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It's Not Your Imagination, Your Health Insurance Has Gotten Worse

Jeffrey Young   |   September 29, 2014    7:15 AM ET

A quiet revolution happened to your job-based health benefits and you may not have noticed. It's happened gradually, but insurance looks a lot different than it did just 15 years ago: Americans are paying more and getting less.

That trend is only getting worse.

Gone are the days of deluxe health plans that simply paid employees' medical bills without questions or problems. Now, faced with their own rising health care expenses, employers are forcing more risk for big medical bills onto workers, and asking them to take a more active role in shopping for lower-cost health care than they have before.

Last year, when Amy Czerwinski learned she had breast cancer and would need a double mastectomy as well as seven months of chemotherapy, she was not in the best place to start bargain-hunting for care.

"This is a life-and-death thing," said Czerwinski, a 38-year-old accountant who lives in Hendersonville, Tennessee. "You go to the specialist, and they tell you who they would suggest. I would be afraid to shop around and get a cheaper oncologist."

And that highlights a key problem with putting the onus on patients to be smart shoppers for doctors: The spread of health insurance that makes us pay more money upfront has outpaced the spread of reliable, accessible information about prices and about the quality of medical services.

Health insurance companies and employers use buzzwords like "consumer-directed health plans" to describe these approaches to health benefits. Higher deductibles and other means of making patients pay more when they receive health care -- like "coinsurance" that requires consumers to cover a percentage of their bills rather than charging a flat copayment -- are a way for employers to save money.

The average annual cost of a single worker's insurance plan more than doubled between 1999 and 2013, rising from about $2,200 to around $5,900, according to a survey of employers published by the Henry J. Kaiser Family Foundation and the Health Research and Educational Trust last month. Over that same time, the average share of that cost paid by single workers inched up from 14 percent to 18 percent -- meaning employers are chipping in less, even as costs rise precipitously.

And in the past five years, another trend has rapidly spread: higher and higher deductibles, which require workers to pay cash upfront for their medical care before the insurance begins picking up a share of the bills. Between 2006 and 2013, the portion of single workers whose plans have deductibles of at least $1,000 jumped from 10 percent to 38 percent, according to the survey.

Deductibles are supposed to give patients a financial motivation -- what insiders call "skin in the game" -- to shop around for less expensive medical providers, and to reconsider treatments they may not need. When you're responsible for paying more of the bill, you're more likely to care about how much something costs.

In some key respects, these changes have been beneficial. In the old days, a patient had no reason to care how much a service or a drug might cost, because their health plan would cover almost all of it. This is one reason U.S. health care spending went up and up over the decades. And the switch to health insurance that requires patients to pay more of the total cost has contributed to a historic slowdown in national health spending and to slower growth in job-based insurance premiums in recent years.

That doesn't mean a whole lot when you get sick, though. Health insurance designed to make workers more cost-conscious also exposes them to big expenses when they need lifesaving care, as Czerwinski learned. "Your insurance won't even touch anything until you hit your deductible," she said.

employee health benefits
Photo courtesy of Amy Czerwinski

Czerwinski racked up more than $15,000 in out-of-pocket costs as she struggled to meet the deductibles for her employer's health insurance while undergoing cancer treatments.

"You pretty much ignore the cost, because you just do," she said. "And then when you finally have to start opening the bills, it's kind of too late because you've already incurred the expenses." Her employer and the Patient Advocate Foundation, which referred HuffPost to Czerwinski, helped cover her expenses, she said.

A key element of the reasoning behind large deductibles and higher cost-sharing is that it will spur patients to become smarter consumers of health care who will do the research on which medical providers charge lower prices or have been proven to offer high-quality treatments.

But the facts that patients need in order to make informed choices are hard to find and complex to evaluate.

"I don't even know how you would do that," Czerwinski said. "I didn't even know that was an option."

And people facing high cost-sharing tend to skip not just expensive care they could do without, but also services they actually need, research shows.

There has been some improvement on this score, as health insurance companies, employers and other organizations are gathering and disseminating cost and quality information for patients to use. A growing number of health insurance companies, for example, are sharing these data with a nonprofit called the Health Care Cost Institute, which will publish them on its website next year.

Yet merely making the information available isn't enough, said David Newman, the institute's executive director. "Transparency in and of itself is not going to be the silver bullet. It can help," he said.

Employers who are shifting more responsibility for managing health care costs to workers should do more to make sure their employees understand how their benefits work and get them invested in the new way of doing things, said Julie Stone, the North America health and group benefits leader at Towers Watson, a consulting firm.

"There is an employer role to keep that front and center, and give examples and illustrate [that] it's in everybody's best interests, it's a win-win for the employer and the employee from a cost-management perspective," Stone said.

Czerwinski is now cancer-free, but she still worries about paying for the doctor visits and drugs she'll need to make sure the disease doesn't come back. And she's not confident her health benefits will keep up with her needs or stay on her family's budget.

"Insurance companies don't pay like they used to. And it's only going to get worse, and that's very scary because our salaries are not increasing at the same rate the insurance costs are increasing," Czerwinski said. "It didn't use to be this bad."

Birth Control Is Free Under Obamacare, But Not Everyone Got The Memo

Jeffrey Young   |   September 26, 2014    4:34 PM ET

One of Obamacare's biggest selling points for women is the guarantee of no-cost birth control, a new benefit that includes all forms of contraception from the pill to tubal ligation.

But two years after the rules eliminating copayments for contraceptives took effect, some women are still forking over cash to the pharmacist when they pick up their pills or at the doctor's office when they obtain other forms of birth control.

Just last week, CVS announced it would send rebates to 11,000 women who were erroneously charged for their birth control pills at the company's stores because of a computer error. The snafu came to light when an aide to Rep. Jackie Speier (D-Calif.) had to pay $20 for birth control at a Washington CVS, which prompted an inquiry by the lawmaker.

So did President Barack Obama break a promise? Are health insurance companies and drugstores picking women's pockets?

The good news is that neither of those things is true, and eventually almost all women with health coverage won't have to pay a dime when they obtain contraceptives. The bad news is that it's a little complicated. Because of course it is. This is the American health care system, after all.

"American women don't really know what all the rules are," said Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center. "All this is relatively new, and it's working fairly well. It just needs to be cleaned up and work better."

Some health insurance plans aren't yet required to comply with this part of Obamacare. Others never will have to cover birth control, such as those plans provided to employees of religious organizations. And as the CVS example illustrates, sometimes insurers and pharmacists just get it wrong, and women have to jump through hoops to set it straight.

"We do hear from women all over the country with what I will call glitches," Waxman said. "Not everybody understands what they're supposed to be doing."

First, the basics: The Affordable Care Act does require health insurance companies to cover all Food and Drug Administration-approved contraceptives -- including the pill, IUDs, the ring and the patch -- without any form of cost-sharing like copayments or deductibles. This requirement comes from the same part of the law that mandates no charges for preventive medicine, such as immunizations and cholesterol tests.

