By STEVE FINDLAY

The third ACA health insurance exchange open enrollment period begins Nov. 1, and things look iffy. The Obama administration this month reduced the estimate of new enrollees for 2016—possibly to lower expectations but also because signs point to the difficulty of luring the remaining uninsured into the fold over the next few years.

It’s time for some fresh strategies to ramp up enrollment and get where we need to go. At the end of this piece I offer some suggestions and invite yours. (This article assumes the ACA will be in place over the next five years even if a Republican becomes president in 2017.)

Health insurance numbers can be confusing (and hyped out of context from both sides of the political aisle), so here’s a quick rundown of the current situation and the Obama Administration’s new projections.

The current U.S. population is 326 million. According to the Census Bureau’s latest authoritative annual report (released in Sept) 10.4% of the population, or 33 million people, were uninsured for the entire year in 2014. That’s down sharply from 13.3%, or 41.8 million people, in 2013. Thus, as of the end of 2014, there were 8.8 million fewer uninsured people, due primarily to Obamacare.

Some details:  66% percent of the population had private sector coverage and 34% had government coverage; 55.4% were covered through their own or a family member’s job; 19.5% had Medicaid; 16% had Medicare; 14.6% had coverage they bought themselves and 4.5% had military coverage. (The breakdown exceeds 100% because of coverage transitions during the year, which affect about 20% of the population.)

As would be expected post-ACA, the biggest change from 2013 to 2014 was in direct-purchase (buy your own) coverage and Medicaid. Direct-purchase (inside and outside the exchanges) ticked up 3.2 percentage points, to 14.6% of the population in 2014 from 11.4% in 2013. Medicaid coverage rose by 2 percentage points to 19.5%of the population in 2014 from 17.5% in 2013.

That brings us to 2015.  Another government survey projected that as of the end of March 15.8 million had gained coverage under the ACA (in the exchanges plus Medicaid plus additional employer or private buy-your-own coverage), reducing the uninsured rate to around 9% or 29 to 30 million people. So, that’s an additional 3 to 4 million covered lives compared to the end of 2014.

HHS and the administration made no update to those overall statistics this month. What they did do was project enrollment numbersin the exchanges—that’s what hit the news and delighted Obamacare opponents.

The bottom line on coverage in the exchanges:  about 10 million people will be covered by late 2016, up from the 9.1 million HHS expects to be covered in the exchanges at the end of 2015.  That’s a potential gain of fewer than 1 million during 2016 open enrollment. (The margin-of-error range is 9.4 to 11.4 million for end of 2016.)

The reason for the hand-wringing (by ACA supporters) or cheering (by opponents) was that the 10 million estimate is half what the Congressional Budget Office (CBO) projected last June as the number of people who would be covered through the exchanges by the end of 2016.  That is, CBO forecast 20 million.

Ouch! Ok, why so much lower? Here’s HHS’s explanation, edited for brevity:

“We adjusted the CBO projections….downward based on employer surveys from Mercer and other industry sources, which suggest that shifts from [employer-based] coverage and the off-Marketplace [exchange] individual market into coverage through the Marketplaces will be smaller than CBO expected and that the remaining uninsured may be harder to reach than in previous years….”

“As Marketplace coverage becomes more widespread and the size of the uninsured population eligible for enrollment in coverage through the Marketplaces shrinks, the remaining uninsured may be harder to reach, slowing enrollment growth. Beyond these factors, there are macroeconomic forces such as changes in population and economic conditions, which are difficult to predict but likely to affect enrollment.”

All logical. Most notable: Fewer people are being dumped from employer coverage, or opting out of it themselves to buy on the exchanges. And fewer people who buy their own insurance already (such as small business owners and the self-employed) are shifting to exchange coverage. The former is probably a good thing; it’s best still to have coverage through your job. The latter may not be so great unless those who are retaining their non-exchange coverage are not eligible for subsidies. (A fair proportion of such people may be self-employed red-state Obamacare critics who just don’t want any part of it.)

What HHS Secretary Sylvia Burwell and her colleagues didn’t say outright, however, is that the CBO projections began to look unrealistic over a year ago given the obstacles to exchange coverage—the main one being cost/affordability.

Thus, on the political front, Republican broadsides suggesting that the downward projections signal an Obamacare failure are not based in any careful or honest analysis (no surprise there, of course).

