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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 HealthCare.gov, 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 HealthCare.gov 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.

5 Things The Obamacare Enrollment Numbers Won't Tell You

Jeffrey Young   |   April 2, 2014   10:19 AM ET

So is Obamacare a success? Has President Barack Obama's signature health reform law revolutionized our broken health care system?

More than 7 million people used the Affordable Care Act's health insurance exchanges to buy private coverage through Monday, the end of the first sign-up period. Certainly the Obama administration is touting this as a huge victory.

"In these first six months, we've taken a big step forward," Obama said in the White House Rose Garden Tuesday. "The Affordable Care Act hasn't completely fixed our long-broken health care system, but this law has made our health care system a lot better."

Yet, there's still much we don't know about what the law has accomplished. Until we have answers to these five questions, it's still early to assess the full impact of Obamacare.

1. How many people really signed up for health insurance?

The 7.1 million figure the White House cited may be too low. The raw number doesn't include all of the most recent updates from 14 states and the District of Columbia, which have their own websites and saw a flurry of activity leading up to the open enrollment deadline. Nor does it include the applications still pending at the exchanges. Also missing: those who will sign up throughout the year when they become eligible because of a major life change, like marriage or moving to another state.

People who bought Obamacare-compliant insurance directly from a carrier aren't counted either.

Confusingly, the 7 million number may also be too high: We don't know how many of those people took the crucial final step and actually paid their first month's insurance premium to lock in coverage. Based on anecdotal reports from individual insurance companies, Health and Human Services Secretary Kathleen Sebelius said 80 percent to 90 percent of consumers thus far had paid up. There also will surely be people who let their policies lapse during the rest of the year.

2. How many uninsured people gained coverage?

It's logical to assume that the Affordable Care Act reduced the ranks of the uninsured. There's a legal mandate to most people get covered or face tax penalties, and the law expands Medicaid and offers generous subsidies to low-income households. But logic isn't the same as data, and the Census survey many consider the gold standard won't even come out until September 2015.

Although the federal government can't or won't say how many enrollees from HealthCare.gov and state exchanges used to be uninsured, some states are reporting those figures. In Kentucky, 270,000 of the 370,000 people who enrolled via Kynect, the state's exchange, were uninsured -- meaning 43 percent of the Kentuckians without coverage are now enrolled. Likewise, more 70 percent of the 865,000 enrollees on New York State of Health previously were uninsured.

And an unknown number of uninsured people bought private insurance outside the exchanges. From Jan. 1 to mid-March, for example, 51 percent of those buying unsubsidized coverage via online broker eHealth reported they were uninsured. In addition, as many as 3 million young adults are now covered because of the 2010 Obamacare rule letting them remain on their parents' plans until they turn 26, according to the Department of Health and Human Services.

There are signs that the impact is real. According to unpublished survey data from the Rand Corp. obtained by the Los Angeles Times, the rate of uninsured working adults fell from 20.9 percent last fall to 16.6 percent on March 22, which the newspaper calculates as 9.5 million people gaining coverage via Medicaid and private insurance. Gallup also has reported a decline in the uninsured rate.

There were 48 million uninsured people in America in 2012, according to the most recent Census report. The Congressional Budget Office projects the share of legal U.S. residents without health coverage will decline from 14 percent this year to 8 percent by 2024.

But even these survey data are open to some degree of doubt. People transition on and off insurance for a variety of reasons that predate Obamacare, like getting or losing a job and its health benefits, so it's difficult to tease what's happening because of the law.

And despite persistent claims from Republican Obamacare critics, the several million people whose policies got canceled last year because they didn't meet the law's standards aren't now uninsured. Nearly all replaced that coverage with other plans, according to the Rand Corp.

3. Did enough healthy, young people get private insurance to balance out the costs of sicker people?

As of March 1, about one-quarter of nationwide private insurance enrollees were between the ages of 18 and 34, according to the Department of Health and Human Services. This matters because if only those who are heavy users of health care get covered, their medical bills will drive up future premiums. The White House originally hoped that 40 percent of those who bought the insurance would be young people, using age as an imperfect proxy for health.

