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How Your Health Insurance Company Can Still Screw You, Despite Obamacare

Jeffrey Young   |   July 21, 2014    7:36 AM ET

No law has done more to reform health insurance and protect consumers against the industry's most heinous practices than the Affordable Care Act. But Obamacare didn't magically transform insurers into benevolent entities solely devoted to taking care of sick people.

Health insurance companies, even those that are not-for-profit, have to collect more money in premiums than they shell out in claims for medical care. That means they have a financial incentive not to pay for things.

And since health insurance companies can no longer shun the sick to maximize profits -- either by denying coverage to people based on their medical histories or by rescinding the policies of paying customers who fall ill and rack up bills -- insurers are employing other tactics to shift costs to sick people and make it harder to get health care, consumer advocates say.

"One of the things that occurred to me, even as the bill was working its way through Congress, was that once it was passed, insurers would do all they could to try to preserve profit margins," said Wendell Potter, a former Cigna executive turned industry critic.

Here are a few of the tactics that consumers and advocates have complained about:

Refusing to pay for medical care that should be covered

Nothing in Obamacare says insurance companies have to pay any bill that comes their way. That's fine, because doctors and patients want things all the time that are wasteful and unnecessary, and everyone shares the cost for that.

But it means the law doesn't prevent stuff like this from happening:

Zoë Keating is a musician with more than 1 million followers on Twitter. Her husband, Jeffrey Rusch, had been diagnosed with cancer at the emergency room, hospitalized and given chemotherapy. The insurance company refused to cover it -- until Keating told her story to a San Francisco television station, according to reports on KPIX.

While the Affordable Care Act beefed up patients' right to appeal denials by insurance companies, people still have to fight, which is to the insurer's advantage. "A lot of people just simply don't understand their appeals rights and don't appeal, or think that they just don't have a chance of getting something overturned," Potter said. "The insurance companies know that." Most people don't have a million Twitter followers, either.

Making patients pick up a bigger share of the bill

To keep premiums as low as possible, insurance companies are pushing more of the cost of actual care on to their customers in the form of things like high deductibles and "coinsurance," which requires patients to pay a percentage of the cost of their care, instead of making a flat copayment.

restaurant check group

"Okay, Ashley, you've got diabetes, so you have to pay half the tab. Oh, and Brittany had a second glass of wine."

And it's virtually impossible to learn in advance how much medical care will actually cost, meaning patients are left in the dark.

"What this means for someone with cancer is that they may end up being directed away from a plan because they can't find out whether their doctor is in the network, or whether the plan covers their drugs, on what tier and how much they have to pay out of pocket," said Kirsten Sloan, senior director policy at the American Cancer Society Cancer Action Network. Sending a cancer patient to a competitor would count as a win in the insurance industry.

Designing benefits to make the sickest patients pay more for drugs

Advocates for patients with serious medical conditions have been incensed by the practice of "tiered" drug lists, which have become a popular way for insurers to limit their expenses. Under this mechanism, the amount patients pay at the pharmacy is generally lower for cheap generic medicines and "preferred" brand-name drugs, higher for other brand-name drugs and higher still for the most expensive specialty medications.

health insurance obamacare

The good stuff is always on a high shelf. Almost got it!

High cost-sharing and top-tier status for drugs that treat ailments like HIV and multiple sclerosis are common in insurance policies bought via the Obamacare exchanges, the consulting firm Avalere Health reported last month. That looks an awful lot like insurers discriminating against sick people, the AIDS Institute claimed in a complaint filed against four Florida insurers with the federal government in May.

"Where we've seen the problems is putting every single HIV drug, including generics, on the highest tier, and that with very high coinsurance, like 40 or 50 percent," said Carl Schmid, deputy executive director of the AIDS Institute. "There's plenty of plans in Florida that don't do this, and charge $10, $20 a copay for the same drugs."

Limiting access to doctors and hospitals

Health insurance plans sold via Obamacare exchanges often have "narrow networks," or shorter lists of medical providers that accept those plans than people with job-based insurance or Medicare might expect. Insurers need to keep costs down, and tough negotiating with high-priced doctors and hospitals can do that. This ends up saving the whole health care system money, including insurance customers.

The trouble is, when those networks don't include enough of the specialty care providers that take care of the sickest, most expensive patients -- like, say, cancer centers -- it has the effect of denying care to those very sick people because they can't get appointments.

health insurance obamacare

"Sorry, bro. Not on the list."

"Insurers might try to avoid people with HIV or cancer or expensive conditions by avoiding the doctors that tend to treat those people, but otherwise their network looks robust," said Karen Pollitz, a senior fellow at the Henry J. Kaiser Family Foundation. "Whether it's happening -- no way to know yet." The Obama administration and state regulators are poised to take action to compel insurers to beef up their networks, The New York Times reported.

Rolling out the red tape

To save money, insurance companies will be stricter about approving and paying for medical treatments, said Carmen Balber, executive director of the nonprofit organization Consumer Watchdog. "I have no doubt that claims denials or delays will be the new discriminatory tactic of the industry," she said.

In Seattle, one doctor said she has to work harder to get treatments approved this year. "There are more hoops that the provider has to jump through," said Grace Wang, the medical director of the International Community Health Services Holly Park Medical and Dental Clinic.

health insurance obamacare

"We'll gladly pay your claim -- after you perform a death-defying escape, Houdini."

Wang returned to the clinic after Memorial Day weekend and attempted to follow up on a request she'd made to refer a patient to a specialist. The insurance company said her request already had been rejected because she hadn't called back quickly enough.

"Their clock started ticking on Sunday. Monday was a national holiday, and so when 48 hours went by, they denied," said Wang. "A conspiracy theorist would wonder."

In States That Didn't Expand Medicaid, Obamacare's Not Reaching The Poor

Jeffrey Young   |   July 9, 2014   11:58 PM ET

Twenty-five states didn't take up the Obamacare Medicaid expansion at the beginning of this year, and the results speak for themselves: A new survey shows more than one-third of their lowest-income residents remain uninsured, a rate virtually unchanged from last year, even as millions gained coverage elsewhere.

Nationwide, the share of Americans 19 to 64 years old without health insurance fell from 20 percent to 10 percent, as 9.5 million people got covered by Medicaid or private health insurance, according to a poll of Obamacare enrollees published Thursday by the Commonwealth Fund.

Among adults who earn less than poverty wages in states that didn't expand Medicaid, the uninsured rate is 36 percent, a decline of two percentage points (termed not statistically significant) from last year. That compares to a dramatic drop from 28 percent to 17 percent in states that expanded Medicaid.

The debate over the Medicaid expansion remains arguably the most consequential unresolved matter related to the Affordable Care Act, as the refusal by Republican governors and state legislatures to accept federal dollars to provide health care to poor people is having real effects on the ground.

Medicaid Expansion Decisions By States Have Predictable Results

obamacare medicaid uninsured

The authors of the ACA didn't foresee this outcome, which was made possible by a Supreme Court ruling in 2012 giving states the right to opt out of Medicaid expansion and granting GOP politicians another cudgel to use against Obamacare.

Source: The Advisory Board Company

The law was originally designed to make Medicaid available to anyone who earns less than 133 percent of the federal poverty level, or $15,282 this year for a single person. The law also lets individuals who make between the poverty level of $11,490 to four times that amount get tax credits to cut the cost of private health insurance. But anyone who makes less than that -- or even nothing -- gets no assistance if they live in Texas, Florida, Louisiana or the other states didn't didn't expand the program.

