A few miles from the Utah Capitol, where politicians pontificate on Obamacare, are two working-class neighborhoods that will have an outsized impact on the law's failure or success.
South Salt Lake and Glendale have the highest uninsured rates in Utah. Just over 38 percent, nearly 4 in 10 residents, of these communities have no health coverage, according to 2011 data from Utah Department of Health.
That's higher than the uninsured rate of 24 percent in Texas, which has led the nation five years running. And it's well above Utah's average rate of 13 percent.
The success of the Affordable Care Act in Utah hinges on getting these and other pockets of uninsured residents to shop on the online insurance exchanges opening Oct. 1.
And by all accounts, it won't be easy.
"Most of the people I talk to have no idea this is even coming, even among the business community," said Lorena Riffo-Jenson, director of community outreach for Arches Health Plan.
The challenge is fighting misconceptions about the law, compounded by deep-rooted disparities.
Landing pads for many refugee and immigrant groups, the two areas are richly diverse, but also among Utah's poorest and least educated.
South Salt Lake and Glendale lead the state in teen pregnancies and emergency visits for asthma attacks. They lag the state for getting preventive cancer screens and making trips to the doctor. They have disproportionate rates of diabetes.
South Salt Lake is second only to north Orem and Riverdale in heart disease deaths. And it has the lowest life expectancy in the state.
"The need is great," Riffo-Jenson said, "but there's a lot of misinformation out there."
Reaching out • Political leaders on both sides of the aisle paint predictions in broad strokes, promising the law will either make health care affordable for all or push prices further beyond reach.
"When we sit down and explain it to people, they say, 'Really? I can get health insurance and money to help pay for it?' " said Riffo-Jenson.
Arches is Utah's newest insurer, competing for customers in a state dominated by two other nonprofits, SelectHealth and Regence BlueCross BlueShield, which serve more than 60 percent of the individual and small-business market.
It's banking on reaching traditionally underserved populations, such as Latinos, young people and the gay and lesbian community.
And though it hopes to low-ball its competitors with attractive prices, it can't afford to wait for customers to come knocking.
Utah is no California, Florida or Texas, which together claim a third of the nation's 46 million uninsured and by virtue of their importance, are benefiting from federal advertising dollars and other resources.
"All our [marketing] efforts really are going to be driven through local partnerships," Riffo-Jenson said.
The insurer has a website in Spanish and advertises on Spanish TV and radio. It canvasses places such as Real Salt Lake games, encouraging young soccer fans to register to receive information. Its outreach workers cross the state, meeting with business and church leaders and attending health fairs.
"If something will work better in Sanpete," Riffo-Jenson said, "we'll do it in Sanpete."
'Obamacare scares me' • A health fair held last week at Salt Lake City's Calvary Baptist Church, sandwiched between gas stations, car dealers and fast-food joints, shows what advocates and insurers are up against.
"I know Obamacare scares me," said Cornelius Netzler, who equates the law with the socialized health systems in Canada and Europe. "I don't like to be forced to buy insurance."
After learning that his family four kids and his wife of 19 years might qualify for Medicaid, or for a hefty subsidy that will reduce the amount he has to pay out of pocket for insurance, Netzler was interested. "That sounds good. It doesn't take no rocket scientist to figure that out."
The 38-year-old self-employed home-electronics installer, an immigrant from Samoa, has needed insurance. He was hospitalized for a respiratory problem and left with a bill of more than $20,000, which he's unable to pay.
He's working hard to stay healthy and has since shed 80 pounds.
Carla Martinez, a bookkeeper for a landscaping company and receptionist at the Sorenson Multicultural Center in Glendale, is equally befuddled. "I haven't really educated myself on the law," she said. "I just figured I wasn't eligible for anything."
A single mom of three, who is also supporting her first grandchild, Martinez works two part-time jobs, earning a middle-class income "just enough to get by, but not enough for much else," she said.
The 36-year-old has arthritis and two compressed discs in her spine, but her kids come first. She recently moved from Glendale to Rose Park, paying extra rent on a home instead of an apartment, so her kids could attend West High. She, like 93 percent of Utah's uninsured those earning incomes between 100 percent and 400 percent of the federal poverty level are eligible for tax credits to buy health coverage on the exchange.
But the subsidies are based on income, and unless they cover most of her premiums, she's not convinced they'll bring insurance within reach.
"The health plans I've seen don't cover everything," she said. "They charge you a little bit here and a little bit there."
Gaps remain • Fueling confusion is the U.S. Supreme Court's decision giving states some flexibility in implementing the Affordable Care Act, which in Utah has created populations who earn too little to qualify for subsidized insurance.
Utah Gov. Gary Herbert has yet to decide whether to expand Medicaid to cover the state's poor who earn 50 percent to 100 percent of the poverty level such as a single person earning less than $15,510 a year, or $1,239 a month.
And if he doesn't, some of those who would have been covered won't be eligible for subsidies on the health exchange.
Ana Faine's family will be among them.
Faine, 23, is the sole breadwinner and the only insured member of her household, comprised of her parents and five siblings. When family members are sick, they use herbal Tongan remedies.
None of them is eligible to enroll in her employer-sponsored plan, and even if any of them were, she said, "there's no way I could afford it on top of the mortgage and grocery bill."
Joyce Kim, outreach supervisor for Health Choice, the state's newest Medicaid program, urges low-income consumers to apply for Medicaid. With or without the expansion, eligibility rules have changed, including the removal of limits on the amount of assets you can have, she explained.
"Even if they haven't qualified in the past," Kim said, "they might now."
There are populations, however, shut out of the health law. Undocumented immigrants don't qualify for Medicaid, and they can't shop on the health exchange.
Private and public charity clinics will remain the safety net for this group.
"We think there will be a shift in the role we play, but we'll still have a role," said Terry Foust, director of community health improvement at Intermountain Healthcare, which runs a charity clinic in Glendale.
Neighborhood Clinic is, in fact, moving deeper into Glendale onto the shared campus of an elementary and middle school, and expanding its services to include dental, vision and mental health care.
"The need is there," said Foust, noting demand for Intermountain's free cancer screenings are so great that they now require people to register in advance. "We take a wait list, and we're usually able to get everyone in, but we can no longer accommodate walk-ins."
Tribune reporter Jennifer Dobner contributed to this report.
Coming Sunday: Is Utah's federally run exchange for you?
O Utah hasn't decided whether to stretch its low-income health safety net to cover more of the poor and uninsured. Doing so would help:
38% of Glendale's uninsured people
53% of the uninsured in South Salt Lake
Source: Utah Department of Health age-adjusted data on percentage of uninsured residents earning 138% of poverty level
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