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Hunt for the young, healthy continues for health care enrollment

'Magic number' of young people elusive for health exchanges

By Meredith Cohn, The Baltimore Sun

11:09 PM EDT, November 1, 2013

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The Obama administration made an appeal in recent days to young uninsured singles: Half of the group may pay only $50 a month with subsidies for a health insurance policy.

Those ages 18 to 34 are crucial to holding down premiums by balancing older adults who typically have more medical problems and are much more likely to buy health insurance.

A month after the launch of the federal and state online insurance marketplaces, it's not clear whether enough young people will buy insurance, even if it looks like a deal. The reasons are manifold: They might not know about it, they might not want it, they might feel they can't afford it or they can't get past the glitches plaguing the online exchanges, according to health economists and other observers.

In Maryland, the young at least appear to be looking. State officials reported that about a third of the 46,000 people who have created accounts on its exchange are under 35 years old.

That engagement is encouraging, "but it is too soon to reach conclusions," said Dr. Joshua Sharfstein, the state secretary of health and mental hygiene.

A Kaiser Family Foundation poll conducted during the summer found about three-quarters of those ages 18 to 30 thought having health insurance was "very important," while just a quarter said they were healthy enough to go without insurance. Two-thirds of the uninsured in general said cost was the biggest barrier.

There may be 2.9 million young, single, uninsured Americans who could buy insurance on the federal exchange, which serves about three dozen states, the U.S. Department of Health and Human Services said this week. Nearly half of them could buy a "bronze" plan, the cheapest, for $50 after subsidies. Another 1 million could qualify for Medicaid.

Young people care most about cost, particularly the monthly premium, said Sheila Mackertich, who heads enrollment efforts for HealthCare Access Maryland.

So far, few young people are among those signed up for plans by the nonprofit group working to enroll consumers, Mackertich said.

The group hopes for more in January once the exchange's technical difficulties are worked out and it launches a big push at community colleges and high schools, she said. But it needs to be able to provide them with exact prices from the system.

"Especially with young people, we didn't want to say 'We don't know what it will cost you, we'll get back to you,' " said Mackertich, adding that those earning $15,800 to $45,000 may qualify for federal subsidies. "When we give them the information, whether they pull the trigger and pay for a policy is the big question we have too."

Danielle Buonaiuto, a 28-year-old self-employed musician in Baltimore, is eager to enroll. She's created an account on the Maryland exchange but hasn't been able to browse plans because of the site's technical troubles. She keeps checking back periodically because she wants to sign up by Dec. 15 for insurance beginning in January.

In the meantime, she has no insurance and figures she can go to a clinic in an emergency and even fly home to Canada for something big but less pressing.

"While I was at Peabody [Institute of Johns Hopkins University] I had insurance, but as an individual it was not affordable," she said. "Now there are some other options, and we'll see what's possible. … I've been waiting for the marketplace. It's been a long time coming."

Buonaiuto isn't sure if she'll go with the cheapest monthly premium, but many other young people will, even though it may not be in their best interest, said Brad Herring, a Hopkins health economist. He pointed to a quirk in the Affordable Care Act that offers some low-income adults who sign up for "silver" plans, a step up from bronze, a cost-sharing subsidy that lowers out-of-pocket costs.

That would be important for those who have a lot of medical bills or one unexpected large bill for health care services, though the premium would be more, Herring said.

"It's tough for people to really comprehend what their out-of-pocket costs will be," he said. "It's hard to convert into something meaningful because it's uncertain. It depends on how much health care you use, like if you have a car accident."

But he said he believes many young people do want health insurance, even if they have trouble navigating the choices or the glitchy exchanges. They should also be motivated by the law.

The so-called individual mandate requires uninsured people to buy coverage or face a penalty in the first year of $95 or 1 percent of pay, whichever is higher. Someone with a $40,000 income would pay $400, for example. Why not pay $600 annually and get a $50-a-month plan, Herring asked.

Another observer came to a different conclusion. David Hogberg, a senior fellow for health care policy at the conservative National Center for Public Policy Research, said many young people will do the math and choose to pay the fine.

He also sees a potential "spiral." As premiums continue to rise, even fewer young people may be interested in coverage, and those who did sign up may drop coverage in later years.

"Anyone making less than $60,000 would pay less than $600, and most young people don't make that much," he said. "I'm not arguing you shouldn't have health insurance. …My argument is that even when you're looking at the incentives they provide, I think they will chase young people away."

The White House, however, has a goal: 2.7 million of the 7 million expected to buy coverage in the first year ought to be under 35.

Administration officials aren't expected to reveal how many people, or the mix of people, who have enrolled in so-called Obamacare until later in November.

Sherry Glied, dean of the Robert F. Wagner Graduate School of Public Service at New York University, doesn't think there is a "magic number" of young adults needed to enroll for health reform to work.

"It isn't exactly about a single number, it's about the composition of people who sign up," said Glied, an economist and health policy expert. "An important component is youth because young people tend to be healthy, but the middle-aged and healthy are good too."

The proof will come next fall, she said. If premiums rise more than the rate of health care inflation, then the composition wasn't sufficient to control costs.

meredith.cohn@baltsun.com