The final share may or may not tick up much higher than 25 percent, but several health insurance companies recently have said their new customers were trending younger near the end of the enrollment period. EHealth reported the share of customers aged 18-34 rose from 39 percent during the first half to 45 percent during the second half.

And the impact on next year's premiums will be mitigated by Affordable Care Act funding mechanisms designed to limit the losses for insurers that attract a larger-than-normal share of sick customers.

4. How many people enrolled in Medicaid coverage?

This one should be easy to answer, but it isn't.

According to the March HHS report, 4.4 million people were deemed eligible for Medicaid or the Children's Health Insurance Program via the health insurance exchanges, including individuals who qualified because the law expanded Medicaid and those who were entitled under the old rules but weren't signed up. That figure doesn't count anyone who signed up for the programs directly through a state agency.

A February report from the Centers for Medicare and Medicaid Services revealing that state agencies deemed 8.9 million people eligible for these programs also is problematic. That figure includes a mix of people gaining access because of Obamacare, people who previously were eligible but not enrolled and people who are simply renewing their existing benefits.

Finally, Medicaid and CHIP enrollment are open year-round, so more people will sign up while others drop out over the remainder of 2014. Twenty-four states haven't adopted Obamacare's Medicaid expansion, however, which will suppress enrollment.

5. How much more is health insurance going to cost next year?

Health insurance companies like WellPoint already are making noises about "double digit" premium hikes for 2015. That reflects their concern that the new customers they gained via the exchanges are sicker than the customers they had last year, since the law now requires them to accept anyone regardless of pre-existing conditions.

There's virtually no doubt that health insurance rates will rise on average next year, because they always do. The questions are: How much will they rise, for whom and where?

The overall enrollment figures and the proportion of healthy and sick aren't what matter here. Under the Affordable Care Act, every state is its own health insurance risk pool, and sometimes it goes down to the county and local levels.

That means insurance companies will base their rates on the medical expenses they incur in each geographic location, not nationwide. The proportion of private insurance exchange customers under 35 years old varies a lot from state to state, as does the health of those populations. So consumers in some regions may get hit with big rate hikes next year, while consumers in others may see much smaller increases, or even decreases.

Obamacare Deadline Safety Valve Comes In Handy As Website Buckles

Jeffrey Young   |   March 31, 2014   10:12 PM ET

The latest tweak to the Obamacare deadline came in handy Monday when HealthCare.gov buckled during the rush by millions to sign up for health insurance by the original midnight cutoff.

Americans seeking to obtain health coverage at the last minute, and avoid tax penalties for remaining uninsured, flooded exchange websites and telephone lines Monday, with a record 3 million visits to Healthcare.gov and 1 million phone calls as of 8 p.m., according to the Department of Health and Human Services.

Federal officials said last week that people who couldn't enroll because of problems with HealthCare.gov would have more time to sign up. Some state-run health insurance exchanges offered similar flexibility for people who started applications prior to the March 31 deadline.

"There will be an opportunity for those who have initiated the process but aren’t able to finish it by midnight tonight to ensure that they get signed up for health insurance," White House press secretary Jay Carney said Monday. "If they start, they’ll be able to finish."

The intense interest in getting covered before the midnight deadline exposed the vulnerability of HealthCare.gov and exchange websites like Covered California and Maryland Health Connection throughout the day. HealthCare.gov went down early Monday, its account-creation system failed during the afternoon and a "virtual waiting room" deployed several times when users stretched the website's capacity.

Although the President Barack Obama's administration and authorities in states such as California and Connecticut didn't technically extend the deadline for the end of the six-month sign-up period for private insurance via the exchanges, would-be enrollees snarled by technical problems can continue to enroll over the coming weeks, the administration said Wednesday.

Glitches on Monday were a far cry from the disaster that occured from when HealthCare.gov launched Oct. 1 through late November, and multiple readers told The Huffington Post that they'd successfully signed up. Others, however, were left without the coverage they sought.

Kelly O'Donnell, 35, of Greensboro, N.C., has been struggling to get an application filed for nearly a week and had no more luck Monday than before. When O'Donnell visited HealthCare.gov Monday, she was greeted by the virtual waiting room and opted to enter her email address to get notified when the website was ready to take on more users. But when the message arrived, the website still didn't work.

