c.2014 New York Times News Service
LOUISVILLE, Ky. — Steve Huber, an affable salesman who is still paying off an unexpected medical bill, was not among the millions of Americans who signed up for health insurance under the Affordable Care Act during the enrollment period that ended March 31.
After seeing television ads for Kentucky’s new online insurance marketplace, Huber, 57, made several attempts to explore the website but found it too complicated. Moreover, his income has dropped in recent years, he said, and he felt certain that he could not afford coverage. So he never priced plans or researched whether he qualified for financial assistance.
“I realize that I’m gambling,” he said, stopping at a coffee shop before a sales call. “But I don’t have a lot of patience, and I’m on a pretty tight budget anyway.”
After a surge of last-minute sign-ups, 8 million people bought private coverage through the federal and state marketplaces during the initial six-month enrollment period, exceeding the Obama administration’s target. Huber represents the next challenge for the administration as it struggles to reduce the ranks of the uninsured and broaden support for the president’s signature health care law.
For every individual who did sign up, there were others who resembled Huber: people who have decided to stay uninsured for now, despite the law’s requirement that most Americans get coverage this year or pay an income tax penalty of $95 or more.
A common thread running through stories of the unenrolled is cost. Many people either do not qualify for federal subsidies or believe that the assistance is not enough to make insurance affordable, interviews with consumers and experts suggested. According to enrollment counselors in several states, people who have gone without health insurance or major illness for years can be especially resistant to investing in coverage.
To be sure, some of those who chose not to sign up were motivated by ideological opposition to Obama, to the law’s mandate that they buy insurance, or to both. And for many others, confusion and lack of understanding, including about whether they could get financial help buying coverage, were the overriding reasons.
But a New York Times/CBS News poll of uninsured people in December found that of those who did not plan to get coverage, half said that cost was the main reason. Nearly 3 in 10 said they objected to the government’s requiring it, while about 1 in 10 said they felt they did not need it.
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Heidi Reinberg, 53, a freelance documentary producer who lives in New York, said she had gone uninsured for most of her adult life and had managed just fine.
She did check out her options through New York’s marketplace but said she was not impressed. She did not qualify for a subsidy based on her 2013 income, she said, and was particularly put off by the high deductibles on many of the plans available to her.
With an income that fluctuates unpredictably, she said that she could not justify a new expense for something that was “not a priority.”
“It doesn’t scare me not to have it,” said Reinberg, adding that she exercised, ate healthily and rarely got sick. “I’d rather pay down my credit cards than take on another bill for something I don’t know that I’m going to need.”
She acknowledges that she could have major medical expenses as she ages. And she might buy insurance in the future if her income stabilizes, she said. But for now, like many others, she has decided that the financial penalty for not buying insurance is more palatable than the cost of premiums and deductibles.
“I know what the penalty is going to be,” she said, “and I can get my head around that.”
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There is no demographic data on the uninsured who could have bought coverage through the exchanges but chose not to. But a federal report last year on the overall uninsured population eligible for coverage under the new law estimated that 45 percent had incomes low enough to qualify for financial assistance buying exchange plans.
Many others were poorer and eligible for Medicaid because their state opted to expand the program. Another federal report last year said that young and healthy people made up nearly half of the uninsured, and that more than half were men.
For Huber, the salesman, the complexity of the process was enough to make him give up trying to enroll.
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In 2011, Huber lost a better-paying job with health benefits. For a while, he paid $450 a month to continue his employer-based coverage under the federal COBRA law. But that quickly grew unaffordable, and he has been uninsured for the last two years. He has a new job as a battery salesman but is making about half of what he used to, he said.
Not having insurance has also carried a price. A bout of diverticulitis, an intestinal inflammation, left him with a $1,100 medical bill last fall. He stretches his blood pressure medicine, taking it “exactly half as often as I’m supposed to,” and pays out of pocket when he sees his internist.