Pushing health care in USA’s poorest big city

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PHILADELPHIA — Christian Hayden, all dreadlocks and do-gooderism, hesitates before knocking on yet another paint-chipped door in the Grays Ferry neighborhood. The graduate student is practicing his pitch — and the name of the group he's representing — as he tries to persuade people to sign up for the new health insurance exchange.

Geoffrey Baker, a classical violinist with a master's degree from Yale, is a 6' 5" guy in a rugby shirt. He's got the spiel down cold but worries some of the residents may feel a little chilly toward him. He hopes a day's growth of beard stubble will help him fit in.

Greg Young, a former waiter, is their leader and the only guy getting paid on this fall day. He's a field organizer for the non-profit group Enroll America, helping sell the idea of health insurance in a target-rich environment.

Today's door-to-door insurance salesmen may seem worlds apart from the residents of these often-tattered row houses, but they share one big thing in common. They haven't been able to afford insurance either. They face the daunting task of helping to convince the nearly 200,000 uninsured residents of Philadelphia County that they can — and should — buy it now. The new exchange's success, the cornerstone of the Affordable Care Act, will hinge on whether it can meet the federal goal of 7 million enrollees, but also on whether it can sign up enough healthy younger people like these canvassers to make up for all the ailing older ones.

Rather than set up and market its own health insurance exchange, Pennsylvania joined 30 other states in defaulting to the federal marketplace. The state is doing some limited marketing — through e-mails and on its own health insurance website — but hasn't heard back on its request for funds to do its own outreach about the exchange and doesn't know when it will because of the government shutdown, says Rosanne Placey, spokeswoman for the state insurance commissioner.

The federal Department of Health and Human Services gave the state $2.7 million to aid "navigators" to help people enroll. An additional $4.2 million went to 40 community health centers to help them reach and enroll uninsured people. That compares with $24 million that the much smaller state of Maryland got from the federal government for its navigator program to use for outreach and enrollment in its state-run exchange.

"Given the huge challenge of reaching everyone who is eligible, we're collaborating with organizations of all kinds to stretch our resources to enroll as many people as possible," says Laura Line, corporate assistant director for health care at Resources for Human Development, the navigator group awarded the largest grant. "It's going to be hard and it certainly will be helpful to have [Pennsylvania] as a partner in this crucial first year."

For now, the task of getting the word out is largely left to the navigators, health clinics and guys such as Young — who recruited his parents — and volunteers struggling to make ends meet. Only three showed up for a phone bank at the YMCA on a recent Friday night to cold call area residents. It took them 215 calls to talk to 15 people and find 12 uninsured.

"It's a shame. A real effort is needed, and it doesn't seem like enough of an effort is being marshaled," Baker says. "It makes it seem a little bit like spitting in the wind."

Those behind the neighborhood doors and at a fall festival at Malcolm X Park are the residents of a hardscrabble area of the poorest large city in America, as ranked by U.S. Census data examined by The Philadelphia Inquirer and a Temple University professor this year. The area can hardly boast of any health accomplishments. Philadelphia County had the worst health score this year for the 67 Pennsylvania counties, according to an analysis by the Robert Wood Johnson Foundation. The ranking was based on morbidity and mortality — how long people live and how healthy they feel while they're alive.

"It's exacerbated by their poverty," says Natalie Levkovich, CEO of the Health Federation of Philadelphia. "They have all of the risk factors and higher rates of chronic disease."

The result, she says, is more than 1,300 people for every 100,000 of population are hospitalized every year for what are known as "ambulatory care sensitive hospitalizations," that is, visits that were avoidable if the person had access to health care.

LESSON IN MEDICAID

Many simply haven't signed up for Medicaid because they can't read or write — possibly in English or another language, says Bill England, Enroll America's Pennsylvania state director, or they are overwhelmed by the lengthy application and its paperwork demands.

Often, the job is giving a how-to lesson in obtaining Medicaid — or listening to the challenges of even getting affordable care while on the federal program. That's what happens as England runs a "tabling event" at the free festival. He hears about knees that need surgery that isn't covered; of prescription bills breaking already empty banks. The plan is to get people to sign cards saying they "commit to learning more about my health care options" and to agree to be texted or called to remind them to sign up. In the five hours England mans the table, his door-knocking team gets 31 cards signed and 11 people confirmed as uninsured in the surrounding neighborhoods.

The "Get Covered America" campaign isn't finding any of the opposition to the health care law that's found in many other parts of the state and country. Even one of the abandoned houses still had an Obama/Biden poster in the broken window; another had photos of President Obama at a reception posted inside a window. Almost without exception, residents opened their doors and told their stories to these soft-sell salesmen.

Armed with data from a vendor that supplies businesses and political campaigns, the three canvassers carry printouts of addresses most likely to belong to the uninsured. Enroll America spokesman Justin Nisly says the initial data set included 230 million people across the USA. The group surveys more than 10,000 of them and used that information "to fine-tune the model" used to predict who's most likely to be uninsured. Among the publicly available information used: age, race, marital status, approximate income, voting history and location.

When people say they're already on Medicaid, the canvassers stay true to their script and ask whether the young children in the house are covered by the state's CHIP (Children's Health Insurance Program) plan for low-income families and if there are any uninsured people in the often multigenerational households. At Sharon McCord's house, daughter LaToya is on Medicaid, son Jordan doesn't have insurance and brother Charles McCoy — who "stays here sometimes" — is both uninsured and out of work after a pipe exploded on him.

McCord says she "lost my career, lost my income and lost everything" after a stroke two years ago. She's on Medicaid but fills out the card with her son and brother in mind.

Enroll America has provided talking points, but the canvassers each deliver the message in their own style.

"I get right to the point because I don't want people to think i'm with the government," Baker says.

Hayden's pitches are more circuitous, but he doesn't give up. If they're already on Medicaid or insured, true to the script, he asks if people would be willing to distribute information about the Affordable Care Act.

Until he got hired by Enroll America in late August, Young was uninsured. He injured his knee and missed two weeks at the Spanish restaurant he worked at, but it healed without a doctor's visit.

Baker wasn't so lucky. When a minor leg injury got infected this summer, his musical income was so low he qualified for free "charity care" at a hospital. That brought him one hobbled step closer to his new calling: health insurance. He's got three applications in to work for one of the state's navigators. He's been uninsured for nine years and never goes to the doctor. He knocks on doors when he can in between gigs, which have included playing with Arlo Guthrie and Earth, Wind and Fire.

BULLET WOUNDS AND FOOD STAMPS

Jeffrey Jones, who spends the afternoon at the festival, was hit with a $13,000 hospital bill after he went to get a bullet removed from his leg.

Was it a stray bullet? "No, they were aiming at me, right out here," he says, pointing to the street outside the park. He lost his Medicaid during a prison stint, so he had to fend off the bill collectors.

"They're always calling, but they don't get anything," he says.

As for Hayden, he's tried to get food stamps, but his work as a mentor in grad school doesn't reach the 10 hours a week needed to qualify for them. It also doesn't give him enough money to qualify for subsidies on the exchange — Pennsylvania is one of the states that didn't expand Medicaid — or to afford insurance without the help. He hopes to get a job using his urban studies major soon — one that has health insurance.

England, a health care veteran who helped get CHIP enacted in the state more than 20 years ago, and Young are doing the best they can to spread the word. England has 121 volunteers in Philadelphia, and they've gotten nearly 400 people to sign commitment cards saying they want to learn more.

"We may go straight through to April," Young says, referring to the March 31 deadline to sign up for insurance. "We put as much into it as we can."