Carol Cain tries to ignore the two lumps in her throat, but some days it's hard because they swell and are tender to the touch.
The 59-year-old, who makes a small income watching her grandchildren, hasn't seen a doctor about the problem because she has no insurance and can't afford to pay. She was on a state health plan for low-income adults for a while, but it only covered primary care.
"Now I doctor myself and hope everything works out," said the tall woman with thick dreadlocks pulled back by a headband.
Cain is just the kind of person being targeted as Maryland prepares for the nationwide health care reforms known as Obamacare — but she also illustrates the challenges of a burgeoning outreach campaign. Some Marylanders have let health problems fester. Others rely on hospital emergency rooms for basic care, an approach that drives up health costs.
Many remain skeptical about the impact of the complex new law or believe that it will be too costly. Outreach workers also have encountered misperceptions about the law, including suggestions that it has been repealed. And some Marylanders have embraced rumors, including claims that home sellers will have to surrender some of their profits to pay for the law.
In Washington, the health care law is still being hotly debated. The Republican-led House of Representatives approved legislation Friday that would strip funding from the law, as part of broader federal spending legislation. But Democrats who control the Senate say that is not an option — creating a stalemate on federal funding overall and raising the possibility of a government shutdown in October.
Most people who get health insurance through their jobs won't see a change under Obamacare. But hundreds of thousands of uninsured will have access to insurance through a state exchange — or pay a penalty if they choose not to buy it. Supporters of the measure say that when everyone gets regular care, it will drive down health costs.
As Oct. 1 nears — the day people can begin enrolling in health plans through the state exchange — an army of educators is hitting festivals, neighborhood association meetings and other community events to reach the estimated 750,000 uninsured in Maryland. In the coming months, libraries will target patrons as they come to check out books, hospitals will tell patients who seek care and churches will preach health reform to their congregations.
Others are treating it like a political campaign, canvassing neighborhoods and stopping people as they walk down the street or wait at a bus stop.
"We can't assume that every person is paying attention and understands what is available," said Vincent DeMarco, president of the Maryland Health Care for All Coalition, an advocacy group. "We have to get the message out there."
Cain was at a festival in the Pennrose Fayette Street Outreach neighborhood in West Baltimore when she was stopped by Lynera Gregory of Health Care Access Maryland Inc., which is helping to promote health reform in the state.
"Do you have insurance?" Gregory asked. "Because health reform is coming and you may be eligible if you're not covered," she continued, thrusting a flier into Cain's hands. Cain learned that she might qualify for free health insurance through Medicaid and finally get to see a doctor about her throat problem.
Outreach workers are discovering that Cain isn't the only one confused about Obamacare. And they're hearing many reasons why health reform isn't on everyone's mind. Some worry more about paying bills. Many don't understand the details of the law or assume they don't qualify for insurance.
The hardest people to reach are those who aren't connected to community groups or social services networks, said Kathleen Westcoat, CEO of HealthCare Access Maryland Inc.
At the West Baltimore festival sponsored by Bon Secours Hospital and two local churches, Annette Wilson, 60, said she planned to stick with her health plan with Priority Partners, which manages government-funded plans for low-income Marylanders. "It's been good for me," she said. "I know how it works."
But she perked up when told by an outreach worker from Baltimore Healthy Start Inc., which promotes the health of babies, that she would probably be moved to Medicaid under the new law and get better coverage. Wilson is among 81,000 enrollees in Maryland Primary Adult Care, a limited program for low-income adults that will get rolled over into Medicaid under reform.
"It's not the best coverage," Wilson later acknowledged about her current insurance, which she said covers only primary care visits.
Then she got skeptical about health care reform.
"It's free?" she asked. "What's the catch?"
Her skepticism reflects concerns about the law, which has proved controversial. Questions persist about how the government can afford to pay for insurance for millions of people. Businesses have complained that they can't afford to offer insurance as required by the law. Amid the criticism, the Obama administration delayed a corporate mandate — employers with 50 or more full-time workers were supposed to provide coverage or incur penalties beginning Jan. 1, but the requirement will now begin in 2015.
