By Katie Kerwin McCrimmon

Cost and confusion prevented many uninsured people from signing up for health coverage this year in Colorado, according to two new reports.

A Rand study, Barriers to Enrollment in Health Coverage in Colorado, found that some consumers didn’t want to sign up because they opposed the individual mandate. Others were frustrated that they first had to apply for Medicaid in a cumbersome process. Still others found Colorado’s exchange website confusing. And many people said costs for insurance and co-pays seemed too high.

Dora Curcio works with Catholic Charities in Pueblo. She said she’s new to health care enrollment and finds it incredibly confusing, especially since she often has to translate documents and resources into Spanish for clients.

Laurie Martin, one of the study authors at Rand, said one revealing comment came from a participant in a focus group who said, “not having health insurance is simpler. You pay once (at the doctor’s office) and it’s a done deal.”

Martin said some low-income people who get care at clinics with sliding scale fees found it easier to pay out of pocket rather than paying premiums up front and not understanding exactly how much they’d owe later for co-pays and deductibles.

“It’s unsettling for people on fixed or limited incomes who buy insurance to not know what it will cost later,” Martin said.

A word cloud from a new report on enrollments shows the overwhelming reason people cite for not getting health insurance. Source: Project Report: Culture of Coverage.

The Colorado Health Foundation commissioned the Rand study to help identify why some people aren’t signing up for insurance. The foundation also commissioned Culture of Coverage, a report with polling about the uninsured from the Global Strategy Group and Hilltop Public Solutions.

Authors of both reports described their work during sessions Wednesday at a conference in Aurora called Building Better Health. It brought together coverage guides and health policy experts from around the state to focus on how to find uninsured people and encourage them to get coverage. The next open enrollment season starts on Nov. 15.

James Delorey, vice president of the Global Strategy Group, said many of the people his group surveyed in online chat sessions and through polls didn’t understand that they could get money to help pay for health insurance. He said messaging is key and that talk of tax credits confuses people while they’re eager to hear instead about discounts.

Delorey cited the success of GEICO insurance ads that use quirky geckos to sell their message.

“The one thing you know at the end of every ad is that ‘15 minutes can save you 15 percent or more on your insurance,’ ” Delorey said.

He suggested targeting the uninsured with very specific messages about how much they can save or how much they’ll have to spend if they get sick. For instance, health guides could tell people that a broken arm could cost $2,500 or a ruptured appendix could set them back $27,000.

Cost tops the reasons people don’t get health insurance. Source: Culture of Coverage report.

The overwhelming reason that people Delorey surveyed said they weren’t buying health insurance was cost. In some cases, people perceived that they couldn’t afford care, but didn’t know about subsidies. In other cases, especially in resort areas, costs truly were out of reach.

In general, he said messages about buying health insurance were “not tailored or actionable.”

People needed to know exactly how much they could save and what to do about it, Delorey said. He suggested newer advertising approaches such as targeting young people who listen to Pandora and sending them texts with specific dollar figures.

Martin of Rand told coverage guides they should consider non-traditional partnerships, like working with churches or day care centers.

She and fellow researchers found that negative attitudes about the Affordable Care Act persist, especially in some rural parts of the state.

“There was disapproval of the individual mandate,” Martin said. “(Some) felt that by enrolling, they were going to be supporting a president that they didn’t want to support. There’s a lot of mistrust in the system,” she said.

Other barriers included:

• Significant confusion and little understanding about Medicaid and private insurance subsidies through the Marketplace
• Messages that insurance was not compelling
• Cost
• Complexity of plan materials
• Lag times and poor communication about eligibility
• Misinformation
• Cumbersome Medicaid application process before consumers could shop for private insurance
• Perception that Connect for Health website was not user friendly

Rand’s recommendations include:

• Supporting and expanding local outreach
• Revised marketing and messaging so that it’s clear, “actionable” and focuses on the benefits of health insurance
• Improving the clarity and transparency of costs and enrollment procedures
• Improving the two-step Medicaid/exchange enrollment process. (State Medicaid managers and Connect for Health officials are expected to debut a new system on Nov. 9.)

Latinos have been hard to reach and most don’t want to face big medical bills. So staffers who can help them will be essential. Many young people don’t think they need insurance, so they’ll be tough to convince. And distrust is especially deep in rural areas of the state. Many seasonal workers want insurance, but their income varies dramatically, making it difficult for them to qualify for subsidies.

Across the state, Martin said it was clear that people wanted help. Once envisioned as self-serve online-only systems, IT portals for insurance sign-up don’t seem to be adequate.

“People loved and valued one-on-one counseling and support,” said Martin.

She cited one participant who told her of a favorite health coverage guide: “If everybody knew this person existed, there would be a line of 50 people out the door.”

Martin advised many small tweaks so people get information they need from people they trust.