Though it's nearly 2,000 miles from Washington, Montana plays an oversized role in the health care debate. Its senior senator, Max Baucus, was one of the biggest players in crafting the sweeping federal health law.
And now Montana leads the country in the proportion of people who have signed up for the health law's insurance program for those with pre-existing conditions.
Still, the absolute number is quite low. Montana has signed up just 198 people.
The numbers remain far below initial estimates for the high-risk pools established in the 2010 health law. Two reasons: high premiums and consumers' lack of awareness about the program.
The plans, which are run either by individual states or by the federal government if the states opted not to participate, became available to most people last September. They are intended to serve as a bridge until the insurance market reforms are implemented in 2014, when insurers will no longer be able to deny coverage or charge higher rates for people with pre-existing conditions.
The Congressional Budget Office had estimated that as many as 4 million uninsured Americans would be eligible for the program and that 200,000 would be enrolled by 2013. And the Chief Actuary of Medicare and Medicaid estimated that 375,000 people would enroll in these high risk pools by the end of 2010.
Citing the low enrollment, some Republicans including Rep. Fred Upton (R-MI), have criticized the administration's handling of the program.
The cost of the plan, and the fact that many people still don't know about it, may be keeping enrollment down.
But administration officials point to the trend and are optimistic.
"We're encouraged by the jump in enrollment and we're excited to build and expand on our recent outreach efforts to reach even more people," said Richard Popper, director of insurance programs at the federal Center for Consumer Information & Insurance Oversight.
Enrollment varies widely by state. Pennsylvania has the highest enrollment with 2,684 people while North Dakota has enrolled just six people.
The U.S. Department of Health and Human Services lowered premiums in the plans it runs by about 20 percent this year and asked the states running their own programs to consider lowering their rates as well. Despite the slow start, Obama administration officials have said they are pleased with the program.
Most states require applicants to show proof that they've been rejected for coverage by a private insurer within the past six months or been denied coverage for certain benefits. At least a dozen states, including Pennsylvania, give applicants the option to provide a doctor's note as proof they have a pre-existing condition such as cancer or rheumatoid arthritis.
HHS has hired a private contractor to administer the programs it runs in states but generally they have enrolled fewer people than states running their own program.
Michael Keough, executive director of Inclusive Health, which runs the plan in North Carolina, credits increased awareness and lower premiums for the enrollment increase.
His plan cut rates by 10 percent across the board in January and rates fell as much as 30 percent for people between ages 55 and 64. The average premium for a 50-year-old in the plan is $285 with a $3,500 deductible.
More than 1,500 people have signed up for the program in North Carolina as of April, doubling enrollment since February.
"The trend line is increasing and that is what you want and the program is starting to have the desired impact," Keough said. "The plans still have the shadow of the original expectations to live with however accurate or not." Copyright 2011 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.