Law Meant To Cover The Uninsured Is Covering Them

obamacare medicaid uninsured

Among Obamacare enrollees with either Medicaid or private health insurance obtained through insurance exchanges, 63 percent didn't have health coverage before. Two-thirds of new Medicaid enrollees were previously uninsured. The greatest gains in health coverage were among young adults, poor adults and Latinos, the survey found.

The Commonwealth Fund poll, conducted through telephone interviews of 4,425 people by the firm SSRS from April to June, focused special attention on the six most populous states.

California, which expanded Medicaid, cut its uninsured rate in half to 11 percent. In Florida, which did not expand the program to more people, the share of uninsured residents declined from 30 percent to 26 percent, a difference deemed statistically insignificant. Texas also didn't expand Medicaid, but its uninsured rate still fell from 34 percent to 22 percent, the survey found. Texas and Florida still have the highest uninsured rates in the nation.

Big Variations In The Uninsured Rate In The Big States

obamacare medicaid uninsured

The Accidental Reason Companies Like Hobby Lobby Control Our Health Care

Jeffrey Young   |   June 30, 2014    4:34 PM ET

The Supreme Court's ruling Monday that Hobby Lobby can refuse to cover contraception for workers is yet another reminder that our bosses have a lot of control over the health care we receive -- and that's not likely to change any time soon.

Jobs are the most common source of health insurance in the United States, a peculiar fact that sets the country apart from its international peers. That's why losing a job typically has meant losing health coverage, and it's why workers whose needs aren't met by their company's health plan have little recourse. They can go work elsewhere, pay much more money for health insurance on the open market or shell out cash for medical care that's not covered by their benefits.

Dumping employer-based health insurance is something of a cause célèbre among liberal and conservative economists alike. These intellectuals believe "decoupling" health insurance from jobs would be a more rational and fair way of pooling medical costs. Whether employer-based insurance should be replaced by a big national health care program or a private insurance system where individuals buy their own coverage depends on which economist you ask.

Getting rid of the current system would also let you avoid situations where your boss decides he doesn't want cover your medical treatments -- or shouldn't have to pay for something he believes is morally wrong, like, say, birth control.

But people who aren't eggheads tend to have a pretty strong bias for the status quo, and so do the politicians they elect.

More than 150 million Americans are covered by employer-sponsored group health insurance. That's more than Medicare, Medicaid and individual insurance plans combined. And workers seem to like it that way: 88 percent said they were satisfied with their insurance last year, according to a survey by the Employee Benefit Research Institute. One reason might be that companies pay part of the monthly premiums.

President Barack Obama and the Democrats who wrote the Affordable Care Act understood this, and they also knew that fear of change among the already insured was a huge reason why President Bill Clinton's health care reform agenda blew up in his face. So they sought to preserve the system that provides almost half the country with insurance, rather than scrapping it.

The furor over the cancellation of a tiny fraction of health insurance plans last year suggests those Democrats were onto something.

hobby lobby employer insurance
President Barack Obama, seen here not rocking the boat.

How did the U.S. wind up with a health insurance system so different from those of other rich nations, nearly all of which have universal health care programs, including those where employers play a role? How did employers became responsible for providing health insurance, and how did workers become dependent on their bosses for health care?

It's an accident of history. During World War II, the federal government imposed wage and price controls on private companies that made it impossible for them to raise pay levels in order to attract employees at a time when a huge chunk of the workforce was fighting (and dying) overseas. But the feds also decided that fringe benefits like medical insurance were exempt from wage controls. After the war, the federal government ruled that these benefits weren't subject to income tax, either.

hobby lobby employer insurance
"The only thing we have to fear is a distorted health care market 70 years from now."

This made juicy benefits cheaper for employers than higher pay, and advantageous for workers, too, since no one pays income taxes on the value of these benefits. The U.S. Treasury would have collected $185 billion more in taxes last year if health benefits weren't exempt, according to the Center on Budget and Policy Priorities. The Congressional Budget Office refers to it as the biggest so-called tax expenditure on the federal books.

The number of Americans who get health insurance at work is expected to rise, not fall, in the coming years, despite the emergence of an alternative in the form of the health insurance exchanges created by Obamacare. For one thing, the exchanges aren't a great option for workers whose companies have health plans, because people with access to health insurance at work mostly don't qualify for federal subsidies if they buy it on their own.

For another, the Affordable Care Act requires companies with at least 50 full-time employees to offer health benefits or pay a penalty to offset the cost of the government doing it instead. That mandate has been delayed twice already, so maybe it'll never take effect. But if it does, the Congressional Budget Office projects that companies will, by and large, continue to provide insurance to workers.

Companies themselves say the same thing when asked, at least when it comes to full-time employees. In a typical poll, published by Towers Watson and the National Business Group on Health in May, 98 percent of employers agreed it was important to offer health benefits to full-time employees next year and in the near future.

Your Boss Still Wants To Give You Health Insurance

hobby lobby employer insurance
Source: Towers Watson/National Business Group on Health

And as much as employers might like to get out of the costly health care business, they're not clamoring to let the government take it over and raise their taxes while taking away the control they currently have.

Plus, American companies are accustomed to using rich benefit packages as a way to lure and keep the workers they value, especially given the tax advantages. Competition for labor makes employers loath to be the first ones to dump their benefits and direct workers to the Obamacare exchanges, lest the employees flee to rival firms where the health plans haven't been killed.

There are some small signals that the status quo might change, however. If the health insurance exchanges stabilize and grow, and people like the coverage they find there, companies could become less fearful of a backlash. The same Towers Watson survey found that just a quarter of employers are "very confident" they will provide health insurance a decade from now, down from 43 percent 10 years ago.

Your Boss Is A Bit Unsure About The Future Of Health Benefits

hobby lobby employer insurance
Source: Towers Watson/National Business Group on Health

New Obamacare Poll Reveals Views Of Winners And Losers

Jeffrey Young   |   June 19, 2014   11:00 AM ET

If you want Americans to like Obamacare, giving them some money seems to help. A new poll reveals that previously uninsured people and those who received subsidies to buy health care under the Affordable Care Act are much happier with the new law than those who were forced to switch health care plans.

Six in 10 of those who received subsidies to offset their insurance costs said they benefited from the law, according to the survey conducted by the Henry J. Kaiser Family Foundation in April and May. A majority of those who obtained their coverage via Obamacare's health insurance exchanges and half of the previously uninsured felt the same way.

The poll focused on those who got health insurance in the so-called nongroup market, as opposed to people covered by job-based health benefits or government programs such as Medicare and Medicaid.

Fifty-seven percent of consumers whose old policies were canceled because they didn't comply with the law feel they were negatively affected by Obamacare. And 47 percent of "plan switchers" who bought different coverage than they had last year said the effects were bad, although 46 percent of them say they are paying less this year compared to 39 percent paying more.

Overall, 47 percent of those with individual insurance policies have a favorable view of the Affordable Care Act, compared to 43 percent who view it negatively. That's a higher approval rating than the public at large gives the act, according to the survey, but still shy of majority support.

More than 8 million people obtained health insurance from an exchange through April 19, and millions more bought Obamacare plans from an insurer, agent or broker.

obamacare uninsured
Note: "ESI" stands for "employer-sponsored insurance."

Among the major effects of the ACA was a disruption of the status quo that realigned the winners and losers in the individual insurance market, which previously was characterized by high prices or outright exclusion of older, sicker people; unaffordable coverage for the poor; and comparatively accessible insurance for younger, healthier consumers.

