Obamacare in Knoxville

The deadline is almost here. So what's keeping people from signing up for health insurance?

Sheila Hayden put off venturing onto the government's health-insurance marketplace website for a couple of reasons. She's a busy student at Pellissippi State Community College, studying business hospitality, and says she usually doesn't get much of a break between 8 a.m. and 8 p.m. But she was also nervous.

"I was afraid there would be a possibility I'd have to pay a [high] premium. I was worried about the financial possibilities," she says. "That was the fear. Am I going to be turned down?"

Hayden, 58, had a job with benefits for 16 years before she was laid off during the recession. She tried to buy a COBRA health-insurance policy, but the monthly premium was $600 and just not feasible for her budget. So Hayden understood the basics of health insurance, and had even tried to sign up for TennCare a few years ago—but was told her husband's pension brought in just $5 too much for her to qualify. Hayden has a computer at home and Internet access, but she still decided to seek help from Certified Application Counselors who volunteer at enrollment events like the one held last Saturday at Mount Calvary Baptist Church.

"I probably could have [signed up myself], but I just feel like it was better to have someone to help me," she explains.

Inside Mount Calvary, about 30 people sat in chairs that lined a hallway off the main foyer. When people came in, volunteers with the nonprofit Tennessee Health Care Campaign handed them information forms to fill out while they waited for assistance from CACs. The forms asked for information that would be used to sign up for insurance on the marketplace. Then, in a small side room, five CACs had laptops set up at small tables where they could sit with an individual person and go through the entire process of signing up for an insurance plan.

The side room was quiet—most of the conversations were held in low tones as people recited their yearly incomes and Social Security numbers. When Hayden and the CAC assisting her determined she actually is eligible for TennCare, they both quietly cheered at their table. Hayden couldn't keep the smile off her face after she'd completed her application.

Hayden heard about the event—organized by the THCC—through her own church, Rogers Memorial Baptist Church, and brought one of her sisters along so that she'd also get signed up for insurance. And after spending about half an hour with a CAC, Hayden was able to sign up for TennCare. For people whose income qualifies them for Medicaid (which is called TennCare in Tennessee), their marketplace application is automatically sent to TennCare for processing. Assuming Hayden's TennCare application is approved, she said she won't have any monthly costs.

"Everybody needs to sign up," she says. "It's not as hard as it looks. It's not a hard process at all. It's easy. It's painless."

But not everyone who is eligible for health insurance through the Affordable Care Act ("Obamacare") insurance marketplace is signing up. The Kaiser Family Foundation estimates that more than 200,000 people in Tennessee are eligible to purchase plans through the marketplace and more than 100,000 are eligible for subsidized premiums. But as of March 1, only 77,867 people have signed up. Though rates of uninsured people are higher in Memphis (16 percent) and Nashville (11 percent) than in Knoxville (7 percent), there are still thousands of people in East Tennessee who, if they miss the March 31 open enrollment deadline, could face tax penalties of $95 or 1 percent of their income, whichever is highest.

So why are Knoxvillians who could find affordable insurance shunning the opportunity?


Co-pays. Out-of-pocket limits. In network, or out of network.

The language of health insurance isn't an intuitive one if you've never had the opportunity to buy a plan. That's one reason people have hesitated in signing up for insurance on the marketplace, says Carl Wheeler, a volunteer with the Tennessee Health Care Campaign. He estimates about 60 percent of the people he meets at enrollment events have never had health insurance, or haven't had a policy in a long time. And they don't understand the lingo enough to choose an appropriate plan.

"When you go to your employer, your employer says, ‘I've got Plan A and B.' And those are your two choices. In the marketplace, you've got 50, 60, 70 different options, three different companies. In my opinion, people don't seem to internalize what it means to select a plan," Wheeler says. "When I get ready to select a plan, I need to look at, ‘Do I have specialty doctors? How many times a year do I go to the doctor? Do I have specific medication?' What [people are] doing is going to the website and getting all this stuff dumped on them at once, and they're not ready for it, at least in my opinion."

