Every year, thousands of people like Blanca Guerra call the National
Guerra rang recently from her home in Arizona, seeking help for her older brother, who had just been diagnosed with advanced stage colorectal cancer.
A few years ago, the call center would have had few solutions.
But between 2012 and 2014, when the major coverage expansion made possible by the
The gains are not being evenly shared around the country, however, highlighting an issue still shadowing the federal healthcare law, even after it survived the latest legal challenge.
Guerra got help enrolling her brother in Arizona's
Many callers from states such as Texas and Florida that haven't expanded their Medicaid safety nets aren't so lucky. Call center data show just 18% of callers from those two states got connected to coverage in 2014, compared with 35% in California and New York, which both expanded Medicaid.
"There are so many more people we wish we could help," said Mandi Battaglia Seiler, who supervises the insurance service at the cancer call center.
The center, which sprawls through a building the size of 2 1/2 football fields in an industrial section of Austin, Texas, was set up by the American Cancer Society nearly 20 years ago.
More than 200 cancer information specialists now field about 80,000 calls a month, helping cancer patients make sense of their disease, find medical providers or sort through their treatment options.
Some callers are just looking for screening programs. Others are seeking clinical trials that may offer hope if their cancers aren't responding to available drugs.
Many of the most needy patients are routed to the center's insurance assistance service.
There, information specialists like Barbara Jones gently talk to callers about their cancers, their incomes and, crucially, what state they live in.
Toggling between computer screens, Jones looks for potential insurance options by state. If none are available, she looks for public hospitals, government health clinics and local charity programs that might help. Some calls last half an hour or more.
"Day in and day out, it can be pretty depressing," said Jones, a former stay-at-home mother who has been working at the call center for 12 years. "There are times when we have to say, 'I'm really sorry. We're coming up blank.' … We have people say, 'Are they going to just let me die?'"
The job has become easier since the health law became fully implemented, though.
Since 2014, the law has guaranteed coverage to Americans making more than the federal poverty level, allowing consumers who don't get insurance through an employer to shop for health plans on new state insurance marketplaces.
That has helped drive a historic decline in the number of uninsured. Nationwide, the share of adults without insurance fell to 11.4% in the second quarter of this year, according to the latest Gallup poll. That is down from 18% in 2013, before the current expansion began.
The cancer center's own numbers, though not a scientific sample, underscore what the expansion has meant for some of the nation's sickest people.
"It is night and day," Jones said.
Overall, the number of callers seeking insurance dropped by nearly half from 2012 to 2014, declining from 5,084 to 2,678.
The American Cancer Society analyzed its data at the request of The Times to identify national and state-by-state trends.
In addition to the marketplaces, the law was also designed to provide free Medicaid coverage to the poorest Americans, providing states with billions of dollars to expand their Medicaid programs to cover working-age adults. (Medicaid historically served poor children, mothers and the disabled.)
But the Supreme Court ruled three years ago that the Medicaid expansion was optional. Since then, Republican elected officials in 20 states, mostly in the South and the Great Plains, have refused to broaden Medicaid access, citing concerns about the program's cost and effectiveness.
That has dramatically affected coverage, surveys show. States that offer Medicaid to their poorest residents through the health law have seen their uninsured rates decline nearly twice as much as states that do not.
The disparities are showing up at the call center, too, data show.
Progress has been much more rapid in states such as California and New York, where the percentage of cancer patients successfully connected to coverage surged from 16% to 35% between 2012 and 2014.
By contrast, the share of callers from Florida and Texas who got insurance increased only from 12% to 18%.
"It's not perfect," said Jones, noting that the call center staff still struggles to find options for patients in parts of California and other states where there are few doctors who take Medicaid.
Affordable insurance options are also limited for people in the country illegally. Still other patients may have to wait to get a health plan because they missed an enrollment period, or they may not want to sign up for a public program such as Medicaid.
"Since the Affordable Care Act, though, there is a whole lot more available," Jones said.
In Arizona, Guerra's brother, Mario Crenshaw, 62, is getting chemotherapy and radiation to shrink a baseball-size tumor blocking his colon.
He still faces major medical hurdles. The cancer has spread to his liver, and he had to have a colostomy to get around the tumor.
But Guerra said he and his family are no longer facing thousands of dollars in new medical bills, as they did before Crenshaw got onto Medicaid.
"Sometimes I wonder how people in states that don't have coverage do it," Guerra said. "What happens to those people?"