However, that said, the adjustment is still sobering and worrisome. And the Obama administration has underplayed the “affordability” issue even as it promotesgovernment-subsidized coverage.

In a 16-page brief HHS released alongside the new numbers, the department examines the remaining uninsured population, and obstacles to corralling them into the exchanges (or expanded Medicaid). See that excellent brief for all the juicy details on the exchange-eligible population—19 million people, 8.5 million of whom currently have non-group, non-exchange coverage, and 10.5 million who are uninsured.  Of the 10.5 million uninsured, 80% are low-income and eligible for subsidies; half are aged 18 to 34; a third are people of color/minorities; and nearly 8 in 10 have less than $1,000 in savings.

As everyone now acknowledges, many of these people are hard pressed to pay for coverage in the exchanges even with the subsidies, and they are leery of the high deductibles and co-pays even though they get some help with those, too.  For many, then, it doesn’t look like such a good deal, they have other bills to pay, and there’s the safety valve of emergency room or free clinics.

At the same time, an awareness problem persists. You and I might think someone would have to have been living under a rock these last few years not to hear about the ACA and subsidized coverage.  But surveys by the Kaiser Family Foundation, Commonwealth Fund and Urban Institute all find that from half to 65% of the uninsured are unaware of or do not understand the available subsidies.

HHS says it’s going to ramp up outreach this fall, to include greater use of social media to reach young adults and in-person assistance (navigators) for people who are hard to reach. This new Health Affairs/RWJF brief explains the role of navigators, who are budgeted at $67 million this year. Enroll America, the private sector collaborative, is on the case again this year, but with sharply reduced funding.

That’s all good, but I think more is needed this fall and over the next few years if we are going to reach these folks and hit a target of near-universal (95% or more) coverage by 2021. Here are a few ideas, humbly offered in the face of an admittedly tough problem:

• Go all out in a targeted campaign to reach the young. Blanket them with social media messages everywhere they work, play, and go to school. Get creative with videos, and engage “tipping point” youth leaders, sports stars, popular bloggers and YouTube personalities in the cause.

• Create a state-based low interest loan program dedicated to paying for exchange-based health insurance. Yes, that’s a heavy lift because this is a high-risk population financially.  So, convene bankers and other experts to explore whether and how it could be structured.

• Partner with employers nationwide (large, mid-size and small) to get their uninsured workers (and dependents) covered. Sure, many businesses are not big Obamacare fans, but it’s a bottom line no-brainer for them, or should be:  whether they offer coverage themselves or not, they benefit from every covered worker. Firms that employ a high proportion of low-wage workers are an obvious priority.

• Fund a contest for filmmakers to create two to three-minute videos on health insurance, the exchanges, and subsidies—with the goal of ending up with 5 to 10 videos (how about $50,000 to $100,000 prize to each winner?) that can be spread around the web and screened in multiple forums.

• Ramp-up efforts with the best-known national and regional Hispanic/Latino organizations to enhance awareness of the exchanges and subsides.

• Get celebrities involved! I know that sounds trite but plenty of them donate their time to disease awareness and public health efforts and other civic, and other philanthropic activities. I don’t see any involved in this issue, though I may have missed it.

I welcome your ideas and pledge to package whatever comes in and forward it to folks at HHS, the White House, and in selected states.

Addendum: The Obama administration on Oct. 26 released premium data for insurance bought through the exchanges in 2016 (after the above blog was written).  The data show an average jump in premiums across the country of 7.5%, based on the second-lowest silver plan—one of the most popular.  The range is wide, from 3% to 7% in a batch of states to more than 30% in Alaska, Montana and Oklahoma.  The big winner: Hoosiers; the average rate in Indiana will drop 12.6%.

The administration stressed that between 70% and 80% of people will still be able to buy a plan for less than $100 a month, after factoring in the federal subsidies.

HHS also said its enrollment outreach efforts this fall will focus on Chicago, Dallas, Houston, Northern New Jersey and Miami.  Rate hikes in all those areas were below average: 1.3 percent in Chicago; 3.9 percent in Dallas; 4.9 percent in Houston; 2 percent in Miami; and 5.1 percent in Northern New Jersey.   The agency also noted that with the penalty for not having insurance in 2016 at $695 per adult, many low income families will find it less expensive to get covered.

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology.