When President Lyndon B. Johnson wanted to enroll seniors for the new Medicare program he had just signed into law, the story goes that his administration sent out workers on dog sleds to reach people in the remote Alaskan tundra. 

“The Forest Service even had rangers looking for hermits in the woods,” recalled the late Robert Ball, Johnson’s Social Security commissioner, in a documentary on Medicare’s 40th anniversary. 

The plan to insure as many as 27 million Americans under the federal health law beginning this fall will be the biggest expansion of health coverage since that launch. Millions will be eligible to shop for insurance in the new online marketplaces, which open for enrollment Oct. 1 with the coverage taking effect Jan. 1.

But six months before the process begins, questions are mounting about the scope and adequacy of efforts to reach out to consumers – especially in the 33 states that defaulted to the federal government to run their marketplaces, also called exchanges. The Obama administration has said little about outreach plans for those states, and neither the money nor the strategy is apparent.

“I’m getting very worried,” says Stan Dorn, a senior fellow at the nonpartisan Urban Institute, who studies outreach and enrollment for health programs. “Most health coverage expansions have not reached their target populations very quickly.”

‘A Pittance’

Ron Pollack, executive director of the advocacy group Families USA, and an administration ally, says he is hearing that as little as $40 million to $50 million in federal grants may be available to hire nonprofit groups to work directly with consumers in the states with federally-run marketplaces – a number the administration declined to confirm.

“That’s a pittance compared to what’s needed to make the application process work,” Pollack says. “It doesn’t even scratch the surface” — even in tandem with privately funded efforts.

That pot of money will cover grants to hire people to help consumers in 33 states with federally-run exchanges, including Texas and Florida, which have some of the nation’s highest uninsured rates. Just for comparison, California has budgeted more than $50 million for ‘in person’ help for consumers this year and next, and another $200 million for outreach and education.

Officials at The Centers for Medicare & Medicaid Services declined requests to discuss their outreach budget or strategy in the marketplaces run by the federal government. In a written statement, the agency says it is “coordinating with federal agencies, states and external partners to educate consumers and motivate them to enroll.”

Enrolling people under a law that few know anything about was always going to be challenging. Three years after the law’s passage, polls show widespread ignorance about its provisions. 

“It’s not hard to get sick people to sign up for health insurance,” says Bob Laszewski, a Virginia-based consultant and former insurance executive. “But it’s really hard to get healthy people to sign up. If we don’t get a healthy cross-section, the financial structure of the [Affordable Care Act] unravels,” and premiums will skyrocket.

‘Ready, Set, Go?’

Resource disparities between states heighten the challenges. The law’s framers gave states broad financial assistance to set up their online marketplaces. They also required the federal government to set up the exchanges if states failed to do so but didn’t create a separate pot of money for that effort. The assumption was that most states would step up.

In the end, however, only 17 states and the District of Columbia did. Resources for the federal effort may also be constrained because of the spending cuts imposed by budget sequestration. 

Private foundations, health industry groups and advocacy groups on the state and national level say they are determined to fill the gaps in states like Texas and Florida, but how successful they’ll be remains to be seen.

“I feel like we need a ready, set, go,” from the federal government, says Bee Moorhead, executive director of Texas Impact, a faith-based group, who is hoping that federal grants to pay nonprofit groups for help will be announced soon.

“In Texas, people have been tapping their toes and drumming their fingers,” she says. “We know we have a big uninsured population, we know we have a strong faith-based community working hand-in-hand with the state, and we know we have the ability to get things done. We need someone to say, ‘It’s time. Let’s do it.'”

Blue Cross Blue Shield of Texas also recently launched “Be Covered Texas,” an initiative undertaken with community-based organizations including churches, school programs and clinics, to educate consumers. 

Enroll America, an offshoot of Families USA staffed with tech-savvy former campaigners for President Obama, is also hoping to step up to fill the gaps. The group has 13 staffers now, but hopes to ramp up to as many as 300 deployed in states with high uninsured rates and scarce resources, says President Anne Filipic, a former White House official. 

The group, which is raising money from the health care industry, among other sources, expects to begin reaching out to consumers in late spring or early summer. It’s relying on the sort of social media campaign that was key to Obama’s 2012 reelection, Filipic says. 

The campaign was about getting votes; now the trick is “how do you use [those techniques] to compel people to sign up for health insurance,” she says.

Still Time For Consumers To Plan

With six months to go, there’s also still time for the president to “use the megaphone,” says Dan Mendelson, CEO of consulting firm Avalere Health and a former Clinton administration official.

When Mendelson worked on outreach for the Children’s Health Insurance Program in the 1990s, “we had Bill and Hillary Clinton and Al and Tipper Gore all going state to state. I attribute our success to that.”

So far, however, Mendelson says the administration has not focused on reminding the public that purchasing health insurance will soon be “an obligation that everyone has,” whether they like it or not. 

That obligation takes advance planning for families with little disposable income. “If people need to pony up $5,000, they need time to prepare for that,” he says. 

And that means telling them the time is coming soon.

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