By opening up this market to people with preexisting conditions and offering financial assistance to low- and middle-income families, Obamacare has begun to achieve its goal of broadening access to coverage, as well as mandating that insurance cover a standard set of benefits and provide a stronger financial protection against catastrophic bills.

In doing so, however, the law also spread the additional cost of covering sicker people to those who previously had coverage and were advantaged by excluding others. And the mandated benefits and elimination of insurance tools such as annual or lifetime caps on coverage led insurers to eliminate less expensive plans that didn't include those features -- forcing their old customers to find replacements, often at a higher cost.

Overall, 34 percent of people who have individual health insurance this year were uninsured before Obamacare, and 13 percent switched from one nongroup insurance policy to a different one for 2014. Among those who purchased their coverage from an exchange, 57 percent were previously uninsured.

obamacare uninsured

The survey also found that people with insurance plans that comply with Obamacare rules report slightly worse health than those in the old policies that excluded people with preexisting conditions. Seventeen percent of those with ACA-compliant insurance said their health is fair or poor, compared to 6 percent of those still covered by pre-Obamacare policies. The shares of those who reported excellent or very good health also varied, at 51 percent for those with ACA-compliant policies and 65 percent for those with pre-Obamacare coverage.

Issues such as the affordability of premiums, future rate increases and the size of the plan's deductibles remain concerns for those who bought Obamacare plans, the survey shows. Consumers report being more confident that they can afford routine health care and that the insurance will protect them against major medical bills.

Consistent with years of polling on the Affordable Care Act, partisan affiliation significantly influenced consumers' opinions about the law. Sixty-nine percent of Democrats view it favorably, compared to 14 percent of Republicans.

obamacare uninsured

CLARIFICATION: This post has been updated with more details about how many people who switched to Obamacare health insurance plans are paying less this year.

Diagnosis: Headaches For Obamacare Enrollees At The Doctor's Office

Jeffrey Young   |   June 18, 2014   12:44 PM ET

Obamacare's enrollment glitches might have been fixed long ago, but they're still causing headaches at doctors' offices and clinics around the country.

Patients and health care providers, in a series of interviews with The Huffington Post, complained that they are having trouble confirming that patients are insured, working out what their plans cover and figuring out which plans doctors will accept.

These complaints are signs that the Affordable Care Act, President Barack Obama's signature health care reform law, is suffering growing pains more than six months since its insurance policies took effect.

The law has provided low-cost, subsidized health insurance to millions of working families and no-cost Medicaid coverage to millions more. It has opened the market to people with pre-existing conditions who were shut out before. And these new plans come with a slew of guaranteed benefits and consumer protections.

But the technical and bureaucratic failures of the six-month open enrollment period that officially ended March 31, the millions of new customers on insurance rolls and a poor understanding among the previously uninsured about how insurance works are combining to create extra burdens for some doctors and their patients.

Such problems serve to highlight the fragmented, complex nature of the existing health care system and the shortcomings the law failed to fix: the hassle of negotiating with insurance companies, the struggle to understand how benefits work, and the difficulty of finding doctors.

Maureen Mandel of North Bellmore, New York, has endured a gauntlet of troubles to get and use her new insurance since October, when she first tried to sign up through New York State of Health, her state's insurance exchange. Mandel, 47, spent countless hours on the phone with the exchange and her insurer, until her plan was finally confirmed in April.

Mandel thought she had it sorted out.

Then she went to the doctor. The front-desk attendant said some other physician was listed in the insurer's system as her primary care provider -- a doctor in Waco, Texas. According to Mandel, an insurance company representative told the attendant their internal records listed this physician, but when Mandel signed into the account herself, it listed her real primary care provider's name. The attendant was still arguing with the insurer about the discrepancy when Mandel's visit with the doctor was over, she said.

"I sympathized with the doctor's office," Mandel said. "I honestly would've understood if they'd said, 'Maureen, I'm sorry. We just can't take you.'"

These experiences soured Mandel, who described herself as politically liberal, on Obamacare, despite her appreciation for the coverage it provides and the tax credits that cut her insurance costs. "I haven't seen any improvement," she said, "and that's what scares me."

Physicians' offices are feeling the pain, too. Seeing patients whose insurance coverage is in doubt risks leaving doctors with unpaid bills. Staff has to spend precious time helping patients resolve issues with insurers, said David Taylor, the vice president of regional services for CoxHealth, a chain of clinics and hospitals based in Springfield, Missouri.

In an April survey by the Medical Group Management Association, which represents large physician practices, 63 percent of doctors' offices said verifying a patient's insurance was more difficult with plans bought through Obamacare exchanges. The same percentage reported greater difficulty getting information from insurers about how much patients had to pay for services, and 59 percent said it was harder to get accurate information about what specialty physicians were in patients' insurance networks.

"The front desk is probably our toughest position," Taylor said. "In some instances, they may be able to help, but in others they may be too busy," he said. When there's uncertainty, the office may demand payment upfront, he said. "We're not turning people away, but we are asking for money," he said.

When Paige Bayer of San Jose, California, took her 9-year-old son to his pediatrician for an ear infection, she ended up paying $125 in cash after learning the doctor wasn't in her new plan's network, contrary to information listed on her insurer's website, she said. "I wanted to get my son seen quickly," she said.

"I didn't get the idea that you don't get to go out of network anymore. If you go out of network, you are paying every red cent," said Bayer, 40. "That was kind of shocking to me."

Bayer is more optimistic than Mandel that such problems will smooth out over time, and her family is benefitting from the law's guaranteed coverage for people with pre-existing conditions. Her 40-year-old husband's chronic back problems made it impossible for him to get private insurance before Obamacare, she said. "That kept me up at night. I started thinking, 'My God, what if he ended up getting cancer or something?'" Bayer said. "We'd lose everything -- and we have a lot of money. But we live in Silicon Valley, and a lot of money doesn't go very far if you end up with cancer."

At her small practice in Wilmington, Delaware, physician Rebecca Jaffe has experienced her share of administrative issues with Obamacare plans. Jaffee worries she won't get paid if a patient's insurance isn't in effect, but tries to accommodate them as much as possible, she said.

Jaffe's staff also spends a lot of time helping patients answer tricky questions about how their benefits work, like whether a service is "preventive" -- and therefore has no out-of-pocket charges -- or a treatment, for which they must pay.

"Patients really, really don't understand that," she said. "We're seeing confusion, because people don't know what's covered and what's not covered." Patients who were previously uninsured and don't understand complex insurance plans need the most help, she said.

Still, Jaffe said, these kinds of problems aren't so different from what happens when insurance plans change every year, and they represent the early struggles of reforming the health care system.

"The ACA was a huge step. I mean, it took 50 years for some sort of substantive change," she said. "We need to fix what we find doesn't work well."

Millions Get Obamacare Plans For $100 Or Less

Jeffrey Young   |   June 18, 2014   12:01 AM ET

Almost seven out of 10 people who bought health insurance on the federal Obamacare exchanges are paying $100 or less a month for coverage, according to a Department of Health and Human Services analysis issued Wednesday.

Tax credits available to people earning between the federal poverty level -- about $11,490 for a single person last year -- and four times that amount are the reason. Of the 5.4 million people in 36 states where the federal government manages the health insurance exchanges, 69 percent are paying monthly premiums of no more than $100 after tax credits, and 46 percent are paying $50 or less, HHS concludes. The analysis doesn't include exchanges run by 14 states and the District of Columbia.