If you receive your health benefits from an employer and you're not sure whether you have to pay out-of-pocket to get contraception, you should ask a manager, the human resources office or the insurance company. If you buy health insurance on your own, check with the plan to find out what your contraceptive coverage is. All health insurance sold on the Obamacare exchanges includes no-cost birth control. If your insurance company still insists you owe copayments, you might have to file an appeal, Waxman said.

If you don't get straight answers from your employer or insurance provider, or if you feel like you're being ripped off, organizations such as the Planned Parenthood Action Fund and the National Women's Law Center can help, as can state insurance commissioners and the U.S. Department of Labor, Waxman said.

Despite its shortcomings and the confusion around how it's supposed to work, the Obamacare birth control mandate has had a huge impact: Many, many more women have access to no-cost contraception than before the law took effect, as this chart from the Guttmacher Institute, a reproductive health research organization, shows.

birth control
Source: The Guttmacher Institute

The share of women who obtained oral contraceptives without copayments rose from 15 percent in 2012 to 67 percent this year, according to a survey by the Guttmacher Institute. Women who used an injectable contraceptive or the ring saw a similarly major improvement in their benefits, and those using IUDs saw a somewhat smaller increase.

The effect on women's pocketbooks is striking: Women using contraceptives saved $483 million in copayments last year, according to IMS Institute for Healthcare Informatics, a branch of IMS Health that tracks pharmaceutical sales. (Obamacare didn't exactly make contraceptives "free," of course, because their cost now just gets included in the overall insurance cost.) The number of prescriptions filled for the pill also increased by 4.6 percent from the year before, IMS reported in April.

obamacare birth controlTop bar in millions of prescriptions. Bottom bar in millions of dollars. Source: IMS Institute for Healthcare Informatics

That's probably a big reason why this part of Obamacare is so popular. In a survey conducted this July, 60 percent of people said they supported mandated no-cost birth control, the Henry J. Kaiser Family Foundation found. Still, one-third of Americans didn't know about the no-cost birth control benefit as recently as March, and only one-fifth said they'd heard a lot about it, another survey by the foundation revealed.

Why do some women still have to pay up at the pharmacy or doctor's office? Because there are types of health insurance plans that currently don't have to provide this benefit.

The main category of such plans is what the Affordable Care Act calls "grandfathered" health insurance, meaning the plans can follow pre-Obamacare rules so long as the insurers don't make more than small changes to the benefits they offered on March 23, 2010, the day the president signed the law. About one-quarter of insured people are enrolled in these grandfathered plans, according to a survey of employers by the Kaiser Family Foundation and the Health Research and Educational Trust released last month.

But fewer and fewer women will have these grandfathered plans in future years as employers who provide health benefits and insurance companies adapt to Obamacare and start following all its rules. More than half of those with insurance had these old plans in 2011, and the share is steadily falling.

Then there are closely held for-profit companies like Hobby Lobby and religiously affiliated nonprofit organizations like Little Sisters of the Poor, which object to at least some forms of birth control. The Supreme Court decided this year that companies like Hobby Lobby can opt out of paying for their employees' contraceptives -- and gave groups like the Little Sisters a temporary reprieve from the mandate while their case moves through the courts. But the Obama administration maintains that women who work for these organizations must still somehow have access to contraception coverage.

These employers and the Obama administration continue to fight about this, so if you work for such an employer, you might have to pay for your birth control.

Hospitals In States That Won't Expand Medicaid Left With More Unpaid Bills

Jeffrey Young   |   September 24, 2014    4:01 PM ET

States that refuse to accept Obamacare's Medicaid expansion aren't just leaving behind poor residents, they're also hurting hospitals' bottom lines.

Because the Affordable Care Act cut the number of people with no health insurance this year, hospitals across the country will see $5.7 billion less in unpaid bills, according to a report issued by the Department of Health and Human Services Wednesday.

But the difference in states that have expanded Medicaid versus those that haven't is stark, the report shows. Hospitals in the 25 states that already have made Medicaid available to more poor residents and the District of Columbia will see $4.2 billion less in unpaid bills and charity care, a decrease of one-quarter. In the other states, the decline will be just $1.5 billion, or 9 percent.

In other words, the reduction in the uninsured brought about by Obamacare has predictably led to a decrease in the number of people turning up at hospitals with no health insurance and no means to pay for their medical care. And that decrease is more substantial in states that allowed their poorest residents access to Medicaid coverage.

"It's actually showing that this provides benefits to states," Health and Human Services Secretary Sylvia Mathews Burwell said at a briefing with reporters prior to the report's release Wednesday.

The findings are a reflection of the fact that the uninsured rate, especially among low-income people, has fallen much more in states that expanded Medicaid than in states that didn't.

In a New England Journal of Medicine article published in July, HHS and the Harvard School of Public Health estimated 10.3 million fewer people are uninsured as a result of Obamacare. HHS also announced this month that 7.9 million more people are enrolled in Medicaid or a related benefit called the Children's Health Insurance Program than before Obamacare enrollment started last October. In addition, 7.3 million people have signed up for private health insurance via the law's exchange marketplaces, Burwell disclosed last week.

The Democrats who wrote the Affordable Care Act intended to expand Medicaid nationwide to anyone earning up to 133 percent of the poverty level, or about $15,300 for a single person. But the Supreme Court ruled in 2012 that states could opt out, enabling Republican governors and state legislators -- mostly in the South -- to refuse generous federal funding to cover low-income residents.

Via: The Advisory Board Company

The failure to expand Medicaid in those states has left 4.8 million people who would have been eligible without coverage, according to the Henry J. Kaiser Family Foundation.

The American Hospital Association, along with other national state hospital groups, endorsed the Affordable Care Act precisely because they wanted more people covered and fewer patients unable to pay for care. That's even though the law also cuts Medicare and Medicaid funding hospitals receive.

In states that haven't expanded Medicaid, hospitals are enduring the funding reductions without the increase in insured patients, though. When the Supreme Court ruling came down, hospital groups in states like Texas and Florida unsuccessfully lobbied in favor of the Medicaid expansion. The figures released by HHS show why they tried.

"Many of the hospitals in these communities feel it already, but I think the data and information will help them make their case more strongly with regard to the importance to their bottom line," Burwell said.

A growing number of states that initially didn't expand Medicaid are signing on, most recently Pennsylvania and New Hampshire, bringing the total up to 27 plus Washington, D.C. Burwell is in discussions with other states, including Utah, about bringing them aboard. "The more that we are able to attract conservative Republican governors, the more that those who have very strong feelings will perhaps listen," she said.

HHS based its analysis on financial reports from hospital chains such as HCA Holdings and LifePoint and on surveys by state-based hospital trade associations. The consulting firm PricewaterhouseCoopers published a similar report this month, and its findings are consistent with HHS's.

