They're using a rock band and social media to attract young people, bilingual radio ads to draw Spanish speakers and needle exchange vans to reach out to drug addicts.
Grass-roots groups and health workers around the state have deployed these tactics to persuade the persistently uninsured to sign up for health plans under the Affordable Care Act. The first deadline in this year's open enrollment period is Dec. 15 for people who want to get coverage by Jan. 1.
While the state has made great strides in the two years since the law took effect, more than 300,000 Marylanders remain uninsured. Health officials have dubbed these people "the hard to reach" and have focused this year on how to persuade them to get insurance.
"We really have been trying to be creative in getting the word out." said Carolyn Quattrocki, executive director of the Maryland Heath Benefit Exchange. She oversees the Maryland Health Connection, the online marketplace where consumers can buy plans.
Early indicators show the strategy seems to be working with enrollment in private plans outpacing last year by 7 percent. Nearly 37,000 people have signed up for private plans since open enrollment began in November. An additional 150,000 enrolled in Medicaid plans, either as new policyholders or renewals.
Nationally, more than a million new customers have signed up for health coverage on the federal exchange and an additional 1.8 million have renewed plans for 2016. People who miss this week's deadline have until Jan. 31 to enroll.
"We're not going to know how it really shakes out until the end of open enrollment," Quattrocki said. "We will have to see who comes back and pays their bills in January."
Young people, residents of rural areas and non-English speakers are some of the groups health officials have found hardest to engage. The reasons why vary. Obstacles include language barriers and the thinking by some that they can't afford insurance.
Part of the messaging this year focuses on the subsidies that health officials have found many people don't know about. Nine out of 10 people received subsidies to help pay for insurance last year. Others may not know they qualify for Medicaid.
The state has run commercials featuring a rock band from Maryland whose members bought insurance on the exchange. They hope it entices the "young invincible" crowd, people who are healthy and believe they can forego coverage. Young, healthy enrollees are a much-needed demographic because they help fund the plans and defray the cost of insuring older and sicker people.
There are plans in January to host an enrollment event with black churches and another event targeted at Hispanic residents. The nonprofit Health Care Access Maryland is running transit and radio advertisements in Spanish too.
"This is a population that relies on word of mouth, so the message didn't really infiltrate before," said Lena Hershkovitz, the group's vice president of health insurance programs. "TV ads really work well in this market and have really been driving people to our enrollment events. We also rely heavily on radio ads to drive people to our website."
The exchange also is sending out information about enrollment in utility bills. Every Baltimore resident who visits a city health clinic will receive enrollment information and health workers are giving out information to those who come to the needle exchange van.
"Prevention is key to staying healthy," said city Health Commissioner Dr. Leana Wen. "You really need insurance to get screenings and preventive services that will keep you healthy."
Some might have more incentive this year to buy insurance because the penalty for opting out is increasing. Next year's penalty is 2.5 percent of gross household income or $695 per individual, whichever is greater. The 2015 penalty was two percent of gross income or $325 per individual.
For the cost, exchange officials are telling people, it makes more sense to get coverage than pay a penalty and not have insurance.
"Those tax penalties have begun to worry me somewhat," said Christopher Woods, a 31-year-old Remington resident who is uninsured and attended an insurance enrollment fair at the Hyatt Regency Inner Harbor hotel Sunday. Given his distaste for what he sees as government interference, he might otherwise not bother to seek coverage, he said.
People also are facing increased premiums in some cases. CareFirst received the blessing of the Maryland Insurance Administration in September to raise rates by up to 26 percent on average, a hike the insurer said was needed to absorb more than $100 million in losses incurred as more older and sicker patients received coverage under the Affordable Care Act. Under that rate increase, a 40-year-old who lives in the Baltimore area will pay an additional $275 a year on average for CareFirst's HMO silver plan, which pays 70 percent of medical costs.
The exchange allowed people who enrolled last year to automatically renew their current plans but encouraged them to shop around because of the rate hikes.
Odette Ramos of Charles Village was forced to shop around for plans after she faced a $300-a-month hike in the price of her CareFirst BlueCross BlueShield PPO health plan for her, her husband and young daughter. She pays $785 a month now and would have had to pay $1,050 under new premiums. The 42-year-old decided to switch to a CareFirst HMO that will cost $920 a month.
Ramos was not happy about the rate hike, but said she is still grateful for Obamacare. Before it passed, she was denied coverage because of a pre-existing condition.
"I am very thankful that I have the opportunity to get health care," she said.
Isaac Poag, a 61-year-old Northwest Baltimore resident, visited the Sunday enrollment fair in search of affordable insurance that would cover hospital stays. Insurance he buys through his job as a security guard costs him $150 a month, but next year, it won't cover hospitalization, he said. When he called for information on plans that would, he was told they cost $400 a month.
While he has no reason to think he'll end up in a hospital bed, "you just never know," he said.
Evergreen Health, a health insurance co-operative, has seen a big jump in its market share and thinks it has benefited some from the CareFirst rate hike and more people shopping around. Nearly 6,000 people have enrolled in plans with Evergreen, compared with 4,500 in all of last year.
"People have now heard of us and our prices are reasonable," said Peter Beilenson, the head of Evergreen.
Those helping people enroll said they expect to be busy in the final days before the Dec. 15 deadline and will extend hours to accommodate people. The state also is moving Medicaid patients from a government computer system to the exchange, creating an even busier atmosphere.
Interest was high at Health Care Access Maryland's enrollment fair. Dozens of people came more than an hour ahead of the fair's 10 a.m. start, and within an hour and a half, more than 60 people had met with navigators who helped them weigh their insurance options.
Sandra Rawlings was one of the eager early visitors — the 63-year-old resident of Allendale in West Baltimore is legally blind and has high blood pressure and congestive heart failure. But she has been without insurance since retiring from her job as a housekeeper at North Oaks Retirement Community in March.
After a visit to the emergency room in October for difficulty breathing, she heard a television commercial for the enrollment fair and made a plan to go. She met with a navigator named Carlos, who helped her start the process of enrolling in Medicaid.
"He was so nice," she said. "He said, 'I got you, Ms. Rawlings.'"
The Morning Sun
Baltimore Sun reporter Scott Dance contributed to this article.
Dec. 15: To get coverage starting Jan. 1.
Jan. 31: Final deadline