High health insurance premiums in the pre-Obamacare market were a key reason why poorer people went without coverage. The Affordable Care Act targets low- and middle-income households with tax credits and additional subsidies. Of the more than 8 million people who enrolled via the exchanges nationwide, 87 percent received tax credits, HHS reported.

Tax credits reduced monthly costs for consumers using the federal exchanges by an average of 76 percent off the full premium, which amounts to an overall average price for subsidized plans of $82, compared with the average $346 sticker price, HHS reports.

That finding underscores that health insurance premiums, which may surpass $1,000 a month for families, are considerably higher than the average paid by subsidized enrollees. Those who earn more than 400 percent of poverty, which was $45,960 for a single person last year, must pay the full price, and those with incomes near that upper limit qualify for small tax credits.

The average premium for a basic insurance plan available during the enrollment period that began Oct. 1 and officially ended March 31 was $249 in 48 states that were surveyed, according to an HHS report published last September. Premiums rise with the generosity of the plan's benefits, vary greatly by geographic location, can be up to three times higher for older consumers, and increase with family size.

For households near the poverty line, even $100 a month can be a burden. In spite of the tax credits, the belief that health insurance on the exchanges is unaffordable was the main reason uninsured people didn't sign up for coverage, according to a survey conducted by the Henry J. Kaiser Family Foundation in April.

Awareness of the tax credits among uninsured and low-income people is poor, other surveys have found. Nationwide, 28 percent of the 28.6 million people eligible to shop on the exchanges actually signed up for a plan, according to federal and state data compiled by the Kaiser Family Foundation.

Premiums are likely to rise for most consumers next year, as they typically have for decades. Health insurance companies already are submitting widely varying proposals for next year's rates to state regulators. Some have requested hikes of 10 percent or more, while others aim to lower prices. Premiums for people who don't get health insurance from their jobs rose an average of 10 percent a year prior to the Affordable Care Act, according to an analysis published by the Commonwealth Fund this month.

People who receive tax credits largely should be shielded from premium increases, however. The Affordable Care Act caps their monthly costs based on income, and uses tax credits to fill the gap between that cutoff and the price of the health insurance plan.

How Obamacare Tries To Make Us Healthier, One Community At A Time

Jeffrey Young   |   June 2, 2014    1:30 PM ET

President Barack Obama's health care reform law will spend more than $1 trillion over the next decade to extend health coverage to millions of people -- and about $20 billion actually trying to make us healthier.

The money supporting these initiatives is tucked inside the Affordable Care Act in the form of the Prevention and Public Health Fund, a pot of money to finance efforts in hundreds of communities to curtail obesity, promote exercise and better nutrition, and reduce tobacco use.

Improving the health of Americans and reducing preventable deaths wouldn't just benefit those individuals. Better health could prove key to reversing decades of skyrocketing health care spending. And the prevention fund is Obamacare's primary means of making inroads on these problems, one community at a time.

“If we removed the barriers to healthy living, we would bend the cost curve in health care spending. In order to do that, we had to target communities," Sen. Tom Harkin (D-Iowa), who created the fund, said in a written statement.

Up to 40 percent of deaths each year from the five leading causes in America -- heart disease, cancer, chronic lower respiratory diseases, stroke and unintentional injuries -- are preventable, the Centers for Disease Control and Prevention reported in May. And medical treatments for the half of the population with chronic health conditions such as cardiovascular disease, diabetes and tobacco-related illnesses account for 84 percent of health care spending, according to a 2010 report from the Robert Wood Johnson Foundation in Princeton, New Jersey.

The Affordable Care Act called for the prevention fund to receive $18.8 billion from 2010 to 2022, then $2 billion annually in future years. But that supply of money has diminished since Obama enacted the law in 2010.

Congress has taken more than $6 billion out of the fund since 2012. Also, the main source of dollars for local initiatives, the Community Transformation Grants program, is ending Sept. 30, two years early, because Congress reallocated the funding to other Centers for Disease Control and Prevention programs. In addition, the Department of Health and Human Services diverted $453.8 million of the money to help finance the implementation of Obamacare's health insurance exchanges.

Perhaps the highest-profile use of the prevention fund is the CDC's $162 million anti-tobacco advertising campaign called "Tips From Former Smokers." The medical journal The Lancet credited these ads with prompting 1.6 million people to attempt to quit smoking and 100,000 people actually to do so in 2012.

The spots feature graphic accounts from individuals with serious tobacco-related ailments, such as a cancer patient from North Carolina who had her larynx removed.

Most of the projects financed by the prevention fund are smaller in scale and cost and based in individual communities, however. These aim to address the underlying cultural and behavioral factors that lead to poor nutrition, inactivity, obesity and tobacco use, and they have the potential to make measurable improvements in health, said Georges Benjamin, executive director of the American Public Health Association in Washington.

"We think that there's evidence that communities have begun talking about those problems, identifying the root causes, trying to use these monies to leverage other funding and other things that they're already doing to begin to make a difference," Benjamin said.

In San Diego County, California, the local government and the Chula Vista Elementary School District used federal grants to make an immediate impact on students' weight, said Nick Macchione, the director of the county Health and Human Services Agency.

School administrators approached county officials in 2010, concerned that unhealthy weight was holding back their students, Macchione said. In partnership with the county's Live Well San Diego initiative, they conducted voluntary body mass index screenings of 25,000 kids in 44 schools. The findings confirmed the leaders' fears: Almost 40 percent of the children were either overweight or obese. "This was shockingly alarming," Macchione said.

Using some of the $8.2 million the county received from the prevention fund, the health agency and the school started making changes, Macchione said. The cafeteria started offering healthier food and local farmers visited to talk about agriculture and provide fresh produce. Math teachers incorporated physical activity into counting lessons. And students and parents received information about nutrition and exercise.

Two years later, Chula Vista schools already could boast gains: a 3.2 percent reduction in the share of students who were obese or overweight. The county has since started spreading this program to 300 schools serving 650,000 children, Macchione said.

Programs in Indiana also focused on children brought home the challenges faced by those working to address health in their communities, said Andrea Hays, the project director overseeing the $3 million in Community Transformation Grants managed by the Healthy Communities Partnership of Southwest Indiana in Evansville.

As in San Diego County, they worked with local schools to incorporate healthier food and physical activity in students' daily routines. Under one pilot program, Healthy Communities Partnership of Southwest Indiana joined with a local hospital to deliver fresh fruits and vegetables to a school, where Hays saw firsthand how deeply rooted the problem was.

"We had kids that had never tried a banana before," Hays said. "It's culture shock for these kids."

In Iowa, the Department of Public Health tapped into $8.2 million in prevention funding to link patients to more medical providers. As part of the Iowa Community Referral Project, a partnership with local health boards and the Urbandale-based Iowa Primary Care Association, dentists received training to take blood pressure measurements and ask patients about tobacco use.

Four of the dental clinics participating in this program provided blood pressure tests to more than 4,000 people and discovered that 6 percent had hypertension, more than 70 percent of whom visited a medical doctor for further care, said Kala Shipley, the executive officer for health promotion at the Des Moines-based department.

Results like these won't reverse years of rising obesity rates and worsening health, but they're a good place to start, Macchione said.

"Culture change takes time," he said. "If we just look back 30 years ago on smoking, can you imagine in our first year and we started our campaign and we showed probably little-to-no impact, if we would've given up?"

