent hunting down and vetting participants, for these stories are gold: both New Orleans newspapers wrote about the 29-year-old mother paying $17 a month for insurance.16,17
In the background are footsteps of the 2014 midterm elections, for which the ACA will be both poster child and piñata. At her New Orleans stop, Sebelius and Mayor Mitch Landrieu reminded everyone that Louisiana’s Republican governor Bobby Jindal’s refusal to expand Medicaid affects 242,000 residents; Sebelius called on everyone to appeal directly to state legislators to change this fate.17 Such an outcome is unlikely, but that’s not the point.
Mitch Landrieu, fresh off his reelection, joked with the local media that he was still speaking with Sebelius even though she’d hired away his health director, Karen DeSalvo, MD, as national coordinator for health information technology.17 But the mayor’s older sister, US Senator Mary Landrieu (D-Louisiana), facing her own reelection campaign when the ACA is less popular statewide, was nowhere to be seen.18 Reminding lower-income voters what they are missing because of a Republican governor will not change Jindal’s mind, but it might energize the voters that Mary Landrieu needs in November.
Impediments to Enrollment
By conventional measures, Sebelius’s outing in Jersey City was successful. The largest daily newspapers based in New Jersey, the Star-Ledger of Newark19 and the Record of Hackensack,20 as well as the local Jersey Journal,13 sent both reporters and photographers to cover the press conference, and all ran stories the next day. A half-dozen radio and Web outlets covered Sebelius as well.
Nothing about the choice of Jersey City was by happenstance: Sebelius’s host, Mayor Fulop, is close to the “young invicible” demographic she most needs to enroll and is a friend of the cause. On October 14, 2013, at the height of the website meltdown, the mayor penned a blog on The Huffington Post taking on the naysayers who continued to throw marbles under Sebelius’s feet as she tried to bring health coverage to the uninsured.21 In the piece, Fulop touted a mobile Navigator Program, federally funded with a $400,000 grant,21 which brought 4 bilingual counselors to one of America’s most diverse cities; program representatives were on hand for the event and mingled with the press after Sebelius departed.
Also important is Fulop’s embrace of multimedia: he brought his own cameraman from “JCTV,” the city’s in-house channel; he updated his Facebook feed about the visit; and he shared the news with 7500 Twitter followers.
But as Sebelius answered questions, the scope of her challenge became evident. In her view, purposeful efforts by some to impede consumers from learning about the ACA have been so profound that some of its basic features—those put in place to create the “affordable” part of the act’s name—remain unknown to the very people the law is meant to help.
When asked by The American Journal of Accountable Care what she sees as the biggest impediments to getting the uninsured to sign up, Sebelius was blunt: “Misinformation.” she said,“If people have never had insurance, they figure it will be unaffordable.” To this day, working-class families who are eligible for financial assistance to bring down out-of-pocket costs don’t realize what’s available to them. When they find out, “That’s news to a lot of folks,” she said.
There is also a lack of awareness that persons with chronic health problems can now gain access to insurance, perhaps for the first time. “No longer can anyone be locked out because of a pre existing condition,” Sebelius said. Independent polling bears her out: the Kaiser Family Foundation Health Tracking Poll from January 2014, taken just before the Jersey City appearance, showed that while awareness of the implementation of ACA had increased slightly, sizable shares of adults—and even larger shares of the uninsured—still did not know about key provisions of the law.22
January’s Kaiser data showed that about 4 in 10 adults, and about 5 in 10 uninsured, did not know that the law includes financial assistance to low- and moderate-income families to help them buy coverage, gives states the option to expand Medicaid programs, and prohibits insurers from denying coverage based on pre-existing conditions.22 Of course, not having information may or may not be due to misinformation.
In Jersey City, Sebelius made a point of mentioning how many New Jersey residents could still sign up for Medicaid. The Garden State is among those with Republican governors, such as Ohio and Arizona, that expanded coverage for lower-income residents but did not create their own exchanges.2 As February drew to a close, Sebelius was turning up the heat on those Republican governors who had not expanded Medicaid, especially when targeting African American audiences.10
Despite her campaign skills, Sebelius’s efforts come as Americans are highly distrustful of government messages and messengers. A Gallup poll taken January 5 to 8, 2014, found that 21% of Americans view dissatisfaction with government, politicians, and poor leadership, including abuse of power, as the top problem facing the country. Poor healthcare and its high cost tied for third (with lack of jobs) at 16%.23
Most startling, after years of healthcare headlines and furious debate, some basics were lost even on the press corps, whose job it is to pay more attention than the typical uninsured person. Before Sebelius arrived, a radio reporter asked a print columnist who covers healthcare, “So… what’s the deadline for this?”
