They're tasked with spreading the word about an initiative that state leaders have strongly denounced and refused to promote. On Tuesday, so-called navigators and other trained personnel across Texas will begin seeing how many of the state's 6 million uninsured will seek coverage through the health insurance marketplace during the next six months.
The response in Texas' Rio Grande Valley -- which has some of the nation's most impoverished communities and more than 300,000 people eligible for coverage through the new law -- will be a closely watched gauge of how well the Affordable Care Act aids its intended targets.
"We will become the poster child for why a comprehensive health plan is a great idea, because you look here and say, `Oh my god, it's diabetes, it's preventable and it's treatable, but you have to do both consistently and cannot do that without a medical home or a health plan," said Michael Seifert, of the RGV Equal Voice Network, a coalition of 11 community organizations in the Rio Grande Valley.
Hidalgo County, located along the Mexican border, has the highest rate of uninsured among urban counties in the country with about one in three people lacking health coverage. Here diabetes and other obesity-related diseases run rampant and often unchecked until reaching the critical stage.
But the health care overhaul is expected to have a major impact across the state, which leads the nation with about a quarter of its population lacking coverage. Millions of Texans will qualify to shop among the subsidized health plans in the marketplace, but some of those will fall into the gap created by Texas' refusal to expand Medicaid and not be eligible for subsidies on the private plans. Those who don't qualify may be able to get one of a number of exemptions from a federal fine affecting those who aren't covered next year.
The Valley's well-established network of community health workers will be a key element in guiding people through the process. Many have already undergone training to work as health care navigators or certified application counselors -- the program's front-line guides for the new system -- and know where to find those most likely to benefit. In the coming months they will carry information into those neighborhoods, explain the system to those already seeking care in community health centers and try to have a presence at a range of community gatherings.
Whether the navigators have the resources to handle the workload during the six-month enrollment period remains to be seen. The groups anticipate the flow of people seeking assistance will be spread out over the coming months. And some hospital staff, insurance agents and others will also be prepared to assist.
"If every single uninsured person in the Valley sought in-person assistance from a navigator or certified application counselor, no, we wouldn't have sufficient capacity," said Rachel Udow, interim program director at Migrant Health Promotion, which received a federal grant to train navigators. "But I think we expect that ... some people may just choose online chat to get their questions answered, some people may log into the marketplace and not seek any assistance, others may try the call center. So it really depends."
Migrant Health Promotion is training seven navigators and preparing a broader outreach campaign in the four-county Valley. Centers for Medicare and Medicaid Services could not provide a statewide total for the number of navigators and counselors who would be trained in Texas, but estimated the number of those providing in-person assistance would be in the thousands with more added as the enrollment period progresses.
Under the Affordable Care Act, states were supposed to expand Medicaid while developing marketplaces where those who made too much to qualify for Medicaid -- but couldn't get coverage through their employers -- would be able to shop for subsidized private coverage. Others could buy plans through the marketplace, but without the subsidy.
Those who pick their plans by mid-December should begin receiving coverage Jan. 1. After that, coverage will start several weeks after enrollment, which runs through the end of March.
In Texas, there will be 54 private health plans offered in the marketplace, with a varying number of those available to people living in different parts of the state. The average premium for the benchmark lowest-cost silver plan will be $287. A 27-year-old in Texas who makes $25,000 per year would pay $83 per month for the lowest cost bronze plan or $145 per month for the silver plan, once tax credits are calculated. For a family of four in Texas making $50,000 per year, the lowest bronze plan would cost $57 per month. Those amounts will vary across the state.
About half of Texas' uninsured are employed but not receiving coverage through their jobs, according to data from the Texas Health and Human Services Commission. The state's Medicaid program is especially restrictive covering mostly children and the disabled. It does not offer coverage to single, childless adults.
This includes 22-year-old Ash Estevan of Pharr. In June, she and one of her older brothers were in a car accident and didn't have health insurance. Both were taken to the emergency room and live in fear of the day the bills arrive.
"I can't imagine what an actual ride in the ambulance to the ER (costs) and we had tests done, we had X-rays and a CAT scan and everything done so I can only imagine the damage," Estevan said. "And it's pretty frightening, because it's not just one; it's me and my brother."
Estevan initially saw the health care overhaul as a chance for her family to get covered. But as a single woman with a part-time job stocking store shelves, she expects she will fall into the gap created when Gov. Rick Perry and the Texas Legislature refused to expand Medicaid.
Perry has maintained Medicaid is broken and refused to commit any additional state funds necessary to draw additional money from the federal government.
More recently he instructed the state's insurance commissioner to enact stricter rules for training those who will help enroll people in the marketplace, drawing accusations of interference from federal health officials. Certified application counselors and navigators are concerned it could have a significant impact on their efforts but are waiting to see how it unfolds.
The state's actions against the health care plan infuriate Estevan. She has protested at the Texas Capitol and volunteered with the Texas Organizing Project to canvass neighborhoods or work in a phone bank to encourage people to enroll in the marketplace.
"It's really scary waking up and not knowing," Estevan said. "All you have to go off is, `I look OK, I feel OK today,' but sometimes there's just stuff that's wrong with you that you don't even realize or see until it's too late."
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