Oregon might be seen as a complete failure or a surprising success when it comes to its health insurance exchange.
One the one hand, the state's website has yet to allow a single person to enroll. That's a big problem for the folks who are hoping to qualify for subsidies and buy insurance that will start Jan. 1.
But for the state's poorest residents, a workaround has helped 70,000 people secure coverage in Oregon's version of Medicaid. The state is one of 25 expanding Medicaid to adults who haven't previously qualified.
One of them is Kyle Thompson, who lives in the farming community of Jefferson. Since his work as a tile cutter ended during the recession, he hasn't been able to afford health care. But his two children qualified for Medicaid (the Oregon Health Plan), and the state had all the family's income and other details on file.
So when the state sent out about 260,000 applications to families like the Thompsons — with incomes less than 138 percent of the federal poverty level — to enroll them in Medicaid, they jumped on the opportunity.
"I filled it out. I sent it off. Me and my wife are really excited in having the health care coming up because it's not something that's been an option for us," he said.
Oregon Health Plan spokeswoman Patty Wentz says the letters were so successful, another batch will go out any day now. There's already been a big response. "People will call and ask if it's real," she says. "Can I really get health care coverage? When they hear that they can, they're so grateful. One call center staff told me that, the person she was talking to said, please tell everyone there, thank you, thank you."
Here's why the Medicaid side of this is working for Oregon: When the state set up its exchange website, it paid more than $43 million to software specialist Oracle to make a one-stop shop for health insurance for everyone in the state, including people buying private policies (with or without subsidies), children qualifying for the Oregon Health Kids Plan as well as the Oregon Health Plan (Medicaid).
"I guess one could argue in retrospect we bit off more than other states," Gov. John Kitzhaber recently said. But, he added "it was an intentional decision. We've got a single portal for Medicaid and for the people who are coming in that are not Medicaid eligible. And once we work out these difficulties I think the people in Oregon will be ahead of the pack."
Officials with the website says they're cautiously optimistic insurance agents and navigators will be able to help customers determine their eligibility for a tax subsidy and choose a health plan by Dec. 1.
But the public won't have access for a while, because of problems with the website. Instead, a series of application fairs have been arranged so that everyone can use old-fashioned paper to apply in time to get covered starting in 2014.
Meanwhile, in Texas, the get-out-to-the-people approach hasn't had much success. Only about 3,000 Texans have signed up for private insurance and the state isn't expanding its Medicaid program.
Navigator Alysia Greer has been trying to encourage sign-ups from a folding table in the lobby of a medical building in northwest Houston. As people walk by, she offers them brochures and asks, "Does everyone in your household have health insurance?"
Most walk right by, but Dorothy Green, who already has Medicaid, grabs a packet for a neighbor who doesn't drive. Greer helps Green, but her hands are a bit tied.
A Texas law doesn't restrict navigators yet, but it gives state regulators that option.
Texas Attorney General Greg Abbott says he's still concerned and has asked the Texas Department of Insurance to regulate the navigators. He thinks they might misuse confidential information they gather while helping people sign up for health plans. "We need to have better training for these people who are — may be completely unversed in how to deal with someone's private information," he says.
Alysia Greer takes issue with Abbott calling her unprepared. She says patient privacy and security were a big part of her navigator training, which lasted over 20 hours and involved several tests. She adds that Abbott may be unnecessarily frightening uninsured people.
"I do think it will scare some people away. Because there are a lot of people who are very influenced, of course, by what the attorney general and other people of political status say," she says.
Greer says when she assists people while using a computer, she turns the screen towards them and away from herself, and never even sees Social Security numbers or income information.
In any case, the Affordable Care Act prohibits disclosure of personal information, and imposes a $25,000 fine for doing so.
And navigators who did steal information would also face 15 years in prison under federal identity theft law. Nevertheless, the Texas Department of Insurance is currently working on more rules for the navigators in Texas.
This story is part of a reporting partnership among NPR, KUHF, Oregon Public Broadcasting and Kaiser Health News.