Obamacare Critics Just Lost Another Talking Point

Jeffrey Young   |   September 23, 2014    4:31 PM ET

Obamacare's so-called government takeover of health care was supposed to destroy the private insurance market. Somebody forgot to tell the health insurance companies.

More health insurers are signing on to participate in Obamacare, Health and Human Services Secretary Sylvia Mathews Burwell said during a speech Tuesday at the Brookings Institution in Washington.

The number of companies offering plans on the Affordable Care Act's health insurance exchange marketplaces for 2015 will jump to 248, a 25 percent increase over this year, in the 44 states where the numbers are available.

The department offered details in a report published at the time of Burwell's remarks.

The increase in participating companies discredits a line of attack against the 4-year-old health care law that said it would crush competition.

UnitedHealth Group, one of the largest insurers in the country, plans to sell coverage on exchanges in more than 20 states for 2015 after sitting out this year in many states where it offered other plans. The firm will join other big players including WellPoint, which sold more exchange plans than any other insurance carrier; Humana; and Aetna, along with numerous state-based Blue Cross and Blue Shield plans. Some major insurance companies continue to avoid the exchanges, however. Wellmark Blue Cross and Blue Shield, the leading insurer in Iowa and South Dakota, is staying out of the exchanges in those states for the second year of enrollment.

Health insurance premiums tend to be lower in markets where multiple plans compete than in locales where one or two companies dominate. Although full information about premium prices on the Obamacare exchanges next year isn't yet available, the consulting firm PricewaterhouseCoopers estimates the average rise will be 7 percent. That is similar to or smaller than price hikes in the years before Obamacare, and rate increases and decreases will vary greatly across the country.

The 25 percent increase in plans on the exchanges for next year represents 77 new health insurance companies joining and 14 leaving. According to the HHS report, California is the only state where fewer insurers will sell coverage on its exchange. Information wasn't provided about Kentucky, Massachusetts, Minnesota, Nevada, Oregon or Vermont. Underscoring the volatility in this new health insurance market, Minnesota's exchange has lost its most popular insurer, meaning some customers will have to select new coverage for next year.

Nine states included in the HHS report will have the same number of health insurance companies in their exchanges for next year as they did in 2014, but the remaining 34 states will have more. Notably, New Hampshire and West Virginia each had only one insurer selling policies on its exchange for last year; for 2015, the states will have five and two, respectively. Indiana will see the most new insurers, with options rising from four to nine. New York has the most insurers in its exchange with 17.

Open enrollment on the health insurance exchanges begins Nov. 15 and runs through Feb. 15.

An estimated 7.3 million people were fully enrolled in private health insurance plans purchased via the exchanges where people buy health insurance as of Aug. 15, Burwell disclosed last week. In addition, millions have been added to the Medicaid and Children's Health Insurance Program rolls since the first Obamacare sign-up period started last October. As a result, more than 10 million previously uninsured people gained coverage, according to an analysis by HHS and the Harvard School of Public Health that was published in the New England Journal of Medicine in July.

But Obamacare enrollment hasn't reached anywhere near its potential -- particularly in the private market. The Henry J. Kaiser Family Foundation estimates the Obamacare exchanges could ultimately sign up almost 29 million people for private health insurance.

This story has been updated to replace outdated information from PricewaterhouseCoopers about projected health insurance increases next year.

More Proof That Anti-Obamacare States Desperately Need Obamacare

Jeffrey Young   |   September 22, 2014    8:42 AM ET

In a lot of big urban areas where a large share of residents lack health insurance, help isn't on the way.

Seven of the 11 large metro areas where the uninsured rate was higher than the 14.5 percent national average last year are located in states that refused to expand Medicaid under the Affordable Care Act. Two are in Florida, three are in Texas, and the others are Atlanta and Charlotte, North Carolina. The metro area with the highest uninsured rate was Miami, at a staggering 25 percent, compared to the national low of 4 percent in greater Boston.

Here's a breakdown of the biggest metropolitan areas' uninsured rates before the Obamacare coverage expansion began, courtesy of figures released by the U.S. Census Bureau this week.

uninsured cities

The Affordable Care Act called for Medicaid benefits to be available to anyone earning up to 133 percent of the federal poverty level, which is about $11,500 for a single person this year. Twenty-six percent of people with incomes in this range were uninsured last year, the Census reported.

To date, 23 states, mostly Southern, haven't adopted the expansion, despite generous federal funding. When the Supreme Court upheld the Affordable Care Act in 2012, justices also ruled the Medicaid expansion was optional for states.

What makes matters worse for the people left out of the Medicaid expansion is that another part of the Obamacare law permits only people who earn at least poverty wages to get financial help paying for private health insurance -- so those who earn less get nothing.

According to the Henry J. Kaiser Family Foundation, those decisions not to expand the program will leave 4.8 million people uninsured. More than 1 million of them live in Texas, 764,000 are in Florida, 409,000 are Georgia residents and 319,000 live in North Carolina.

Four other large metro areas that the Census Bureau reported had higher-than-average uninsured rates are in states that expanded Medicaid this year: Los Angeles, San Diego and Riverside, California, and Phoenix, Arizona.

In a survey published in July, the Commonwealth Fund found that the states that expanded Medicaid saw a combined drop in the uninsured rate for people with incomes below poverty from 28 percent to 17 percent after the first round of Obamacare enrollment. In the states that didn't, the share without health coverage was 36 percent -- barely changed from before.

A Gallup-Healthways survey from August also revealed wide variation between Obamacare's effect on the uninsured rate between states that cooperated with the law's implementation, such as by expanding Medicaid, and those that didn't.

Almost All Obamacare Enrollees Are Paying For Coverage

Jeffrey Young   |   September 18, 2014    1:23 PM ET

The Obama administration on Thursday finally revealed how many people paid for Obamacare on the national and state health insurance exchanges: 7.3 million.

Since President Barack Obama announced in April that sign-ups on the Obamacare exchange marketplaces had surpassed 8 million, skeptics have demanded to know what portion of health insurance enrollees had actually paid for their coverage. At a hearing of the House Oversight and Government Reform Committee, Centers for Medicare and Medicaid Services Administrator Marilyn Tavenner offered a partial answer at last.

"As of Aug. 15 this year, we have 7.3 million Americans enrolled in health insurance marketplace coverage and these are individuals who paid their premiums. We are encouraged by the number of consumers who paid their premiums and continue to enroll in the marketplace coverage every day through special enrollment periods," Tavenner said.

But the 7.3 million enrollment figure doesn't tell the whole story. The Department of Health and Human Services can't provide the total enrollment tally, including paid and unpaid, since April because the computer system that would process those records isn't fully operational, a department official said. A manual evaluation would be required to find that number, the official said.

Compared to the enrollment total of 8 million detailed in a May report about the sign-up period that began last October, the retention rate for private Obamacare coverage would be more than 90 percent.

