Myeshea McKinney owed nearly $1 million by the time her twins were healthy enough to leave the hospital.

Myeshea McKinney owed nearly $1 million by the time her twins were healthy enough to leave the hospital.

The infants were born 12 weeks premature. They weighed a combined 4 pounds and spent months in a Denver hospital while their lungs developed.

When McKinney finally returned home to Casper, the bills were waiting.

“Have you ever watched the cartoons where they jump into those little black holes, where they throw them out and just jump in? That’s how it felt,” she said. “You open that bill, and it’s like this sinking feeling … If I could have found a black hole to jump into, I probably would have taken that route.”

McKinney had no way to pay the staggering medical costs. So, at 27 – and with six children – she declared bankruptcy.

The decision crushed her.

“You’re in your late twenties, you’re ready to buy a house, your credit should be good, and all of the sudden you have a medical emergency and everything goes downhill for you,” she said.

Fifteen years have passed. The twins are fine now, but paying for healthcare is still a challenge. McKinney’s real estate job doesn’t come with health benefits, nor does it pay enough for her to purchase insurance. She doesn’t qualify for government coverage.

“I’m no spring chicken,” the 42-year-old single mother said. “I’m getting older. There are probably things that I need to go to the doctor for, that I just don’t do because I don’t have health care.”

McKinney is one of roughly 89,000 uninsured people in Wyoming. The Affordable Care Act – the controversial health reform law passed three years ago – is designed to help them. It will establish health insurance marketplaces that allow people to shop online for coverage like they do airplane tickets. Many will qualify for subsidies that could save them hundreds of dollars each month.

For someone like McKinney, the subsidies might finally make insurance affordable.

But consumers have to know about the program to take advantage of it. When the marketplaces begin enrollment Tuesday, many consumers, including those who could benefit the most from subsidies, won’t know they exist.

Public understanding of the law remains mixed at best. A survey conducted earlier this year found four in 10 adults didn’t even know the Affordable Care Act was still the law of the land. Another survey in June showed 80 percent of Americans knew little to nothing about the marketplaces designed to help cover millions of uninsured people.

Federal authorities developed Wyoming’s marketplace – also called a health insurance exchange – after the state Legislature declined to create a state-run program. Some of the same lawmakers decided to delay promoting the exchanges until at least January out of concern the law might fail.

Several organizations, including the state’s largest hospital, are now preparing to launch programs aimed at educating people about Wyoming’s marketplace. Their success could mean the difference between a thriving exchange and one troubled by low enrollment.

The job will be difficult. They’ll need to reach a far-flung population that’s largely unaware of how the law works.

McKinney falls in that category. She knows the law will penalize most Americans who lack insurance, but isn’t familiar with the marketplace that could provide her with coverage.

“For me, I hate to sound ignorant, but I just go on with everyday life,” she said. “And if it affects me at that point, then I’ll deal with it.”

A farmers' market

A health exchange is sort of like a farmers' market. The market itself doesn’t actually sell anything, but it provides a venue for farmers and artisans to offer their wares.

Similarly, companies will use the exchange to sell private health plans to individuals and small businesses. Consumers can compare insurance products knowing that all the plans will cover certain basic services, like pediatric care.

People who earn between one and four times the federal poverty level will qualify for subsidies. A couple in their mid-30s with two children and a $56,000 a year income – the average for Wyoming – would pay $356 a month for a plan that covers 70 percent of their medical costs. The actual cost of the plan would be much greater, but the government would provide a subsidy that works out to nearly $430 a month.

Exchanges are intended to assist uninsured working people, individuals with pre-existing medical conditions that have made it difficult to find insurance, and small business owners searching for an affordable way to cover employees. They won’t offer much help to poverty-stricken adults without children. The Affordable Care Act was designed to help that group by expanding Medicaid, but state lawmakers rejected the plan earlier this year.

Lawmakers also chose to observe how the federal marketplace performs before deciding whether to create a state-run program.

In July, they decided to remain on the sidelines while other groups promote the exchange. That task will largely fall to a group of nonprofits spread around the state. Chief among them is Cheyenne Regional Medical Center. Its Wyoming Institute of Population Health is launching a statewide program to inform people about exchanges.

A $400,000 federal grant will fuel the effort. The institute plans to hire 10 people to serve as “navigators.” They will travel the state sharing information about marketplaces and the health law, said Cindy Pomeroy, a consultant who’s helping on the project.

“It’s going to be our job to continually get to people so they understand the options they have, and know how to enroll in the marketplaces,” she said.

The institute will spread its message through partnerships with safety-net hospitals and other healthcare providers across Wyoming. They will contact patients who have had trouble affording care in the past and invite them to events where they can learn about exchanges – and begin enrolling on the spot.

The group plans stick to the facts rather than rehash old political debates about the law, Pomeroy said.

“Our funding was provided to educate and inform those folks who are in need of insurance,” she said.

The uninsured

There are plenty. About 15 percent of Wyoming’s population lacks health insurance, according to U.S. Census figures released this month. Even more have coverage, but not enough to prevent financial ruin if they suffer a serious illness or injury.

Studies performed two years ago projected between 24,000 and 41,000 people in Wyoming might use an exchange. Those estimates were made when the state was considering whether to run its own program.

Hospitals have a financial incentive for steering people to the exchange. Statewide, hospitals perform roughly $200 million a year in care for people who can’t afford to pay their bills. Those costs are either written off or shifted to patients who can pay – raising the cost of healthcare in the process.

At Wyoming Medical Center in Casper, administrators hope the exchange will translate into more paying customers. The hospital is training its financial counselors to help uninsured patients enroll in the exchange, CEO Vickie Diamond said.

But she’s not counting on a sudden influx of new paying customers. Wyoming is a right-leaning state, and President Barack Obama’s chief legislative accomplishment remains unpopular among many residents. State lawmakers voted down an attempt to extend Medicaid coverage to about 17,000 poor adults, leaving them ineligible for both government coverage and subsidies through the marketplace.

“That’s the person who most likely needs subsidies, but they will be excluded,” Diamond said.

Can it work?

Hospitals won’t be alone in promoting the exchange. Community health centers, state libraries and a nonprofit that serves seniors will also help educate people.

But will that effort pay off?

Sen. Charles Scott, an influential state lawmaker when it comes to health issues, is skeptical. He’s one of the legislators who pushed to delay promoting Obamacare out of fear it will fail.

It’s possible the exchange will succeed despite the normal bumps expected with a big, expensive product launch, he said. But the Natrona County Republican suspects it will more likely collapse under its own bureaucratic weight.

That, he admitted, is just a guess.

“I think anybody who tells you they know is blowing smoke,” he said. “It’s so complicated. There are so many other things that haven’t worked. Now this is the centerpiece. They may get it right. But I don’t know.”

University of Wyoming professor Anne Alexander worked on some of the early state studies related to the insurance marketplaces. It’s possible a sizeable population will eventually use the exchange. However, she doesn’t expect a flood of customers at the start.

Penalties for lacking insurance will be low at first. Young, healthy people might decide they’d rather pay the fee and gamble they won’t get sick.

“I think that human nature being what it is, people are going to hang back for the first couple of years,” she said. “Not everybody, but they’re going to hang back and pay the fine and wait and see how things play out.”

Wyoming lacks a viable alternative for covering the uninsured. Several years ago, lawmakers enacted a state program designed to help the poor pay for coverage, but have since cut its funding. If the exchange fails, people like McKinney will be forced to continue making tough choices.

“Ramen noodles or health care,” she said. “You stop and say, ‘Are you really sick?’”