"Sometimes we set up events and we don't know if it's going to snow or not," Bojorquez-Flores says. "And then if it snows, we cancel them. Either they close the road or nobody shows up."
Weather is just one of the problems with the open enrollment health period—a few months when the uninsured can register for health coverage for the year through the federal Affordable Care Act. The most recent enrollment period began in mid-November 2014 and ended Feb. 15. That time includes two major holidays—Thanksgiving and Christmas.
"People are short on money and short on time," says Barbara Webber, executive director for the health advocacy nonprofit Health Action New Mexico, which is Bojorquez-Flores' employer, "and they're not thinking of health."
Since the ACA, better known as Obamacare, took effect in the fall of 2013, one-third of the estimated 166,000 uninsured who don't qualify for Medicaid have enrolled through the state's Health Insurance Exchange. While that number, coupled with 150,000 new Medicaid enrollees, certainly represents progress in the past two years, poor planning and ideological opposition from the top have hampered the state's advance.
"We could have done so much better for New Mexico," says Dan Derksen, who for eight months served as director of the state's Office of Health Care Reform.
To examine what the ACA is, it's important to lay out what it's not. Obamacare is not the "free health care for all" single-payer model that mandates government to pay for all health care costs. Instead, the health care law aims to achieve universal coverage by expanding the country's current federal health program for low-income people—Medicaid—and covering other uninsured through mandated private insurance plans.
Several challenges to the health care law have been in play for all states—last year's widespread failure of the healthcare.gov website launch comes to mind—but others are uniquely local. Plenty of disdain for the federal health care law comes from the very officials in charge of implementing it in New Mexico.
The state chose to comply with the federal law by establishing an exchange, jargon for administration of a website and support staff to help people apply for insurance coverage.
Last fall, Gov. Susana Martinez and state Human Services Department Secretary Sidonie Squier wrote letters approving the state exchange's application for a $97.9 million federal grant for the next three years. Though their letters endorsed the effort, they also used tongue-in-cheek language questioning the very purpose of the federal dollars they were seeking.
"The amount of funding in this grant application greatly exceeds that necessary to produce our vision of an exchange to allow New Mexicans to shop for and purchase insurance," Squier wrote.
As a result, the federal Centers for Medicare & Medicaid Services denied the grant—a big blow to a poor state with a high uninsured population.
"It's very significant, given [the state's] plans going forward, of how they wanted to design the website," says Webber. "No one was predicting a complete rejection."
Now the remaning options for funding the exchange include asking the feds for up to $48 million that's already been offered through another avenue.
Squier left her job in December. But her letter to the federal agency that administers Medicare and Medicaid was the capstone of a rocky four-year tenure for the woman in charge of key public health programs in New Mexico. To Derksen, the attitude in the letter is vintage Squier.
"It was entirely consistent with Sidonie Squier's approach to obstruct, undermine and oppose every effort to adequately fund the state health insurance exchange," he says. "Apparently she was successful again."
The loss of the grant also likely means fewer opportunities for the type of on-the-ground outreach that Bojorquez-Flores has done for the last three months.
At Sunset Mobile Home Park near the busy Southside intersection of Airport and Cerrillos roads, Bojorquez-Flores is knocking on doors.
She has a little more than a week to go before the open enrollment period ends and is handing out pamphlets for an event at Santa Fe Place the following day. She's targeting neighborhoods where people aren't as likely to be covered. But those are just a few of her hurdles.
"Do you have medical insurance?" she asks a man who's standing behind his screen door on the phone.
"I'm on a real important call," he responds.
Bojorquez-Flores gives him a flier for the event, thanks him and continues down the street. This isn't her first time door-knocking at Sunset Mobile Home Park.
"I just try to hit everywhere, because sometimes people forget," she says.
On this particular day, Bojorquez-Flores started canvassing at 9 am, visiting three other mobile home parks and one apartment complex so far. It's now the middle of the afternoon, and she's planning to work her way south—toward Madrid—until 8 pm.
"Our job as specialists is to reach out to the communities who are left out," she says.
She's tried leafleting in the parking lots of Target and Wal-Mart, only to be told by store employees to go away. Some of the doors she knocks on are marked with the words "no soliciting." But Bojorquez-Flores argues that that's one of the biggest misconceptions of her door-knocking.
