10 things Obamacare won’t tell you

The health exchanges, central to the law, are also its biggest mystery

By Jen Wieczner

John Ueland

1. “You might want to avoid signing up right away.”

In the offices of certain government officials and health insurance companies, a ticking countdown to a specific date was posted on the walls for months: Oct. 1. That was the day of the official ribbon-cutting for the exchanges created by the Affordable Care Act (commonly called Obamacare), when Americans began lining up for 2014 individual health insurance. But because the law’s future was uncertain until the Supreme Court upheld it in mid-2012, the exchanges had to scramble to get ready for opening day. Thirty-six states declined to set up their own exchanges for 2014 (each state has just one), so federal health officials had to do it instead — cramming years of work into a tight time frame. “Some people we’ve talked to will count it as a victory if the lights come on Oct. 1,” said Eric Johnson, a Columbia business professor and co-director of the university’s Center for the Decision Sciences, before the launch. (The small-business section of the exchanges in those 36 states won’t be able to accept online applications until November, the administration said, and some of the states running their own exchanges may also be running behind, having not yet announced when they will open to small employers.)

Indeed, grand-opening snafus ranged from jammed telephone lines and websites to technological glitches. “As much of a big deal as is made about [the launch] date, it is still a soft opening,” says Bill Melville, a market analyst for HealthLeaders-InterStudy, a research firm covering the exchanges. Lawmakers and even President Obama have acknowledged that the beginning has been more of a bumpy dress rehearsal, during which they’ve identified problems and deployed legions of software engineers to fix them.

Still, health officials assure there’s still plenty of time until Dec. 15, the deadline to enroll for coverage starting Jan. 1, when the law requires most Americans to be insured. The exchanges will actually be open for a full six months before closing March 31, so stragglers can still avoid paying the penalty that the ACA imposes on those who don’t buy insurance, even if they enroll after St. Patrick’s Day or wait till the very last minute, the Health and Human Services Department recently confirmed. “Unless you are desperate for health insurance, our advice is wait till November or December,” says Bryce Williams, a managing director of exchange solutions for professional services firm Towers Watson. “It’s kind of like not buying the first model of a car when it comes out: Wait until the kinks get worked out.”

2. “Yes, some workers are being required to use exchanges — but not these exchanges.”

Three of the country’s biggest companies — IBM, Time Warner and Walgreen — announced in recent weeks that instead of offering traditional health benefits, they would send some of their current or retired workers to purchase coverage on insurance exchanges. That caused a panic among some Americans who believed major corporations were ending job benefits and turning them over to the government. But health-care experts say it was all a big misunderstanding: The corporate exchanges are completely separate from the exchanges created by the Affordable Care Act.

The new ACA exchanges, also known as health-insurance marketplaces, are run either by states or the federal government and cater to individuals. Employers, in contrast, are using private exchanges operated by benefits firms like Towers Watson and Aon Hewitt, which serve employee groups. The private exchanges are not “a result of Obamacare — that’s false,” says Williams, who runs Extend Health, an exchange that has been selling Medigap plans for seven years and will host IBM’s retirees. Sears Holdings and Darden Restaurants already moved active employees to Aon Hewitt’s health exchange in 2013, long before the rollout of the public exchanges.

Still, the trend is spreading, and some analysts worry it’s a sign of deteriorating employer health benefits. In the next three to five years, 44% of employers plan to offer health insurance through a corporate exchange, giving workers a fixed dollar amount to spend on coverage, up from 4% today, according to Aon Hewitt.

3. “Expect to be confused.”

While the exchanges are the centerpiece of the health care law — the mechanism for bringing health insurance to the uninsured — they have long remained an abstract concept. Health officials and advocates have compared the exchanges to brick-and-mortar institutions such as shopping malls, farmers markets and a stock exchanges, leaving many Americans with the wrong picture of what the marketplaces will actually be. Indeed, a survey by insurance-rate site InsuranceQuotes.com found that 90% of Americans didn’t know when the insurance exchanges would open, and 22% thought they were already open — six months before they actually were.

In reality, each exchange is essentially a website, where people can log on to compare insurance plans similar to the way they compare airline flights on websites like Orbitz.com or Priceline, say experts. If consumers need help shopping, special government “navigators,” as well as customer service agents, are available by phone and in community health centers. Other businesses, including pharmacies and H&R Block, can also provide in-person assistance. Americans can choose to submit insurance applications by mail, but their information will ultimately be processed through an electronic portal known as the federal “data hub.” Some online insurance brokers, such as eHealthInsurance.com, function as a private version of the exchanges, selling the same subsidized plans and directing people through the same process. If a consumer is not eligible for subsidies, however, these brokers are not required to mirror the government exchanges and may only present plans on which they receive commissions.