ER Visits Jump As Obamacare Kicks In, Doctors Say

Jeffrey Young   |   May 21, 2014   12:00 AM ET

More people may be visiting hospital emergency departments this year as health benefits from Obamacare went live, according to a survey of physicians published Wednesday.

The American College of Emergency Physicians polled more than 1,800 emergency room doctors last month, and 46 percent reported increases in patients coming through their doors since Jan. 1, the day coverage took effect for millions under Obamacare. Twenty-seven percent said the number hadn't changed and 23 percent had seen a decline since Jan. 1. Over the next three years, 86 percent of these doctors believe emergency room use will increase.

The survey findings underscore the challenges beyond extending health coverage to more people, including improving access to primary care and changing the habits of patients accustomed to using the emergency room as a one-stop-shop for medical care. One of Obamacare's selling points was its potential to reduce costly emergency room visits for care that could more efficiently be delivered in a doctor's office or other setting, especially for patients who previously were uninsured. Increases in ER visits may provide critics fodder to contend the law isn't fulfilling that promise.

"Coverage does not equal access," said Rebecca Parker, an emergency room doctor in Chicago who is on the board of directors at the Irving, Texas-based American College of Emergency Physicians. "Just because you gave somebody Medicaid doesn't mean that there's a place for them to go in terms of a primary care, outpatient facility," she said.

According to the Association of American Medical Colleges, there will be nearly 30,000 too few primary care physicians in the United States to meet patient demand next year, and that gap will widen in the future as more people gain coverage and the population ages.

Patients with and without health insurance seek care from hospital emergency departments for a variety of reasons, including knowledge that hospitals offer a wider array of services than a doctor's office.

A federal law dating to 1986 forbids hospitals from turning patients away from emergency rooms regardless of their ability to pay, which attracts individuals who lack the means to afford medical care elsewhere. In addition, emergency departments lure patients who don't have access to a nearby doctor, or when physician offices are closed at night and on weekends. And patients don't have the medical expertise to tell whether symptoms like chest pains mean they're having a heart attack or indigestion.

obamacare emergency room

Most of the patients who visit the emergency room actually should be there, or at least can't be blamed for going to a hospital when experiencing pain or illness that might be serious, Parker said. "The majority of folks do belong in a kind of acute care setting, which is what we provide," she said. Based on her observations, an increase in emergency department visits could be explained by newly covered patients seeking medical care they postponed while uninsured and choosing a provider they know will treat them, Parker said.

While a survey of emergency department physicians' impressions lacks hard data about patient behavior and can't be considered conclusive, the results are consistent with studies about the effects of Massachusetts' 2007 health care reform law and a 2008 expansion of Medicaid in Oregon. Trevor Fetter, CEO of the for-profit hospital chain Tenet Healthcare, told CNBC this month that his company's facilities also are seeing an uptick in emergency room visits.

Another recent survey, however, reports the opposite is occurring in Arkansas this year. Forty-two hospitals in the state told a legislative committee that emergency department visits are down 2 percent so far this year, and that the number of emergency room visits by uninsured patients fell by 24 percent.

Likewise, nearly a quarter of the doctors who responded to the American College of Emergency Physicians survey observed fewer visits to their facilities, and more than one-quarter report no change, Parker said. Emergency departments seeing a smaller number of patients may be those doing a better job educating individuals about the availability of non-emergency care at other settings, such as urgent care clinics, she said.

The information released by American College of Emergency Physicians is the latest indicator of how the Affordable Care Act's coverage expansion is affecting patients and the health care industry.

Gallup and other organizations have reported reductions in the uninsured rate, although the extent of the decline greatly varies in those surveys and estimates. The Department of Commerce Bureau of Economic Analysis issued a preliminary finding last month that national health care spending has been growing more quickly since late 2013, apparently spurred by more people having health coverage and by consumers who had postponed medical care during and after the Great Recession. A Harvard University study published this month concluded the Massachusetts health reform law saved lives by covering the uninsured also sparked debate about the cost of expanding coverage.

Obamacare Could Save A Bunch Of Lives: Harvard Study

Jeffrey Young   |   May 5, 2014    5:01 PM ET

Fewer people died in Massachusetts after the state enacted its landmark legislation to cover the uninsured, according to a new Harvard University study that could have implications for the effects of Obamacare.

A Harvard team compared the mortality rates in Massachusetts before and after then-Gov. Mitt Romney (R) signed the health care reform bill into law in 2006 with the mortality rates in similar counties in other states during the same time periods. Based on their calculations, the mortality rate declined 2.9 percent overall among adults 20 to 64 years old after the law went into effect -- which translates into 8.2 fewer deaths per 100,000 people. So-called Romneycare served as a model for President Barack Obama's Affordable Care Act.

The analysis, which was published by the Annals of Internal Medicine Monday, is the latest attempt by researchers to prove the seemingly obvious relationship between health coverage and the access to medical care it brings with improved health and longer lives. In spite of this intuitive connection, previous research has produced inconclusive results and inflamed scientific and political controversy about whether being uninsured consigns people to poorer health and shorter lives.

Researchers led by physician and economist Benjamin Sommers of the Harvard School of Public Health didn't attempt to provide a definitive answer to these larger questions. However, they did conclude that the lower mortality rate they observed appears to be real, even if its national implications are uncertain amid the reduction in the number of uninsured people seemingly brought about by Obamacare.

"We find a significant reduction in mortality among nonelderly adults in Massachusetts since its 2006 reform relative to a control group of similar counties in states without such reforms. Although this analysis cannot demonstrate causality, the results offer suggestive evidence that the Affordable Care Act -- modeled after the Massachusetts law -- may impact not only coverage and access but also mortality," the report says.

"The extent to which our results generalize to the United States as a whole is therefore unclear, which underscores the need to monitor closely the Affordable Care Act’s effect on coverage, access, and population health across all states," Sommers and his co-authors wrote.

The researchers emphasized that their findings cannot prove that expanding health insurance coverage led directly to lower mortality, and noted that they did not have access to information about specific, individual cases. Researchers used data in Massachusetts and elsewhere in the county from the federal Centers for Disease Control and Prevention and the U.S. Census Bureau to create their comparisons.

The effects of expanding coverage in Massachusetts appear more significant when narrowed down to health problems that can be treated or prevented when individuals have access to medical services. The researchers found the mortality rate for people with these "causes amenable to health care" -- including issues like cancer, infections and cardiovascular disease -- decreased by 4.5 percent in Massachusetts after Romneycare when compared to counties with similar populations. And the connection between expanded coverage was even stronger among people who live in counties with lower income and higher rates of uninsurance, the report says.

If the results of the Harvard analysis are correct and can be applied nationwide, the impact of Obamacare would be significant. According to the Congressional Budget Office, the Affordable Care Act will reduce the number of uninsured people by 12 million this year and by 26 million as of 2017.

Past research attempting to measure the effect of health coverage on health and mortality has produced mixed results. In 2002, the prestigious Institute of Medicine issued research concluding that 18,000 people died in 2000 because they had no health insurance. Six years later, an attorney at the Urban Institute, Stan Dorn, duplicated the IoM study with new data and reported that 22,000 people die each year because they have no health insurance.

But in 2009, political scientist Richard Kronick, a former adviser to President Bill Clinton's administration who was then employed by the University of California at San Diego, reexamined the Institute of Medicine research. Kronick determined that when underlying health factors of the population were considered, no connection could be proven between health coverage and lower mortality. Kronick currently serves in the Obama administration as director of the Agency for Healthcare Research and Quality.