The Ground Game
All modern political campaigns have multiple moving parts. There are the parts seen, represented by the candidate or spokesperson and the media operation; and the unseen, which involves the vast apparatus of identifying and fine-tuning lists of persuadable customers. Most often, these people are converted into votes, and the Obama for America operation was legendary for its ability to slice and dice the electorate24 and then bring people willing to vote for the president to the polls on Election Day, in what is called “the ground game.”
The organization Enroll America, a 501(c)3, is attempting to do something unprecedented: take the data, people, and knowhow of recent voter turnout efforts and use this infrastructure to identify and sign up the uninsured.25 It’s a promising idea, but simple it is not. Voting and enrolling for insurance are vastly different decisions, as the Enroll America canvassers are learning.
Voting, especially in presidential contests, may mean one likes his choice, but it can also mean a person simply dislikes his choice less than the alternative. Long lines aside, the act of voting is brief. And most importantly, it’s free. An 18-to-34 year old— a special focus of this effort—may have to surrender a few minutes of his time to vote, but he does not have to scramble for a car payment or forgo a night out with friends, which might be necessary to buy something ethereal like health insurance.
Enrolling young people is essential to ensure a proper mix in the risk pool. No traditional campaign faces this challenge: even if Sebelius could somehow hit the 7 million mark, she also needs to properly balance the cost of taking care of older, sicker Americans by enrolling sufficient numbers of younger, healthier ones so that rates don’t skyrocket in the future.26 For a politician, this is counterintuitive. Typically, one seeks to run up the numbers where support is easiest to find. Sebelius must ensure that either she or someone else is finding those Americans most skeptical and unwilling to sign up for coverage.
This task is being aided by the “young invincibles,” which is not just a description of the demographic that is relatively healthy, relatively broke, and often hard to engage. Young Invicibles is an actual group, started among Washington, DC, law students, some of whom have worked for such liberal luminaries as US Representative Chris Van Hollen (D-Maryland) or the late US Senator Edward M. Kennedy (D-Massachusetts).27
But if January brought a respite from Website woes, February brought the reality that time was running out. The New York Times story of February 18, 2014, “Obama’s Vote-Getting Tactics Struggle to Find the Uninsured,”28 read like a mushroom cloud to anyone who understands how such operations work. Reporter Michael D. Shear wrote that over 4 hours, 41 canvassers in Broward County, Florida, made contact with 2623 people and signed up just 25.28 At well under 1 enrollee per canvasser over half a day, the results are, in their own way, as stunning as the early days of HealthCare.gov.
The operation’s Florida director directly compared the effort to reaching voters. “They are going to hear from us multiple times between now and the end of March until they tell us they have insurance,” Nicholas Duran told The Times. “It’s just like a campaign.”28
The Times also revealed the scale of the enterprise: Planned Parenthood is paying 400 people $12 an hour to canvass; Enroll America has hired 266 workers, trained 14,000 volunteers, and raised $7 million to reach the uninsured on the Web.28 But if this campaign resembles traditional ones in other ways, the Times story would likely have had an immediate effect: It could not have been easy to raise money for the cause in the succeeding days.
Another shoe dropped February 19, 2014, when The Washington Examiner reported on e-mails that revealed extensive interaction between Enroll America and HHS, including a weekly conference call and encouragement from the nonprofit for Sebelius and her top aides to fund-raise on their behalf.8
The next day, Vice President Joe Biden predicted that the final enrollment figure would land between 5 and 6 million, in line with estimates the CBO revised after October’s botched launch. After 5 more days, Sebelius herself was backing off even that downgraded forecast, and being lampooned for doing so.9
The Road Ahead
Research by the Kaiser Family Foundation and Massachusetts’ experience with healthcare reform suggest a final enrollment wave could come: the oldest and sickest sign up first, and the younger and healthier wait until the last minute.26 HHS data show that the share of 18-to-34 year-olds enrolling in January 2014 was 27%, compared with 24% for the first 3 months. In raw numbers, enrollment on the federal exchange was pulling away from the state exchanges.