Wheeler, a retired engineer who says he felt compelled to spread the word about the ACA, has been working with THCC for about a year, and spent much of last summer and fall helping explain the basics of health insurance. He'd attend rallies, set up booths at events like the Hola Festival, and handed out fliers at food pantries. In January, he started organizing enrollment events, where people could come and get face-to-face help in getting their marketplace account set up with THCC volunteers, and then get help from certified application counselors and navigators in actually selecting and signing up for a health-insurance plan.

THCC was started in 1989 as a social justice-type organization based in Nashville. It had a hand in expanding health-care coverage to low-income pregnant women and uninsured children in the 1990s, and has advocated on behalf of low-income Tennesseans who need access to health care since it was started. The organization relies on local organizing groups to carry out grassroots campaigns, the latest of which was getting the word out about the ACA.

But it's not just THCC that's been trying to encourage people to enroll in health insurance. Get Covered America is a national campaign arm of Enroll America, a nonprofit whose goal is to enroll as many people as possible in a health-insurance plan. Get Covered America's focus is on educating people about the ACA; it operates in 11 states, including Tennessee. The director of the Tennessee office, Tobi Johnson, is based in Knoxville. Organizing for Action, another nonprofit, is dedicated to advancing policies voted for in 2012, which includes the ACA, gun-violence prevention, climate change, and immigration reform. The organization is officially nonpartisan, but it's closely tied to President Obama's campaign team. Jim Messina, who was Obama's campaign manager in 2012, is the chairman of the organization, and Jon Carson left his Obama White House job to become the executive director of the organization. Its focus is also education, and it trains volunteers to go out and share facts about the law and how to sign up for insurance.

Knoxville Area Project Access is the only organization in Knoxville with federally recognized "navigators"—people who can help sign up for insurance. KAPA is sponsored by the Knoxville Academy of Medicine's philanthropic foundation, and partners with local entities like Cherokee Health Systems, the Knox County Health Department, the Interfaith Health Clinic, and the major hospitals in the area. They're the ones who were in the side room of Mount Calvary helping people actually sign up for insurance policies. There's plenty of overlap among these organizations—their navigators and CACs were at the THCC-organized enrollment event this past Saturday

For now, Wheeler says having eight to 10 volunteers helping "triage" folks who come to enrollment sessions—getting all their information and situations written down before they walk through the process—and then about four navigators and CACs has been working for the THCC events. As the March 31 deadline for open enrollment approaches, he expects turnouts to increase.

But Wheeler says that when people come in for help from the THCC, their knowledge of the ACA and health insurance in general is rather scant. And, he says, there are a few reasons for that.

First of all, he says, people don't seem to understand that the ACA is a law, which requires people to have health insurance or pay a tax penalty. And that misunderstanding, coupled with the general distrust of anything with the name "Obama" attached to it, leads to bad information spreading, Wheeler says.

"It is a red state. And the media hasn't really covered it [a lot]," he says. "If you ask people if they've heard of Obamacare, they'll say yes, because that's what you hear on the news, that's what you see on MSNBC, that's what you see on FOX, is Obamacare. If you ask them if they've heard of the Affordable Care Act? ‘No, I've never heard of that.'"

While he was handing out fliers with information about the ACA at the Fish Hospitality Pantry in North Knoxville, Wheeler spoke to one woman who said her husband didn't agree with Obama. Wheeler told the woman, "It would seem to me, regardless of who the president is, this is a law, and if I needed health insurance, I'm going to [do it]. We've got 435 members in Congress, and 100 people in the Senate—there's a whole lot of them I don't agree with, but I live within the laws they put on the books."

Tonya Sweet, who's worked with Cherokee Health Systems for about 14 years, was asked by her boss to become a CAC last year. She estimates she's helped about 500 people sign up for insurance on the marketplace since October. Sweet works in Claiborne and Grainger counties but spent the morning helping out at Mount Calvary. She assisted Sheila Hayden in signing up for TennCare. And, like Wheeler, Sweet says many people don't understand that the ACA and "Obamacare" are the same thing.

"I had a lady the other night say she was ashamed because it's Obamacare. I said, ‘It's Affordable Care Act insurance. It's Blue Cross Blue Shield. It doesn't say "Obamacare" across the front.' And I had another little lady say, ‘I don't want no part of that Obamacare.' And I said ‘Okay. It's also called the Affordable Care Act.' And she said ‘That's what I want,'" Sweet says.