Results of the Oregon Health Study, a major project attempting to measure the effects of health coverage among individuals who won a lottery to sign up for Medicaid in the Beaver State, have also fueled debate about whether providing insurance benefits improves health and prolongs lives. In 2012, researchers revealed that new Medicaid enrollees reported they were in better health than those who lost the Medicaid lottery. But last year, another Oregon Health Study publication didn't find significant improvements in blood pressure and cholesterol among these Medicaid beneficiaries compared to those who couldn't join the program, although those on Medicaid showed improved mental health.

Harvard's Sommers, the author of the new study looking at Massachusetts, serves as an adviser to the U.S. Department of Health and Human Services. The report states that the study's conclusions do not represent the views of the Cabinet agency, and Sommers and his colleagues received no outside funding for their work.

More Than 8 Million Have Signed Up For Obamacare, In Latest Tally

Jeffrey Young   |   May 1, 2014    2:17 PM ET

Over 8 million individuals signed up for health insurance via the Obamacare exchanges through April 19, according to an official report from the Department of Health and Human Services that confirms an announcement made by President Barack Obama last month.

During the six-plus months of the first open enrollment period for these marketplaces created by the Affordable Care Act, 8.02 million people chose a health plan. Sign-ups surged during March and April, when 3.8 million signed up for private coverage through the exchanges, according to the department's report. That total represents 47 percent of all enrollments. Eighty-five percent of those customers received financial assistance, the report said.

The 8 million total is subject to change in the final accounting, but nevertheless represents a notable rebound from the disastrous October launch of, the website for exchanges in more than 30 states, and early troubles for many state-run marketplaces. On Oct. 1, just six people were able to enroll via the federal exchange site, and only 106,000 had signed up nationwide by the end of the month. The tally is also 1 million more than the highest total projected by the Congressional Budget Office.

obamacare enrollment report

This chart shows the increase in sign-ups via the marketplaces. FFM stands for the federally facilitated marketplace, and SBM are state-based marketplaces.

"Because of the Affordable Care Act, more than 8 million Americans now have the peace of mind of knowing their coverage can't be taken away if they get sick and won't run out just when they need it the most," Health and Human Services Secretary Kathleen Sebelius said during a conference call with reporters Thursday.

The March and April surge also boosted the share of health insurance exchange customers under the age of 35, a critical metric for the stability of the new state-based markets. Younger customers are considered less costly to insure, so a significant share of these customers -- who tend to use fewer health care services -- is a key counterweight to the costs of covering older, sicker customers.

By the end of the sign-up period, 28 percent of enrollees were aged 18 to 34, and 34 percent were under 35, including children. This share fell short of the White House's goal of 39 percent young adults, but the Health and Human Services report shows that 1.1 million younger consumers flooded the exchanges near the nominal March 31 deadline, doubling their participation in the exchanges from the first five months of sign-ups.

obamacare enrollment report

Although enrollments of young adults came in below the Obama administration's target, the prices on the health insurance exchanges shouldn't be markedly higher next year, Michael Hash, director of the HHS Office of Health Reform, said on the press call.

"We believe, based on the data that we've seen and independent data that is out there, that premiums will be stable and that the risk pool is sufficiently large and varied to support that kind of pricing in every state," he said. Mechanisms built into the Affordable Care Act to compensate insurance companies with sicker-than-average customers will help keep prices from spiking, he said.

This assessment mostly aligns with guidance from health insurance companies, which also stress that prices for next year will vary geographically to a significant degree. Health insurers already are at work trying to project next year's prices based on meager data from their new customers.

HHS did not provide information on how many of the 8 million enrollees have paid their first month's premium and actually activated their health insurance coverage. It won't have that information until later this year, Julie Bataille, a spokeswoman for the Centers for Medicare and Medicaid Services, said during the conference call. The HHS report cites anecdotal accounts from major insurers that have reported 80 percent to 90 percent of customers paid up. Those disclosures are at odds with a House Republican report published Wednesday claiming only 67 percent of enrollees from the federal exchanges had paid by April 15, though that date precedes when bills are due for most of the final weeks' sign-ups.

Likewise, the department did not offer data to indicate what proportion of the 8 million private plan enrollees were previously uninsured, but it noted outside analyses from the Congressional Budget Office and others indicating millions have gained coverage since last year. The HHS report said that 87 percent of the 5.2 million exchange users who applied for financial assistance reported being uninsured before, but officials on the conference call stressed that figure is subject to significant uncertainty.

The national enrollment figures will shift over the remainder of the year for a variety of reasons. Individuals who never pay a premium or allow their coverage to lapse later will reduce the total. The HHS report also doesn't include enrollments still being processed from states that extended the final deadlines further, including Hawaii, Oregon and the District of Columbia, which were still accepting customers through Wednesday. And individuals who experience a "qualifying life event" during the year, such as getting married or moving to a new state, can access the exchanges before the next enrollment period, which begins Nov. 15.

The federal government's report also doesn't include any of the millions of people who purchased an Obamacare-compliant health insurance policy directly from an insurer or broker. Even though these so-called off-exchange purchases aren't tracked by the federal government, those customers are part of the same risk pool as those who used the marketplaces, so their medical bills will be part of the equation used to set next year's prices.

In addition to the 8 million private health insurance enrollees from the exchanges, the department reported that 6.7 million individuals were determined eligible for Medicaid or the Children's Health Insurance Program, a tally that does not include anyone who signed up for those programs through state agencies. Since October, 4.8 million people in 47 states have joined these programs, according to a separate report issued by the Centers for Medicare and Medicaid Services Thursday. The Medicaid enrollment total is depressed because 24 states declined to accept federal funding to expand the program to more poor residents.

Your Guide To The Latest Freakout Over Health Care Spending

Jeffrey Young   |   April 30, 2014    1:29 PM ET

Health care spending appears to be on the rise after several years of historically low growth, provoking a minor freakout about whether the bad old days are back and whether Obamacare is ruining everything.

The latest data point being used to declare the Affordable Care Act a failure and get everyone all worked up is an advance estimate from the Department of Commerce's Bureau of Economic Analysis, which says health care spending increased 9.9 percent during the first quarter of this year after growing 5.6 percent in the last three months of 2013.

Those are big jumps! And it's especially striking considering national health spending rose just 3.7 percent to $2.79 trillion in 2012, the most recent year analyzed by the semi-official arbiter of these things, the Office of the Actuary at the Centers for Medicare and Medicaid Services. In fact, as Business Insider noted, the 9.9 percent spike is the largest three-month increase since 1980.

Who could have predicted that a recovering economy, higher incomes and a rise in the number of people with health coverage brought about by Obamacare would increase how much Americans are spending on medical care?

Well, pretty much anyone. And they did. Here's the Medicare and Medicaid actuaries in January, illustrating that spending would spike this year after several years of low growth, after which the rate of increase goes back down closer to historical levels.

health care spending
Note: ACA refers to the Affordable Care Act. SGR refers to the system that determines how much Medicare pays physicians. The Office of the Actuary assumed Congress would prevent scheduled cuts to doctors' pay, including a 24.7 percent reduction set to take effect Jan. 1., which it did.
Source: Health Affairs

The Congressional Budget Office expects federal health care spending to follow a similar trajectory, according to a report issued this month.

health care spending
Source: Congressional Budget Office

So what happened from January through March? The crazy-high prices Americans pay for health care didn't change much. Mainly, it seems that more people went to the doctor. Here's health care expert Larry Levitt, the senior vice president for special initiatives at the Henry J. Kaiser Family Foundation, to explain:

In other words, when people are broke or feel like they're broke, as many Americans did during the Great Recession and the lagging recovery, they spend less money on things they believe they can do without (or simply cannot afford). When people feel less broke, they start spending money on those things again. Likewise, people without health insurance don't get medical care they need, so when they get insurance, they might want to go see a medical professional.

