Getting people to sign up for health insurance under the Affordable Care Act remains an uphill battle in much of Florida.
Politicians in the state erected roadblocks to the law from the beginning — from joining in the 2010 lawsuit to thwart the law to placing restrictions on what insurance helpers called navigators can tell people seeking advice.
Even so, advocates have been trying to get the word out to an estimated 1.6 million Floridians who qualify for new subsidies to make coverage more affordable. Florida has the second-highest rate of uninsured residents in the U.S., yet it seems many who could benefit the most aren't interested in listening.
The message will be hardest to get across, many say, in the Florida Panhandle, where sandy white beaches on the Gulf Coast back up to vast pine forests. Towns are small and scattered. The area is closer both politically and geographically to neighboring Georgia and Alabama than faraway Miami.
At local events like the recent Florida Forest Festival and the self-proclaimed World's Largest Free Fish Fry in Perry, it's not hard to find people like Elijah Mott, an itinerant heavy equipment operator who says he doesn't know much about the health care law, and that most of what he's heard is bad.
"I think it sucks," he says.
The median household income in this county is about $40,000 a year. Lots of jobs here don't come with health insurance. That means many here like Mott, who doesn't have steady work at the moment, probably qualify for subsidies to help them afford coverage.
But Mott isn't buying the idea that the health law could possibly be good for his family. "I would have to say no," Mott says, "I haven't investigated deep enough to know if there is anything."
Mott and 41-year-old Michael Dees of Mayo, who works in a paper mill, have mostly heard that Obamacare is going to increase the price of health insurance, making it more unaffordable for people like them.
Dees says he expects to be laid off soon, and worries about how he's going to buy coverage for his family.
"Who can afford $700 a month?" he asks. "It's easier to pay for the damn penalty at the end of the year the IRS is going to charge you than pay $500 a month."
Dees says it's news to him that the health law offers people making less than $45,960 a year help paying monthly premiums.
"I really hadn't heard about the subsidy," he says.
Guys like Dees and Mott are exactly who health law advocates like Karen Woodall are trying to reach. A longtime lobbyist for children's and family issues in Florida's capital, Tallahassee, she says it's tough to convince people here that the law might help them.
"It's challenging to overcome messages that are coming out of elected officials' offices and a governor's office," she says.
Florida said no to both the law's Medicaid expansion, and to tens of millions of dollars to advertise new subsidies for those with incomes between 100 and 400 percent of the federal poverty level
Privately funded groups like Enroll America are trying to supply the outreach and education in Florida. That includes partnering with churches like the Sanctuary at Mt. Calvary in urban Jacksonville, on Florida's Atlantic coast about three hours east of Perry.
Pastor John Allen Newman invited Enroll America representatives to address his congregation one recent Sunday. From the pulpit, he warns his flock of several hundred against misinformation he says opponents of the law are spreading.
"People perish for what?" he asks.
"Lack of knowledge," comes the practiced response.
Newman tells congregants that the law helped him get coverage after a large private insurer turned him down because of a pre-existing condition. "This Affordable Care Act is saving lives," he says.
The message hits home with 23-year-old truck driver Anthony Person. "I never knew what it was before until I started coming to this church," Person says. Pastor Newman, he says, "started explaining it to us the way I could understand it."
Person left his contact information at the Enroll America table in the church's lobby to get help signing up for new Obamacare coverage.
"My job is one that does not have the best benefits, so I need health insurance to cover myself," he says.
And then, there are those who might just fall through the cracks.
Back in the Panhandle, Karen Ray wishes subsidies to help working people afford coverage had been available when she was running her small business out of Delray Beach.
"There hasn't been a realization how many people out there are the working poor," she says, "working hard and not getting health care. And just living paycheck to paycheck and hoping nothing goes wrong."
Things went wrong for Ray in a big way after the BP oil spill in 2010.
"I had a beach wedding business, and it kind of went downhill after the oil spill," she says. "I've just been trying to get back on my feet since then."