"I have used three different browsers and every time I am able to login but it takes me to a blank page," O'Donnell wrote in an email to HuffPost. Initially, O'Donnell worried she'd be subject to tax penalties for violating the Affordable Care Act's individual mandate that most Americans obtain health coverage, but now will give it another shot after the deadline.

"We're trying to start a family this year, so I definitely need health insurance," O'Donnell said by telephone.

The Obama administration hasn't said when the "special enrollment period" will end for people in the 36 states using the federal health insurance exchanges. State-run exchange policies vary and the extra time will extend as late as April 30 in Oregon. Health insurance exchanges like New York State of Health, Vermont Health Connect, Maryland Health Connection, AccessHealth CT in Connecticut, and Covered California took to social media to promote the extra time for those who couldn't complete their applications by midnight.

In spite of the problems, others reported the website and enrollment process functioned smoothly.

Oklahoma City resident Louis Dollarhide, 62, spent 45 minutes on HealthCare.gov Monday morning and encountered no difficulties, he told HuffPost in a telephone interview. "It just clicks right through. I thought it was very straightforward, and I'm not a tech geek at all," he said.

Dollarhide has been uninsured since his previous employer closed four years ago. Now self-employed, he has been unable to afford new coverage because he has a condition called hereditary hemochromatosis that causes high levels of iron in the blood. "It's very easy to manage but it freaks these insurance companies out."

"I had a pre-existing condition, and so when I would get quotes for insurance, it was just astronomical. And I've always been in good health, even though I have this strange deal. It never causes any problems," Dollarhide said. An insurer once quoted him a $800 monthly premium, which was more than he could pay, he said. Health insurance companies can neither turn down people with pre-existing conditions nor charge them higher rates than healthy people under the Affordable Care Act.

Using HealthCare.gov, Dollarhide signed up for a "silver" plan, the second-lowest level of coverage available on the exchanges, for $289 a month, including tax credits that reduced his costs. Asked why he waited until the last day of the enrollment period to shop, Dollarhide replied: "Laziness and procrastination."

Obamacare Enrollment Surging With Last-Minute Sign-Ups

Jeffrey Young   |   March 31, 2014   12:27 PM ET

On the last day to sign up for Obamacare, evidence appears to be mounting that what started as a disaster may turn out a success.

Monday is the deadline to enroll in health insurance for 2014 via the health insurance exchanges created by President Barack Obama's Affordable Care Act, and it's clear that many waited until the last minute. The looming deadline and fear of the penalty for not getting covered has driven millions of people to the exchange websites, enrollment events and health insurance companies over the past few days.

HealthCare.gov and some state-run health insurance exchanges suffered software glitches and buckled under heavy demand Monday.

The final rush could push the total number of private insurance enrollments well past the 6 million figure touted by the Obama administration last week. Obamacare sign-ups may wind up closer to the 7 million originally predicted for the first year.

"It's kind of the lead-up to Christmas right now, and all the last-minute shoppers are out," said Brian Lobley, senior vice president for marketing and consumer business at Independence Blue Cross in Philadelphia.

The company, which serves the city and its surrounding suburbs, signed up 28,000 customers in less than three weeks in March. It signed up 90,000 in the five months prior.

Edward Patton, 43, became one of those last-minute sign-ups Saturday afternoon. Patton, who works at a gas station, stumbled onto an enrollment event at a ShopRite grocery store near his home in Philadelphia.

"I just came to pick up a couple things," said Patton, who has never had health coverage before. He also picked up a "silver" level health insurance plan, the second-lowest level of coverage available on the exchanges, for $77.49 a month, including tax credits, which was far less than he expected to pay, he said. "This is good, just in case, because I barely get sick," he said.

obamacare deadline day
Paydon Miller of Enroll America, left, and enrollment counselor Francine Piesto at a ShopRite in Philadelphia Saturday.

Signing up the healthy and the young is critical to the health of the healthcare law. And based on anecdotal accounts from health insurance companies, the surge is also bringing along young adults in greater numbers.