ALSO SEE: Do Obamacare exchanges offer enough choice?

People can get the latest information at HealthCare.gov, which will directly serve the federal exchanges in 36 states and also refer Americans to the other states’ exchanges.

4. “Don’t bother asking our staff for recommendations.”

Cardon Outreach, a Texas-based organization that helps lower-income Americans enroll in health insurance, planned to use an $833,000 federal grant to provide similar services as a navigator in the new health insurance exchanges, the organizations and staff charged with guiding consumers. But just a few weeks later, Cardon declined the money. Helping consumers would be a “huge risk” under current regulations, says Chuck Kable, Cardon’s chief legal officer. The insurance commissioner in Oklahoma, one state where Cardon planned to work, had warned that navigators were forbidden to discuss with consumers how specific health plans might affect them. Kable worried other states would also enforce these restrictions.

Under Affordable Care Act rules, finalized in July by the U.S. Department of Health and Human Services, navigators are not allowed to receive money from the insurance industry — that’s supposed to keep them “neutral and impartial,” according to an HHS spokesperson. But the regulations also bar navigators from recommending and choosing a specific health plan on a consumer’s behalf. Those services have traditionally been the purview of insurance brokers, who must be licensed to sell health plans under existing state regulations (and who usually receive commissions from insurance companies). Indeed, agents and brokers lobbied heavily for restrictions on navigators, who they say are unqualified to recommend plans — and also threaten brokers’ livelihood. The ACA rules adopted several of those suggestions, say legal experts, and limit navigators to “facilitating enrollment,” which includes helping consumers set up their online account at the exchange and apply for a subsidy, the HHS spokesperson says.

While some states have said they’ll allow navigators more leeway, others have imposed further regulations, often as a result of political opposition to the ACA or lobbying by insurance agents. These range from requiring them to pay fees or obtain surety bonds to banning them in certain places; some states require navigators to hand consumers off to brokers for enrollment advice. “It’s difficult, where do you cut yourself off in that conversation?” Kable says, adding that he believes the line between navigator and broker is gray.

See also: Meet Obamacare’s insurance salesmen

To be sure, there are benefits to using brokers, which don’t cost any extra, says Laura Adams, an analyst for InsuranceQuotes.com: “You may get a lot more service upfront.” But brokers’ recommendations could also be biased toward the insurance companies that pay them commissions, says Jennifer Tolbert, director of state health reform for Kaiser Family Foundation. Navigators are required to show consumers all their options for health insurance, but brokers don’t have to, the health department spokesperson says.

5. “Blue states do it better.”

In a recent speech, Georgia Insurance Commissioner Ralph Hudgens said that to “solve” the “problem” of Obamacare, officials in his state are doing everything in their power “to be obstructionist.” The first part of that strategy? Refusing to run Georgia’s exchange altogether. It’s a tactic adopted by 34 states — most of them led by Republicans — often to express their opposition to the ACA. Instead, federal health officials took over in those states (plus in two others that asked for extra help their first year), hurrying to set up exchanges in hostile territory. As a result, those exchanges generally have fewer resources supporting enrollment and have encountered more setbacks than exchanges run by their own state, exchange analysts say. Politicians opposed to the health law have also created “new roadblocks to enrollment,” says Melville of HealthLeaders-InterStudy, which published a report card for the state exchanges, assigning lower marks to states that have enacted anti-exchange regulations. In a recent survey by the Pew Research Center, 23% of Americans said elected officials “should do what they can to make the law fail.”

By contrast, Democratic states running their own exchanges have invested more in marketing and supporting them, Tolbert says. Connecticut, for example, sent enrollment representatives to the state’s public beaches over the summer, while Maryland partnered with the Baltimore Ravens to promote its marketplace. “That’s a kind of readiness you can’t get necessarily if the federal government is running the exchange,” Melville says.

See also: The 50 states of Obamacare

6. “Abuse our honor system at your peril.”

A key component of the Affordable Care Act is the ability for lower-income people to receive subsidies on health insurance they buy through the exchanges. People up to 400% of the federal poverty level are eligible. But after the Obama administration announced that it would delay till 2015 certain verification processes to determine whether people are eligible for the health insurance subsidies, analysts speculated that exchanges would rely on the honor system to calculate the subsidies for 2014. And of course, if people lie to receive money they don’t deserve, experts say, that could make the ACA much more costly to implement.

“It’s more likely someone is going to get caught cheating on this than on their small business taxes.”