Even before the oil spill, her business never generated enough income to provide health insurance, says Ray, 60. She used to get coverage through her husband's job.
"I lost my business, and my marriage and my house, at the same time," she says, laughing wryly.
That's left her uninsured. She knows about the law — and she also knows that because she lives in Florida, she is unlikely to benefit from it.
If Ray lived in one of the 25 states expanding Medicaid, she would qualify for new coverage. But because Florida isn't expanding, being poor alone isn't enough to get Medicaid here. Benefits here are reserved primarily for children, pregnant women and the disabled.
And because Ray has no income, she won't qualify for new Affordable Care Act tax credits designed to help the working poor afford private health coverage.
"I could maybe scrounge up the money to go get a mammogram. What if it comes back positive? What happens to me? It's not like you can show up in the emergency room and say, 'Ooh! I have an emergency lump!' That won't happen," says Ray.
"I think a lot of us are gonna fall through the cracks," she says, "and I'm very irate about that, very irate about that."
This story is part of a partnership with NPR and Kaiser Health News, with support from the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism's California Endowment Health Journalism Fellowships.
MELISSA BLOCK, HOST:
From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.
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The success of the Affordable Care Act depends in part on a handful of big states with large uninsured populations. Near the top of that list is Florida. The northern part of the state ranges from urban Jacksonville to beaches on the Gulf of Mexico, to the pine forests of the panhandle. The region has more in common with neighboring Georgia and Alabama than Miami or Tampa Bay. It's conservative and, economically, people are struggling. As Eric Whitney reports, politicians there actively oppose the health care law, even while many of their constituents are uninsured.
ERIC WHITNEY, BYLINE: The PanCare community clinic for the uninsured in Freeport, Florida takes care of people who take care of tourists. It's just off the Gulf Coast on what a lot of people call the Redneck Riviera. People who come to this clinic make a living cleaning hotel rooms, guiding fishing trips, working in restaurants. Small businesswoman Karen Ray is here to see about becoming a patient. Her business never made enough money to provide health insurance.
KAREN RAY: There hasn't been a realization how many people out there are the working poor - working hard and not getting health care and just living paycheck to paycheck and hoping nothing goes wrong.
WHITNEY: Ray used to get health insurance through her husband's job, but then things went wrong for her in a big way after the BP oil spill in 2010.
RAY: I lost my business and my marriage and my house all at the same time.
I had a beach wedding business and it kind of went downhill after the oil spill. And so I've just been trying to get back on my feet since then.
WHITNEY: Ray has a claim into BP for compensation but has been out of work and uninsured since the oil spill. She hopes the Affordable Care Act will help her get covered again but isn't sure it will at this point.
RAY: I fear because of my income level that I'm going fall through the cracks.
WHITNEY: In the 25 states that expanded Medicaid under Obamacare, anyone making less than about $16,000 a year now qualifies for Medicaid. Florida is not one of those states. And Ray doesn't make enough to qualify for one of the health law's tax subsidies to buy private coverage. That means she'll remain uninsured and have to get by with what health care she can afford.
RAY: While I could maybe scrounge up the money to go get a mammogram, what if it comes back positive? What happens to me? It's not like you can show up in the emergency room and say, oh, boy, I have an emergency lump. That won't happen.
WHITNEY: But where the law fails some in Florida, it offers hope for others. An estimated 1.6 million people here are eligible for subsidies to help them afford health coverage, but they may not know it.
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WHITNEY: Five hours drive from Freeport, over on the Atlantic coast, is urban Jacksonville, and the Sanctuary at Mt. Calvary Church. It's equal parts high energy celebration and sober reflection. When Pastor John Allen Newman steps into the pulpit, he encourages his congregants to learn more about the national health care law.
JOHN ALLEN NEWMAN: There's a lot of disinformation that goes on about this Affordable Care Act because there are people who want it to fail. There are people who believe that this is a giveaway for lazy people who don't want to work. But the truth of the matter is, is that this Affordable Care Act is saving lives.
