HOUSTON Behind the political battle lines on Obamacare, the three-story headquarters of Change Happens rises like a fortress in a blighted southeast Houston neighborhood of tiny wood-frame shacks, empty lots and crack houses.
The Rev. Leslie Smith has been running the nonprofit that helps poor adults and children with Medicaid enrollment, homeless support and HIV prevention since 1989. Now he is planning how best to reach uninsured people in the communities he serves with the offer of new healthcare benefits under President Barack Obama's landmark reform law.
"Two weeks ago, there was a shootout at the corner that left over 200 shell casings on the ground," Smith said, speaking in the parking lot as he noted a row of first-floor windows set high and narrow to protect against stray bullets from gunfights between rival gangs. "This is the bottom. This is crack alley. All the ills of the community are around us."
Even among "red" states, Texas has stood out in its fierce opposition to the Patient Protection and Affordable Care Act, better known as Obamacare. Republican Governor Rick Perry has long been an opponent, and Republican Senator Ted Cruz is leading a charge in Congress to eliminate funding for the healthcare law at the risk of shutting down the federal government.
But in their backyard, one of the best-organized of red-state efforts to reach millions of America's uninsured has taken root.
Healthcare reform advocates like Smith believe the realities of life without health coverage will drive large numbers of young, healthy, low-income people to subsidized insurance premiums and other benefits that Obamacare will begin offering to the public starting on October 1.
His organization is part of a loose confederation of nonprofits, charities, universities, religious groups, government agencies and private companies, known collectively as "navigators," that is helping Americans sign up for coverage. It is a task Smith zealously embraces.
"Something great is going to happen from this effort," he says. "I believe this is history."
ORGANIZED IN TEXAS
Obamacare's success or failure depends on how many healthy young adults enroll in health insurance that will be sold on new state exchanges, helping offset the cost of sicker beneficiaries. Administration officials hope they will account for about 40 percent of the 7 million people expected to sign up for private coverage in 2014.
That calculation has put a premium on urban neighborhoods in places like Houston, Los Angeles, Miami and Chicago, four metropolitan areas with a combined uninsured population of 4.8 million - many of them lower-income blacks and Latinos aged 18 to 35, according to U.S. Census figures.
Organizers face special challenges in Texas and Florida, where Republican leaders rejected the opportunity to set up new insurance marketplaces and collect billions of dollars in government funds to expand Medicaid. Perry and other Texas Republicans are now pushing to impose regulations including fees, extra training and surety bond requirements on navigator groups.
Conservatives in the state echo claims made by critics elsewhere, who say the navigator program has been put together too rapidly and requires too little training to safeguard the public. They also contend that Obamacare will raise healthcare costs overall and strap low-income beneficiaries with plans that restrict access to medical services.
Meanwhile, they dismiss the network of volunteers and nonprofits lining up to promote Obamacare as overly optimistic about its value to the public.
"It's a touch naïve," said John Davidson of the conservative Texas Public Policy Foundation. "There's a feeling that the law is half-baked and that the navigator program is half-baked."
Political opposition has created an atmosphere that makes it difficult even for Democrats to talk openly about the law.
"I don't want to talk about the Affordable Care Act on camera," Dallas County Administrator Clay Jenkins, a Democrat and healthcare reform supporter, joked as local TV crews set up for a summer press conference with U.S. Health and Human Services Secretary Kathleen Sebelius. "I want to talk about the opportunity to get people covered," he said.
But it has also helped turn grassroots Obamacare advocates into a well-oiled network. In Texas, the effort was born of an intensive, but ultimately fruitless, months-long attempt to persuade Perry to expand Medicaid last spring.
Change Happens is one of three navigator organizations that have received federal money to hire and train staff to help enroll people in Houston's Harris County, home to nearly 20 percent of the state's 5.8 million uninsured. The group has pledged to reach nearly 100,000 people by the time enrollment wraps up in March. Smith thinks the final number could be close to 300,000 with help from sister organizations across five southeast Texas counties.
Houston's Health and Human Services Department - an agency in a city government whose elected officials are largely Democratic - is also a navigator. It has organized outreach groups under a command structure developed to combat hurricanes. Its public-health database, which is normally used to track epidemics, will measure the enrollment effort's penetration of neighborhoods with large uninsured populations. The city is also providing a consolidated "800" number for public queries, has set aside a "war room" for organizers and is encouraging other major cities to consider the same strategy.
"We really have to bring some science into our approach," said Stephen Williams, the department's director. "This is an opportunity of a lifetime."
The Texas Organizing Project (TOP), a grassroots advocacy group with nearly 20,000 low- to moderate-income members, many of them uninsured, has also been running Obamacare canvasses and workshops since May. Earlier this month it packed hundreds of uninsured people into a university auditorium for an Obamacare rally and information session.
"We run the largest issue-driven grassroots get-out-the-vote campaign, and in 2012, we targeted roughly 200,000 voters. Their No. 1 issue, that we identified after talking to them door to door and over the phone, was healthcare," said TOP Executive Director Ginny Goldman.
Houston's Erenea Perez has heard the message from TOP organizers.
Perez, a single mother in her late 20s who says she is a U.S. resident from El Salvador, works two minimum-wage jobs but can't afford insurance. She counts off the benefits she hopes to obtain with Obamacare subsidies: "Extended maternity services. Pediatric services. Coverage for exams or the ER. Medicine. In-patient services. Ambulatory services."
Many of her uninsured peers across the country are only now starting to pay attention. Local advertising is expected to begin in earnest across the country on October 1. Earlier this month volunteers in 10 states, including Texas, Florida, Illinois and Michigan, began canvassing campaigns.
(Editing by Michele Gershberg and Douglas Royalty)