Johnson, director of the Tennessee arm of Get Covered America, says she and her volunteers keep their conversations with people non-political, and she says conveying the basic facts about the ACA is what gets people's attention. Another one of the biggest misconceptions about marketplace insurance policies she hears from people is that it will be too expensive.

"We know that eight out of 10 people can get financial help. We know that half of people under age 35 can get a plan for less than $50 a month," she says. "When people go online [they] see ‘Oh, this is actually affordable!' Yeah, they don't call it the Affordable Care Act for nothing."

That lack of information, plus previous experiences trying to get insurance, can also discourage people from signing up for insurance.

"People have had the experience of getting screened out [for preexisting conditions], people have had the experience in the past of seeing the prices of upwards of $1,000 for a family. So they're like, ‘Oh, there's no way,'" Johnson adds.

But she wants to set the record straight: "You cannot be turned away. You could be in the middle of cancer treatment, and they have to give you a plan. That's a big deal."

But first they have to sign up, and even that can be a challenge for a segment of the population. Whether you sign up on the website or over the phone, you must have an e-mail address.

"You'd be surprised at how many people come in and sit down with them [to make an e-mail]. They don't even know how e-mail works," Johnson says.

And that could, in part, be due to a lack of access to a computer at home. Erin Hill, the executive director of KAPA, estimates that about 30 percent of people who seek help from KAPA do not have access to a computer at home.

But Hill says the part of the process that navigators at KAPA spend the most time on with people coming in for assistance is actually choosing an insurance plan.

"There's usually about 60 to 70 options for people to choose from, so it can be very overwhelming," she says.

Navigators can discuss individual health needs, prescriptions, whether doctor visits are frequent, and then help people choose a plan that will meet their needs. Still, Sweet says, "very, very few" people come to her with much, if any, knowledge of how the ACA or insurance works.

"They're just relying on our help to explain what it is, and what they're eligible for," Sweet says.

And, contrary to Hill's experience at KAPA, Sweet says about 80 percent of the people she helps do not have access to a computer at home.

"The other [20 percent]—the website intimidates them. They just need reassurance from someone to say ‘It's okay to press that button,'" she says.


The one thing absolutely no one, not even Obama, is saying is that the ACA and the website are perfect. Though the website has been repaired since its October crash, it can still prove to be a confusing place to navigate.

Rena Reeve attended the Saturday enrollment event after misunderstanding some information on the website, which she took to mean should apply for TennCare on TennCare's website. After getting frustrated and confused on the TennCare website, Reeve decided to get a little help from a real person.

"The people were very nice and helpful. It was as satisfying as insurance-related things can be," she says. "There wasn't anything confusing today. It was what I did at home [that confused me]. It was not clear. … When I got here today, she just said, ‘You don't have to do that.'"

And, she says, she recommends to anyone having trouble with the marketplace to look for enrollment events like the one at Mount Calvary.

"They should look for places like this where they can talk to a real person, who they can ask questions and get answers," Reeve says.

Stanley Madden has some direct experience with some bureaucratic inconveniences. He and his wife had chosen and signed up for a health-insurance policy on the marketplace in January. But when Madden's wife sent the insurance company their first premium payment, they were notified the amount on the check was short by 2 cents. Madden says the whole policy was canceled, and he had to re-apply through the marketplace.

Madden works as a custodian at Mount Calvary, so he dropped in before he had to get some tables set up for a wedding there. He says he was able to get a silver plan that fits into his family's budget after going about six months without insurance. (COBRA premiums were too costly.)

"I knew it was getting close to the deadline, and I had to do what I had to do," he says. "They were very helpful and kind [here]. There's a lot to know, and a lot of processes. I wish I'd known [more] about it before."

Tonya Sweet, the CAC who was working at the enrollment event, says that even though the website was built with more computer-savvy folks in mind, she sees no reason for people not to get signed up for insurance.

"We're out there to help. It shouldn't be an excuse to not have insurance. We're only a few and all that, but we've already seen lots and lots of people," she says. m

The open enrollment period for insurance through the marketplace ends March 31. People without insurance after that will have to pay a penalty when they file their taxes in 2015. The next open enrollment period starts Oct. 1.