At a recent meeting of the Brooklyn Park Community Association in Anne Arundel County, many of the elderly members seated in the library of the local elementary school wondered whether they could keep their coverage under Medicare, the federal health program for senior citizens. They were told that they could and that coverage wouldn't change for them.
Paul Kowalski,80, a retiree from the rail giant CSX Corp., had other concerns. He has Medicare and his insurance coverage won't change, but that didn't stop him from peppering representatives from Rep. C.A. Dutch Ruppersberger's office with questions.
Kowalski had heard that doctors would have to get permission to perform surgeries from bureaucrats in Washington with no medical experience and that anyone who sells a house would have to give part of the proceeds to the government to help fund health reform.
"No, no, no, that is not right," said Jennifer Riggs Driban, a Ruppersberger district director.
Outreach worker Bernard Turner has heard other myths — the most outrageous being that the law requires people to get a computer tracking chip implanted in their bodies.
Enrolling Marylanders in insurance plans is key to the success of Obamacare, supporters say. The uninsured don't get basic care and often seek treatment in hospital emergency rooms — which is more expensive — when preventable health problems fester. Reform advocates say regular care will promote a healthier population and drive down costs.
Turner, 55, is reaching out to residents on behalf of Evergreen Health, a co-op being started by former Baltimore Health Commissioner Peter L. Beilenson.
Turner and others also pass out fliers about the expansion of Medicaid to those who they think might qualify. On a recent Thursday evening, he and co-worker Grace Jackson succeeded in reaching out to seven people on one block and collected phone numbers for follow-up as they knocked on doors in the Bel-Air Edison neighborhood in Northeast Baltimore.
Malcolm Grimes, 32, a special events coordinator at a local museum, was about to leave for work when Jackson knocked on his door. He has no insurance and hopes he doesn't get sick. But he goes to a hospital emergency room when he does.
Grimes figured that he would qualify for insurance under Obamacare but wasn't sure how to sign up and worried that it would be too expensive. He said the information he got from Jackson and Turner would help point him in the right direction.
Turner and Jackson also talked to people as they walked down the street or hung out on the corner.
"We don't let anybody walk by," said Turner, who says that having insurance should be a basic human right.
Curtis Brown, 51, was carrying groceries down the street when the pair stopped him.
"If you don't have affordable health insurance, we have a path for you," Turner said.
Brown, a food service worker at a university, doesn't have health insurance and didn't know he could get it under the federal law. He was grateful to learn that he might finally get to see a doctor regularly. Brown said he doesn't get sick often, so he hasn't worried too much about the lack of coverage.
Every now and then he has to go to the emergency room, he said, but he doesn't have money for treatment.
"I can't afford to pay, so I just don't," he said. "I don't know what happens to the bill."
The state's 183 public libraries will pass out fliers and help clients find information about health plans. Some people will likely use library computers to sign up for insurance.
"Librarians are trained to help people do their research," said Paula Isett, who does public relations for the state's libraries. "Librarians are trained to assist people, and that is why this is a perfect connection."
Bon Secours Hospital in West Baltimore serves a largely low-income population who wind up in its emergency room because they have no basic health care. Because of that, Bon Secours officials say the hospital is a logical place to encourage people to get insurance.
"This is really about reaching people where they are," said Dr. Samuel L. Ross, CEO of Baltimore Bon Secours Health System.
Outreach efforts will intensify when open enrollment begins Oct. 1. It will be more effective to reach people when they can actually sign up, outreach workers said. They know they won't sway everybody. But they said they will try.
In Brooklyn Park, Kowalski wasn't convinced by Driban's answers. The government needs to make money in certain ways, such as taking a portion of home sales to pay for Obamacare, he insisted.
"I don't believe her," he said after the meeting. "If they are going to provide all these people with free care, they are going to have to have some way to pay for it."