Public opinion in the Kaiser tracking poll for February was mixed: half of the uninsured still said they didn’t have enough information to understand how the law would affect their families, and a majority of the uninsured (56%) retained a negative view of the ACA.30 But the poll also found that 56% believe the ACA is here to stay and don’t want Congress to repeal it, even though 48% want some changes.30 An Associated Press account from the February meeting of the National Governors’ Association said members at this pragmatic gathering agree that, practically speaking, the ACA won’t be repealed.31
HHS reports that Sebelius will stay on the road until the end of March, although a spokeswoman declined to say how many cities she would visit or to characterize her activity. Campaign schedules are always in flux. But if the boss starts joining her on the road, it will be a sign that Kathleen Sebelius’s numbers are looking brighter.Author Affiliation: Mary K. Caffrey is the managing editor of the Evidence-Based series at The American Journal of Managed Care.
Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.1. Wemple E. Fox News’s Bill O’Reilly aces Obama interview. The Washington Post. http://www.washingtonpost.com/blogs/erik-wemple/wp/2014/02/02/foxnewss- bill-oreilly-aces-obama-interview/. Published February 2, 2014. Accessed February 24, 2014.
2. State Health Insurance Marketplace Profiles. Kaiser Family Foundation website. http://kff.org/state-health-marketplace-profiles/. Published April 18, 2013. Updates ongoing. Accessed February 24, 2013.
3. Logiurato B. Obama and Bill O’Reilly just had an extremely tense pre-Super Bowl interview. Business Insider. http://www.businessinsider.com/obama-bill-oreillysuper- bowl-interview-2014-2. Published February 2, 2014. Accessed February 25, 2014.
4. US Centers for Medicare & Medicaid Services. Marketplace enrollment hits 4 million. https://www.healthcare.gov/blog/marketplace-enrollment-hits-4-million/. Published February 27, 2014. Accessed February 28, 2014.
5. Casey C. HealthCare.gov cost: price unlisted: Wall Street cheat sheet. http:// wallstcheatsheet.com/stocks/healthcare-gov-cost-price-unlisted.html/?a=viewall. Published December 10, 2013. Accessed February 27, 2014.
6. Delreal J. Darrell Issa: health site may top $1 billion. Politico. http://www.politico. com/story/2013/12/darrell-issa-health-website-cost-100661.html. Published December 4, 2013. Accessed February 27, 2014.
7. Cooper M. Why Obama won’t fire Sebelius. The National Journal. http://www. nationaljournal.com/health-care/why-obama-won-t-fire-sebelius-20131029. Published October 29, 2013. Accessed February 24, 2014.
8. Crabtree S. Exclusive: Kathleen Sebelius won’t say whether still fundraising to promote Obamacare. http://washingtonexaminer.com/exclusive-kathleen-sebelius- wont-say-whether-still-fundraising-to-promote-obamacare/article/2544121. Published February 19, 2014. Accessed February 25, 2014.
9. Batley M. Sebelius denies 7 million was Obamacare’s target. Newsmax. http:// www.newsmax.com/Newsfront/sebelius-denies-obamacare-target/2014/02/26/ id/554854. Published and accessed February 26, 2014.
10. Schuster A, Hill, ML. Kathleen Sebelius distances Obama administration from lofty Obamacare signup goal. The Huffington Post. http://www.huffingtonpost. com/2014/02/25/kathleen-sebelius-obamacare_n_4854288.html. Published and accessed February 25, 2014.
11. Fletcher M. Sebelius’ political skills, experience win plaudits. The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2009/03/01/ AR2009030101742.html. Published March 2, 2009. Accessed February 25, 2014.
12. Kansas secretary of state official vote totals. Rehttp://www.kssos.org/elections/ 06elec/2006GeneralElectionOfficialResults.pdf.
13. McDonald TT. Health chief Sebelius visits Jersey City to push for healthcare enrollment. The Jersey Journal. http://www.nj.com/hudson/index.ssf/2014/02/ health_chief_sebelius_visits_jersey_city_to_push_for_healthcare_enrollment.html. Published February 4, 2014. Accessed February 26, 2014.
