Lee Nathans, like insurance brokers in many states, expects to be crazy busy for the next several weeks, fielding calls from "people who are not going to be happy."
Open enrollment for Affordable Care Act coverage started Nov. 1, and the approximately 10 million people who buy their own health insurance are only now getting a look at what's being offered. It's daunting.
"There will be a lot of people who will need to use a broker," said Nathans, of Columbus, Ohio.
The enrollment period is also shorter than in previous years, ending Dec. 15.
In many places, there are fewer health insurance carriers offering coverage -- and those that remain have sharply raised prices and changed their networks of doctors and hospitals.
More perplexing for people sifting through these options is the fact that this year there's less on-the-ground assistance to help decode those complexities because of Trump administration funding cuts.
All that means brokers are coping with what may be the most challenging sign-up period since the ACA marketplaces, also known as exchanges, debuted in 2014.
When the ACA became law, some thought the days of brokers were numbered.
The ACA's rules and online state and federal exchanges were supposed to make comparing plans and purchasing health insurance easier.
But for many consumers -- particularly those who have never bought insurance before -- having help is vital.
"Yes, health insurance is complicated," said Lisa Hamler-Fugitt, executive director for the Ohio Association of Foodbanks, which provided such help for the past four years through federal grant-funded navigator programs in the state. Navigators are trained individuals or groups that guide consumers and small businesses through the process, for free.
"(Customers) didn't turn to us just during open enrollment, but also when they had questions about how to use their plan, about deductibles and copayments."
This year is different.
The Trump administration, criticizing the navigator effort nationwide, slashed funding. The Ohio program learned it would get a 71 percent cut and reluctantly closed its doors for this enrollment season.
There were also cuts to other states, which varied, but averaged 40 percent nationally. In Tennessee, for example, navigator funding was reduced by 16 percent, while in Indiana it fell 82 percent.
The Department of Health and Human Services appears to be turning to brokers to fill this gap. It announced in late October that the federal online marketplace, healthcare.gov, has a new resource under its "Find Local Help" tab. Consumers can enter their contact information in the "Help On Demand" feature -- and get a call back from a state licensed broker.
It isn't known how many brokers signed up to participate, but agent John Dodd thinks it's a good idea.
"This move of working more with brokers will help make up some of the difference (from losing the navigator program), although anytime you remove help, that's not a positive step," said Dodd, president-elect of the Ohio Association of Health Underwriters and owner of his own agency in Westerville.
But growing pressure on brokers -- from smaller commissions to increased complexity of the health offerings -- means they may be harder to find.
Last year, several big Blue Cross Blue Shield insurers cut or reduced their commissions, citing it as a cost-cutting move, following a similar action in 2015 by UnitedHealthcare. Some brokers then began charging a fee to help people enroll, while others stopped entirely.
When insurers pay commissions, the amounts are included in premiums and can be between 2 and 5 percent, depending on the carrier.
This year, "I'm still going to help my clients, but I'm not doing direct enrollments," said Nathans. He will refer customers who need this assistance to a colleague.
There are reasons why the enrollment process is a heavy lift.
Licensed insurance broker John Jaggi of Forsyth, Ill., said he and his daughter, Anne Petri, also a broker, often spend the first 35 minutes of appointments just helping clients figure out the math to determine if they can get a premium subsidy. People who qualify earn less than 400 percent of the federal poverty level ($48,240 for an individual) and don't have other coverage.
By that point, clients are exhausted and don't even want to talk about the details of the plan, Jaggi said. And he's paid "almost nothing" for his efforts.
Still, Jaggi and Petri plan to continue helping individuals with this year's enrollment.
A Trump administration decision in October likely has created even more demand for these services. President Donald Trump said then that he was stopping federal "cost-sharing reduction" payments to insurers. These payments were used to offset the costs of coverage for certain low-income policyholders by reducing their deductibles and copayments.
Even without the federal assistance, insurers are still required to provide these cost reductions. To make up for them, insurers boosted premiums, particularly in middle-level "silver" plans. Because the cost of these plans is also the benchmark used to set the tax-credit subsidy many people receive to help pay their premiums, eligible consumers will likely receive more federal assistance this year and have more affordable options from which to choose.
In other words, people who receive the tax credits are not likely to feel a financial pinch. People who don't, though, will likely take a hit.
"You have to feel bad for them," said Petri. "How can they afford another $100 to $200 a month in premium?"
The individual market has always been volatile, but brokers say the situation is bad this year.
Dodd, the Westerville, Ohio-based broker, said he hopes Congress acts to stabilize the market. And soon.
Without that, "2019 could be Armageddon, off-the-charts bad," he said.
(Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.)
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