"We're definitely seeing some younger consumers, as our average age of an applicant is going down," said Kurt Kossen, the vice president for retail marketing at Chicago-based Health Care Service Corp., which operates Blue Cross and Blue Shield companies in Illinois, Montana, New Mexico, Oklahoma and Texas. Online insurance broker eHealth reported a similar trend last week.

obamacare deadline day
Insurance agents working for Independence Blue Cross assist customers signing up for health coverage at the company's Philadelphia headquarters Saturday.

In order to make premiums affordable in future years, insurers need healthier people to offset the high medical costs of older, sicker people who now have guaranteed access to coverage. Adults 18 to 34 years old made up one-quarter of nationwide enrollments through March 1, according to the Department of Health and Human Services, a proportion lower than the roughly 40 percent the White House is seeking.

Not everyone is so pleased with their new health plans. Households with incomes above four times the poverty limit, or about $95,400 for a family of four, don't qualify for financial assistance and can face hundreds of dollars in premiums every month for even basic coverage. And many people who previously purchased their own coverage directly from insurance companies saw their policies canceled last year because they didn't meet ACA standards, and had to replace them with plans that are often costlier because the mandated benefits are more generous.

The vulnerability of Obama's signature domestic policy achievement was evident during the early hours of Monday morning, when HealthCare.gov went down due to what the White House described as a software error not related to traffic on the website. The outage echoed the technical failures that marred the debut of the health insurance exchanges on Oct. 1 and hampered the first two months of the six-month enrollment period.

HealthCare.gov also drew record demand Monday when 1.2 million users visited the website by noon Eastern Time. First-time users of the website weren't able to create accounts for about an hour Monday afternoon and administrators twice activated the site's "virtual waiting room" when the number of people trying to log in surpassed its capacity, which is estimated at 100,000 users at once. State-run exchange websites in places like California and Maryland also experienced some difficulties. Telephone call centers for the exchanges were swamped by consumers seeking help, as well.

Although Monday is the nominal deadline for anyone who doesn't have health coverage to get insured this year, enrollments will continue through the coming weeks, since the Obama administration and most state-run health insurance exchanges are leaving the systems open for those who already started their applications but have not completed them by the end of the day.

Consumers in states using federally managed exchanges via HealthCare.gov can self-attest that they began the process prior to the deadline to qualify for a so-called special enrollment period. Across the remaining states, the rules vary. For example, in Connecticut, Monday remains the hard deadline, while Oregon residents have until the end of April.

Those who don't get health benefits from their jobs or through a government program won't be able to purchase private health insurance until the next open enrollment period begins Nov. 15 for policies that will take effect on Jan. 1, 2015.

Most people who fail to enroll in coverage for this year will face tax penalties under the ACA's individual mandate. There are a slew of exemptions from the mandate, however, and the health insurance exchanges will remain open for people who experience "qualifying life events," such as moving to a new state or losing their current health insurance plan. In addition, individuals eligible for Medicaid and the Children's Health Insurance Program can enroll year-round.

Despite the apparent turnaround since the disastrous October launch of the exchanges, the future of Obamacare is uncertain. Comprehensive data on how many people fully enrolled by paying their insurance premiums and how many of the previously uninsured gained coverage because of the law won't be available for some time, nor will information about the medical costs of those who purchased private insurance via the exchange or directly from an insurer.

The process of preparing for the 2015 enrollment period will start almost immediately after the inaugural sign-up period ends, as health insurance companies must begin making projections about how much their new customers will cost them, and therefore how much to raise rates for next year. The federal government and states like Oregon and Maryland, which faced major technical problems, also must decide how to improve their performance so that next year's enrollment period goes more smoothly than this year's.

This post has been updated with information on traffic to Healthcare.gov on Monday afternoon.

What You Need To Know About Obamacare's Individual Mandate

Jeffrey Young   |   March 25, 2014    8:41 AM ET

The big Obamacare deadline looming on March 31 isn't just the last chance for most Americans to buy health insurance this year. It's also the last chance to avoid paying penalties under the Affordable Care Act's dreaded "individual mandate."

