By Jenny Gold

Kaiser Health News

Signing up for Affordable Care Act insurance was nothing like that. It involved questions about income, taxes, family size and immigration status. And in most places in the country, there were myriad choices of plans with subtle differences between them.

Guess what? People looked for help on the decision.

During the Affordable Care Act’s first open enrollment period, about 10.6 million people received personal help from navigators and other enrollment assisters, according to an online survey of the programs released Tuesday by the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

And the assistance was time consuming: 64 percent of the programs reported that they spent an hour to two hours with each consumer on average. The assisters and navigators included 28,000 full-time-equivalent workers across the country, funded by federal and state governments as well as outside sources, the survey found.

But those assisters were not distributed equally across states.

The 16 states that elected to run their own state-based exchanges had about twice as many assisters per 10,000 uninsured compared to the 29 states that defaulted to a federally-facilitated exchange. (The other five states set up a partnership with the federal exchange.) People in states running their own exchange were twice as likely to receive help with enrollment.

The discrepancy is not terribly surprising: the states running their own exchanges had significantly more funding available for outreach and enrollment. The Centers for Medicare and Medicaid Services awarded a much smaller $67 million in federal grants to fund navigator programs in the 34 states with federally-facilitated or partnership exchanges.

The entire state of Ohio, for example, had gotten just $3 million in grants to do consumer outreach by October 2013. That’s compared to $24 million in Maryland, which had half as many uninsured residents.

“It’s not just the money,” says Karen Pollitz, lead author of the KFF survey. “The culture of coverage might also have been different. [States with their own exchanges] might not have been working uphill against the barrage of bad noise against the ACA.”

In addition, the mostly Republican states that defaulted to the federal exchange tend to have higher rates of individuals without insurance. Some 33 percent of the nation’s uninsured population lives in states running their own exchanges, while 68 percent live in states that defaulted to the federal exchange or set up a partnership.

Almost 90 percent of assister programs surveyed reported that most or nearly all of the people they helped were uninsured. More than 40 percent said that most and or nearly all of the people they helped did not have Internet access.

In the end, it wasn’t the broken website that was the top reason people sought help from an assister – it was a lack of understanding of the law. About 65 percent of the program said that most or nearly all consumers had online difficulties. But more than 85 percent said that most or nearly all had a limited understanding of the ACA and needed help understanding their plan choices. And three-quarters said that most or nearly all needed help understanding basic health insurance terms.

“How can you explain coverage options to someone who doesn’t know what a deductible is?” asks Pollitz. “It’s just a much longer conversation,” which might help explain why most of the programs reported that assistance required one to two hours per client. “And those same people, at least some of them, are starting to come back with post-enrollment problems,” Pollitz adds.

The need for help selecting the right plan is not likely to disappear in the coming years. “It’s a fundamental need people are probably going to have for the foreseeable future,” says Pollitz, especially as consumers experience a change in their family size or employment.

In the end, about 8 million Americans signed up for a plan on the health insurance marketplaces in the first year. Others enrolled in Medicaid or CHIP plans, and some of those who received help from assisters did not enroll in coverage at all.

The survey also found that federally qualified health centers and nongovernmental funds played a surprisingly important role in enrollment. Of the 4,400 different assister programs, 70 percent were supported either by the federal safety net clinic program or were privately funded.

The survey was conducted online from April 24 through May 12 among assister programs nationwide; 843 out of the 4,445 programs responded. The margin of error is +/- 4 percentage points.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.