Carolyn Artes was in the middle of her shift ringing up customers at Stop & Shop when she felt a wave of light-headedness. Her pulse quickened and she braced herself for a fainting episode.
But Artes stifled her impulse to seek medical help, and turned down colleagues’ offers to call an ambulance. The 56-year-old West Haven resident has been uninsured for years.
“I wouldn’t let them call because I can’t pay for it,” she said recently, remembering the frightening ordeal eight months ago. “I’m not going to go to the emergency room because I can’t pay for that.”
Artes used to have health insurance, but her employer stopped offering it to part-time workers years ago, she said. She has a second job, which pushes her earnings above the qualifying limit for state-subsidized coverage. And Artes is skeptical that she brings in enough money to buy private insurance and still pay her bills.
“I’m not going to go to the emergency room because I can’t pay for that. I always worry about my health.”
West Haven resident Carolyn Artes
That means she postpones regular check-ups, forgoes medications and avoids trips to the emergency room.
“I always worry about my health,” she said. “My daughter works, and before she gets home I’m here with my grandson. I think, God forbid, if something ever happened to me, what would happen to him if he were here alone?”
With open enrollment for 2020 health plans set to begin Friday, employees at Access Health CT, the state’s insurance exchange, are exploring new ways to reach people like Artes who don’t have coverage.
Connecticut’s uninsured population dipped last year – to 5.3 percent, down from 5.5 percent – bucking a national trend, according to Census figures. Many states saw an increase, and the national uninsured rate also jumped, to 8.5 percent, up from 7.9 percent.
But nearly 187,000 Connecticut residents still lack coverage, a data point that is troubling state health officials. Low income families and people of color are more likely to be uninsured here, the figures show.
“Even though we are proud of the low uninsured rate, this is more than just a number,” James Michel, head of Access Health, said recently. “It stands for people out there who still need our help.”
To reach residents, officials at the exchange analyzed census tracts and focused on areas with high rates of uninsured people. They began in Hartford, targeting some of the city’s most impoverished North End, South End and central neighborhoods.
Taking a page from politicians, Access Health hired workers to “canvass” homes in those areas – knocking on doors to chat with people about the range of health plans, state subsidies and other available services.
The organization identified 7,500 to 10,000 residences in Hartford it plans to visit. The effort began earlier this month with a series of mailers sent to homeowners letting them know workers would be in their neighborhoods. The exchange also reached out to small businesses and left posters about open enrollment at 150 or so establishments.
Then the door-knocking began. At its Oct. 19 meeting, Access Health officials said they already had visited 6,000 homes and spoken to about 1,000 people. They left literature behind when no one answered the door.
Andrea Ravitz, marketing director for the company, said the aim wasn’t to persuade people to buy plans on the exchange. The group is trying to help residents navigate the complicated system of obtaining coverage, whatever path that might take.
That could include a referral to the Department of Social Services or another agency, she said. It’s also getting the word out about open enrollment.
“Buying insurance, it’s kind of the end result. For some of these individuals … they might have a language barrier or a cultural barrier that we need to be able to understand, to be sensitive about before coming in with the, ‘Here’s what you should do. This is what you should purchase,’” she said. “We have to go back to really understanding their needs.”
As the program expands to other cities – there are plans to begin canvassing in Bridgeport, Norwalk and Fairfield next month – health officials are taking a closer look at why a segment of Connecticut’s population has remained uninsured.
Who is uninsured, and why?
Since the Affordable Care Act was adopted in 2010 and Connecticut set up its health exchange three years later, the state’s uninsured rate has plunged. When the federal law passed, Connecticut’s uninsured rate hovered around 9 percent.
But despite the progress, state officials are concerned about the tens of thousands who are still without coverage. That includes low-income families, legal immigrants who are not citizens, families with a mix of immigration statuses, non-English speakers, and people of color.
Data show Connecticut residents who identified as black or African American are one-and-one-third times more likely to be uninsured compared to the total population. People who identified as Hispanic or Latino are two-and-a-half times more likely to be uninsured. And households earning between $25,000 and $49,999 are one-and-two-thirds times more likely to lack coverage.
Undocumented residents are nearly five times more likely to be uninsured, Census data show, because their status makes them unable to secure coverage.
Access Health reached out this year to people who don’t have insurance and others who recently obtained coverage to examine the barriers and motivating factors in signing up for health plans.
The reasons for being uninsured are myriad, but a study commissioned by the state’s exchange shed light on some of the common causes. Assuming that coverage is unaffordable, being unable make monthly payments, believing insurance is a bad deal and having a personal plan for self-care, being ineligible for assistance or priced out of the market, and having difficulty obtaining information are among the top reasons, the assessment concluded.
Some people found themselves without coverage due to the loss of a job, a divorce, or because a boost in income made them ineligible for state subsidies.
Barriers to insurance include insufficient wages, coverage that is unaffordable and a lack of access to relevant resources. People also reported bad experiences with insurance companies and brokers who attempted to sell or market plans “at every step in the decision process,” Access Health noted.
The group’s findings mirrored national studies and first-hand accounts from health workers in communities that serve the neediest people.