The individual mandate is one of the best-known but least-understood parts of President Barack Obama's signature health-care reform law. Here's how the mandate works, how much it costs to ignore the rule, and how you may be able to get out of it.

Who must have health insurance under Obamacare?

Practically everybody. But most Americans won't have to do anything on March 31. That's because about 80 percent of Americans already have health coverage -- through their jobs, a government program like Medicare or Medicaid, or directly from an insurance company. The small percentage of Americans who aren't insured risk having to pay a penalty under Obamacare. The complicated official name for this is the "individual shared responsibility payment." The IRS has more information, in case you thirst for still more complicated official language.

Who is exempt?

Many people are exempt from the mandate. Undocumented immigrants don't have to comply because they're not even allowed to use Obamacare's new insurance exchanges to buy coverage. Many Native Americans also don't have to comply, nor do those whose religious beliefs reject health insurance, people who don't make enough money to file federal income taxes, and people who can't find a health plan that costs less than 8 percent of their incomes. There's a full list here.

Then there's the "hardship exemption." The Obama administration is interpreting this part of the ACA very broadly, opening the door for lots and lots of people to potentially qualify.

There are 14 different categories of hardship exemption, including things like being homeless, experiencing a death in the family, and filing for bankruptcy. And the administration is letting anyone whose old insurance policy was canceled because it didn't meet Obamacare standards apply for an exemption. The vaguest exemption, and therefore potentially the most useful to people who don't want to get health coverage, is described as: "You experienced another hardship in obtaining health insurance." And for some of these 14 reasons, you're not even required to show documentation of your hardship.

What's the penalty for not having health insurance?

People who go without coverage for more than three months this year will owe the IRS money for each additional month they are uninsured when they file their federal income taxes next year. The minimum penalty is $95 for each adult in a household and $47.50 for each child younger than 18 years old, capped at $285 no matter how large a family is. There's also some wiggle room regarding the three-month grace period: Anyone who enrolls by the end of this month won't owe a penalty even though their benefits may not kick until May 1.

Most taxpayers subject to the penalty will owe more than that, though. Under the law, the amount is the higher of $95 or 1 percent of household income minus the first $10,150 for a single person or $20,300 for a married couple filing jointly. So a married couple with two minor children and $50,000 in taxable income would owe $297, according to a calculator created by the Tax Policy Center at the Brookings Institution.

But there's a limit to how much anyone would ever pay. The penalty is capped at the national average annual price for a "bronze" health insurance plan on the Obamacare exchanges, the lowest-level plan available to everyone. The IRS hasn't calculated what that amount is yet, but the Tax Policy Center estimates that it's $3,600 for a single person and $11,000 for a family of four.

The penalties start getting bigger next year and will be $695 or 2.5 percent of income by 2016. So being uninsured when you can afford coverage -- according to Obamacare, anyway -- will get expensive. While it's cheaper than health insurance, you don't get anything in return and are still responsible for paying your own medical bills.

How is the individual mandate enforced?

In a word? Lightly. The ACA doesn't let the IRS come after you if you don't pay the penalty. Failing to pay isn't a crime. The government can't garnish your wages or put liens on your property to collect the money. Basically, the only way the IRS can get the dough against your will is to deduct it from your tax refund.

What's more, the IRS really doesn't have any way of checking whether you're really insured if you say so when you file taxes.

Why are we doing all of this anyway again?

The theory behind the individual mandate is that the way to create an insurance market that lets people with pre-existing conditions get covered at reasonable prices is to make everyone participate.

Without some way to push healthy people into the insurance market, the fear is that it'll fall apart. Mostly sick people would get insurance, which would drive up prices, which would lead to healthier people deciding not to buy any, which would force insurers to raise rates to cover their expenses, which would lead to even more healthy people opting out. That cycle is called a "death spiral" in insurancespeak.

The individual mandate is not a popular policy at all for obvious reasons (Obama himself even used to oppose it). But the Supreme Court ruled two years ago that it's Constitutional, so we have to deal with it. Massachusetts has had an individual mandate since 2007, and it's worked out pretty well there.