Facing the highest percentage of uninsured people in the nation, hospitals and health systems in Texas are employing multi-pronged strategies to spread the word about expanded coverage that will soon be made available under a health insurance exchange.

"Hospitals throughout Texas are looking at ways to educate the population and work with them as we move forward with the insurance exchange," says W. Stephen Love, president and CEO of the Dallas-Fort Worth Hospital Council, which has 80 member organizations in north Texas. "Oct. 1 is crucial because we've got to get people enrolled as soon as possible."

Love says that Texas hospitals are using all sorts of vehicles to try and get the message out, knowing that some potential enrollees may not have Internet service or a firm grasp of the English language. The council is working with others to try and secure a grant from the Centers for Medicare & Medicaid Services for exchange navigators. CMS is expected to award a total of $54 million in grants in August.

Created by the Patient Protection and Affordable Care Act, health insurance exchanges will open for enrollment on Oct. 1 and officially launch at the beginning of 2014. But Texas hospitals, like many nationwide, still face the challenge of educating patients about the law. A recent Kaiser Family Foundation poll found that only about 42 percent of Americans are aware that the Affordable Care Act is still law, and 19 percent think Congress or the Supreme Court has already overturned it. Organizations such as Enroll America, a nonprofit working to help enroll the uninsured, are urging hospitals to train their staff to answer basic questions about coverage, and refer patients to the proper resources.

Having experienced a similar open enrollment process under the Massachusetts health reform law, consultant Ron Hill is concerned that there isn't more advertising to get the word out about enrollment. He thinks that hospitals should be working closely with health plans to coordinate their points of view and devise a single way to talk to the marketplace. Developing a marketing and engagement strategy is key, he says. Hill, now a consultant with Guide IT, previously worked for Perot Systems Corp., which provided IT services for Massachusetts' Health Connector and ran a call center with employees speaking more than 20 different languages.

"It's not the population you've seen through traditional insurance: Americans who grew up with coverage since childhood," he says. "This is a group who's never seen it; it's a foreign concept. How do you engage them and make this work?"

In California, Scripps Health may be a little further along than systems in other states. Covered California, the state's insurance exchange, announced the 13 different health plans it would offer in May. Four insurers are available in Scripps coverage area and the system has decided to work solely with Blue Shield, says Marc Reynolds, senior vice president of payer relations.

Scripps is mostly relying on the state and to get the word out about the exchange. Reynolds says that Scripps' leaders are more concerned about capacity and whether there will be enough primary care physicians to serve a larger number of patients.

"Everybody is real excited they're going to have coverage. What they don't realize is they won't be able to find a doctor," Reynolds says. "These people will all come into the system pretty much on Jan. 1. It's not like they'll come in spread out over a two-year period. "So it may create some tight spots in a few markets. I don't know if that's San Diego for sure. I don't think anybody really knows."