A Final Push for Health Care

It's last call for health insurance.

A new insurance company in Colorado dispatched a throng of models dressed as cocktail waitresses onto the streets in recent days, offering nonalcoholic shots of juice to lunch-hour crowds in Denver. The models, in form-fitting dresses and high heels, handed out fliers reminding people of the fast-approaching March 31 deadline to sign up for health care coverage this year under the federal law.

In Philadelphia, Independence Blue Cross held an enroll-a-thon that involved a 16-hour marketing blitz on a local television station during daytime talk shows; a tractor-trailer, the Independence Express, parked in a shopping center parking lot in Bala Cynwyd; and an event at Love Park, featuring free coffee, near City Hall.

Humana, a large national insurer, has been traveling by bus through Mississippi, making stops at churches and community centers to get the word out, especially to those without easy access to the Internet.

As the end of the month nears, insurers like Colorado HealthOP, which sponsored the 'Last Call' event, are scrambling to sign up holdouts, using all sorts of marketing tools.

Many are concentrating on hard-to-reach groups, sponsoring community events to attract people who had trouble enrolling on their own or need a nudge to take the time to sign up. Some are offering policies inside highly trafficked venues like drugstores or local Y's; Arkansas Blue Cross and Blue Shield even had sign-up stations in Goodwill stores.

'We're in the home stretch,' said Jon Urbanek, an executive with Florida Blue, which will have held 3,000 town halls across the state in the eight months before the enrollment period ends. 'We're not letting up on it at all.'

In Philadelphia, despite the frigid temperature of a mid-March day, the trailer and park tent drew hundreds of visitors, among them Arik Dayan, a 29-year-old who was serving coffee at the park and went to find out about coverage.

He had intended to sign up when the federal website, healthcare.gov, opened in October but was one of the thousands of people thwarted by repeated breakdowns of the site. He had planned to try again, he said, but 'I just totally forgot.'

Independence Blue said it signed up more than 2,000 new customers that day, bringing its total enrollment above 90,000 individuals. The day was one of its busiest.

With some exceptions, people who do not sign up for insurance by the March 31 deadline face financial penalties of up to 1 percent of their yearly household income, or $95 a person, whichever amount is higher. Some people can sign up throughout the year if they experience a major life change, like losing a job or having a baby. The next open enrollment period begins in November.

Insurers have had to pivot during this first year, adapting to abrupt regulatory shifts from the Obama administration and making a series of midcourse corrections. 'You really have to be nimble to make this work,' said Daniel J. Hilferty, the chief executive of Independence Blue. Many insurers have invested heavily in the first year, although Obama administration officials seem willing to be lenient on the law's requirement that they cap their profits. Federal officials are contemplating changing the way the plans calculate their costs so they include some of the higher expenses that resulted from the difficult start.

The insurers' marketing efforts started slowly because of the federal website's troubled introduction, which forced them to change from marketing aimed at specific audiences to campaigns that tried to sell the program all over again. Jaime Estupiñán, a health care consultant for Booz & Company, said, 'They've gone broader.'

And at the end of the year, many insurers were also busy trying to ensure that people whose plans were canceled would be enrolled in new ones without an interruption in coverage.

These days, some of the insurers seem to be in step with the playbook at the White House - chasing the hard-to-get, healthy young customers who are viewed as critical to balancing the pool of people who may need more care.

'The focus has really shifted to the young invincibles,' said Mr. Hilferty of Independence Blue, referring to those who think they don't need health insurance.

The company tried to entice the young through a contest for the best 90-second videos showcasing why coverage makes sense.

In addition, Hispanic residents in many states have been among the most elusive, insurers say. 'It's taking much more effort than expected to bring them into the enrollment experience,' said Patrick Blair, an executive with WellPoint, a large national insurer that operates Blue Cross plans in several states. 'A deeper personal touch and targeted and consistent grass-roots outreach is required to better engage,' he said in an email.

WellPoint's experience is not unusual. 'With different levels of foresight, people realized a lot of this is grass-roots effort,' Mr. Estupiñán said.

Other insurers have focused on regions where there is a significant need for coverage. 'We viewed Mississippi as a very underserved area,' said Dr. Roy A. Beveridge, Humana's chief medical officer. The state has a high rate of uninsured residents, a significant proportion of unhealthy people and lack of access to medical care, all of which intensify the insurer's need for deeper outreach.

'This is a long slog,' he said. 'We're not there for six months.'

Even when potential customers have an idea now of how the law works, many still need help sorting through options or figuring out how to prove their identity on the federal website if they have never had credit.

The process can take hours. In other cases, though, it's about making the final decision. 'We're there to help them round out the story,' said Mr. Urbanek of Florida Blue.

But as the deadline nears, insurers are quicker to mention the possible penalties faced by those who don't enroll.

In one advertisement for Blue Cross and Blue Shield of Nebraska, titled 'Time is Almost Up,' an announcer reminds viewers that 'Most Nebraskans are required to have health insurance, or face penalties.' It's part of a media campaign that includes billboards and radio ads that have increased since the beginning of February.

Tom Gilsdorf, an executive at Blue Cross of Nebraska, said the shift in tone reflected how the target consumer had changed over the last several months. Those who were the most motivated signed up late last year, while the procrastinators are still dithering.

He said the company had tried to soften the message's looming-penalty phase by featuring images of smiling babies, mountain bikers and a farmer petting a cow. 'Health care is complicated, and I think it's that fear of the unknown that keeps people from jumping in,' he said.

At Independence Blue, people do seem to be aware that they have only a limited amount of time left to sign up. 'They understand this time is the tail end of the process,' said Christopher McIlvaine, who was signing up people in Love Park. 'They understand the urgency.'

On the radio in Philadelphia, a popular hip-hop artist, Lady B from Old School 100.3, beckoned listeners to enroll at the tractor-trailer in Bala Cynwyd.

Yvonne Jackson, a 55-year-old who lost her health coverage when she was laid off, heard the pitch and ventured in after realizing how close it was to her home. 'I've been putting it off,' she acknowledged, adding that she had been frustrated by trying to sign up online.

'I can do this,' Ms. Johnson told herself, and discovered inside the trailer that the plan for her would cost only $19 a month, after federal subsidies.

Correction: March 24, 2014