Washington state’s uninsured rate has dropped 40 percent since the provisions of the Affordable Care Act took effect, boosting coverage to about 91 percent of residents. But reaching those who still lack health insurance remains a big job, officials say.

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Health-insurance holdouts — people who don’t want or haven’t found coverage in the era of Obamacare — will be the focus starting Nov. 1 as state and federal officials launch the Affordable Care Act’s third open enrollment period.

The stakes are higher this time for everyone involved.

For people without health insurance, the fines for ducking the ACA’s individual mandate are rising sharply this year — to $695 per adult — to the point where advocates say it might be better just to buy a policy than to pay the penalty.

Open enrollment starts Nov. 1

Open enrollment for Washington state’s health- insurance marketplace begins Nov. 1 and runs through Jan. 31, 2016, for people seeking coverage starting next year.

People can choose from 136 qualified health plans offered by a dozen insurers, an increase from 2015. Average cost without a tax credit was $381.15 per month this year, while the average cost with a tax credit was $173.89.

For more information or help, visit www.washingtonhealthplanfinder.org

Source: Washington Health Benefit Exchange

And for the Washington state officials determined to get everyone covered, it will be harder than ever to reach the rest.

“This year’s going to be interesting,” said Michael Marchand, spokesman for the Washington Health Benefit Exchange, the state-run health-insurance marketplace. “There’s a lot fewer uninsured in our state.”

Among them is 20-year-old Jael Sullivan, of Tacoma, who showed up at the four-day free health clinic held at Seattle’s KeyArena last week. Sullivan, who said he’s just about to start a new job laying flooring, has no medical or dental insurance and came to the clinic in pain from erupting wisdom teeth.

“I don’t think I’ve been to a dentist since I was 10,” he said.

But Sullivan doesn’t plan to join the nearly 10,850 people in Washington ages 18 to 25 who have opted to buy insurance on the state exchange.

“To me, I don’t really ever go to a hospital, even when I need it,” he said. “If I’m not going to use it, why would I pay for it?”

Sullivan is among about 600,000 people without health insurance in Washington, down about 40 percent from the nearly 1 million who lacked coverage in 2013, before the requirement that people get insurance or pay penalties took effect. He is also among the most difficult consumers to get into the pool — young, healthy people willing to forgo health coverage to save cash.

The U.S. Census Bureau says about 9.2 percent of state residents still have no health insurance; the insurance commissioner’s office says it’s more like 8 percent.

Nationwide, about 10.4 percent — some 33 million people — remain uninsured, according to the most recent figures from the U.S. Census. Most people in the U.S. are covered through employer-based insurance plans, Medicare or Medicaid. About 9.9 million people had signed up as of June for plans authorized under the 2010 law that mandated health insurance coverage for most Americans.

In Washington state, about 3.8 million people have employer-based insurance coverage, and about 1 million are covered by Medicare, census figures show.

The big driver behind the newly insured has been the expansion of Medicaid through the Washington Apple Health Plan. The state started early expanding Medicaid to low-income adults, and more than 560,000 have enrolled since 2013, driving total enrollment to about 1.4 million, according to the state exchange.

An additional 152,000 people have enrolled in qualified health plans on the state insurance exchange, up about 18,500 since the same period last year, according to the Washington state exchange. About 170,000 people have private insurance plans outside the exchange.

Sign-ups during open enrollment, which runs through Jan. 31, 2016, are projected to boost the exchange numbers by 3 percent to 5 percent, to nearly 160,000, Marchand said.

Reducing the remaining uninsured is a big challenge, experts say.

Medicaid enrollments are expected to rise incrementally, nothing like the huge spike seen in past years, according to projections from the state Health Care Authority.

“It’s hard to imagine that there are many more people who are eligible for Medicaid,” said state Insurance Commissioner Mike Kreidler.

And people who are eligible for the exchange but haven’t signed up are a tough crowd, too.

“There’s still a set of people who haven’t come to the Washington Healthplanfinder to see what meets their needs and budget,” Marchand said. “Many are still of the mind that they won’t find anything there for them.”

But this is the year that those who remain uninsured may feel the pressure of financial penalties. Families who don’t have health coverage can expect to pay a flat fee of $695 per adult and $347.50 per child in fines or 2.5 percent of yearly income, whichever is higher, according to the law.

“For many of them, it’s going to be as much as half a year’s premium,” Kreidler said.

The Washington exchange has earmarked about $3.2 million in grants to help health organizations connect with hard-to-reach populations, Marchand said. At Public Health — Seattle & King County, that means that Daphne Pie, manager of access and outreach, has narrowed her search based on new data about particular pockets of uninsured people.

“We’re looking at really targeted outreach,” she said. “We know that in the Auburn area, there’s 5,000 people estimated to be eligible for a qualified health plan, and another 5,000 eligible for Apple Health. We have 10,000 people there who could be eligible for insurance.”

In the new several weeks, her crew will be setting up enrollment events at shopping malls, schools and libraries in vulnerable areas and targeting employees of small businesses who may not know they can get coverage.

“We know there’s a need in South King County,” she said. “How do we really look at who’s there?”