As thousands of Marylanders begin enrolling in health insurance on the state exchange starting next week, they'll face significantly higher premiums that nationwide have turned the Affordable Care Act into even more of a political issue that it already was.
Rates for insurance plans purchased through the online marketplace will increase no less than 20 percent, making it even more important for the state health officials and advocates to conduct outreach and explain the subsidies available to many buyers.
Maryland exchange officials also are touting a streamlined website, new mobile app and widespread assistance to make the open enrollment period — slated to run from Nov. 1 to Jan. 31 — go more smoothly than ever.
The soaring cost of insurance is perhaps the biggest growing pain for what is known as Obamacare, the law designed to cover people who don't get insurance through their employer. The costs have prompted some insurers to stop offering insurance on the exchanges, including UnitedHealthcare in Maryland.
That's added fuel to many Republicans' arguments to repeal the law, a position echoed by Donald Trump, the party's presidential candidate. Meanwhile, his Democratic rival, Hillary Clinton, has called for a public insurance option to spur more competition and higher subsidies for consumers to buy coverage — positions President Obama has embraced.
"At end of day, if the prospective customers don't see value for the price they pay, it's tough to get them to buy," said Alfred W. Redmer Jr., commissioner of the Maryland Insurance Administration, which recently approved rate hikes of 20 percent to 30 percent for insurers selling 2017 plans. "A broad segment of the middle class finds the insurance unaffordable."
Exchange officials and consumer advocates note that subsidies will increase with the premiums and some consumers can get help paying out-of-pocket costs.
The law has succeeded in getting more people insured. The state's uninsured rate dropped to 6.6 percent in 2015 from 10.2 percent in 2013, according to the U.S. Census Bureau. Before the Affordable Care Act of 2010, about 14.5 percent lacked insurance, according to estimates from the Hilltop Institute at the University of Maryland, Baltimore County. Some state residents remain ineligible because they are undocumented immigrants.
This year, nearly 163,000 Marylanders enrolled in private health plans on the exchange, a gain of 33 percent from the year before. And more than 278,000 were added to the state rolls for Medicaid, the insurance program for those with limited incomes.
Carolyn Quattrocki, who stepped aside as the exchange's executive director for a position in the state attorney general's office, said she's pleased the exchange already has gotten so many people insurance who didn't have it before.
"It's important to take the long view," she said.
During open enrollment, consumers will decide whether to keep or change their coverage. The Maryland exchange has set a goal this year of enrolling about 171,000 in private plans, up about five percent.
Quattrocki's replacement, Jonathan Kromm, takes the helm as the exchange shifts focus to reaching hold-outs and making enrollment and re-enrollment easier. He said many people were initially frustrated because the website didn't work, and even in subsequent years some found the process confusing. Some now need help finding more affordable plans.
"Going forward we have to get increasingly more focused on the populations that remain uninsured and tailor our messaging and outreach," Kromm said. "We have to make the case that insurance is affordable even as rates have gone up."
Maryland lost only one exchange insurer, leaving four others selling policies for 2017. UnitedHealthcare, which pulled out of all but a handful of states, insured about 10 percent of those on Maryland's exchange this year.
CareFirst BlueCross BlueShield covered about 60 percent of people enrolled through the state exchange, Kaiser Permanente covered about 23 percent and Cigna covered 1 percent. About 7 percent got insurance through Evergreen Health, a struggling co-op seeking to become a for-profit insurer.
"The key issue nationwide has been the willingness of insurers to participate," said Justin Giovannelli, an associate research professor at Georgetown University's Center on Health Insurance Reforms. "The idea is to have a competitive marketplace, and if you have few willing to compete it puts consumers in a tough spot."
Many states have more insurers than Maryland, but Giovannelli said some now have only one or two and face larger rate increases.
Premium subsidies will help cover costs, but continued double-digit rate hikes eventually could put insurance out of reach. He said it's unclear if this year is a "correction" aimed at helping insurers account for a less healthy pool of consumers than expected, or if more large increases are coming.
"We'll have to see if it continues to be viable for insurers to stay on the exchanges," Giovannelli said.
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Federal health authorities are seeking to attract more young adults who had the highest uninsured rates before the Affordable Care Act passed, a move attacked by critics such as the conservative Heritage Action for America for leading more people to a "failing" system.
Giovannelli said the challenge now is enrolling more healthy people generally. That will mean explaining that subsidies are available and there are tax penalties for going without insurance. The 2016 penalty is 2.5 percent of household income or $695 per adult, whichever is higher.
With Republicans continuing their legislative and legal assaults on the health law, he said the exchanges will have to cut through the "vocal and concerted attacks ... that create a potentially challenging environment even in a state like Maryland."
Vincent DeMarco, president of the Maryland Citizens' Health Initiative, said reaching the uninsured gets tougher each year especially if they have entrenched opinions. The simpler website and new mobile app should help appeal to younger and lower-income consumers who often exclusively use smart phones for Internet access, he said.
His group has created a network of faith leaders to reach out to their communities and run advertisements featuring celebrities.
"We're all focused on being more targeted," he said. "We have to make sure people who are reluctant to sign up because they heard of costs going up know there are subsidies."