She recalls one woman asking her how much she would have to pay for an enrollment fee.
"I told her we don't charge anything," Bojorquez-Flores says. "The lady that signs you up for insurance will ask you for your income. She'll input that, and then you'll see how much the plan comes up to."
If anyone does offer to enroll people in a health care plan for a fee, it's fraud.
"I don't know how people come up with those ideas," she says. "I think it's just people coming to their own conclusions. They'll say, 'Oh, you guys charge for everything, so you're going to charge for this too.'"
Her door-knocking continues.
"Tia, I got some people at the door," says a man on the phone as Bojorquez-Flores approaches his home.
He hangs up and asks how he can help her.
"I was just here today to invite you to a health insurance enrollment event that's going on tomorrow from 12 pm to 5 pm at M & J Bridal Boutique," Bojorquez-Flores responds.
"Oh, you know what?" the man asks. "I've got real good health insurance."
"Great, that is great—"
"OK, buh-bye," he says quickly as Bojorquez-Flores is pulling out a flier.
She offers the flier to him: "Well, if you know anybody—"
The man shrugs off the piece of paper. "I wouldn't give it to anybody, you know. I'll be honest with you," he says. "That way you don't waste your resources."
"That's good to know," she responds.
Then the man slips, perhaps unconsciously.
"My dad's the only one I know that needs health insurance," he says, "and he's got his own—he's in good health."
At the next door, Bojorquez-Flores sees a familiar face. It's Ana Green, a mother who says her monthly health insurance premium of $179 for her and her son went up in the previous year. Green jokes halfheartedly that she won't be able to pay for food anymore because of her high insurance costs.
"I'm making way less than when I signed up," she tells Bojorquez-Flores in Spanish. "What's the reason I'm paying so much?"
Bojorquez-Flores explains to Green that at the enrollment event, she'll be able to compare her current plan to other plans and potentially find cheaper coverage.
The last two door-knocks are more promising than the first few. At the first home, a young woman says she's already covered through Presbyterian Healthcare, but she still grabs a flier.
"That means someone in their household doesn't have insurance," Bojorquez-Flores says.
At the next home, a man and a boy are seated in their yard frying corn tortillas on a portable propane fryer. Speaking in Spanish, the man explains he has a friend who doesn't have health insurance. He takes a flier.
To be fair, convincing people to pay more bills and add more headache-inducing paperwork isn't a simple task.
Although she spends her working hours trying to persuade people to enroll in coverage, Bojorquez-Flores admits she wasn't convinced that health insurance was the best thing for her until recently. At age 22, her current monthly premium comes to $121.
"OK, it's expensive," she concedes.
But once she understood that insurance would cover all but a fraction of her hospital bill if something catastrophic happened to her, Bojorquez-Flores warmed to the idea.
"You can see that difference," she says. "If I were to have an accident and be at the hospital, I would only have to pay $6,000—which is a lot, but it's less than $16,000."
While challenges abound, the state's health exchange, which was recently rebranded as BeWellNM, has made changes from the previous year to improve the enrollment process.
"This is a very young program still," says Amy Dowd, who took the reins as CEO of the health exchange last August. "We have a lot to learn about the reasons why people purchase insurance."
The first period, which lasted six months from October 2013 through March 2014, saw 32,062 enrollees. The exchange reports it has enrolled 51,857 people since mid-November for the latest open enrollment period. More than half of those people enrolled during the first year, and trends are similar nationwide.
It's also not a secret that ideological opposition to the health care law is strong in certain segments of the population—and also sometimes downright silly.
"There was this gentleman who said, 'I'm not going to enroll in that; they said they were going to put a microchip in my neck,'" Bojorquez-Flores says.
The misconception apparently comes from people confusing a microchip with CHIP—the Children's Health Insurance Program—a federal health care program that covers children in families that are poor but earn too much to qualify for Medicaid.
Many of New Mexico's top policymakers in charge of implementing Obamacare don't appear to be big fans of the law. Emails from 2012 reveal giddiness from upper-level staffers anticipating the possible US Supreme Court rejection of the health care law.
In March of that year, Brian Moore, who at the time ran Martinez' Washington DC office, sent Squier a Politico article titled "Mandate could be in big trouble at SCOTUS," with the subject headline "Interesting."
