Love it or hate it, Obamacare enrollment starts on Tuesday

Oct. 29--Tuesday marks the start of enrollment for 2017 Affordable Care Act plans -- and as has become common over its first six years, the health insurance system consumers know as Obamacare remains steeped in complexity, uncertainty and political debate.

Still, consumers in South Florida, considered one of the nation's most successful Obamacare markets, remain in better shape than many in the United States with lower premium increases, more health care providers and more insurance plan choices.

Across the United States, uncertainty clouds the future of Obamacare. Citing higher-than-expected losses, Aetna and UnitedHealthcare, two of the nation's largest insurers, pulled out of the ACA marketplace in most states for 2017, leaving fewer competitors and heightening doubts about the program's long-term survival prospects.

Ed Olsen, a Boynton Beach retiree, said he was worried that the pull-outs would leave him with fewer plan options that include his chosen doctors next year. When prices and plans were made public Oct. 24, he found "except for one or two cases, [my doctors] won't be accepting these plans," Olsen said. "My next step is to contact my doctors directly and see which companies they'll actually accept and go from there."

About a third of U.S. counties will only have one company offering plans on the ACA marketplace -- meaning eligible for federal tax credits and other financial help -- according to an analysis by The Associated Press and consulting firm Avalere Health. That's more than 1,000 counties in 26 states.

In Florida, 49 of the state's 67 counties are left with just one insurer -- Blue Cross and Blue Shield affiliate Florida Blue -- offering marketplace plans.

However, in Broward, Palm Beach and Miami-Dade counties, consumers can choose from four companies: Florida Blue, Humana, Ambetter and Molina. While that's four fewer than in 2015, it's more than in most counties. Only 157 of 3,129 U.S. counties will have access to more than four companies in 2017.

Meanwhile, the ACA remains a lightning rod for political debate, adding to the uncertainty over its future.

On the presidential campaign trail, Republican candidate Donald Trump promises to repeal President Obama's signature policy achievement and replace it with a number of free market fixes that include allowing insurers to sell across state lines and making premiums fully tax-deductible for consumers. Trump would eliminate the "individual mandate," the requirement that nearly all adults must buy health insurance.

Democratic candidate Hillary Clinton acknowledges that premiums and care costs have grown more burdensome for many enrollees who make too much money to qualify for government subsidies. She supports a number of tweaks, including increasing subsidy eligibility and creating a government-run insurance option.

Monday's news that premium costs would increase an average 25 percent in 39 states served by HealthCare.gov was greeted with disappointment by some ACA advocates.

Part of the reason for the steep increases, experts explained, was that the number of young consumers enrolling has fallen short of expectations. Too many who aren't afraid of getting sick have chosen to pay the penalty for not having insurance, which rose this year to $695 or 2.5 percent of income, whichever is highest.

Young, healthy enrollees are needed to balance the risk pool and help pay for health care needed by the older, sicker population, industry experts say, or companies have little choice but to raise premiums.

Premium increases will be lower in Florida, and especially South Florida, according to a report by the federal Department of Health and Human Services. While premiums and increases will vary depending upon an enrollee's age, choice of plan and county of residence, the average premium for a 27-year-old choosing the second-lowest-cost Silver plan will increase 14 percent statewide, 4 percent in Broward and Palm Beach counties and 16 percent in Miami-Dade counties, the report said.

Average monthly price nationwide for that Silver plan is $302, the report said, compared with $270 in Florida, $249 in Broward, $244 in Palm Beach County and $251 in Miami-Dade.

Complexity in how the ACA marketplace works leaves many pieces of news open to interpretation. For example, while reporting the 25 percent premium increase for 2017, federal officials were quick to point out that nearly eight in 10 of about 12.6 million marketplace enrollees will qualify for tax credits that reduce their monthly premiums to $100 or less. Many of those will qualify for additional help to pay for medical care.

Those numbers ignore the 6.9 million customers paying full price -- and coping with premium increases -- for individual plans that aren't on the HealthCare.gov exchange but still have to meet ACA coverage mandates. Many of those consumers buy plans off the exchange after finding out they make too much money, as part-time, self-employed or contract workers, to qualify for tax subsidies.

Only consumers getting tax subsidies must buy on the exchange. Consumers who don't qualify are free to shop off the exchange, where companies such as Cigna, Aetna, AvMed and Coventry continue to sell plans despite pulling out or curtailing their on-exchange presence.

