More than 200 bus stops later, Mississippi enrollment numbers remain dismal. | MADELINE MARSHALL FOR POLITICO ACA bus rolls, enrolls in Mississippi

GREENWOOD, Miss. — In the poorest state in the nation, where supper is fried, bars allow smoking, chronic disease is rampant and doctors are hard to come by, Obamacare rolls into town in a lime green bus.

It took some real convincing by the Obama administration and a leap of faith by one state Republican official to get one of the nation’s largest insurance companies — Humana — to set up shop across Mississippi. Virtually no other insurer was willing to do so, discouraged by the acute health needs here and most elected officials’ outright hostility to the law.


Four months and more than 200 bus stops later, enrollment numbers here remain dismal. Only 9 percent of the state’s Obamacare-eligible population have signed up, putting it near the bottom of yet another national statistic.

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Yet the Humana bus rolls, pulling into hospital parking lots and Wal-Mart shopping centers, parking at churches large and small and hitting other obvious targets to find and convince the uninsured that President Barack Obama’s signature health achievement will benefit them. Sometimes the company’s agents see dozens of people per stop. Other times, just a few individuals climb aboard.

The effort in Mississippi illustrates the obstacles the health law must overcome in many parts of the country, particularly in deeply conservative areas where antipathy toward Washington mixes with challenges of geography, education and general skepticism or ignorance of the Affordable Care Act. High rates of poverty and disease — which mark much of this state — don’t necessarily aid recruitment. Add the strident opposition of GOP leaders and enrollment gets that much tougher.

“This law’s letdown in my home state and the premium hikes on hardworking families are no different than the problems we are seeing across the country,” said Rep. Gregg Harper, whose congressional district cuts diagonally across Mississippi. “I have heard from folks I attend church with to small-business owners and everyone in between about their issues enrolling.”

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Humana knew the obstacles it faced would force intense outreach. And even after aggressively crisscrossing the state, that only pushed sign-ups as of early March to 25,554 residents — results that were worse than in all but eight states, according to an estimate from the Kaiser Family Foundation. Even an enrollment surge in the last days before the March 31 deadline won’t change the standing much, if at all.

A few days ago, one of the insurer’s two Obamacare buses stopped at the Greenwood Leflore Hospital in this small town on the eastern edge of the Delta. Once called the Cotton Capital of the World for its booming cotton trade and access to the Yazoo River, Greenwood today is down to a population of 15,000. It’s a majority African-American town where the median income is $25,000 less than the national average.

It’s where Rosie Olive showed up to look for coverage.

“I was just on pins and needles every day because I was trying to find insurance,” said Olive, who lost her job and health insurance two years ago. “Every day I prayed pretty hard for God to keep me healthy.”

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She sat down with an agent in a tiny, retrofitted cubicle on the Wi-Fi-equipped bus. Together, they found a policy that would cost, after subsidies, $73.44 a month for the 49-year-old Olive, her husband and daughter.

“I was skeptical about coming, to tell you the truth,” she said afterward. “I was worried I was going to pay this on my own, and this is going to cost us an arm and a leg.”

Despite all the political rhetoric about a government-run health program, Obamacare relies on private insurers to sell policies on the state and federal exchanges. If there’s no insurance company, then there’s really no Obamacare.

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And Mississippi is one of the last places the typical risk-averse health insurance company would choose to sell policies under the law. Statistically, it’s one of the unhealthiest states, topping the charts in all kinds of negatives such as obesity, diabetes, hypertension and cardiovascular disease — conditions that can be stabilized with treatment or kill without.

That’s why Mississippi Insurance Commissioner Mike Chaney, a rare Southern Republican working to implement the law, was so worried when he realized last summer that no insurer had signed up to sell policies in nearly a third of the state. A local company named Magnolia was operating in some areas, but about 36 counties with about 1 million people, many with incomes low enough to qualify for federal subsidies, would have had no access to coverage.

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The Obama administration had the same concern and contacted Chaney early last summer to see whether he would help them recruit an insurer. Both Blue Cross Blue Shield and United HealthCare turned him down, Chaney said. He tried Humana, and CMS Administrator Marilyn Tavenner also made a plea. In July, the company agreed to expand from four to 40 counties.

Tavenner’s involvement made a difference in other ways, too. Beginning this summer, Mississippi will have one of the nation’s few state-run small-business exchanges. Federal officials approved the request even though Chaney doesn’t have the support of Gov. Phil Bryant, a Republican who doesn’t want anything to do with the law. Bryant didn’t expand Medicaid and shunned creating a state insurance exchange, which he called a portal to a “massive and unaffordable” new federal entitlement.

Mississippi is the only place where Humana is running a bus tour. It’s also the only state where the company is covering the co-pay for customers’ first doctor’s visit before June, immediate cash savings that it hopes will get people to start a relationship with a primary-care physician. Officials declined to say exactly how much is being spent on the dual strategies.

But Humana has every incentive to sell as many policies as possible. The math involved is simple: Insurance works when there are more people enrolled, which spreads the risk of high costs across hundreds or thousands of customers. To succeed in a state like Mississippi, it had to go all out to get customers.

“Back in August, when we added on an additional 36 counties, we had to act really quickly on how we would get to all of the people in those counties at such a last minute,” said Stacey Carter, the company’s Mississippi market director. “Operating this mobile tour has allowed us to get to people, instead of waiting for them to come to us.”

Rep. Bennie Thompson, Mississippi’s only Democrat in Congress, is grateful that the whole state is covered. “When you have a population where people die more often than in any other state, that’s a risk,” he said. “I think a lot of other companies looked at it and said, ‘That’s a risk and we won’t make enough money.’”

There’s not much other outreach in Mississippi beyond Humana. Chaney said the federal government’s enrollment effort has been dismal: The Obama administration sent about $1.1 million to fund sign-up efforts by a major medical center and a Baptist church ministry. And Enroll America, the nonprofit with close ties to the administration, is focusing only on select states. Mississippi is not one of them.

The lack of competition comes at a price, too. Obamacare rates here are, on average, the third-highest rates in the country, according to the Department of Health and Human Services, although state officials say that more than nine out of 10 people who signed up for plans qualified for subsidies.

Ahmad Wilder is one of them. He came to the Humana bus when it arrived recently at a community center in the capital city of Jackson.

The 37-year-old father had been paying $5,000 annually for an individual market policy for himself and his daughter. He’s now on a $52.33-a-month plan.

Wilder said he expects it to take a while before word gets out about Obamacare in Mississippi — because of all the controversy and confusion surrounding the law.

“It’s just a little rough down here when you’re trying to mix in politics with things,” he said with a laugh. “Some people call it Obamacare and some people call it affordable health care and some people don’t even know that it’s the same thing.”

This story was produced with the support of the Dennis A. Hunt Fund for Health Journalism, a program of the USC Annenberg School of Journalism’s California Endowment Health Journalism Fellowships.