"OMG!" Squier responded. "There is hope."
At other times, Squier's optimism that the Supreme Court would strike down the law appears to recede. "I'm so afraid to get my hopes up," she wrote to Human Services Department spokesman Matt Kennicott the following month. "If they uphold this thing our lives (and liberty) are forever changed."
"I'm w you there," Kennicott wrote back. "But sometimes hope and change are all we really have. :-)"
Those hopes would fall flat when the high court upheld the law.
Squier left her job just weeks after writing the letter that simultaneously asked for and criticized the necessity of a $97.9 million grant from the federal Centers for Medicare & Medicaid Services.
"I am concerned," she wrote in the grant application, "by your department's decision to require changes in New Mexico's exchange design—a design that your department had reviewed and approved. These changes have significant implications for the stand-up of New Mexico's exchange and add unnecessary cost. Yet the changes offer little value to consumers."
In its explanation of why the federal government rejected the grant application, CMS told the state health exchange that sections of its application lacked details, specifically the "IT work plan."
CMS also accused the exchange of failing to disclose how much money it was paying its contractors and disagreed with the assertion that the feds had already approved New Mexico's exchange design. But the explanation for rejection that got the most attention was uproar over the written criticisms from Martinez and Squier.
Dowd says CMS mentioned the letters in its feedback, but she doesn't know "specifically how much that factored into the final decision."
If the negative language played a role in the grant rejection, it wouldn't be the first time the state's health officials blocked federal funding for the exchange.
Derksen left the New Mexico Office of Health Care Reform in mid-2012, shortly after he says Squier blocked him from applying for a similar CMS grant worth $117 million. Derksen recalls going over the grant details with her and other officials at the state HSD the day before the state was set to submit the application to the feds.
"I was walking her through it page by page," he says. "At the end, she turned bright red, threw the grant application on the ground and said, 'You're just letting Obamacare in the door! This is not what we're doing in New Mexico!' and stormed out [of] the room."
Derksen says Squier's actions amount to a poor state thumbing its nose at available federal money. And the consequences are serious.
"People aren't getting necessary care because one person has undermined the situation," he says.
Derksen's background lends credibility to his claims. A doctor licensed in family medicine, Derksen taught at the University of New Mexico for 25 years before being appointed by Martinez in 2011 to draw up the early plans for a state-based health exchange.
Derksen has been a registered Republican for his entire voting life and worked with the state Legislature to pass laws to improve health care access in rural areas. One of his allies was state Sen. Keith Gardner, a Republican who is now Martinez' chief of staff.
In 2008, Derksen went to Washington DC on a fellowship and worked closely with former Democratic Sen. Jeff Bingaman. Legislative provisions he wrote at the time ended up in the ACA. While acknowledging that Obamacare isn't perfect, Derksen speaks highly of bringing health insurance to the uninsured, especially through a market-based mechanism.
"It's certainly better for my patients than the alternative," he says.
He also praises Martinez for being one of only four Republican governors in the nation to implement all the provisions of Obamacare.
"It takes some courage, if you're a Republican governor, if you adopt a state health insurance exchange and Medicaid expansion," he says. "I certainly applaud Gov. Martinez' efforts."
But the latest grant rejection has advocates like Webber warning that the consequences will be devastating. Loss of the grant, she says, means nonprofit health advocates won't be getting money from the state to do grassroots outreach to get people enrolled.
"The pullback in funding means all those contracts are going to disappear," Webber says.
Gov. Martinez' letter recommending the grant application is practically identical to Squier's, although she went further by stating that CMS' mandated changes offer "marginal, if any, value to consumers."
The mandated changes both Squier and Martinez refer to are requirements from CMS that call for the state to create an enrollment website that serves health care shoppers who qualify for either new private plans or Medicaid.
Just before the state applied for the grant this time, CMS told managers of the exchange that its marketplace should include Medicaid.
HSD spokesman Matt Kennicott says that the original state health exchange design included a CMS-approved plan that would lead those eligible for Medicaid to proper coverage. But the feds, according to Kennicott, "changed their minds at the last minute" and told the state it must implement "single door"—a more direct means to integrate the website with Medicaid.