Why should anyone even care? In one sense, greater spending on health care after the implementation of Obamacare suggests the law is succeeding at one of its goals: increasing access to medical care for the people who needed it. Extending coverage to tens of millions of people will increase health care spending by one-tenth of one percentage point each year over a decade, the Medicare and Medicaid actuaries projected in 2012.

But as with anything else, spending more money on health care means we have less money to spend on other things, and that applies to households, businesses and the government (which pays the bills for tens of millions of people on Medicare, Medicaid, subsidized private insurance and other programs).

Over the last several decades, health care has eaten up a greater share of our gross domestic product.

health care spending
Source: Health Affairs

That suddenly changed from 2010 through 2012, when national health spending increased at a slower rate than the economy for the first time since 1997. However, no one expected that slow-down to last. Overall spending and health care's share of GDP was expected to tick back up. Here's another illustration from the federal actuaries.

health care spending
Source: Health Affairs

These are all just projections and estimates, so reality could turn out to be very different, in either direction. Adding millions of people to the coverage rolls via private insurance or Medicaid, as the ACA appears to be doing, could boost spending by more than expected. Or the law's cost-saving mechanisms, which range from raw cuts to Medicare fees for health care providers to experiments designed to link payments to better-quality health care, could be more effective than expected.

Because everything with the words "health care" in it have been intensely politicized since 2009 when Congress started writing what eventually became the Affordable Care Act, every number that comes out has a tendency to be overanalyzed, and people on the left and the right have a tendency to draw grand conclusions from what can be pretty meager, preliminary information.

Case in point: Obama himself. The White House has been promoting analyses, both its own and from outsiders, that gave more credit to Obamacare for the recent slowdown in health care spending than the Medicare and Medicaid actuaries or lots of other experts. Now that the trend may be reversing, it's giving critics of the law an opportunity to say, "I told you so!"

It's going to be long time before anyone gets to say that and be sure they're right.

The Biggest Reason People Didn't Sign Up For Obamacare

Jeffrey Young   |   April 29, 2014   12:01 PM ET

The top reason uninsured people didn't enroll in coverage under Obamacare this year is they still don't feel like they can afford health insurance, according to a new survey.

The findings in a report published by the Henry J. Kaiser Family Foundation Tuesday highlight the affordability gap facing some U.S. households, especially those with incomes near or above the income cutoff for tax credits that reduce premiums, or those who simply don't believe health insurance is a good value.

Thirty-six percent of people without health coverage reported they looked for health insurance during the enrollment period that nominally ended March 31, but found the available plans too expensive, according to the Kaiser Family Foundation survey. Just 7 percent said they preferred to pay a tax penalty under the law's individual mandate, rather than purchase an insurance policy. Others said they believed the mandate doesn't apply to them, didn't know about the mandate, or tried and failed to enroll.

obamacare affordable

Health insurance remains a costly product and the Affordable Care Act targets its financial assistance to low-income families. Tax credits to defray the cost of coverage aren't available to households that earn more than 400 percent of the federal poverty level, which is $45,960 for a single person. The law also provides subsidies to reduce out-of-pocket costs for those who earn up to 250 percent of poverty, or $28,725 for an individual.

The tax credits provided under the Affordable Care Act are pegged to the price of the second-cheapest "silver" level plan in a person's geographical area, and to household income. The subsidy gets smaller as income increases, so people who earn near 400 percent of poverty receive relatively little help paying for their coverage, and those who make just a little more pay full price.

The average national price for one of these benchmark silver plans is $808 a month for a household of two 40-year-olds with two minor children that earns over 400 percent of poverty, which is $94,200 for a family of four, according to a calculator on the Kaiser Family Foundation website. The same family making exactly 400 percent of poverty would be eligible for a tax credit worth $63 a month.

The vast majority of those enrolling in private insurance under Obamacare are getting help paying for their coverage. As of March 1, 83 percent of enrollees received tax credits for premiums, according to the Department of Health and Human Services.

The Kaiser Family Foundation report includes quotations from some of those surveyed that illustrate the point of view that health insurance is too costly. "What's out there now is just unaffordable," one respondent said. "Because I think food on the table is more important," wrote another. Coloring those views may be a general lack of awareness about the availability of the tax credits, previous surveys have shown.

Although not addressed in the Kaiser Family Foundation poll, the largest affordability gap in health coverage is found in 24 states that didn't adopt the Affordable Care Act's expansion of Medicaid to more poor people after the Supreme Court made it optional for states. Those earning up to 133 percent of poverty, or $15,282 for a single person, were supposed to have access to Medicaid, while tax credits are reserved for those who earn at least poverty wages, which amounts to $11,490 for an individual. That means the poorest residents of those 24 states aren't eligible for any help, so millions are expected to remain uninsured.

The Kaiser Foundation Family poll also shows a majority of Americans continue to disapprove of the Affordable Care Act, with 46 percent having an unfavorable view, compared with 38 percent holding a favorable opinion. These attitudes are closely tied to partisan affiliation, with Republicans being much more likely to disapprove and Democrats more likely to approve. A majority, however, wants Congress to improve the law, compared with more than one-third who would prefer it to be repealed and replaced with an alternative.

obamacare affordable

Despite President Barack Obama trumpeting the news this month that private insurance enrollments via the Obamacare exchanges have exceeded 8 million -- or 1 million more than the highest projection from the Congressional Budget Office -- the public doesn't see it that way. Even though more than 40 percent were aware that signups had topped 8 million, nearly six out of 10 said enrollment came in below the federal government's expectation.

obamacare affordable

Obamacare Sign-Ups Hit 8 Million In Remarkable Turnaround

Jeffrey Young   |   April 17, 2014    3:54 PM ET

In a remarkable rebound from the botched rollout of Obamacare, 8 million people have signed up for private health insurance via the exchanges created by the Affordable Care Act since October, President Barack Obama announced during a press briefing at the White House Thursday.

March and April saw an uptick in the share of young people signing up for private plans using the exchanges. These people, who are presumably healthier, are needed to balance out the medical costs of older, sicker consumers. About 35 percent of people who signed up throughout the open enrollment period were under 35 years old, including children, Obama said. Twenty-eight percent were between the ages of 18 and 34, according to a White House fact sheet.

The official six-month enrollment period ended March 31, but the federal government and most states accommodated people trying to complete applications in April amid a last-minute surge for subsidized private coverage and Medicaid benefits.

"This law is working," Obama said. "This law won't solve all the problems in our health care system. We know we've got more work to do, but we now know for a fact that repealing the Affordable Care Act would increase the deficit, raise premiums for millions of Americans, and take insurance away from millions more."

Obama urged Republicans, who remain almost universally opposed to the health care law, to move on. "I find it strange that the Republican position on this law is still stuck in the same place that is has always been. They still can't bring themselves to admit that the Affordable Care Act is working," he said.

