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Obamacare 4.0 is shaping up to be the most challenging version since Obamacare 1.0.
Open enrollment in individual health insurance plans kicks off Tuesday, with millions of people facing much-higher prices and fewer insurers to choose from.
People who need to buy an individual health plan — as opposed to job-based insurance, Medicare or Medicaid — have until Jan. 31 to sign up, to avoid a potential tax penalty for failing to have coverage.
"We've certainly seen pretty significant premium increases this year, as many [insurance] carriers exit or significantly scale back participation, " said Elizabeth Carpenter, senior vice president of the Avalere Health consultancy.
Estimates say more than 1 million consumers will have to pick a new insurance carrier because their current insurer is exiting the Obamacare exchanges, Carpenter said.
Those exchanges opened for business in 2013, with the largest one — the federal marketplace HealthCare.gov — crashing upon launch, and struggling for more than a month to enroll meaningful numbers of people.
HealthCare.gov, which now serves residents of 39 states, was soon fixed, and has since run smoothly.
The key question facing Obamacare this year is whether HealthCare.gov and the state-run insurance exchanges can significantly grow enrollment beyond the nearly 12 million people who signed up during the last open-enrollment period. Insurers want more healthy customers to sign up, to offset the costs of less-healthy customers.
Another big question is how the many consumers who don't get financial assistance will deal with increasing costs of coverage. About 85 percent of people who buy plans on Obamacare exchanges qualify for subsides that can lower the cost of their premiums, even if those premiums are rising by a large amount.
That financial aid, which comes in the form of tax credits, is available to people whose household incomes fall between 100 percent and 400 percent of the federal poverty level (or $24,300 to $97,200 for a family of four).
But people who earn more than 400 percent of poverty don't get financial aid — and thus must bear the entire brunt of the price hikes.
"Certainly, if you aren't getting a tax credit subsidy in the individual market, you are likely to face significant premium increases, depending on where you live," Carpenter said. She noted that the actual price a consumer will pay, particularly one who isn't subsidized, is directly related to the state, county or insurance rating area where they live.
The Obama administration last week revealed that the price of a so-called "benchmark" plan sold on HealthCare.gov is growing by an average 25 percent. Benchmark plans, whose prices are used to calculate the amount of subsidy that eligible consumers receive, are the second-lowest-cost "silver" plan. Silver plans, which are the most popular type of exchange-sold plans, cover 70 percent of their customers' health costs.
Some states are seeing premium price hikes for their benchmark plans well above that average. In Arizona, which will go from five insurers selling Obamacare plans this year to just four in 2017, benchmark plans are rising by 116 percent on average.
Oklahoma, which will have just one insurer offering Obamacare plans in 2017, down from two this year, has benchmark plans rising by an average 69 percent. In Tennessee, benchmark plans are rising an average 63 percent.
Many other states are seeing double-digit price hikes. A handful of others, including Michigan and New Jersey, are seeing single-digit premium increases. In Indiana, the benchmark plans are actually decreasing in price, by an average 3 percent.
When CNBC noted that state-wide drop in benchmark plans last week, spokesmen for Indiana Gov. Mike Pence, the Republican vice presidential nominee, said reporting only that figure was "misleading." They cited data they said shows that the average rate increase for all plans sold in the state are rising by an average of 18.7 percent.
The rising average premiums nationally are the result of a number of insurers low-balling their initial Obamacare prices, and then being faced with a customer base that used more in health services than they paid in premiums. Insurers are also dealing this coming year with the expiration of two Affordable Care Act programs that were designed to mitigate the financial risk of selling Obamacare plans.
The Obama administration has repeatedly noted that because of the effect of the subsidies, the large majority of customers on HealthCare.gov will be able to find a plan that will cost them less than $100 per month, after tax credits are factored in, if they shop around for a better deal.
More than half of such customers have low enough incomes, below 250 percent of poverty, that they also qualify for extra financial aid to lower their out-of-pocket health costs.
Despite that message, many people aren't hearing it — or don't care when they do.
Karen Pollitz, senior fellow of the Kaiser Family Foundation, said the initial wave of millions of people signing up for Obamacare included many whom had pressing health needs, and who had been priced out of the individual plan market beforehand.
Since then, Pollitz said, "it's been a harder effort to find people who are probably eligible for [financial] help, but don't come forward to whatever reason."
Pollitz pointed to Kaiser research which last year estimated that out of about 27 million non-elderly people who lacked health coverage, 43 percent, or 11.7 million people, were eligible either to enroll in Medicaid or in subsidized Obamacare coverage.
"I think the challenge continues" to reach those people, Pollitz said. "Some people don't have the Internet, they don't speak English, they don't read the Federal Register."
"Or they don't realize this is the time to sign up," she said. Kaiser's polls, Pollitz said, have repeatedly found that many people eligible for coverage are not aware of deadlines for signing up.
Obamacare critic Robert Laszewski, president of Health Policy and Strategy Associates, said Obamacare is "working pretty well" for people who earn less than 200 percent poverty — and thus get the most help paying for their premiums and out-of-pocket health costs.
"This really works for low-income people," Laszewski said. "Who is getting clobbered are the middle class and people without subsidies."
About half the total number of people who buy individual health plans — either on the Obamacare exchanges or outside of them — don't qualify for a subsidy, Laszewski said.
For those unsubsidized people, he said, "Their premiums are going up, their deductibles are going up, and their networks [of health providers] are getting narrower." That dynamic, he argued, has created a "god-awful market" that will not attract significantly more customers in coming years unless improvements are made to the program.
Laszewksi said the premiums can get so expensive in some cases that they exempt a person from the Obamacare penalty for failing to have coverage.
He cited the example of a broker in Florida, whose customers included a family of four that earned too much to get a subsidy. Their lowest-priced option was a "bronze" Obamacare plan that had an annual premium of $13,176, and a $7,150 deductible for just one of the family members.
The premium plus that deductible exceeded 16 percent of their adjusted household income, meaning they didn't have to pay a penalty Laszewksi said.