Yet monthly premiums for off-exchange plans are increasing at rates similar to those of the on-exchange plans, according to a September report by the Florida Office of Insurance Regulation. This year, state regulators approved a 25 percent average increase for Aetna Life Insurance Co. off-exchange HMO plans and a 27.3 percent average increase for AvMed off-exchange HMO plans, the report shows.

Consumers, whether they are enrolling for the first time or looking to shop for a different plan, should not base their decisions on price alone, advocates say.

Cliff Eserman, a Wilton Manors-based health insurance broker, warns his clients to look carefully at in-network hospitals and providers before selecting a plan. Reduced competition is empowering remaining insurers to save costs by cutting back on the number of providers offered in their plans, he said.

Reviewing one company's offerings after HealthCare.gov posted previews of prices and plans on Oct. 24, Eserman noted, "There's 50 doctors and just one HIV clinic. They have [two Broward Health hospitals], but I don't see Holy Cross or Cleveland Clinic." The company, he said, offered comparatively few providers on the east side of Broward County.

So-called narrow networks help insurers keep their ACA programs profitable and their plans affordable, experts say, but put the onus on consumers to ensure their providers are in their new plans' networks.

"My concern is people are going after [low] price, like we expect them to, then discover the network has been trimmed down," Eserman said.

Looking at comparatively low-priced plans by Ambetter, Mark Cherry, principal analyst with health care industry analyst Decision Resources Group, noted that no hospitals owned by Memorial Healthcare System -- the public hospital system that serves most of southern Broward -- came up in his search results.

"Ambetter may have been able to achieve the county's lowest exchange premiums in part by offering products that don't include Memorial Healthcare System in-network," he said. "If that remains true, Ambetter may be less popular in the southern part of the county."

Not everyone sees the Obamacare glass as half-empty. Jodi Ray, who oversees the statewide network of ACA plan navigators at the University of South Florida's federally funded Florida Covering Kids and Families program, says her team is gearing up for the start of enrollment period "not really having a lot of concerns."

Between 2013 and 2015, the number of uninsured declined by 1.19 million in Florida and 487,000 in the tricounty region, according to U.S. Census estimates released in September.

Since 2013, Ray said, navigators in Florida have become better skilled at finding uninsured people, helping them find plans to fit their needs, and showing them how to get the greatest amount of government assistance possible, she said.

"We keep exceeding our projections," she said. Navigators work in partnership with public health agencies and private nonprofits throughout the state, reaching people who speak Arabic, Vietnamese, Cantonese and Portuguese, she said.

They target young adults through employers and at universities and find, contrary to reports from other parts of the country, that most want to buy insurance but can't qualify for subsidies if they are full-time students living on loans, or if they make less than the federal poverty level, Ray said. The federal government expected states to help cover non-qualifying students by expanding their Medicaid programs, but Florida so far has not done so.

This year, navigators will continue to sign up new enrollees, Ray said. There are plenty remaining. An October report by the Kaiser Family Foundation estimates 614,000 of Florida's remaining 2.4 million uninsured population are eligible for subsidized health insurance plans.

In addition, about 100,000 consumers are currently paying full price for off-exchange plans, even though they are eligible for tax credits that could bring prices down, she said. "We have to get those people in."

Renewing consumers will seek help, particularly if their 2016 provider pulled out or if they want to change plans. "We'll help them look at other products on the market and tell them, 'There might be something better for you.'"

Many will come to the navigators far more educated than they were when Obamacare plans first hit the marketplace in 2013, Ray said.

"The consumers are very proactive and are more informed each year," she said. "Even where I get my nails done, people know that Nov. 1 is the date. They tell me, 'I'm coming in on Nov. 1.' They know that date."

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Obamacare 2017 signup begins Tuesday

What is ACA (Obamacare)?

It's a law that required nearly everyone to buy health insurance, removed pre-existing conditions as an eligibility criteria, and established a national marketplace, among other mandates.

Who qualifies for subsidies?

Individuals and families with gross adjusted incomes between 100 percent and 400 percent of the federal poverty level. Cost sharing for care is available to enrollees between 100 percent and 250 percent of the federal poverty level.

Companies offering health insurance plans qualifying for federal tax subsidies:

Florida Blue (A Blue Cross and Blue Shield company): floridablue.com

Molina Healthcare: molinahealthcare.com

Ambetter: ambetterhealth.com

Humana: humana.com

Where to sign up:

HealthCare.gov (official site)

Where to get help:

enrollamerica.org, getcoveredamerica.org

More information: healthinsurance.org, kff.org/health-reform (Henry J. Kaiser Family Foundation)

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