These design requirements, Kennicott argues, are costly. "As was pointed out in the letters, the feds must remain flexible with the states," he says.
Kennicott asserts that the $48 million in federal money "should be more than enough to sustain the building and completion of the exchange."
Phone calls and messages to Squier were not returned for this story.
Debra Aragoncillo knows what it's like to be stuck between the exchange and Medicaid. At 58 and unemployed in Santa Fe for almost a year, she hasn't had health insurance in a long time.
Her most recent employment consisted of a temporary office job with the Federal Emergency Management Agency, which expired last May.
"No employer I've worked with has offered me insurance in the last 15 years," she says.
Because of her low-income level for 2014, Aragoncillo believes she'll qualify for Medicaid. But she's had no luck trying to find a plan herself on the state health exchange's website, where she says it wasn't easy to "differentiate the way the questions were set up."
"I could not do it," she says. "And I'm not a stupid person—trust me. I do my own taxes. I just got totally confused. Maybe it was my particular circumstances."
Her confusion wasn't limited to trying to enroll for coverage online. A recent trip to the state HSD's Income Support Division didn't help.
"I went down to the ISD, so I could speak to someone face to face about seeing if I qualified for Medicaid," she says, "and they pointed me to a computer. They didn't have anybody I could talk to. I was frustrated, because it's like, 'I already did that, but I don't know!' And I kind of gave up until now."
Today, Aragoncillo is attending an open enrollment event put on by Christus St. Vincent Regional Medical Center.
At the event, representatives from insurance companies and health policy nonprofits flood the hospital's hallway. Free classes are underway for those interested in understanding how to navigate the system. Even free lunches and day care are being offered so people have enough time to register for coverage. Upstairs, certified enrollers sit ready to help people register for plans through Medicaid and the exchange.
It's a far cry from the last enrollment period, when events like this weren't as organized.
"We didn't have anywhere near this capacity of design or thought or process or structure," says April Mendoza, the patient access services director at Christus.
Around the corner, Jim Lewis pokes around, asking insurance representatives about health care options. A 51-year-old substitute teacher for Los Alamos Schools, Lewis doesn't have coverage because of his part-time status. Today he's on a mission to get the cheapest health care plan possible.
"Catastrophic only," he says, "because my health is pretty good. I mean, I don't anticipate being in the hospital for the next three, four or five years. Unless I get hit by a car, which could always happen."
Husky and gregarious, Lewis speaks in a booming voice. He once worked on Wall Street, where he built up a generous retirement account. He shifted to teaching and academia and has more recently worked as an adjunct teacher.
Lewis last had health insurance two years ago, when he was enrolled in a student health care plan while studying public administration at UNM. Still, health care has been a big part of his life of late.
"My mom actually has been in there this week quite a bit," he says, pointing to the Anticoagulation Management Service office behind him. "She had a couple of brain seizures."
One of the seizures apparently happened at the doctor's office.
Lewis' mother is old enough to be covered by Medicare, the federal health care program for the elderly and disabled.
"I'm too young for that," he says. "I've got 15 more years, if there is Medicare then."
Though he's being forced to buy insurance by the government to avoid a fee, he isn't opposed to the idea because he says he can still "get minimal coverage for cheap."
"That's a punishment and a blessing," he says.
Aragoncillo is a bit more cautious. It's the degree of the penalty for not having insurance that gives her cold feet. This year, the fee for not having health insurance is $325 per adult and $162.50 per child, though low-income earners can be exempted from parts or all of the penalty.
"I think $100 is reasonable," Aragoncillo says. "I think the $400, for my personal circumstances, is expensive. I mean, I'm on a real tight budget."
With the second Obamacare open enrollment period now closed, Dowd says the next steps involve evaluating how the state exchange is working. The board that oversees the exchange recently approved a financial sustainability plan.
Still, Dowd acknowledges that the rejection of the federal grant presents "implications."
"We have to be very prudent in the partners that we select in moving forward," she says.
After the rejection, CMS recommended that the state apply for a separate Medicaid eligibility improvement grant. Dowd says the HSD hasn't expressed interest in applying for the money.
Still, there's one thing she stresses the exchange is committed to moving forward on: a strong outreach ground game.
Santa Fe Reporter