Three years after the launch of the state's health insurance exchange under the Affordable Care Act, three in five of Maryland's eligible uninsured still lack coverage.
Despite the state's outreach efforts — and penalties imposed on those who don't buy health plans — officials acknowledge that they are having a hard time reaching most residents without insurance.
While nearly 162,000 previously uninsured people have enrolled in private health plans, the Maryland Health Benefit Exchange says another 240,000 Marylanders, or 60 percent of eligible state residents, remain uninsured.
Maryland has made more progress than most states. A recent survey by the Centers for Disease Control and Prevention found that the national uninsured rate fell to 9.1 percent in 2015. In Maryland, the uninsured rate was 6.9 percent.
"The problem we are trying to address has been intractable for a long time," said Carolyn Quattrocki, executive director of the Maryland Health Benefit Exchange. "People who have dealt with this issue for a long time think this is great progress for the amount of time we have been at it."
Those involved with enrollment believe this hard-to-reach population includes a broad range of people with many reasons for not getting insurance.
They might think they can't afford it. They might find the process daunting. In some cases, they might not even know that health insurance options are available to them.
They include farmers and watermen on the Eastern Shore and immigrants in Ellicott City who know little about health care reform. Some are political conservatives who are philosophically opposed to the mandate and believe they should not be forced to buy insurance.
David Bozowski doesn't have health insurance. The 39-year-old Baltimore sous chef said he rarely gets sick. When he does, he says, he treats himself with Nyquil, Airborne, echinacea and other over-the-counter drugs or natural herbal supplements. He saves money for the rare times he has to go to the doctor.
Even though federal law requires all Americans to have health insurance, Bozowski has many reasons for not getting it. For one, he doesn't like that it's a government mandate. He hasn't looked at the various plans available on the state exchange, but said he has heard from others that they are expensive and that the deductibles are high.
"It's not like a top priority," he said. "I know it is required. Eventually, I guess, I will have to get it."
Enrolling people like Bozowski is critical to the success of exchange plans, which need a large number of young and generally healthy people to be financially viable.
Insurers nationwide are complaining that they're losing money on exchange plans because the pools are too small and too sick.
To help reach more people, the Maryland exchange asked the State Health Access Data Assistance Center, a program of the Robert Wood Johnson Foundation, to analyze where the remaining eligible uninsured lived.
Undocumented immigrants or uninsured workers who declined insurance from their employers don't qualify for exchange plans under the Affordable Care Act.
The exchange estimates that thousands of the eligible uninsured live on the Eastern Shore and in rural Southern Maryland, but also in other surprising places such as eastern Howard County and the Washington suburbs.
The Eastern Shore poses a challenge because people live far apart and many work long hours in agriculture or crabbing and fishery jobs.
Some targeted efforts, such as going out to the boats where watermen work, running ads featuring watermen in local newspapers and attending watermen's association conferences, all helped increase enrollment this year, said Kat Gunby, who coordinated outreach through the Worcester County Health Department.
Enrollment navigators in the area are planning to hold focus groups to figure out more ways to reach people in the next enrollment period, which begins Nov. 1.
There are plans to do outreach at flea markets and farmers' markets, which attract large numbers of people. They also are looking for a Creole-speaking navigator who can speak to the Haitian migrant workers who come to the area each year.
Brian Mattingly is director of the Door to Health Care program for Healthy Howard, which helps people enroll in plans.
In Howard County, he says, there is a large immigrant population that might find enrolling for insurance and accessing the health care system confusing.
Immigrants also might not go to the places where people typically sign up for insurance.
"We try to work with the local trusted messenger, if you will, for the various organizations," Mattingly said. "We use them as a way to get the message out or to collaborate."
Mattingly and enrollment navigators in other parts of the state say the perception remains that insurance is not affordable. Many people don't realize they likely would qualify for subsidies to help offset the costs.
Nine in 10 people insured through the marketplace have received financial support to lower or waive the cost of private insurance or Medicaid.
There are middle-class households that aren't getting insurance on the exchange because they believe it's a program for the poor and not them, those who help people enroll people said. In some cases, they worry about how they might be perceived if they accept government assistance through the subsidies.
Large populations of eligible uninsured residents also remain in Carroll and Harford counties, according to the exchange.
"There is so much education about the program we have to do," said Sue Ehlenberger, who leads enrollment efforts in Harford County for the nonprofit SEEDCO. "That is where health insurance literacy comes in."
One place where outreach efforts appear to have been more successful is Baltimore, where there is significant infrastructure for public health outreach. The exchange found strong enrollment progress throughout the city. East Baltimore remains a weak link, which many attribute to difficulties figuring out how to reach the Hispanic immigrant population.
Lena Hershkovitz is vice president of health insurance programs at Health Care Access Maryland, an advocacy group that helps people enroll in health plans.
She said outreach efforts in the last enrollment period were disrupted when the state moved Medicaid enrollment from a separate computer system onto the exchange's database. Thousands of Medicaid patients needed to be re-enrolled on the new system, she said.
Enrolling young people also continues to be a challenge, she said, but their numbers are increasing.
Health Care Access Maryland is considering new places at which to do outreach, such as holding enrollment and educational fairs at large companies, such as Maryland Live Casino.
So far, more than 1 million Marylanders have signed up for health coverage, including Medicaid, through the state exchange.
The obstacles to reaching the uninsured are not unique to Maryland, said Hector De La Torre, executive director of the TransAmerica Center for Health Studies.
A survey the group conducted last fall found that 24 percent of uninsured Americans did not support the Affordable Care Act on principle and another 18 percent didn't know how to apply.
In coming years, De La Torre said, it will be even more difficult to reach the remaining uninsured.
"You can't just do TV commercials with this group," he said. "It is face-to-face or person-to-person contact. You can't do the wholesale thing. You have to sit down and educate them about it where they live, where they work and where their kids go to school."
Quattrocki, of the Maryland Health Benefit Exchange, said the state made major inroads in some hard-to-reach groups in the most recent enrollment period. The number of Hispanics who enrolled jumped 240 percent from the previous year and the number of uninsured African-Americans was reduced by half.
Karen Pollitz, a fellow with the Kaiser Family Foundation, said states such as Maryland that expanded Medicaid tended to do better at making a dent in their uninsured numbers.
The state was an early supporter of the Affordable Care Act, and Republican Gov. Larry Hogan has not tried to dismantle the system. The technical problems that marred Maryland's exchange the first year have been resolved.
"Maryland is doing great and it looks like they are working hard to maximize every opportunity to expand coverage that the Affordable Care Act created," Pollitz said.
Quattrocki said the state will continue to look for the best ways to get people enrolled.
"It really just speaks to the need out here," Quattrocki said. "There's still a lot of Marylanders without health insurance, and we will do everything we can to get to them."