However, because people have been allowed to buy health insurance on the exchanges since then under special circumstances, such as marriage or the birth of a child, the count of people who were enrolled at any given time this year likely rose higher than 8 million.

Nevertheless, the confirmed 7.3 million paid sign-ups appears to repudiate the predictions of doomsayers that huge numbers of Obamacare enrollees would dump their plans or fail to pay their premiums. This tally also exceeds last year's Congressional Budget Office projection that 7 million people would enroll and its revised projection from earlier this year of 6 million enrollees.

Tavenner didn't provide details about the paid enrollments number or the individuals who gave up their Obamacare coverage, or never paid for it. But there are a variety of common reasons people abandon insurance plans, or switch to a different benefit.

Some enrollees may have determined they couldn't afford the insurance or that it wasn't a good value. Others may have experienced drops in income that qualified them for Medicaid, while some may have secured jobs that provided health benefits.

"Historically, there has been enormous churn in the individual insurance market," Larry Levitt, senior vice president at the Henry J. Kaiser Family Foundation, wrote in an email.

"Of the people buying individual at any given time, almost half of them will no longer be in the market a year later," Levitt wrote. "People get jobs with health benefits or turn 65 and become eligible for Medicare. On the other side of the ledger, people also lose jobs and enter the individual market."

Over time, Levitt wrote, about the same number of people enter the individual insurance market as leave it.

Obamacare Is Doing At Least One Big Thing Right

Jeffrey Young   |   September 16, 2014   10:06 AM ET

Another day, another survey showing that Obamacare is beginning to cure America's uninsured problem.

The latest numbers come from the federal Centers for Disease Control and Prevention, which polled more than 27,000 people during the first three months of the year. Forty-one million U.S. residents, or 13.1 percent, were uninsured during the quarter when benefits started to kick in for people who signed up for coverage into private insurance or Medicaid via the Obamacare exchanges or elsewhere.

That's the lowest number and percentage of uninsured people since the CDC started using this version of its survey in 1997. It's also down 3.8 million people and 1.3 percentage points from the end of 2013.

The Affordable Care Act's impact on the uninsured actually is understated by the CDC survey. More than 30 percent of Obamacare's 8 million private health insurance enrollees signed up in March or later. That means their benefits wouldn't have kicked in by the end of the third quarter, so a portion of them wouldn't have had coverage by the time of the CDC poll.

Polling and research by other organizations indicates a greater reduction of the uninsured after March. By the end of June, the uninsured rate fell to 13.3 percent, the lowest since 2008, according to Gallup survey findings released last month. Gallup's number for the second quarter was down down from 17.1% at the end of 2013. In an article published in the New England Journal of Medicine, the Department of Health and Human Services and the Harvard School of Public Health pegged the number of people who gained coverage since last year at 10 million. The Congressional Budget Office projects 12 million people will gain health insurance by year's end.

While the CDC survey shows the uninsured rate for children and adults over 65 years old didn't change much, the share of working-age adults who had no health coverage fell from 20.4 percent at the end of the last year to 18.4 percent during the first three months of 2014. The biggest drop was among adults 19-25 years old; the uninsured rate for this group fell more than 5 points to 20.9 percent.

As other studies have shown, states that adopted Obamacare's expansion of Medicaid benefits to more poor residents covered a lot more uninsured than those that didn't. During the first quarter of this year, the uninsured rates in Medicaid-expansion states fell from 18.4 percent to 15.7. In states that refused to accept the Medicaid expansion, the uninsured rate was virtually unchanged, the CDC found. Twenty-three states, mostly in the South, have not opened up Medicaid to more people.

The CDC report also makes plain the connection between income and health insurance. The uninsured rate for poor U.S. residents was 24.1 percent, compared to 26.2 percent for "near-poor" people and 9 percent for everyone else. Obamacare provides financial assistance to people who earn up to four times the federal poverty level, which is about $94,000 for a family of four.

The ethnic group with the highest uninsured rate was Hispanics, at 27.2 percent in the first three months of this year, a decline of more than three points since 2013. The uninsured rate also fell for African-Americans, from 18.9 percent to 15.1 percent. Asians had the third-highest rate at 13.3 percent, followed by whites at 11.5 percent; the share of uninsured Asians and whites didn't significantly change.

The Census Bureau also released survey findings about health insurance in the United States Tuesday, but its figures are from 2013, before benefits from Obamacare enrollment began to take effect. The Census also changed the way it conducts this survey, making comparisons to previous years impractical.

In 2013, 13.4 percent of the population, or 42 million people, lacked health insurance for the entire year, the bureau found. By contrast, the CDC survey asks respondents whether they have coverage at the time of the interview, meaning they may have had coverage at another point during the same year.

The next phase of sign-ups on the health insurance exchanges begins Nov. 15 and will run through Feb. 15. According to the Congressional Budget Office, 7 million additional people who currently lack coverage will gain it during the open enrollment period, and more are expected to sign up in the coming years.

But neither the Congressional Budget Office nor anyone else believes Obamacare will ever bring the number of uninsured Americans down to zero. A decade from now, CBO projects 31 million people will not have health insurance, 25 million fewer than if the Affordable Care Act hadn't been enacted, but still 11 percent of the population.

This story has been updated with figures from the Census Bureau survey.

360,000 Obamacare Enrollees At Risk Of Losing Subsidies

Jeffrey Young   |   September 15, 2014    4:45 PM ET

More than 360,000 individuals enrolled in health insurance via the Obamacare exchanges must provide federal authorities with updated information about their incomes by Sept. 30, or risk losing the subsidies that cut the cost of their coverage, the Centers for Medicare and Medicaid Services announced Monday.

Federal authorities will begin contacting 279,000 households, representing 363,000 individuals, on Monday to urge them to provide additional information about how much money they make because the figures submitted in their Obamacare subsidies applications don't match federal tax records, said Andy Slavitt, the principal deputy administrator of the Medicare and Medicaid agency, which also oversees the health insurance exchanges. More than 8 million people enrolled into private health insurance plans via the Obamacare exchanges during the six-month sign-up period that began last October, and 85 percent received subsidies.

Consumers who do not contact health insurance exchange authorities to verify the accuracy of their income or to offer up-to-date information risk seeing their tax credits reduced beginning next month, Slavitt said. These people may also have to repay the government if they received more subsidies than their income should have allowed.

Discrepancies between Obamacare applications and other federal records don't necessarily indicate consumers attempted to defraud the government, and enrollees may have submitted more accurate information than found in previous tax records, the agency emphasized in a press release.

The Centers for Medicare and Medicaid Services already has worked through the majority of the cases where records didn't match. As of May 30, income information about 1.2 million households, and more than 1.6 million people, wasn't consistent with other federal records. Since then, issues for 467,000 households have been resolved, and another 430,000 cases are in progress, according to the agency.

