In The South, Obamacare Advocates Try to Outmaneuver Opponents

In North Carolina, there's a staff of dozens of people, led by a director, who are in charge of getting people enrolled in Obamacare. The operation, which serves all of the state's 100 counties, includes a toll-free number where you can call and set up an appointment with an Obamacare specialist. The staff meets constantly to see if its methods are working, and they are getting results: the state had the ninth highest enrollment in the nation.

Here's what may surprise you: none of these people work for the state of North Carolina, the federal government or any of North Carolina's cities. North Carolina may be a purple state during presidential elections, but its state politics right now are very red. The state legislature passed a bill barring North Carolina from expanding Medicaid under the Affordable Care Act, which Republican Gov. Pat McCrory has opposed anyway. The state has also not set up its own health care exchange and has done little to encourage ACA enrollment.

But North Carolina is at the forefront of a strategy being employed in conservative states across the country: Obamacare advocates working around their state governments to implement the law. In Alabama, Georgia, South Carolina, Texas and other states, there is intense organizing by coalitions of groups to sign people up for Obamacare, which started open enrollment on Nov. 15 for its second year. In some states, these efforts are led by openly liberal groups, such as the Texas Organizing Project, which is involved heavily in ACA promotion but also backed Democrat Wendy Davis' unsuccessful gubernatorial campaign.

In North Carolina, meanwhile, more than 100 groups, mostly non-partisan, have joined the 'Big Tent,' ranging from community hospitals to the Legal Aid of North Carolina.

'It really has been a substitute for the state government,' said Lee Dixon, who was the director of the North Carolina initiative during the first year of ACA enrollment. 'The role the state government would usually play has been assumed by the Big Tent.'

The need for these outside entities to be involved illustrates the enduring divide over the health care law. Nationally, Republicans in Congress continue to say they will seek to repeal the Affordable Care Act, and the Supreme Court will consider in its upcoming term a case that could radically weaken the law. At stake is whether people in the 36 states that have not set up their own health care exchanges can get the subsidies for insurance under the ACA. The public remains polarized on the law, with Democrats supporting it and most Republicans in opposition.

'We are under a microscope, we are constantly brought before committees of the legislature, we are constantly getting open records requests, we are constantly being asked 15 things 15 different ways'

On the ground in states, the conservative opposition to the health care law is not as tense as it was in the midst of the failures of the website in 2013, say Obamacare advocates.

'The first year, there was an atmosphere in which state agencies were not providing any public information about enrollment options. There was no information beyond the bare minimum,' said Jim Carnes, of the Montgomery-based Alabama Arise. 'Now, I'm sensing a more relaxed attitude' from the GOP-led state government.

But the estimated 10 million Americans who got health insurance during the first enrollment period did not change the political environment around the law. Conservatives, particularly Republicans in state legislatures, remain very opposed to the law.

'We are under a microscope, we are constantly brought before committees of the legislature, we are constantly getting open records requests, we are constantly being asked 15 things 15 different ways,' said Audrey Hayes, who runs the Health and Family Services department in Kentucky, where the Democratic governor has implemented the law but the state's GOP-controlled Senate remains opposed to it.

In 23 states, all of which either have a GOP governor or GOP-legislature opposing the law, Medicaid has not been expanded.

Only one of these states (Idaho), which are almost all in the South or West, have set up their own exchanges, which would put them in charge of enrolling people, instead sending people to the federal healthcare.gov site.

So instead, throughout the South, independent groups are trying to fill a void. Usually, the coalition working on enrollment is a combination of black churches, community hospitals, who will benefit financially if more people have health insurance, and groups like the Legal Aid Society. The uninsured are disproportionately low-income and minorities, so these organizations already have experience working with those segments of the population, many of whom either can't or choose not to simply log on to healthcare.gov at home to enroll.

The Obama administration is involved too, but indirectly. The Department of Health and Human Services has allowed groups to apply for grants to help enroll people in the ACA, and North Carolina's organizers have received more than $4 million over the last two years. A non-profit called Enroll America, which is run by former Obama aide Anne Filipic, has staffers in 11 states helping with enrollment.

And Dixon and officials in states say they often talk to officials who work in regional offices for HHS.

But most of the work is done by these local organizers. In North Carolina over the weekend, the ACA coalition held events at churches, libraries and community centers all over the state, encouraging to people enroll. Officials in South Carolina, led by a local group called the Palmetto Project, set up their own-toll free line, borrowing from their neighbor to the North, as well as building a website called signupsc.org for people to get more information about the ACA.

In Texas, separate coalitions have been created in Houston, Dallas and San Antonio, to set up huge events on weekend afternoons where people can meet Obamacare specialists who speak both English and Spanish, get information about the program and enroll in one single stop.

'We call our program Sign Up South Carolina. We make no reference to Obamacare, because Obama is not going to be president in two years, and people will still need health insurance after that,' said Steve Skardon, the executive director of the Palmetto Project.

These grassroots efforts, say Obama administration officials, were important to reaching the goal of enrolling 7 million in the ACA last year. But the advocates themselves note that while they enrolled thousands of people, the states that showed the biggest drops in the uninsured were Kentucky and Arkansas. Those states, with Democratic governors, did what none of these non-governmental groups can do: expand Medicaid.

'One of the biggest setbacks for enrollment is that we didn't expand Medicaid,' said Tiffany Hogue, statewide healthcare campaign coordinator at the Texas Organizing Project. 'The states that expanded Medicaid enrolled many more people in health insurance. Until we expand Medicaid, Texas will never get over the hump.'

First published November 17 2014, 12:30 PM