WHITNEY: Pastor Newman has invited representatives from the nonprofit Enroll America to set up a table in the lobby of his big church. A couple of dozen congregants drop by and leave their contact information so an enrollment specialist can follow-up with them later. Among them is a young, uninsured truck driver. Walking with his fiancee out to their car, he says he doesn't know much about the health care law.
ANTHONY PERSON: My name is Anthony Person, and I'm from Jacksonville, Florida. I never knew what it was before until I started coming to this church and he started, you know, explaining it to us the way I could understand it, so...
WHITNEY: Person says he doesn't know all the law's details, but if it means affordable health coverage, he'll be grateful.
PERSON: I need the coverage because my job is one that does not have the best benefits. So I need health insurance to cover myself.
WHITNEY: Enroll America has private backing to publicize the health care law in Florida. States that embraced the law got government grants to do that but Florida's political leaders turned those down. Advocates here say that makes it harder for people who qualify for benefits under the health law to get them. And not everyone in Florida who might qualify for help getting health insurance buys the idea that Obamacare could possibly be good for them.
KAREN WOODALL: The challenge is greater because we haven't availed ourselves of additional resources that would mean that we could have more people on the ground and increase the outreach.
WHITNEY: Karen Woodall is a longtime lobbyist on children's and family issues in Florida. She says most outreach resources are concentrated in Florida's cities. She worries that pro-enrollment messages won't reach rural Florida.
WOODALL: It's challenging to overcome messages that are coming out of elected officials' offices and the governor's office.
WHITNEY: Anti-Obamacare messages resonate in small towns like Perry, on the panhandle a couple of hours back inland from Jacksonville.
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WHITNEY: There's a parade down Main Street today celebrating the local timber industry. Perry is in Florida, but it's more like Mayberry than Miami. Think pine trees, not palm trees. Florida Forestry queens ride on floats in ball gowns and tiaras. Fire engines and 18-wheel log trucks bring up the rear.
After the parade, what's billed as the world's largest free fish fry draws thousands to a local park. This county has one of the highest uninsured rates in Florida. Fewer than one in three people here have health coverage. Not a lot of jobs around here offer health insurance. Elijah Mott works those kinds of jobs.
What do you think of Obamacare?
ELIJAH MOTT: I think it sucks.
WHITNEY: You don't think there is anything in it that would help you and your family out?
MOTT: I honestly can't say. I haven't investigated deep enough into it to know if there is anything, but I would have to say no.
WHITNEY: Mott doesn't have a steady job at the moment. Michael Dees does at a paper mill, and it comes with insurance but he's heard he'll be laid off soon. He'll need some other way to get coverage then. Dees says he doesn't know much about Obamacare either, but he's inclined not to like it. Mostly he's heard it's making health insurance too expensive.
MICHAEL DEES: Who can afford $700 a month? It's easier to pay for the damn penalty at the end of the year that the IRS is going to charge you than pay $500 a month.
WHITNEY: Dees and Mott are both married and have kids. Most households around here make less than $40,000 a year, meaning many qualify for Obamacare tax credits to reduce monthly insurance bills. That's news to Dees, who doesn't expect it to save him money.
DEES: Really, I don't think that subsidy is going to lower it that much. Because I really hadn't heard about the subsidy, I really hadn't researched it because I hadn't needed to, you know, this Obamacare - just to see how much it's going to cost me.
WHITNEY: Guys like Michael Dees are exactly who advocates like Karen Woodall want to reach. She's now recruiting volunteers to tell people in rural Florida they may qualify for benefits under the law.
WOODALL: It's not going to be necessarily people responding to a TV ad or a newspaper ad. It's going to be that personal contact. That's why it's so important to work with trusted individuals that they know in their communities.
WHITNEY: Problems with the HealthCare.gov website Floridians are supposed to use to get benefits aren't helping Woodall's efforts. But she says there's still plenty of time for people to sign up and what resources Florida has to do that are just now being put into motion. For NPR News, I'm Eric Whitney.
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