In addition, the agency disclosed that 115,000 enrollees haven't verified their citizenship or their immigration status, and will lose their health insurance coverage if they do not. Federal authorities set a Sept. 5 deadline for these individuals to provide accurate information about their legal status when they contacted 310,000 people last month. Advocates for immigrants have complained that some enrollees who attempted to comply encountered bureaucratic obstacles.

The Centers for Medicare and Medicaid Services will begin notifying those 115,000 enrollees that their coverage will be cut off at the end of the month. Those who wish to re-enroll with updated citizenship or immigration status documentation will be allowed to do so, Slavitt said.

The next Obamacare enrollment period begins Nov. 15 and runs through Feb. 15.

Employee Health Insurance Costs Barely Increased This Year

Jeffrey Young   |   September 10, 2014   10:01 AM ET

For a change, the cost of the health insurance you get at work didn't go up much this year.

The cost of job-based health benefits stayed nearly flat in 2014, according to survey results released Wednesday. This year's figures continue a trend of slow growth in premiums for health insurance provided by employers.

The average annual premium for a family plan rose 3 percent to $16,834, and the average price for a single worker increased 2 percent to $6,025, the Henry J. Kaiser Family Foundation and the American Hospital Association's Health Research and Educational Trust found. Workers on family plans are paying an average 29 percent of that cost, while single employees are paying 18 percent of it. The groups polled more than 2,000 small and large employers for their report.

Workers aren't reaping much of a tangible benefit because the cost of job-based health insurance is still increasing faster than wages and overall inflation. But the growth over the last five-year period is much lower than during the two five-year periods preceding it, the survey findings show. From 1999 to 2004, family health plan premiums exploded by a total of 72 percent, followed by a cumulative 34 percent from 2004 to to 2009. Since 2009, these costs have risen 26 percent.

employee health benefits
Source: Henry J. Kaiser Family Foundation

Despite the recent trend of smaller increases, the cost of employer-sponsored insurance has ballooned over the past 15 years, eating up a larger share of workers' total compensation. Since 1999, the average annual cost of health benefits has nearly tripled.

employee health benefits
Source: Henry J. Kaiser Family Foundation

The historically slow increases in national health spending during recent years contributed to lower premium hikes for employer-sponsored health insurance. But companies also are limiting their health benefit expenses by making workers pick up a bigger share of the monthly premiums and of their medical bills, the survey found.

High-deductible health plans with lower premiums but greater out-of-pocket costs have become increasingly common. In 2006, just 6 percent of workers were enrolled in these plans, compared to 26 percent in 2011 and 32 percent this year. And the average size of the deductible for a single employee has risen from $584 in 2006 to $1,217 in 2014. Under plans with deductibles, policyholders must spend the full amount of the deductible out of pocket before the insurance coverage kicks in.

employee health benefits
Source: Henry J. Kaiser Family Foundation

"The relatively low growth in premiums this year is good news for employers and workers, though many workers now pay more when they get sick as deductibles continue to rise and skin-in-the-game insurance gradually becomes the norm," Kaiser Family Foundation President Drew Altman said in a written statement.

Eighty percent of workers covered with company health benefits have plans with deductibles this year, the survey found. More than 40 percent of covered employees have plans with deductibles of $1,000 or more, and 18 percent of the plans carry deductibles of at least $2,000. Workers at firms with fewer than 100 employees are more likely to face high deductibles than those at larger employers.

The survey also found that the share of employers that offer health benefits to workers, 55 percent, was about the same this year as last year. Small companies are less likely to provide health insurance, but 90 percent of workers are employed by a company that offers benefits to at least some of its workforce. Eighty percent of employees who have access to job-based health insurance accept it, according to the poll.

Looking ahead to next year, the Kaiser Family Foundation and the Health Research and Educational Trust expect the Affordable Care Act, or ACA, to exert greater influence on job-based health insurance. Beginning in 2015, the law requires companies with at least 100 employees to offer health benefits to full-time workers, or pay penalties when employees obtain subsidized coverage via the Obamacare health insurance exchanges. In 2016, that employer mandate will extend to companies with 50 or more workers.

"The relatively quiet period in 2014 may give way to bigger changes in 2015 as the employer shared-responsibility provision in the ACA takes effect for large employers," the report says.

According to survey findings released last month by the National Business Group on Health, premiums for job-based coverage at large companies will rise 5 percent next year, and more employers will offer only plans with high deductibles. These companies expect the ACA to have only a modest effect on 2015 health benefit costs, the poll found.

Why Is CVS Walking Away From $2 BILLION A Year?

Jeffrey Young   |   September 3, 2014    9:04 PM ET

The company formerly known as CVS Caremark made a big splash Wednesday by yanking whatever tobacco products it had left on the shelves a month earlier than planned, becoming the first big pharmacy chain to do so. The company, now known as CVS Health, has estimated it will lose $2 billion a year in revenue as a result of the move.

That sounds like a lot of of money, until you consider two things. First, CVS recorded $126.7 billion in sales during the last fiscal year. In other words, it took the company less than six days to generate $2 billion in revenue. Second, the United States will spend more than $3 trillion on health care this year and more than $5 trillion by 2023, according to projections released by federal auditors Wednesday.

CVS dumping tobacco sales and rebranding itself says more about the future of the American health care system and emerging areas of competition for shares of those trillions than it does about smoking cessation. (One smoking-related fact that CVS' actions do point toward is that way fewer people use tobacco now than did decades ago, making it easier for a chain store to ditch cigarettes -- although CVS's competitors like Walgreens and Rite Aid aren't doing so, despite urging by state officials.)

By ending sales of cigarettes and other tobacco products and changing its corporate name, CVS is signaling that it wishes to be known as a health care provider, not merely a convenience store with a pharmacy in the back and wide array of smokes up front. After all, you can't buy cigarettes at the doctor's office. In numerous interviews with news outlets tipped off to the company's announcement, CVS CEO Larry Merlo has made a similar point, though often worded a bit differently.

That messaging is consistent with Merlo's statement in the company's annual report issued in February, just after CVS first said it planned to end tobacco sales.

As the delivery of health care evolves with an emphasis on better health outcomes, reducing chronic disease, and controlling costs, we’re playing an expanded role in providing care through our pharmacists, nurse practitioners, and physician assistants. This significant action further distinguishes us in how we are serving our patients, clients, and health care providers, and better positions us for continued growth in the evolving health care marketplace. Although this decision will have some impact on revenues and profits, we believe that it is the right thing to do given our expanding role as a health care company.

One area in which companies like CVS, Walgreens and Walmart are making bets is so-called retail clinics, where customers can get basic medical care like flu shots and treatments for minor injuries and ailments at low cost during hours more like those of a hospital than a doctor's office, and without the long waits and indignity of visiting an emergency room.

CVS already has more than 900 "MinuteClinic" locations, and it plans to expand over the next few years. Walgreens has close to 400 "Healthcare Clinics" in its stores. And Walmart, which dipped its toes in the water several years ago by partnering with independent clinic operators, is in the process of opening more than a dozen company-owned primary care clinics this year.

