Making the numbers work

Last year, Jimmy and Angela Clark bought Independence Blue Cross' best-selling silver Proactive plan.

For the first time in five years, the Germantown couple had health insurance. And they loved it.

Having coverage was especially important to Jimmy Clark, 62, who needs blood tests every six months to track high cholesterol. He also needs a colonoscopy every three years - something that, until last year, he pretty much had to forgo.

"I got back on [a plan], and colonoscopies are free," said Clark, who got a clean bill of health. "I'm very happy that the [Affordable Care Act] started up and we could get on it."

The Clarks, self-employed ceramics artists, live "paycheck to paycheck" with a household income of about $33,000 a year. That made them eligible for a hefty tax-credit subsidy, which they used to reduce their monthly premium payment to $14.

So when he went online to renew the Proactive plan, Clark expected the premium to be higher. And because he was going on Social Security, raising the couple's yearly income by about $8,000, he figured their subsidy would be smaller.

"When you are paying $14, you can expect it to rise exponentially, maybe 10 times more," he said. "I could have handled that."

But the premium price for the Proactive plan was $455 a month. And that was with their subsidy.

Even though more insurers joined the marketplace in Pennsylvania and New Jersey this year, an Inquirer analysis has found that plan premiums in many of the ACA's four metallic tiers, including catastrophic policies, have jumped.

The premium for IBC's Proactive plan went up 14.9 percent. But federal subsidies were also slightly reduced.

Whatever forces were at work didn't matter to Clark.

"It was absolutely unaffordable to us," he said.

Two months after the marketplace reopened, 9.5 million people have either bought into or been automatically reenrolled in their plan, according to the federal government.

Counted in that number are almost 423,000 Pennsylvania and 212,000 New Jersey residents. In both states, an overwhelming majority of consumers (81 percent in Pennsylvania and 83 percent in New Jersey) qualified for a tax-credit subsidy.

People have until Feb. 15 to buy health insurance on the ACA marketplace. Once it closes, consumers can buy insurance only if they have a life-changing event, such as marriage, a baby, or losing job-based health insurance.

Anyone who doesn't have coverage is subject to a fine when filing a tax return. The fine for 2014 is $95 for an adult and $47.50 for each child, or 1 percent of household income, whichever is greater.

In 2015, the fine escalates to $325 for an adult and $162.50 for each child, or 2 percent of household income.

After venturing onto the marketplace alone, Clark considered paying the penalty.

That's when he remembered that his neighbor Pedro Rodriguez worked for Enroll America, a nonpartisan nonprofit whose goal is to get Americans covered by health insurance. The two had talked about health insurance when they met at a community function in October. "I asked, 'Do you guys have health insurance?' " Rodriguez said. "They said, 'Oh, yeah, and very happy with it.' "

One evening, Rodriguez got a call from Clark, who explained how his new "premium went through the roof, and I don't know what to do." Rodriguez told Clark that he would set up an appointment with one of Enroll America's certified application counselors, who would help the couple find and sign up for health insurance.

Starting with an explanation of the meaning of a deductible (the amount you must pay each year before coverage kicks in), the two counselors helped the couple find a new plan. The Clarks settled on Aetna's Bronze $20 co-pay HMO and pay $50 a month. But it comes with a combined $11,500 deductible.

"I couldn't have figured this out myself," Clark said. "Without the counselors, I don't know that I would have gotten through it."

As the days to open enrollment dwindle down, Clark has this advice to anyone thinking about buying health insurance: "Get help."

Navigators "are out there and free," he said. "If more people knew about them, I'm sure they would take advantage of it."

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This article was written in partnership with Kaiser Health News, an editorially independent program of

the Kaiser Family Foundation.