Alex Wayne May 02, 2014 12:30 pm ET

(Adds comment from Karen Ignagni in sixth paragraph.)

May 2 (Bloomberg) — The push to sign up people for Obamacare won’t get any easier in Year 2.

The Obama administration needs to improve everything from customer service to Spanish-language outreach if it’s to parlay a functioning website and recent enrollment momentum into even more Americans with health coverage, supporters said.

“Adding new people — the marginal enrollment — only gets harder and harder,” George Brandes, director of health-care programs at tax preparer Jackson Hewitt, said in a telephone interview. “For whatever reason these people sat on the fence. This is no longer the low-hanging fruit.”

Eight million people signed up for private plans under the Patient Protection and Affordable Care Act through April 19, the U.S. government reported yesterday. The total includes a surge of 910,000 enrollments in the past month highlighted by young, low-income applicants.

The Congressional Budget Office expects an average of 13 million people to enroll in private health-insurance plans for 2015 using the marketplaces created under the law known as Obamacare. Enrollment surpassed expectations this year, and next year a penalty on people who don’t carry insurance will double to as much as 2 percent of income. The federal website that is expected to serve 35 states next year,, no longer suffers regular malfunctions.

Front Door

“The most important thing, from a consumer-facing point of view, is: does the front door work, No. 1, and it does now,” Karen Ignagni, the president and chief executive officer of America’s Health Insurance Plans, the industry’s Washington lobbying group, said in an interview.

There remains an ample market of uninsured Americans. About 48 million people in the U.S. lacked coverage in 2012, according to the Census Bureau, and indications are that few of them signed up this year. About 5.5 million people who filed applications for insurance through government exchanges and were told they were eligible to purchase a plan never finished the process, according to federal data released yesterday.

“I don’t think we really have the answer for that right now,” Mike Hash, director of the Office of Health Reform at the U.S. Department of Health and Human Services, said when asked why those applicants didn’t sign up for coverage.

Administration Challenges

The administration faces challenges to reach those potential customers, supporters of the health-care law said. The enrollment period for 2015 begins Nov. 15 and is just three months, half as long as this year. The federal government may not have as much money to spend on advertising or on groups that help people sign up. Negative ads and speeches about the law from Republicans leading up to Nov. 4 congressional elections may confuse uninsured Americans, deterring enrollment.

The law’s supporters say the Obama administration can take steps unilaterally, without the help of Congress, to boost participation.

The Spanish-language health-exchange websites still lag behind English versions. Better coordination of enrollment with tax season may raise awareness about the penalties for not carrying coverage. Customer-service representatives at call centers should be trained to better respond to off-script questions, said Tricia Brooks, a researcher at the Georgetown University Center for Children and Families.

“To get to 13 million we want to make sure we don’t slide backward at all,” she said in a phone interview.

Signing Up

Enroll America, a nonprofit group allied with the White House that organized enrollment efforts in 11 states, contacted about 354,000 people without insurance over the course of the law’s enrollment period. Only about 44 percent so far confirmed they signed up, Justin Nisly, a spokesman for the group, said in an e-mail.

“We want to understand both why some people enrolled and why other people didn’t,” Anne Filipic, Enroll America’s executive director, said in a phone interview. The group plans a conference for enrollment workers in June and is assembling a report on best practices for outreach to the uninsured.

One finding so far, she said: canvassing neighborhoods door-to-door to sell Obamacare didn’t work as well as meeting people where they congregate in their communities, such as churches, schools and grocery stores.

The health department, which manages the program, doesn’t yet know which outreach and enrollment methods worked best, said Jason Young, a department spokesman.

Seeking Feedback

“HHS just concluded the first open enrollment, which successfully signed up 8 million Americans for quality, affordable coverage,” he said in an e-mail. “We are analyzing our data and seeking feedback from partners and stakeholders, which will inform planning for the next marketplace open enrollment and help us reach as many Americans as we can efficiently.”