It's a growing market: In 2009, retail clinics at CVS, Walgreens and the grocery chain Kroger recorded nearly 6 million patient visits, which was almost exactly four times the amount in 2007, according to a study published in the journal Health Affairs this month. That's still a tiny number compared to the hundreds of millions of doctor and emergency department visits annually, but the growth trend is clear -- and demand for health care services is only becoming greater.

These companies are responding to other trends in the health care system, starting with the expansion of health coverage brought about by Affordable Care Act. There are as many as 10 million more people with health insurance or Medicaid benefits now than before Obamacare enrollment began.

These patients need someone to treat them, and retailers figure it might as well be them, not least because those patients are probably already customers. CVS has been transforming from a retailer into a big health care company for years already, notably since the company merged with Caremark, a provider of prescription-drug benefits for employer-provided health insurance plans.

The movement toward health insurance plans with deductibles in the thousands of dollars -- meaning policyholders have to spend that much out of pocket before their insurance kicks in -- could also drive people to clinics that will charge them an affordable fee for minor care, rather than the costlier bill associated with a doctor's office or emergency department visit.

What's more, there's a well-known national shortage of primary-care doctors -- although supply varies a lot by geography -- and retail clinics, along with urgent care facilities and other sites of care, could be key to ensuring access to timely, cost-effective treatment in some areas.

What changed Wednesday is this: Those patients will have to stop somewhere other than CVS if they want a pack of smokes for the drive home. Maybe there will be a Walmart, Walgreens or Rite Aid nearby.

Health Care Spending To Tick Up In 2014, But Just A Little

Jeffrey Young   |   September 3, 2014    4:02 PM ET

After five years of historically low inflation, national health care spending will grow a bit faster this year, according to a federal audit released Wednesday. The expected increase is due to the economy's continued recovery, millions gaining health benefits from Obamacare and more baby boomers signing up for Medicare.

Households, businesses and the government will spend $3.06 trillion on health care in 2014, a 5.6 percent increase from projected expenditures during the previous year, according to a report by the Office of the Actuary at the Centers for Medicare and Medicaid Services published in the journal Health Affairs. From 2009 through 2013, growth came in below 4 percent, the actuaries estimate. In the two decades before that, there were much higher increases; health care spending has nearly quadrupled since 1990.

Despite the uptick in spending on health care services and products like hospital procedures and prescription drugs, these expenditures are still expected to rise more slowly than they did from 1990 to 2008. Even though the economy will grow faster, more Americans will have health coverage and more will age into Medicare, other factors will keep spending increases below those historical highs, the audit concludes.

"The growth rate that we're projecting would be higher than the recent past, but much lower than the previous two decades," Sean Keehan, an economist in the Medicare actuary's office, said at a press conference Wednesday. "We're not projecting that growth will get back to its rapid pace of the '90s and early 2000s."

Health care spending will rise 5.7 percent during the 10-year period that began in 2013, which is lower than the 7.2 percent increase from 1990 to 2008 and higher than the 3.7 percent increase from 2009 to 2012, when the Great Recession drove down demand, the report says. Data from 2013 to 2023 represent the auditors' projections. A separate report next year will detail actual spending in 2013, and the tally for this year won't be available until 2016.

health care spending 2013

Source: Centers for Medicare and Medicaid Services

The last year for which actual spending information, not projections, is available from the Medicare actuaries is 2012. That year, health care expenditures rose 3.7 percent, which was lower than the rise in gross domestic product for the first time since 1997. The actuaries expect the increase in spending in 2013 to be lower than economic growth as well, but they say it will outpace GDP starting this year.

By 2023, health care will make up 19.3 percent of the U.S. economy, as spending will rise 1.1 percentage points faster than gross domestic product. From 1990 to 2008, health care spending grew 2 percentage points faster than the economy.

health care spending 2013

Source: Centers for Medicare and Medicaid Services

The reasons health care spending inflation has slowed down are disputed. The White House and some analysts partially credit the Affordable Care Act with constraining health care spending directly via lower payments to medical providers and to health insurance companies serving Medicare beneficiaries. They say it has had an indirect effect as well, spurring private health care entities to become more efficient.

The actuaries at the Medicare agency mainly attribute the very low growth in recent years to a poor economy, which caused workers to lose jobs and health benefits and gave individuals less income to spend on medical care, and to strained state and local government budgets for health care programs. Other factors include the proliferation of health insurance plans with high deductibles and other requirements that patients pay a larger share of their medical bills, and Medicare spending cuts from Obamacare and a federal budget law enacted last year, the report says.

The Office of the Actuary estimated last year that Obamacare would account for less than 2 percentage points in the increase in health care spending during 2014, despite millions gaining coverage, and just one-tenth of a percentage point in the growth through 2022, compared to expenses if the law hadn't been enacted.

But the auditors are no longer breaking out Obamacare's effects on health care spending and drawing comparisons to a hypothetical world in which the law doesn't exist. "Now that the Affordable Care Act has been in place for well over four years, it is becoming increasingly difficult to accurately estimate a counterfactual -- meaning, what the world would look like in the absence of the Affordable Care Act," Andrea Sisko, an economist in the actuary's office, said at the press conference.

Here's Where Obamacare Has Made The Most Progress

Jeffrey Young   |   September 2, 2014   10:10 AM ET

More than 8 million people enrolled in private health insurance under Obamacare for 2014, topping expectations despite a rocky start. But that's less than one-third of the number of people who could have signed up -- a sign of the huge untapped market for Obamacare coverage and the challenges still facing the program.

In their first year, the Affordable Care Act's insurance exchanges signed up 28 percent of the people eligible to use them -- mainly people who don't get health benefits from their jobs or from a government program like Medicare or Medicaid -- according to an analysis by the Henry J. Kaiser Family Foundation.

And there was a lot of variation among the states: Some captured a big share of the market for these customers and others barely made a dent, as this map illustrates:

Infographic by Jan Diehm for The Huffington Post.

Using data from the Census Bureau and the Department of Health and Human Services, the Kaiser Family Foundation estimates 28.6 million U.S. residents are eligible to buy health insurance via an exchange, compared to the 8 million who did.

Growing the insurance exchanges created by President Barack Obama's health-care reform law is key to continuing to shrink the ranks of the uninsured and to enrolling a broad and diverse population of customers that can spread the cost of the sickest patients across a large number of people.

The foundation's analysis includes people who remain uninsured and people who buy their insurance directly from an insurance company without accessing the exchange or applying for financial aid. The estimate excludes people who qualify for Medicaid, and those who aren't allowed to use an exchange, such as undocumented immigrants and workers who turn down their employers' health plans. It also excludes people who live in states that didn't expand Medicaid and who earn too little to qualify for subsidized private insurance.