—Timothy Jost, professor at Washington and Lee University School of Law

But legal experts say that dishonesty is risky on the exchanges because the actual checks in place may be far more rigorous than an honor system. And besides the federal penalty for perjury, which is up to three years in prison, the ACA outlines additional consequences for falsifying income, with fines ranging from $25,000 for negligent misrepresentation to $250,000 for intentional misrepresentation, says Timothy Jost, a professor at Washington and Lee University School of Law who is studying the marketplaces and calls the idea of an honor system “nonsense.” Even without the fines, people will owe the money back after they file tax returns.

See also: Before delay, most firms were ready for Obamacare

Of course, a few fraudsters may still get away unscathed, especially in 2014 before all verification mechanisms are in place, Jost says. After all, the IRS loses hundreds of billions of dollars every year to tax cheats. But the ACA may have even more safeguards than the IRS — requiring verification of tax forms, Social Security data, and electronic wage information, according to the Centers for Medicare and Medicaid Services. “It’s more likely someone is going to get caught cheating on this than on their small business taxes,” Jost says.

7. “You’ll still pay for this, even if you don’t use it.”

Americans who receive affordable health benefits through their employer aren’t eligible for health insurance subsidies on the exchanges, so the company plan is almost always going to be a better deal than individual policies, just as it is today. But that doesn’t mean people won’t pay for the plans sold on the marketplace — at least indirectly. A lesser-known ACA provision requires employers to pay fees that will go toward the cost of covering Americans who were previously uninsured — often people who have chronic health conditions that will be very expensive to insure. “The assumption is, people who will be taking the coverage first are going to be the ones who are the sickest,” says Helen Darling, CEO of the National Business Group on Health, which represents large employers.

That tax is known as the Transitional Reinsurance Program, and will charge health insurers and self-insured employers (that is, companies that provide their own insurance) $63 per person covered on their plans, with payments eventually tapering off as the exchange plans collect enough premiums to be self-sufficient. Employers and insurers, already saddled with their own rising health care costs, are likely to pass those fees on to consumers in the form of rate increases, Darling says.

See also: Why your boss is dumping your wife

8. “We’re a magnet for hackers and con artists.”

Government officials are cautioning consumers to beware of threats when attempting to buy insurance in the marketplace: Con artists attempting to swindle their money or steal their identity. “At the FTC, we know all too well how scammers invariably try to take advantage of developments in the marketplace and new government programs,” Federal Trade Commission chairwoman Edith Ramirez said in a statement. While officials say they are not yet seeing large-scale fraud surrounding Affordable Care Act programs, previous federal benefits initiatives, including Medicare, have attracted criminals.

“Scammers invariably try to take advantage of developments in the marketplace and new government programs.”

—Edith Ramirez, Federal Trade Commission chairwoman

The concerns range from the security of the exchange websites to unscrupulous staff who may come into contact with consumers’ information, to potential scams asking people to pay, say, $200 in order to sign up for health insurance. Scammers have already targeted the elderly with false Obamacare pitches by email or telephone.

Administration officials, however, say that the federal exchange website has advanced security systems to prevent breaches and punish unacceptable behavior. Officials are also telling consumers to know the rules, so criminals can’t manipulate them: “If you have Medicare, you don’t need to sign up for one of the marketplaces. You should not be asked to pay any advance fees in order to enroll in the marketplace.”

See also: Have Medicare? Don’t worry about Obamacare

9. “You might not be able to keep your doctor.”

When the health law was being debated in Congress in 2009 and 2010, President Obama said that people buying insurance through exchanges would be able to keep their doctor. It turns out, though, that many plans strictly limit the network of doctors they pay for. Consumers can try to stay on their same plan or look for one that covers their doctor, but this might not be possible in some marketplaces, especially if their current insurer is not participating there. (Many uninsured people, of course, will be able to see a doctor for the first time as they gain health coverage.)

“The narrow-network plans are kind of the name of the game in health exchanges,” Melville says. An analysis of exchange plans in 13 states by McKinsey & Co. found that nearly half of them had limited networks. Some people who currently have individual insurance and stick with their current policy may find that it becomes more restrictive after the insurer enters the exchange. Wellpoint’s Anthem Blue Cross and Blue Shield has been criticized by state senators and consumers in New Hampshire, Indiana and Maine for excluding major hospitals from coverage, but a spokesman says the “narrower network” products, available on exchanges in 14 states, meet or exceed the ACA’s standards for “convenient access,” while also being affordable. Centers for Medicare and Medicaid Services official Gary Cohen says that many insurers are taking this tack because the limited-network plans can lower costs — and are a “positive development” for health care.

10. “Competition is for the greater good — except when there aren’t any competitors.”

Government officials have said that the exchanges will keep insurers’ prices down by making them compete with each other. Prices on the exchanges have been lower than government forecasts, partially a sign of “healthy competition,” Cohen says, and are generally lower in more competitive markets. So far, though, the marketplaces seem to be having another effect on major insurance companies, too: Scaring them away.

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