The moment of truth

It's the question on everyone's mind. With open enrollment on the state insurance exchanges starting Oct. 1, will uninsured and underinsured Americans flock in large numbers to sign up for the new coverage? Or, when faced with technical glitches, lack of accurate information, uncertainty about out-of-pocket costs and tight household budgets, will they take a pass?

The individual calculations of millions of Americans will determine whether President Barack Obama's landmark effort to extend comprehensive, secure health insurance to nearly everyone succeeds or fails. Many people will be shopping for health insurance for the first time, and it's a daunting process for anyone.

Whatever the ultimate verdict, many experts are predicting a sluggish start as consumers take time to weigh their options under the Patient Protection and Affordable Care Act's broad new system of health plan marketplaces, standardized benefits, consumer protections and premium subsidies.

“I would expect enrollment to be quite slow in October, and then ramp up toward the end of the year,” said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation. And since plans don't start providing coverage until Jan. 1, there should be no rush, he said. “October seems like a good month for window shopping.”

Jessica Barba Brown, national communications director for Enroll America, a pro-ACA group, also forecasted low enrollment numbers at the outset, followed by a spike when the actual coverage starts in January. The organization has targeted 10 states—mostly ones led by Republicans opposed to the ACA such as Florida, Michigan and Ohio—for an aggressive enrollment campaign.

“This is a marathon, not a sprint,” Brown said. “Right now we're in the information phase, helping people to understand what these plans cover and what financial help is available to them.”

In an August poll conducted by the Kaiser Family Foundation, consumers said they're most likely to trust information about the ACA when it comes from doctors and nurses, as well as from federal and state agencies.

Louisiana Insurance Commissioner Jim Donelon said his department is gearing up for a flood of consumer questions about the exchanges. Louisiana has a federally facilitated exchange and state Republican leaders have been vehemently opposed to the reform law. But Donelon said he and his staff will handle consumer concerns directly rather than forward them to HHS, unlike in some other GOP-led states.

“We consider it our responsibility to assist folks the best we can,” said Donelon, calling the ACA's complexity “mind-boggling.”

Federal officials hope an HHS report released last week showing lower-than-expected premiums and ample plan choice in the 36 states with federally facilitated exchanges will go a long way toward quelling consumer concerns about affordability and choice in the new markets.

According to the Sept. 25 report, individuals and families will have an average of 53 plan choices, nearly everyone will have at least two insurance carriers to choose from, and the average monthly premium nationally for the second-cheapest silver-tier plan will be $328 before taking into account the federal subsidy for households with incomes between 100% and 400% of the federal poverty level.

The number of plan choices available to consumers in states where the federal government partly or fully runs the exchange will range from six to 169, with an average of eight participating insurers.

With a premium tax credit, a family of four in Texas with income of $50,000 could pay as little as $57 a month for the lowest-cost bronze plan; that plan will cover an average of 60% of costs. In Jackson, Miss., a 27-year-old earning $25,000 will be able to pay $8 per month for the lowest-cost bronze plan after the tax credit.

But some policy experts are warning that consumers still could face high costs in the form of deductibles, copayments and coinsurance. A Sept. 25 report from Avalere Health found that consumers buying plans on the exchanges can expect to pay more out-of-pocket than those with employer-sponsored coverage. Still, individuals and families with incomes up to 250% of the federal poverty level will qualify for a substantial subsidy limiting their out-of-pocket costs.

“Consumers will need to balance lower monthly premiums against the potential for unpredictable, expensive, out-of-pocket costs in plans with higher deductibles,” Caroline Pearson, vice president for Avalere Health, said in the analysis. “Furthermore, there is a risk that patients even forgo needed care when faced with high upfront deductibles.”

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