The insurance marketplaces that form the centerpiece of President Obama's health care law are scheduled to open on Tuesday, a watershed moment for the Obama administration, but also a crucial turning point for millions of Americans who will finally get the chance to square the law's lofty ambitions with their own personal needs.
While some people desperate for coverage will need no persuading to sign up, for others the decision will amount to a series of complicated calculations that would challenge an accounting whiz, let alone an ordinary human: Are the new plans less expensive or more generous than existing ones? How do premiums and out-of-pocket costs compare? Are the networks of doctors and hospitals the most desirable? Who qualifies for how much of a subsidy, and what is the tax penalty for a miscalculation?
How millions of people answer these questions over the next six months will be vital to determining whether the Affordable Care Act lives up to its name and its ambitious goal of helping more people buy the coverage they need.
Much is at stake for insurers as well: they must attract enough healthy people to pay for the care of sicker patients and price their offerings to keep premiums low enough to be competitive but high enough to be sustainable.
Health insurance "is a very complex product," said Lynn Quincy, a senior health policy analyst for Consumers Union in Washington. "It is going to be more complex this time around because things are changing, and people are confused about the changes."
As the state insurance exchanges are set to open, we talked to people around the country who will be among the first to give them a test drive. For some, the law could provide welcome relief from mounting medical bills; for others, a break from rising premiums. Still others must decide whether insurance is right for them at all.
Michael Nagle for The New York Times
Mitchell McGovern works part time and has no health insurance.
Young and Healthy
Mitchell McGovern, 26, lives in Brooklyn and works as a part-time sales associate at a Crate and Barrel store in Manhattan. He earns about $15,000 a year and does not have health insurance of any kind.
A bout with pneumonia in January sent him to the doctor's office, which cost him $75, and $150 for medication. Mr. McGovern said he would love to buy health insurance — and he was mindful that the law requires him to do so — but only if it cost him less than $100 a month. "I live paycheck to paycheck," he explained.
Mr. McGovern is exactly the sort of person the Obama administration needs to enroll in the new insurance marketplaces if the federal health care law is to succeed — young, healthy people who until now have not been covered by insurance, either because they couldn't afford it or because it wasn't a priority. If a critical mass of these people doesn't enroll — the federal government hopes to sign up about 2.7 million of them — the premiums for plans offered on the exchanges could skyrocket and cause the market to fail as fewer and fewer people take part.
Mr. McGovern's current income will probably qualify him, just barely, for Medicaid in New York State. But for Mr. McGovern and others like him, predicting how much he will make even a few months from now is hard, and he may end up qualifying instead for tax-credit subsidies in the state marketplace. Mr. McGovern recently moved to New York from California and sees his job at Crate and Barrel as a foothold until he finds work that would offer more money and perhaps coverage paid largely by the employer.
His uncertain financial situation is typical of the population most likely to consider the insurance marketplaces, said Ceci Connolly, managing director of the Health Research Institute at PricewaterhouseCoopers. Only about 51 percent will have full-time jobs, with a median annual income of about $21,700, according to an analysis by her firm based on government data like the census. She said 38 percent of the people expected to enroll will end up shuttling several times between Medicaid and the marketplaces over the next four years.
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