Dec. 23--When she turned 26 in October, Elif Karatas of Chicago was no longer covered under her parents' health plan. She also wasn't eligible for coverage from her employer because she works part time.
So she turned to the public marketplace in Illinois created by the Affordable Care Act, President Barack Obama's signature health care law. But picking a plan on healthcare.gov, the online insurance exchange, was more difficult than she expected for a first-timer.
"I had no idea about coinsurance," Karatas said. "I didn't understand how it was different than a copay and what contributes to a deductible."
Fortunately, she knew someone who had been trained to help consumers using the marketplace. She ended up buying a plan from Blue Cross and Blue Shield of Illinois with the help of a federal subsidy that reduced her monthly premium.
Karatas exemplifies the progress and challenges of Obamacare as it enters its third year.
The law is credited with reducing the number of Americans without insurance. According to census data, the uninsured rate in 2014 was 10.4 percent, down from 13.3 percent in 2013.
New enrollees like Karatas are crucial to the success of state insurance marketplaces. Young adults are needed to offset often costlier and less healthy older enrollees.
There is other good news, including evidence of fewer Americans having trouble paying their medical bills or going without care because the cost is too high, said Sara Collins, a vice president at the Commonwealth Fund, a nonpartisan private foundation that supports independent research on health and social issues.
In a study released last week, the policy journal Health Affairs also found increased access to care from September 2013, just before the first open enrollment under Obamacare, to March 2015, after the end of the second enrollment period. For example, the share of adults younger than 65 who reported a routine checkup in the past year increased from 60.6 percent to 64 percent during the time researchers studied. The share of adults who reported trouble obtaining health care decreased, from 18.7 percent to 16.4 percent.
But problems remain. Although technical glitches that the website experienced in its first year were fixed, buying insurance is a complex transaction. This year, healthcare.gov tested new tools that let consumers see which plans covered their doctors or their prescription drugs. But consumers still needed help choosing a plan and contacted government call centers in huge numbers. Because of the volume of calls last week, the Obama administration extended the deadline by two days for people to sign up for coverage that begins Jan. 1. That window has now closed, but uninsured can still buy coverage until Jan. 31 or pay a tax next year of $695 per person or 2 percent of income.
In some cases, premiums rose dramatically. Blue Cross, which has about 80 percent of the individual market in Illinois, increased rates by an average of 17.8 percent; premiums at Land of Lincoln Health jumped by nearly 30 percent on average.
Next year's premiums reflect higher-than-expected medical claims for some carriers in 2014. But federal subsidies in the form of premium tax credits protect many consumers from price increases. About eight in 10 individuals who selected a 2015 exchange-based plan qualified for federal assistance.
Blue Cross, the state's largest health insurer, disrupted the Illinois market by dropping a popular PPO plan available on the exchange for two years. The decision sent thousands who want to keep their doctors scrambling to find new plans that often came with higher premiums, deductibles or out-of-pocket maximums.
For Libertyville's Larry Simon, 60, the replacement plan Blue Cross offered him didn't include his cardiologist or primary care physician, and the only hospital near him is in Waukegan, a 30-minute drive in good traffic, he said.
"The pain they are causing individual health plan subscribers in Illinois is much more significant that a mere increase in rates," Simon said.
After hours of research, Simon found an Aetna plan that included his doctors. The premium is about $200 less than what he was paying Blue Cross, but his deductible is $3,500, compared with $1,500 with Blue Cross. His out-of-pocket limit on medical expenses went up to $6,250 from $3,500. Aetna came back to the Illinois exchange after dropping out in 2015.
Administration officials emphasize their view that the Illinois market continues to have a lot of insurance choices. UnitedHealth Group started a new insurance company called Harken Health that offers PPO plans in Cook County. Another insurer, Centene, restructured its exchange-based plans and offers the lowest-priced policies in Cook under the Celtic brand.
But Celtic restricts access to physicians and hospitals. Smaller provider networks are a trend in Illinois, as Aetna and Blue Cross teamed up with large hospital systems to offer new HMO plans that offer competitive pricing.
Land of Lincoln, a federally funded startup, was one of the first insurers in Illinois to introduce hospital-sponsored plans on the exchange. Putting a hospital name on an insurance product makes it easier to sell, said Dan Yunker, CEO of Land of Lincoln. But it's more than marketing, he added.
"If done right, we believe these organizations are better aligned to improve quality, reduce costs and improve access," Yunker said. "We believe that's where the market is going."
The introduction of new plans and canceling of others are a sign that insurance companies are still trying to find their way in the federal exchange, said Andy Slavitt, acting administrator of the federal Centers for Medicare and Medicaid Services.
"The thing that's important to me is are there enough choices, are there enough strategies in the market so consumers can choose?" Slavitt said. "And I'd say in the vast majority of the markets in the U.S., fortunately that's the case."
But he acknowledges that Obamacare has been a "bumpy ride" for consumers.
"You have to be a little bit more of an educated consumer," Slavitt said. "You have to think about the choices you want to make. ... We're trying to offer people a level of help that will help them through these challenges."
More than 8.2 million consumers, including about 340,000 in Illinois, have signed up for 2016 coverage through healthcare.gov as of Saturday, according to the U.S. Department of Health and Human Services. This compares to 6.4 million people who enrolled as of the same time last year. The 2016 total includes 2.4 million new consumers.
"We're seeing more young people enroll," HHS Secretary Sylvia Burwell said during a media conference call Tuesday. "That contributes to a more stable marketplace."
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