With the congressional GOP continuing its nationwide anti-Obamacare campaign heading into this fall's congressional elections, Obama's exhortations are in vain. “The president may want to silence any further debate about Obamacare, but in doing so he betrays a lack of confidence in his own policies and scant regard for those most affected by the law,” Senate Minority Leader Mitch McConnell (R-Ky.) said in a written statement.

Nevertheless, the inaugural Obamacare sign-up period managed to exceed expectations in the end, despite the disastrous rollout of and troubles with state-run exchanges in Oregon, Maryland and elsewhere. The Congressional Budget Office originally predicted that 7 million people would enroll in private coverage via the exchanges, and later downgraded it to 6 million to reflect the troubled enrollment websites.

On Oct. 1, only 6 people were able to enroll using the federally run health insurance exchanges, and just 106,000 enrolled nationwide in all of October.

By contrast, 3.7 million people have signed up since March 1, reflecting a massive influx of new customers into the system as the March 31 deadline to get private coverage -- and avoid paying tax penalties for violating the law's individual mandate -- loomed. The Obama administration and most states permitted enrollments to continue into April for those who had started applications or whose applications were snarled by technical problems.

The share of young adults who signed up over the six-plus months of enrollment represents an increase from the first half of the sign-up period, when less than one-fourth of private plan customers were younger than 35. The White House originally hoped that around 40 percent of private insurance customers would be younger, and presumably healthier. The proportion of younger customers who signed up this year is nearly identical to the first year of Massachusetts' health care reform program in 2007, which served as a model for the Affordable Care Act.

The ratio of young to old -- being used as an imperfect proxy for the ratio of sick to healthy -- will help determine premiums for plans sold on the exchanges next year. Although health insurance companies like WellPoint already are speculating about rate hikes that exceed 10 percent, price increases on that scale may not be in the offing, and other insurers are more bullish on Obamacare.

A fellow at the Society of Actuaries who analyzes insurance, Dave Axene, predicted to USA Today that average premiums will increase 6 percent to 8.5 percent next year, compared to 7 percent to 10 percent in previous years. Rate increases will vary by state and locality, as well.

The Obama administration hasn't yet released a breakdown of the enrollment figures that would allow for a full analysis of the first year of sign-ups through the exchange marketplaces.

The 8 million figure touted by the president Thursday doesn't include what likely is millions of consumers who purchased plans directly from health insurance companies or through a private agent or broker.

Those policyholders are as important to the insurance systems in each state as those who signed up via an exchange because their medical costs will be pooled together, which will determine how much premiums will rise next year. According to a Gallup poll, this segment of the market disproportionately avoided the exchanges and obtained coverage directly from an insurer, a finding supported by previous data released by eHealth, an online insurance broker.

The latest numbers also don't fully account for the effects of the Affordable Care Act's expansion of Medicaid to more low-income people, which 26 states and the District of Columbia adopted. Between October and February, total enrollment in those programs increased by 3 million people, according to the White House. The number may increase, however, as federal and state authorities sort through incomplete and stalled enrollments in these programs.

Moreover, crucial information remains unavailable, such as what proportion of customers secured their coverage by paying premiums to their health insurance providers, and how many of the private plan and Medicaid enrollees previously were uninsured.

Polling, estimates from outside groups, and leading indicators from sources beyond the Obama administration hint at the answers to some of these vital questions.

Survey data from Gallup and others indicates the share of Americans without health insurance has declined since the exchanges opened for business in October. According to Gallup, the uninsured rate went down from 18 percent in the fourth quarter of last year to 15.6 percent in the first three months of 2014. The rate declined further in states that adopted the Medicaid expansion, created their own health insurance exchanges, or both, Gallup reported.

The Congressional Budget Office expects the number of uninsured to decline by 12 million during 2014, according to a report issued this week. The CBO maintains that 6 million, not 8 million, people will secure private coverage via a health insurance exchange, largely because some customers won't pay their first premium or will let coverage lapse during the year, and because some will cycle out of the exchanges into other forms of insurance. The CBO also reduced its estimates for the cost of the Affordable Care Act.

Most, but not all, of those who enrolled using a health insurance exchange seem to have paid premiums, with estimates cited by former Health and Human Services Secretary Kathleen Sebelius, health insurance companies and some state officials at 80 percent and higher. That share may rise in the coming weeks as bills become due for those who signed up near or after the March 31 deadline for coverage that begins May 1.

The enrollment numbers will continue to be fluid throughout the year. People who experience "qualifying life events," such as getting married or moving to a new state, can shop for health insurance on the exchanges year-round, and enrollment in Medicaid and the Children's Health Insurance Program can be done at any time. The next open enrollment period begins Nov. 15, 2014, and ends Feb. 15, 2015.

CORRECTION: An earlier version of this article incorrectly attributed a projection about future health insurance premium increases to the Society of Actuaries. The analysis actually from one fellow at the society, Dave Axene.

Americans Pay Way More For This Than People In Other Countries

Jeffrey Young   |   April 17, 2014    8:00 AM ET

As anyone who's ever paid a health insurance premium or a hospital bill knows, medical care is expensive. What Americans may not know is that residents of other countries don't pay nearly as much for the same things.

The latest data from the International Federation of Health Plans, an industry group representing health insurers from 28 countries including the United States, once again illustrates that American patients pay the highest prices in the world for a variety of prescription drugs and common procedures like childbirth and hospital stays.

And despite the persistent claims by nearly anyone holding or seeking public office in the U.S. that America has the best health care system in the world, there's scant evidence that we're getting higher-quality medical treatment or enjoying healthier lives than our counterparts abroad. What's more, the U.S. still leaves tens of millions of its own citizens without health coverage, and will continue to do so even a decade into the implementation of Obamacare.

To illustrate just how much more Americans pay for health care, the International Federation of Health Plans compared the prices for common medicines and services around the world in a report released on Thursday.

A prescription for Nexium, a popular remedy for acid reflux disease and other stomach ailments, costs $215 on average in the U.S., which is more than 3.5 times the cost in Switzerland, the second-most-expensive nation for Nexium prescriptions, and almost 10 times more than what Dutch people pay.

health care costs

Prescription drugs are particularly expensive in the U.S. relative to elsewhere in large part because most other countries set prices for medicines through their universal health care programs, which the U.S. doesn't have. This can hit hardest for people, even those with health insurance, when they need the latest medicines to treat serious diseases.

Look at the price differences in the U.S. for these big-ticket prescription drugs, which are about twice as expensive in America as in the next-highest country and much more so than in the lowest-cost nations.

health care costs

health care costs

health care costs

Sticker shock isn't just due at the pharmacy counter. U.S. hospitals, which took in the largest share of the $2.79 trillion Americans spent on health care in 2012, also charge more for many procedures than hospitals overseas, the report shows. The average daily cost of just being in a hospital is almost twice as expensive in the United States as it is in New Zealand, and almost 10 times as costly as stay in a Spanish hospital.

health care costs

Likewise, the average price for heart bypass surgery in the U.S. is quite a bit higher than what the rest of the world pays, especially people in the Netherlands, who get off comparatively cheaply.

health care costs

Being born in the United States has loads of advantages, but the cost of doing so isn't one of them, the report shows. A normal delivery is more expensive in the U.S. than in any of the other countries studied, and a Cesarean section is even costlier.

health care costs

health care costs

Read the entire International Federation of Health Plans report below:

International Federation of Health Plans 2013 Comparative Price Report

CORRECTION:An earlier version of this story incorrectly stated that the drug Nexium is available over the counter.