Health Site’s Woes Could Dissuade Vital Enrollee: the Young and Healthy

Gabriella Demczuk/The New York Times

Organizing For Action workers in Arlington, Va., inform the public about the launch of Obamacare on Oct. 1.

WASHINGTON — Sean Jackson, like tens of thousands of other Americans, has had trouble signing up for medical coverage using the HealthCare.gov insurance marketplace, despite several attempts.

"I was able to create an account on Oct. 2, and I haven't been able to get into there since," said Mr. Jackson, a sports journalist living in Ohio, a note of annoyance in his voice. "I'll try at random times, like late at night or early in the morning. I sign in. It just goes to a blank screen."

The economists and policy wonks behind the Affordable Care Act worry that the technical problems bedeviling the federal portal could become much more than an inconvenience. If applicants like Mr. Jackson decide to put off or give up on buying coverage, rising prices and even a destabilized insurance market could result.

The enrollment of people like Mr. Jackson, who is 32, is vital for the health care law — and, for that matter, the entire health care system — to work. Younger people, who tend to have very low anticipated medical costs, are supposed to help pay for the medical costs of older or sicker enrollees. Without them, so-called risk pools in Ohio and other states might become too risky, forcing insurers to raise premiums. Those higher premiums could dissuade more of the young and healthy from signing up, forcing insurers to raise prices again.

Economists call the process "adverse selection" and warn that in its worst iteration it could lead to a "death spiral" of falling enrollment and climbing prices.

Economists and health analysts said the chances of such a spiral were slim in most states because Americans who go without insurance would face penalties, starting next year. But they said that the endemic problems with the Web site posed a serious question about the enrollment balance in many state plans.

"If there are significantly more of the older and higher-cost people purchasing coverage than are expected, that's going to have a significant impact on premiums for the following year," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a lobbying group for insurers covering 200 million Americans. He added, "It could ultimately destabilize the market."

The young and healthy have always been seen as crucial to making the health law work, and the Obama administration and many state governments have focused on getting them to sign up.

For the White House, that has meant using the demographic microtargeting techniques used during the 2008 and 2012 presidential campaigns to identify and reach young people in the hope that they would make up about 40 percent of new enrollees in the health exchanges. For Colorado, it has meant creating an advertisement showing "bros" drinking beer while celebrating insurance coverage. "Keg stands are crazy," the ad reads. "Not having health insurance is crazier."

But getting "young invincibles," as insurers sometimes call them, to sign up for insurance is an uphill climb. Even with the public campaigns, only about one in four 19- to 29-year-olds is even aware of the exchanges where they might buy affordable insurance, and the ignorance is especially acute among the uninsured, according to a survey this year by the Commonwealth Fund, a nonprofit research group.

"There's very low awareness among young adults," said Sara R. Collins, an economist with the Commonwealth Fund. "It's a concern in states that aren't actively promoting these exchanges. People might remain unaware," she said, referring to the 36 states that have opted to let the federal government run their exchanges for them. They include Texas and Mississippi, where public officials are campaigning against the health law.

That lack of awareness makes it all the more important that those who do know about HealthCare.gov — and try to purchase insurance there — are not dissuaded because of the glitches, the analysts said. Older and sicker Americans have a stronger incentive to keep trying to sign up despite the clunky site, they said.

Though economists, insurers and health analysts are concerned about the problems with HealthCare.gov, which the Obama administration has promised to fix by Nov. 30, they said it was too early to tell whether the problems would cause an underenrollment of the young and healthy.  Insurers would have a good sense of any problems by next spring, they said. 

No statistics are available on how many of them have signed up. States are providing no demographic details on enrollees. And the Obama administration has declined to say how many people have purchased insurance in the 36 states where it runs the exchanges.

Jonathan Gruber, an economist with the Massachusetts Institute of Technology who helped create the Affordable Care Act, said lessons could be drawn from Massachusetts, which in 2006 implemented a similar law to provide near-universal coverage in the state.

Many Massachusetts residents waited until just before the state law's tax penalty kicked in before signing up for insurance, he said. Just 123 people signed up for subsidized insurance in the first month of enrollment, and only about 2,000 in the second month.

Ms. Collins, of the Commonwealth Fund, also said the federal requirement to buy insurance might compel the young and healthy to sign up. "As people learn about the provisions, and become aware of them, enrollment increases," she said. "It may be that healthy people procrastinate longer than unhealthy people."

Gary Claxton, a policy expert with the Kaiser Family Foundation, noted that provisions in the law help ease the costs to insurers if the enrollment mix raises medical costs more than expected, so they might not increase premiums too sharply.

"If insurers are convinced the people that they've enrolled are going to continue to be sicker than expected, premiums will go up," he said. "But if they believe people who didn't enroll in the first year will show up in the second, it might not have that big an impact on premiums."

For now, the Obama administration is rushing to make signing up as smooth as possible to ensure that the young and healthy enroll. Mr. Jackson, of Ohio, intends to see his application through.

"At this point, I'm just printing it out and sending it in," he said, referring to one of the offline options for signing up. "I'll probably have it done by the end of the month."

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