The early enrollees also are seen as those in greatest need: They had pre-existing conditions that shut them out of the pre-Obamacare market, qualified for subsidies available to people who earn up to four times the federal poverty level -- about $94,000 for a family of four -- or both. Eight-five percent of the 8 million people who enrolled received tax credits that reduced their monthly premiums, and millions more who didn't sign up for the financial assistance are eligible.

People who earn too much to get financial help or are eligible for only small subsidies may have preferred to avoid the exchanges, especially given their glitches. And insurers in some states offered products outside the exchanges with more choices of providers and other features.

The technical failings of the federal website and several state-run exchanges hampered exchange enrollment, driving some consumers to buy directly from an insurance company, even if they might have gotten subsidies on an exchange. Poor public understanding of how the exchanges worked, and especially about the availability of financial assistance, also depressed enrollment.

The share of the potential market that signs up through an exchange is expected to grow. Enrollment on the exchanges for next year begins again Nov. 15 and runs until Feb. 15, and millions more people are expected to use these marketplaces to shop for coverage. By 2017, the Congressional Budget Office projects, 25 million people will get their health insurance this way, including those who get subsidies and those who don't.

Websites that actually work would boost enrollment. More choices of insurance companies in most states, modest premium increases for a significant number of plans and the ability to comparison-shop should lure more consumers to explore the exchanges. And people who were allowed to keep their pre-Obamacare insurance this year after having it canceled will have to transition eventually to plans that meet the law's benefit standards.

What's more, the minimum penalty for not complying with Obamacare's individual mandate that nearly everyone be covered jumps from $95 this year to $325 in 2015.

Policy decisions made by state leaders partly account for the wide variation among states.

"States that wanted to make the law work clearly did better than states that didn't. It's not a one-to-one correspondence, but it's a strong effect," said Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation.

Seven of the top 10 states had exchanges that were either state-operated or jointly run by the state and the federal government. That includes California, which signed up 1.4 million people, or almost 43 percent of the potential market.

But a large share of eligible Floridians signed up via the federal exchange, owing to concentrated efforts by the Obama administration and enrollment organizations, Levitt said. The troubles with the state-run exchanges in Minnesota, Maryland and Hawaii put them in the bottom 10, along with the federal-state partnership exchange in Iowa.

The ranking also reveals some peculiarities among the states. Vermont consolidated more than 85 percent of its individual health-insurance market into its exchange, largely because that state and the District of Columbia are the only jurisdictions that don't let consumers buy insurance another way.

In Iowa and South Dakota, the company that had the most customers before Obamacare, Wellmark Blue Cross Blue Shield, didn't participate in the exchanges. The federal marketplace in those states was denied the biggest player's marketing muscle, and Wellmark customers inclined to stay with the company didn't use the exchanges, Levitt said. Wellmark also will not join the Iowa or South Dakota exchanges for 2015, the company announced in June, reversing the decisions made public about the Iowa and South Dakota markets in July 2013.

Massachusetts has had an insurance exchange since 2006 and near-universal coverage before Obamacare, leaving a small pool of people not already participating. And the state's exchange website performed poorly.

Although the exchanges will attract more customers next year and in the future, there are obstacles, Levitt said.

The 2015 enrollment period is just three months, half the duration of the 2014 sign-up window, and there will be fewer resources available to help people with the application process. Federal and state authorities also will have to devote efforts to retaining current customers. And there will be less publicity about the exchanges the second time around because it's no longer novel. Plus, the people who didn't sign up already may be the most challenging to enroll, Levitt said.

"It's going to be a lot harder for the program to exceed expectations in the second year than in the first year -- and the first year was plenty hard," Levitt said.

CORRECTION: An earlier version of this article incorrectly stated Wellmark Blue Cross Blue Shield would sell health insurance on the exchanges in Iowa and South Dakota for 2015.

Here's What's Going On With Obamacare Premium Increases

Jeffrey Young   |   August 21, 2014   10:59 AM ET

Health insurance premiums are going to skyrocket under Obamacare next year, maybe even double! No, wait -- they're only increasing a little, and less than before Obamacare! No, wait -- they're … decreasing in some places?

The crucial question about the second year of enrollment on the Affordable Care Act's health insurance exchanges is: How much will coverage cost? Actual prices won't be available in most states until the exchanges open Nov. 15, or shortly before that, so consumers are left to sort through political spin and preliminary reports that don't make things any clearer.

So what's going on? First, most people will pay more for health insurance next year. That's true whether you get coverage from a job, on your own through an exchange or directly from an insurer, or from Medicare. Health insurance prices tend to go up. It's their nature, and it's closely tied to how much the cost of medical care rises.

The good news is that available information indicates the doomsayers were wrong, and premiums under President Barack Obama's health care law aren't going through the roof.

The average increase for Obamacare plans will be 8.2 percent next year in 29 states and the District of Columbia where data about health insurance premiums for 2015 are available, according to PricewaterhouseCoopers, which has conducted the most thorough review to date. That's significant, but it's a little lower than the 10 percent annual rate hikes typical before the Affordable Care Act, according to a recent analysis published by the Commonwealth Fund.

The map below shows average premium increases in the states PricewaterhouseCoopers reviewed, with darker shades indicating higher rate hikes. States with limited information are shown in gray and states where no data were available are shown in white.

obamacare premiums 2015
See an interactive version of this map from PricewaterhouseCoopers.

But none of that is worth much to an individual consumer worried about her pocketbook, and it's no consolation to the family seeing rates for their coverage increase by 10 percent or more, even if that happens only to a fraction of the more than 15 million people the Henry J. Kaiser Family Foundation estimates are in this market.

Averages mask a lot of variation between the states, and even within them, because rates typically are set on a local level. Also, these big-picture numbers don't account for individual variables that affect prices, like age, family size and tobacco use. There are multiple health insurance companies operating in nearly all states, and each sells numerous products to individual households, both on and off the exchanges. The plan one consumer has this year could cost 15 percent more, while her next-door neighbor may see his price go down.

What's more, the numbers used by PricewaterhouseCoopers and others are preliminary in most states, meaning they could change after insurance regulators review them. Plus, states report the prices differently, making comparisons difficult.

Take Florida, where the anti-Obamacare administration of Gov. Rick Scott (R) says health insurance premiums will go up 13.2 percent on average next year. The U.S. Department of Health and Human Services responded to Florida's announcement by arguing that rates for the most popular type of insurance are actually going down in the areas where three-quarters of Sunshine State Obamacare enrollees live.

Similarly, in California, the health insurance exchange touted a 4.2 percent "weighted average" statewide increase, a calculation that considers the number of people on each health insurance plan, rather than a simple average of the price hikes. The state didn't release a plain average.

Comparing states, there's a wide gulf between a place like Oregon, where the average rate will be 2.5 percent lower, and Indiana, where the average price is set to increase 15.4 percent, the PricewaterhouseCoopers report shows. Even within those two states, the change in premiums varies a lot -- from 20.6 percent lower to 10.6 percent higher in Oregon, and from no increase to 35 percent higher in Indiana. Rates vary this year, too, as they have in the past.

