Why Florida Hit No. 1 In ACA Enrollment

April 07--When Florida racked up impressive enrollment numbers in 2014 for insurance plans offered under the Affordable Care Act, some healthcare analysts were surprised.

In 2015, the Sunshine State did it again, surpassing enrollment projections and beating out much-larger California and even Texas, a state more populous, more uninsured and with similar Republican opposition to the law.

Despite an uninsured rate among the top five highest in the country, Florida's Republican-led Legislature harbored an anti-Obamacare sentiment, making it an unlikely candidate to embrace healthcare reform. With the second Obamacare enrollment period all but over, why did Florida take the top spot, with 1.6 million enrollees?

Experts point to a variety of factors that, combined, likely elevated the state's numbers. Using enrollment specialists that spoke a variety of languages helped bridge cultural and language divides to enroll specific groups such as the large pool of uninsured Hispanics. Small businesses jumped into the Obamacare field by selling policies alongside groceries and bill-paying services. And the Florida economy, based mostly on tourism and small businesses, helped the enrollment process because many mom-and-pop operations don't offer insurance to employees.

Florida was primed to be an enrollment powerhouse.

Cashing on Culture

Just after sunrise on a January morning earlier this year, Miami-based Jessie Trice Community Health Center parked its traveling enrollment bus outside a Walmart opening event in North Miami. Health counselors for the federally qualified health center fanned out to look for potential enrollees, talking to the groggy morning crowd lined up outside the big-box retailer looking for early-bird deals.

One woman spoke up, offering a phone number for her brother who did not have insurance.

"When I get to work tomorrow, I"m going to give him a call. He needs his preventative care," Jessie Trice health counselor Randell Perry told the woman, adding his name to a clipboard-pinned list of followup calls that grew throughout the morning.

Linda Lott, program coordinator of outreach and affordable healthcare for Jessie Trice, said going into the community to find people where they already were gathering -- rather than waiting for the people to seek out healthcare -- was key to their enrollment efforts. The center also partnered with school board members, local and state representatives and enrollment organizations to reach more people.

During the ribbon-cutting for Walmart, Miami-Dade School Board member Dorothy Bendross-Mindingall encouraged the crowd to sign up at the Jessie Trice bus: "Someone told me that we would not get it done but you've heard the number of people who have enrolled in insurance. Don't take your health for granted."

Outreach efforts like the one at Walmart, where community leaders played a role, helped boost Florida's enrollment efforts this time around, experts agreed.

The Urban Institute projected Florida would enroll 917,000 Floridians in 2015. Actual enrollment nearly doubled that number, surpassing projections by about 74 percent.

The Epilepsy Foundation of Florida, the second-largest provider of enrollment assistance in the state, operated in 35 of Florida's 67 counties -- including Miami-Dade and Broward -- and enrolled thousands in places as unexpected as Microsoft stores.

In South Florida, where Spanish is spoken as much as English and Creole is common, too, organizations trained enrollment counselors who came from the communities they served and spoke the languages. It was a trust-building strategy designed to overcome the perception that complicated government programs like healthcare were inaccessible.

"The message was being put out so much more and it was in the languages that people needed to hear it in," said Monica Gonzalez, navigator program manager for the Epilepsy Foundation.

That kind of personalized approach seems to have worked.

At the end of enrollment, the Miami metropolitan area enrolled more than 750,000-- more sign-ups than those reported in 35 entire states. Epilepsy Foundation spokesman Franco Ripple said that 44 percent of people the foundation helped enroll in Miami-Dade County spoke a language other than English as their primary language.

In South Florida, where the word "socialism" was tossed around in conversations about the ACA as it was in other parts of the country, enrollment surged partly thanks to independent businesses that saw the potential in health insurance.

"Inside a check cashing place in Hialeah, you could: A, cash your check; B, enroll in affordable healthcare -- and also do your taxes," said Lott, the Jesse Trice coordinator. "You had it all right there."