14. Memmot M. Sebelius: “Hold me accountable for the debacle,” National Public Radio. http://www.npr.org/blogs/thetwo-way/2013/10/30/241791725/comingup- sebelius-to-face-health-care-questions. Published October 30, 2013. Accessed February 25, 2013.
15. Joiner R, Rosenbaum J. Sebelius puts a price and face on health insurance coverage in Missouri. St. Louis Public Radio. http://news.stlpublicradio.org/post/sebelius- puts-price-and-face-health-insurance-coverage-missouri. Published January 31, 2014. Accessed February 25, 2014.
16. Vanacore A. US health secretary visits N.O. to tout healthcare law. The New Orleans Advocate. http://www.theneworleansadvocate.com/home/8318840-172/ushealth-secretary-visits-no. Published February 9, 2014. Accessed February 24, 2014.
17. Catalanello R. Sebelius visits New Orleans, urges Louisianans to sign up for Obamacare by March 31. The Times Picayune. http://www.nola.com/health/index. ssf/2014/02/kathleen_sebelius_urges_louisi.html. Published February 7, 2014. Accessed February 24, 2014.
18. Email correspondence from A. Vanacore, confirming that US Senator Mary Landrieu did not attend Sebelius visit, February 26, 2014.
19. O’Brien K. Kathleen Sebelius reminds NJ: just 8 weeks to sign up for Obamacare. The Star-Ledger. http://www.nj.com/news/index.ssf/2014/02/nj_to_get_xx_in_ health_care_grant_from_obama_administrationhold.html. Published February 4, 2014. Accessed February 25, 2014.
20. Williams B. Sebelius promotes Obamacare in New Jersey. NorthJersey.com .http://www.northjersey.com/news/Sebelius_promotes_Obamacare_in_New_Jersey. html. Published February 4, 2014. Accessed February 25, 2014.
21. Fulop S. Americans must be able to obtain health care coverage as is their right under the law. The Huffington Post. http://www.huffingtonpost.com/steven-fulop/ affordable-care-act-coverage_b_4096820.html. Published October 14, 2013. Accessed February 25, 2014.
22. Kaiser Health Tracking Poll: January 2014. Kaiser Family Foundation website. Gallup Polling January 2014. http://kff.org/health-reform/poll-finding/ kaiser-health-tracking-poll-january-2014/. Published January 30, 2014. Accessed February 24, 2014.
23. Strauss A. The Obama campaign won GOTV gold in the 2012 campaign games. The Washington Post. http://www.washingtonpost.com/blogs/monkey-cage/ wp/2014/02/21/the-obama-campaign-won-gotv-gold-in-the-2012-campaigngames/. Published February 21, 2014. Accessed February 27, 2014.
24. Enroll America website. http://www.enrollamerica.org/. Accessed February 26, 2014.
25. Levitt L, Claxton G, Damico A. The numbers behind “young invincibles” and the Affordable Care Act. Kaiser Family Foundation website. http://kff.org/ health-reform/perspective/the-numbers-behind-young-invincibles-and-the-affordable- care-act/. Published December 17, 2013. Accessed February 26, 2014.
26. Young Invincibles website. http://younginvincibles.org/. Accessed February 26, 2014.
27. Shear M. Obama’s vote-getting tactics struggle to find the uninsured. The New York Times. http://www.nytimes.com/2014/02/19/us/proven-models-breakdown- in-search-for-the-uninsured.html. Published February 18, 2014. Accessed February 24, 2014.
28. Simons A. Biden in Minneapolis: health insurance signup is ‘hell of a start.’ InsuranceNetNews.com. http://insurancenewsnet.com/oarticle/2014/02/20/ biden-in-minneapolis-health-insurance-signup-is-hell-of-a-start-a-463425.html#. Uw-oW4WGe_U. Published and accessed February 20, 2014.
29. Kaiser Health Tracking Poll: February 2014. Kaiser Family Foundation website. http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-february- 2014/. Published and accessed February 26, 2014.
30. Peoples S, Thomas K. Governors: “Obamacare” here to stay. Associated Press, Portland Press Herald. http://www.pressherald.com/news/Governors___ Obamacare__here_to_stay_.html?pagenum=full. Published February 23, 2014. Accessed February 26, 2014.