The problem is, all of these numbers can be correct, but are are being placed into context by people who have an agenda. And they don't factor in the tax credits that subsidized premiums for 85 percent of the 8 million people who signed up on an exchange this year. While subsidies could shield those enrollees from higher premiums, these consumers still may have to shop around for a new, cheaper plan to keep their costs down next year.

Why will health insurance premiums rise, and why does it vary so much from location to location? There are a host of reasons. Some reflect the nature of the U.S. health care system, and some are Obamacare-related.

Mostly, insurance rates climb because health care costs climb, even though the growth in national health care spending has been historically slow for several years. Factors like prices for medical services and drugs and how much health care people use, vary by state and local area, for reasons that aren't always clear. Generally, premiums are lower in states where multiple insurers compete. All of this was true for 2014, and for every previous year.

What about the Obamacare effect? The most important change this year is that the law required insurance companies to cover people with pre-existing conditions, which led to the expectation that they would need more health care and drive up costs. The share of young adults who enrolled is below what the Obama administration hoped, and there's evidence that previously uninsured people are getting medical care, but that doesn't seem to be leading to widespread, massive price hikes.

The initial enrollment period didn't end until spring, so insurers still don't have a great idea of how much their new customers will cost them, As a result, they're making educated guesses about next year's premiums. This is one reason some companies are cutting rates or seeking big increases -- they guessed wrong last year and set prices too high or too low and want to boost enrollment next year. Increased competition in states where more insurers are joining exchanges also could keep premium increases down.

Why Obamacare May Have Trouble Signing Up As Many Uninsured Next Year

Jeffrey Young   |   August 14, 2014   12:46 PM ET

Obamacare made huge strides in extending health coverage to millions of uninsured people in its first year. Keeping up that momentum could be challenging.

An estimated 54 million Americans are still uninsured. But many of those who haven't yet been helped by the Affordable Care Act might be some of the hardest people to get signed up, according to the people trying to reach them.

"The people the second year are going to be a little bit harder. We got the low-hanging fruit," said Richard Onizuka, the CEO of the Washington Health Benefit Exchange, the insurance marketplace for consumers in Washington state.

More than 10 million previously uninsured people signed up after Obamacare enrollment began last October. That group is considered the most eager for coverage. People with pre-existing conditions, who had been shut out of the market under pre-Obamacare rules and needed health care the most, were now able to get covered. Lower-income families were offered expanded Medicaid and subsidized private insurance.

One big hurdle to future sign-ups is the public's chronically poor understanding of how key parts of Obamacare can help low- and middle-income people afford coverage. These include the availability of Medicaid or subsidies for people who earn up to four times the federal poverty level -- or $46,680 for a single person this year. And public opinion about the law itself is negative.

Certain segments of the population also proved more difficult to reach during the initial sign-up period. Sign-ups of Hispanics lagged behind those of other groups, even though the uninsured rate is higher among Hispanics. People who have less education, live in remote rural areas, are disconnected from community or religious groups, are homeless, don't have Internet access or don't consume news often may not always know that new programs are in place. And smaller numbers of people will find they can't afford even subsidized insurance, or will simply opt to remain uncovered.

And as evidence from California suggests, those who have been without health insurance the longest may turn out to be the most difficult to get signed up. Eighty-two percent of those still uninsured in the Golden State have lacked coverage for at least two years or have never had it, according to a survey by the Henry J. Kaiser Family Foundation in Menlo Park, California.

"There's an expectation that the farther along we go, that it will be the kind of chronically uninsured who end up being the hardest to reach," said Karen Pollitz, a senior fellow at the foundation.

No one expected Obamacare to give everyone health insurance in a single year -- or ever.

The Congressional Budget Office projects the law will reduce the uninsured by 12 million through the end of this year, but that just 7 million will gain coverage in 2015.

And the CBO also expects there still will be 57 million U.S. residents without health insurance a decade from now. That equals 11 percent of the population, including undocumented immigrants who are ineligible for government-supported health benefits. Though it's 26 million fewer uncovered people than there would be absent the ACA, the gap suggests the law can never achieve universal coverage.

Besides undocumented immigrants, there's another category of people left out of the coverage expansion: residents of the 24 states that took advantage of a Supreme Court ruling allowing them to refuse expanding Medicaid eligibility up to 133 percent of poverty, or $15,521 for a single person. The uninsured rate fell in states that expanded Medicaid, but barely moved in those that didn't, a July Gallup poll found. According to the Urban Institute, more than 60 percent of the remaining uninsured live in states that opted against expanding Medicaid.

The results of the first year of the coverage expansion, however, can't be denied. The most official national count of the uninsured, from the census, won't be available until more than a year from now. But numerous polls and analyses make plain that the ACA has made rapid progress in reducing their ranks despite the law's rocky rollout last year.

Obamacare reduced the number of people without health insurance by 10.3 million people in 2014, researchers from the Department of Health and Human Services and the Harvard School of Public Health reported in the New England Journal of Medicine in July. The uninsured rate fell 3.7 percentage points to 13.4 percent between last fall and this March, the lowest rate since 2008, according to Gallup.

Kentucky, which expanded Medicaid and operated a state-run exchange, achieved a big reduction in its uninsured rate, largely through Medicaid. With more than one-quarter of the state's residents now enrolled in that program, finding and signing up more eligible people may not be easy, said Lisa Lee, deputy commissioner of the state's Department for Medicaid Services. "It's almost like looking for a needle in a haystack at this point, but we will continue our aggressive outreach," she said.

In states that resisted Obamacare and didn't expand Medicaid, the path to making major progress on the uninsured is steeper, said Jodi Ray, program director of Florida Covering Kids & Families at the University of South Florida in Tampa.

"There's a huge number of folks," Ray said. "To assume we've captured all the low-hanging fruit would be a gross misstatement in a state like Florida."

An Enroll America survey conducted in April provides some insights into why uninsured people didn't get covered, and what might work to get them enrolled. One key finding is that 61 percent of them want health coverage, compared to 15 percent who don't.

Improving public understanding of the subsidies appears to be crucial to boosting enrollment. More than half of the people who signed up were aware there was financial assistance available, compared to just over one-quarter of those who didn't enroll, the survey shows. Likewise, nearly half of people who didn't try to enroll believed they couldn't afford it, according to the survey.

"There was sometimes a mismatch between perception and reality," said Jenny Sullivan, director of Enroll America's Best Practices Institute. "They didn't necessarily have the knowledge that financial help was available."

Advocates believe they can build on their success with methods that have already proven effective, such as in-person help with applications and spreading the word about financial assistance. Groups plan to expand such efforts to more communities and more people.

"We're going to see continued progress there," Sullivan said of the strategies. "It's really leaning into some of those very same messages that worked well during the first open enrollment period and making sure that we get those to an even broader swath of folks."