Hialeah, the largest primarily Hispanic city in Florida, is also the location of the ZIP code with the highest enrollment rate in any state using the federal marketplace. During the peak of enrollment this year, streets in Hialeah were lined with signs advertising assistance enrolling in Obamacare. The mall located in the top ZIP code, 33012, was book-ended by two storefronts dedicated to enrollment. The ZIP code is also overwhelmingly Republican.

South Florida boasts the top 10 ZIP codes for enrollment, in fact, and four are in Republican-heavy Hialeah.

But healthcare has a way of cutting across politics -- especially when it's your own.

"The realization is that the ACA has many many different aspects to it," said Steve Ullmann, director of the Center for Health Sector Management and Policy at the University of Miami. "So what you are seeing are people saying, 'I like this part of it, I don't like that part of it.'"

Economic Impetus

Florida's demographics also made it ripe for ACA enrollment.

Its high uninsured population is partly powered by its large Hispanic population. Many Hispanics have historically worked in industries that don't offer employer coverage, leaving many uninsured. And the economy overall is largely based on the tourism, service industries and small businesses, which are less likely to offer health insurance, said Sean Snaith, an economics professor at the University of Central Florida.

Those who did have coverage before the ACA, Snaith said, may have lost it when employers learned about the law's requirements that insurance offer broader coverage.

Florida's large population of retirees may also play a role in the state's high participation in Obamacare plans.

Those who are under 65 and don't qualify for Medicare are looking to the ACA to offer the care they need to fill the cracks. In 2015, consumers between ages 45 and 64 were responsible for nearly half of Florida's enrollment, according to federal data.

"The early retirees, that is one of the demographic groups that is especially benefited by the exchange subsidies," said Devon Herrick, a health economist with public policy think tank the National Center for Policy Analysis. "I can easily understand how a place like Florida would have a disproportionately high number of enrollment."

He said another factor, and probably the most obvious, is that people signed up because their health demanded it.

The top 10 Miami-Dade County ZIP codes in enrollment exhibited higher rates of hospitalizations due to diabetes, hypertension and heart failure when compared to the county's other ZIP codes, according to Miami Matters, a site created by the Health Council of South Florida that analyzes quality of life indicators in the county.

The reality is that we [in Florida] tend to have high risk of diabetes and that's a major driver for other illnesses," Ullmann, of UM, said. "That becomes a major driver because you want to have access to care and better care."

An Uncertain Future

Still, Florida's level of momentum cannot last forever, experts say, now that the most enthusiastic consumers have signed up.

Ullmann said he expects the penalty for failing to enroll in coverage, which in 2015 is the greater of $325 or 2 percent of household income, will keep pushing the uninsured to sign up.

"I'm a strong believer in incentives," he said. "So you adjust the incentives and you watch the behavior change."

In 2016, the penalty will be $695 or 2.5 percent of household income, whichever is greater.

But Herrick, of the National Center for Policy Analysis, added that about 80 percent of the country's uninsured qualify for an exemption from the penalty, such as recently losing a family member. Only one in five people would be fined, he said.

Many, Herrick added, chose the cheapest plans which came with high deductibles, or the amount paid out of pocket before insurance kicks in, making access to anything beyond preventative care expensive.

"They may well find out that they don't have the care they thought they had," and drop out of the market, he said.

What's more, the subsidies that make insurance affordable are threatened by a Supreme Court case that could throw a monkey wrench into any healthcare enrollment.

King v. Burwell challenges a line in the ACA stating that only consumers who purchase coverage through an exchange established by the state, and not the federal government, will get financial assistance with their monthly premiums.

According to the Urban Institute, 1.07 million Floridians who signed up on its federally-facilitated marketplace in 2015 would become uninsured if the court rules to remove the subsidies.

Florida, the leader of enrollment, would stand to lose the most.

Follow @MHhealth for health news from South Florida and around the nation.

This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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