Mixed messaging, because of continuing opposition to the law by Republicans, and low knowledge of the Affordable Care Act’s benefits may deter enrollment. Filipic said her group found that many of the people it contacted assumed they couldn’t afford health insurance and didn’t know that subsidies are available to defray premiums.

The Obama administration faces particular problems combating unfamiliarity with the law in states with governments that are hostile to it and with Latinos, who didn’t sign up in the expected numbers. In California, for example, where better than 60 percent of the uninsured population is Latino, they made up just 28 percent of the 1.4 million people who enrolled for 2014.

Latino Community

“The Latino community does have some unique challenges,” Mayra Alvarez, associate director of the Office of Minority Health at HHS, said yesterday. The hurdles include educating Latinos on “the concept of health insurance,” she said, and reassuring “mixed status” families that apply for coverage that the effort won’t result in legal action against relatives who are unauthorized immigrants.

While the federal government and California offer Spanish- language enrollment websites, “not all of the information that you could need, that’s available in English, is in Spanish,” said Hector De La Torre, executive director of the Transamerica Center for Health Studies, a nonprofit in Los Angeles.

“That’s problematic,” he said in a phone interview. “Between now and November, I would expect that every word that’s in English would be available in Spanish on their websites.”

States such as Texas remain controlled by Republicans who oppose the law and won’t help promote it. As a result, the administration is likely to see more success expanding enrollment in friendly states, including California and New York, said Robert Blendon, a professor of health policy at the Harvard School of Public Health in Boston.

Negative Reinforcement

Additional enrollment “is twice as hard to get if the environment is people in leadership groups criticizing the policy, criticizing how it’s going to work, criticizing how it’s going to work for you,” Blendon said.

Congressional campaigns also may complicate the task, Blendon said. Even in states friendly toward the law, competitive elections may mean uninsured people hear one set of advertising and arguments in favor of the law from the government or Democratic candidates, and a counter-argument from Republicans.

“In congressional races where there’s a lot of it, it will deter people,” he said.

Hadley Heath, director of health policy at the Independent Women’s Forum, a nonprofit that opposes the health-care law, said that even facing obstacles, the Obama administration is likely to achieve its enrollment targets. The increasing penalty for not carrying insurance will persuade more Americans to sign up, and some employers may decide to send workers to the exchanges instead of providing health benefits, she said.

Narrow Measure

“Conservatives are making a mistake if they focus on the enrollment metric as a metric for failure,” she said in a phone interview. “That’s not the only metric we should be examining when we make our arguments about whether it’s a good law or a bad law.”

More important is whether people in exchange plans are satisfied with their coverage and have access to care, she said. That’s a concern for advocates of the law as well.

“We think a good many people who have gotten coverage have never had it,” Georgetown’s Brooks said. “They don’t know how to use it. Educating people is going to be very important so that the next time around, they don’t decide to go bare because they weren’t able to access care or didn’t find it affordable.”

Renewal Suggestion

Brooks suggested the administration ease the renewal procedure to help keep those who signed up in 2014 on their plans. The government has laid out a system to renew coverage involving correspondence between insurance exchanges and customers of exchange plans. Timothy Jost, a law professor at Washington and Lee University in Lexington, Virginia, who has tracked implementation of Obamacare, said in an e-mail that it is “about as simple a procedure as they could design, although there are sure to be complications.”

Ignagni said that most customers are likely to shop around first: “Without a doubt, people will take a look before they make a decision.”

One additional headache looms. Even as the government enrolls people for 2015 plans, it will simultaneously conduct a bit of house-cleaning from 2014: determining from tax returns whether customers of exchange plans received the correct discounts on their premiums this year.

“The potential for refund fraud and related schemes could increase as a result of processing ACA Premium Tax Credits unless the IRS builds, implements, updates, and embeds ACA predictive analytical fraud models into its tax filing process,” the Treasury Department’s inspector general for tax administration, J. Russell George, told a congressional committee on April 30.