Health and Human Services Secretary Sylvia Burwell has her work cut out for her.
She has to convince millions of people who get their health insurance through the Affordable Care Act exchanges or who have no coverage at all that they should go online and shop for a good deal.
It's a big challenge because Tuesday is the first day of open enrollment for Obamacare health insurance, and it comes just a week after HHS announced that the prices of policies sold on the exchanges would rise an average 22 percent this year.
What's her biggest challenge? "Helping people focus on what the consumer pays because that's the most important thing," Burwell said in an interview with NPR on Oct. 26, "and that's what consumers actually care about."
But it's not always easy to figure out what the consumer pays. That's because the approximately 10 million people who buy policies through the Affordable Care Act can qualify for discounts on premiums and out of pocket expenses based on income.
"Eighty-five percent of those folks actually receive tax credits or subsidies and for them that insulates them from these changes," she said.
That's what's happening to Darvin Bentlage, a farmer in southwest Missouri, outside the town of Lamar. Like many farmers, he has been having a rough time recently. He raises corn, soybeans and beef, and prices for all his products have plummeted in the past two years.
In late October he was pretty upset because he got a letter from his insurer, Anthem Blue Cross and Blue Shield, saying his policy was going up about $200 a month. Even after his subsidy, he thought he'd be paying $500 a month just for his premium. On top of that he spends about $300 a month on medications to control his diabetes.
"So I'm going to be paying close to $10,000 on my medicine and my insurance on a $20,000 income," he said.
But Bentlage, 60, hadn't yet logged on to HealthCare.gov, the federal insurance marketplace, to shop for a plan. He did that over the weekend and afterward, he was much happier.
His tax credit more than doubled to $664 a month, and he found a policy that would cost him, after that subsidy, about $150 a month. And his deductible was lower, too.
"So that was a pleasant surprise, you know," he said on Monday.
Bentlage said he's glad he doesn't have to go without insurance like he did before the Affordable Care Act. At that time he couldn't find coverage because of his diabetes.
He paid his own medical bills and had to refinance his 1,200 acre farm to pay for two colon surgeries.
"So from my view here, the ACA was a good thing to get people with pre-existing conditions health insurance," he said.
If Bentlage is the story Sylvia Burwell wants to hear, Will Denecke is her nightmare.
Denecke, 63, is a self-employed urban planning consultant in Portland, Ore. He makes too much money to quality for financial assistance.
He's also pretty healthy and doesn't use much medical care. But his premiums have almost tripled in the past three years. To him it's just too much.
"I am not willing to pay $930 for coverage and to pay a $3,000 deductible," he said. So he's going to shop around on HealthCare.gov for a better deal. But if he doesn't find one, he said he may skip buying insurance and hope for the best.
"I'm going to hope that if I have a health issue, I can go back during the year, not during open enrollment and go onto the marketplace and buy insurance," he said.
The purpose of having a limited open enrollment period in the Affordable Care Act is to ensure that people don't only buy health insurance when they get sick, and then drop it when they're healthy. That would make insurance even more expensive.
The ACA allows people to buy a policy outside of open enrollment if they've had a big change in life — maybe they got married, or they lost their job.
But Denecke said those rules are easy to get around. He knows from experience.
"I've done it before," he said. "And my broker helped me. And the great thing was we got an answer within two minutes."
He said that as a consultant he was able to claim a change in income that allowed him to buy insurance midyear a couple of years ago, when he got some bad results on a prostate screening.
"I know that that undermines the economics and the premise of the ACA," he said. "You don't buy car insurance after you have an accident. You buy before it."
Insurers have complained to Burwell that the so-called special enrollment periods are too liberal, and HHS has been working to tighten up the rules. Denecke knows this, but may take his chances anyway.
But he, like many people, said the policies are just too expensive otherwise.
Burwell would like to see some changes to the law that might help lower premiums for consumers and health costs overall.
She said lawmakers should consider increasing subsidies so the policies are even cheaper on a monthly basis, and she'd like for HHS to be allowed to negotiate lower drug prices, which could lower the cost of health insurance in the long run.
And, she said, policymakers should reconsider allowing the government to offer health insurance in markets where there's little competition.
After three insurance companies pulled out of several ACA markets and premiums rose, analysts say this enrollment period will be crucial to ensure that enough people like Will Denecke buy policies to ensure the system remains stable.
Burwell agrees. "Is it an important year to make sure that we're getting more folks in and to make that risk pool better? Yes," she said.
But Burwell said changes mandated by the ACA — such as the ban on rejecting people who have pre-existing conditions — are now so integrated into the health care system that they aren't going away.
"This is health care in the United States now," she said. "And so what we need to do now is make sure we're working to make this system and these changes work the best they can."
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