Arsine Sargsyan is 23 years old, healthy and uninsured. She chooses to forgo coverage for one simple reason: "I never get sick."
Despite her reluctance, Sargsyan is exactly the type of person insurance plans, states and the federal government are counting on to make health reform work.
As the clock ticks toward the 2014 launch of the Affordable Care Act, health leaders across the nation are embarking on a tough task: persuading young adults like Sargsyan to enroll. Their participation will be critical to balance out older, sicker patients more likely to sign up for health insurance as soon as they are able.
The success of the healthcare law "depends on reaching everyone who is uninsured, but particularly young people who may feel like they don't need insurance," said Larry Levitt, a senior vice president at the Kaiser Family Foundation. Convincing them to spend money on insurance, he said, will be a "marketing challenge."
Getting young adults on board will require changing cultural norms, Levitt said. "For kids in their 20s ... following convention isn't their first instinct," he said.
The federal law allows young adults to stay on their parents' policies until they are 26. About 425,000 people in California have taken advantage of the new benefit, officials say, leading to savings for them and their families when they go to the emergency room.
Still, more than 2 million Californians ages 19 to 34 are uninsured, according to the UCLA Center for Health Policy Research.
Beginning in 2014, nearly everyone will be required to have insurance or face a fine -- $95 or 1% of their household income in the first year. Many young adults who are not covered through work or their parents may be eligible for Medicaid or the new state-based insurance market places known as exchanges.
Health officials worry that the fine, which increases over time, isn't high enough to convince people to sign up for coverage. "The penalty itself will not convince a young person, or any other person," said Oscar Hidalgo, a spokesman for Covered California, the state's exchange. "Young people will need to understand the risks of not having health insurance."
Osvaldo Lopez, 24, of El Sereno said he understands the risks because he plays soccer and worries about getting injured. But Lopez, a student who works part time, said he can't afford it. After graduation, he hopes to get a law enforcement job that provides insurance so he won't have to pay for his own.
Another student, Zach Gaul, 19, said he was thankful to still be covered under his parents' plan, even though he has to pay them a portion of his paycheck for the coverage.
"I do reckless things all the time," he said, listing recent activities: skateboarding, bike riding, drinking, racing cars, jumping off a waterfall. "If I get hurt, I'd like to be able to afford getting airlifted out."
Covered California is developing media messages that are "a little edgier" and specifically target young adults, Hidalgo said. The state plans to use a financial security argument, telling young people that insurance can protect them from going broke if they are hospitalized after a car accident, a broken bone or an illness.
"This will have its challenges, kind of like talking to your kids when you are trying to advise them of the right thing to do," Hidalgo said.
Last week, the state released its rates for health insurance under the exchange. While costs vary based on age and income, young adults with low or middle incomes are likely to receive substantial subsidies -- for premiums, deductibles and co-pays. For example, a 21-year-old who earns about $16,000 would pay about $45 each month for the mid-level plan. State officials point out that costs could rise in subsequent years if not enough healthy people enroll.
In an effort to educate and enroll young adults across the state, Covered California also awarded millions of dollars in grants to the University of California, Cal State L.A. and the Los Angeles Unified School District.
Many Cal State students are young, low-income and minority and probably eligible for Medi-Cal or subsidized health coverage, said Walter Zelman, chairman of the public health department at Cal State LA. Zelman, who is overseeing a $1.25-million grant, said he plans to hire graduate students at most of the Cal State campuses to lead the way on outreach. The campuses will also conduct training, hold forums and enroll as many students as possible, he said.
"Not only is this a needy population and a deserving population, but it is a population that is relatively easy to reach," he said.
The Young Invincibles, a policy and advocacy organization, has also started a campaign and a mobile app to raise awareness about health coverage. The organization's California director, Tamika Butler, said the group was focusing on both enrollment and education. And staff, who are young adults themselves, are telling other young people that insurance can give them financial peace of mind as well as help them get preventive and mental healthcare.
Butler said young people who learn about the benefits of insurance can spread that knowledge to friends and family. "Young people are a gateway to not just get insured themselves, but to get other community members insured," she said.
Bianca Gonzalez, 23, said she and her family have long been uninsured and rely on herbal remedies whenever they get sick. Gonzalez, who lives in Eagle Rock, said she never thought much about insurance because she didn't think they qualified for anything affordable. But after learning about Medi-Cal in a health policy class at Cal State L.A., Gonzalez said she realized her family may be eligible in 2014.
"It's awesome," she said. "If I need to go to a doctor ... I will be able to go and get service without worrying about how I am gonna pay for it."
Sargsyan, meanwhile, hasn't seen a doctor in five years. Even though she recognizes that health plans need people like her, she doesn't want to pay a costly monthly premium. Unless she finds a job by 2014 that offers inexpensive insurance, Sargsyan said she will probably just pay the penalty.
"God forbid something happens," she said. "Until then, I'm living healthy and happy."