At Charter Oak Health Center in Hartford’s Frog Hollow neighborhood, Jennifer Stewart said affordability is the biggest issue for those who are uninsured.
“For some patients it’s, ‘I have to make a choice between having a shirt over my head and providing food, or this – and I don’t have to do this,’” she said.
Some people will sign up, but later drop the coverage as their work hours are scaled back or their annual earnings are reduced.
“They might start off paying it and then afterward, seeing perhaps the burden of it, they will stop,” said Stewart, who oversees enrollment at the health center. “But we always encourage them to enroll. You might be healthy today, but you don’t know what will happen tomorrow.”
Community Health Services, a federally qualified health center in Hartford’s North End, has seen more uninsured patients in recent years as the cost of plans has gone up and the individual mandate requiring coverage was eliminated. The center won’t turn anyone away – those who don’t have insurance are charged a fee on a sliding scale based on household income.
“The premium for a health plan might have been $100 a month and now it’s $200 or $300,” said Judy Tallman, director of grants and outreach at CHS. “If it’s food or insurance, people are going to go for food.”
Some residents have opted against insurance after hearing about proposals by the Trump administration. The attack on the Affordable Care Act and a new rule supported by the president that would impose serious impediments to legal residency for people who use benefits such as Medicaid have created a chilling effect, health officials said.
Courts in several states recently blocked the so-called “public charge” rule, but the proposal already stoked fear in immigrant communities.
“There is a fear for many of those families of being found out or of being labeled a public charge, even though we know accessing health insurance, food and nutrition services has not necessarily been counted for public charge,” said Liany Arroyo, health director for the city of Hartford. “There is still that fear and I think it has become more heightened.”
“The premium for a health plan might have been $100 a month and now it’s $200 or $300. If it’s food or insurance, people are going to go for food.”
Judy Tallman
Director, Community Health Services
At Community Health Services, Eligibility Specialist Zenia Camp said a woman recently came in seeking assistance for her family after terminating their health coverage.
“She was afraid that having HUSKY would not allow her to be a citizen in the long run,” Camp said, referring to Connecticut’s Medicaid program. “I have families that qualify for food stamps for their kids and they will not apply if they think their immigration status will be in jeopardy.”
Advocates called for better education and outreach to the uninsured. Even for sophisticated customers, the system is complex and difficult to navigate. And many people don’t know what they qualify for or what’s available.
“Insurance is complicated and figuring out what you need and how to access it can be complicated,” Arroyo said. “There is generally a lack of information about the process and how to go about it.”
Officials at Access Health are using their study to come up with new strategies for reaching the uninsured.
Fresh attempts
Along with an expanded canvassing program, the state’s health exchange has started to host Tupperware-style parties at people’s homes – gathering family and friends together to talk about insurance and the importance of preventative care.
“We pay the host to bring their friends, their families, their influencers and have a conversation about health insurance and help us spread the word,” said Ravitz, Access Health’s marketing director.
That effort will soon move to local businesses. Gatherings will be held in barbershops and other small companies that are pillars of their communities.
The exchange is also boosting its number of enrollment fairs to 30 – up from 11 last year – given its success in attracting people for one-on-one conversations.
Officials are looking at ways to reach people during key points in their life – showing up at unemployment offices, hospital emergency rooms, faith-based institutions and divorce attorneys’ offices, among other places. That might include partnering with the state’s public health department, the labor department and local housing authorities.
Access Health employees developed a tool using Census data to focus on neighborhoods with high rates of uninsured people. And Access Health is designating workers to help people navigate the enrollment process from start to finish.
“Individuals may end up in our call center three or four times because of various stop points or misunderstandings and just complexities with the process,” said Robert Blundo, director of technical operations and analytics at the exchange. “We think that if we can connect them with one individual who is a more personalized agent to work them through it, it may actually amount to a lower interaction time and just make it more efficient.”
Uninsured residents said the new strategies might prove helpful during open enrollment. Kara O’Dwyer, Artes’ daughter, liked the idea of having step-by-step assistance when exploring options for her mother.
“If you’re not an insurance agent, you don’t really know what to look for or how to figure out what’s going to work for you,” she said.
Astrid Lopez, a Stratford resident who’s been without coverage for about three years, said she would try again this fall to find an affordable option. Lopez said her household income makes her ineligible for a state-subsidized plan and she can’t afford the insurance offered by her employer.
“It’s very hard. I try to do the regular checkups, physicals and follow-ups, but sometimes I just postpone it. I don’t have the money and I don’t have insurance.”
Stratford resident Astrid Lopez
She hopes to find coverage that would fit her earnings, but she’s been discouraged by previous attempts.
“It’s very hard,” said Lopez, 49. “I try to do the regular checkups, physicals and follow-ups, but sometimes I just postpone it. I don’t have the money and I don’t have insurance.”
Artes, the Stop & Shop worker who lost her insurance years ago, said she might take another crack at trying to sign up for a plan that fits her budget. She is dealing with high blood pressure, asthma, and aches that come from lifting and caring for patients in her second job as a home care attendant.
“I need to get some medical care. I haven’t been to the doctor in years,” she said. “I just don’t feel well a lot of the time. I know it has a lot to do with running around. And I’m no spring chicken anymore, you know?”