Most are satisfied, but change is coming

Seven months after coverage began for people who bought health insurance under the Affordable Care Act, more are now insured and most of the nearly 10 million people who have signed up say they are satisfied with their plans.

Yet now a new set of challenges looms. Will the plans be affordable, and will users know how to use tiered networks and other innovations without incurring huge bills?

"The law has pretty much met the early benchmarks, but if it stopped here, I don't think anyone would declare it a success," says Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation, which is tracking the law.

The law offers new insurance options for the individual market. Enrollment for this year closed on March 31 and will reopen in mid-November, but individuals can buy in before then if they get divorced, lose their jobs, or have other qualifying events.

One popular feature of the law is that 2.6 million people under age 26 are now covered by their parents' plans. Total signups in Pennsylvania reached 318,077. In New Jersey, 167,775 people signed up, and 155,000 more qualified for coverage as part of the state's Medicaid expansion. Pennsylvania did not expand Medicaid. The state is waiting for the federal government to act on a waiver for its controversial Healthy Pennsylvania plan.

"It is clear from the Gallup Survey, the Rand survey, the Urban Institute survey, the Commonwealth Fund, and ours [Kaiser] shows that six out of 10 enrollees were previously uninsured," Levitt says. "It is now crystal clear that the law is actually covering people."

Another positive indicator is that the industry is bullish on the ACA. UnitedHealthcare, the nation's largest insurer, participated in only four marketplaces this year during ACA 1.0. Next year, the company said, it will compete in 24 of the exchanges.

"I know of almost no cases where anybody is dropping out of these exchanges," says Joel Ario, a managing director at Manatt Health Care Solutions and former Pennsylvania insurance commissioner. "Some of the plans are expanding into other states."

For a time, it seemed the ACA might not survive its dreadful Oct. 1 rollout. The website healthcare.gov was a flaw-filled mess, prone to lockouts.

A December surge salvaged the site and helped boost signups. But many purchasers went on to experience delays and snafus, with insurers inundated by new customers.

Doctors braced for waves of new patients, but that hasn't materialized.

Affordability is likely the next major ACA concern. Bronze plans, the lowest tier, have average deductibles of more than $5,000, a sum many Americans cannot raise in a pinch.

About 85 percent of signups are getting some kind of subsidy. That's why a silver-tier plan, the second-cheapest, can be incredibly reasonable, depending on age and income. But if you are over 45 and not eligible for a subsidy, that same plan can be costly.

"Is it affordable for an individual?" said Mark Duggan, an economics professor at Stanford University. "Yeah, if you are under 400 percent of the federal poverty level, which is a majority of the population." That line is $45,960 for an individual and $94,200 for a family of four.

Levitt believes affordability is such a big issue that Congress will have to debate whether to increase the size of subsidies and who is eligible for them.

Premiums - what you pay for insurance each month - are the metric most people use when choosing a plan. In 2014, they "came in 15 percent lower than expected," Levitt says. "That doesn't mean they are what people consider affordable even once you take subsidies into account."

Premiums in 2015 are expected to rise 7 to 8 percent. Experts say it will be worth it to shop around and not automatically renew.

Experts also recommend that you consider other factors. Some plans require you to pay up to half of the full cost of specialty drugs. Insiders call this co-insurance, where you pay a percentage of the cost.

Look also at deductibles (the yearly amount you must pay before coverage kicks in), copayments (a fixed amount you pay for an office visit or for covered prescription drugs), and other non-covered services.

To further curb costs, some plans include limited networks. A network is the group of doctors and hospitals that have agreed to provide care to a plan's members at discounted costs.

Ario said networks are "incredibly important" because they help insurers keep costs low while providing quality care. And while some dislike the limited selection of providers, surveys show that networks are second only to premium price when consumers choose a plan.

Tiered plans - consumers can visit any network provider but pay different out-of-pocket costs depending on the tier - are another cost-saving device. These plans generally have lower copayments and coinsurance contributions if you see doctors and hospitals in the lower tiers. But before buying a tiered plan, make sure you understand how it works and the costs associated with each level.

Independence Blue Cross' Proactive Plan, its best seller on the marketplace, has three tiers - Preferred (lower cost), Enhanced (middle), and Standard (most expensive). Each represents a rising level of out-of-pocket payments. Members are free to visit any facility or provider in the Independence network and pay according to the tier.

With many obstacles ahead, the ACA's future is anything but certain. No one knows what awaits April 15 when people have to reconcile their projected salary and their actual income, or how court decisions will affect the law.

"This is a very complicated undertaking," Levitt said. "You just can't really come to a conclusion about whether or not it's working or not after just a few months."

Did you buy insurance under the Affordable Care Act through Healthcare.gov? How is it going? We would like to hear about your personal experiences with the ACA, including the expanded Medicaid program in New Jersey. E-mail us at fieldclinic@philly.com.EndText

A specially trained navigator can help untangle the many variables in choosing a plan:

NEW JERSEY

Center for Family Services Inc. 877-9-ACCESS (922-2377) or 856-964-1990

Serves Camden, Burlington and Gloucester Counties

PENNSYLVANIA

Resources for Human Development 855-668-9536

Serves Philadelphia, Bucks, Chester, Delaware, Montgomery Counties

Mental Health America 866-468-9199

Serves the same five counties

Health Federation of Philadelphia 215-567-8001

Serves Philadelphia

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