Cindy Purvance of Park City, Utah, was incensed when she received a letter in the mail alerting her that her family's health insurance premium would skyrocket to $1,300 a month next year — a $500 increase.
Purvance vented on social media, called her insurance company and eventually consulted with an expert who helps people sign up for health plans. She learned something counterintuitive: She would probably see a smaller increase if she bought the same kind of plan she currently has — but off the Affordable Care Act exchange.
"We're in no man's land," said Purvance, 44, who makes too much money to qualify for federal assistance. "You know how it is with health insurance — it's so confusing. It becomes this game of: Which plan can I find that most of my doctors are on, and how much am I going to have to give up?"
Shopping for health insurance has always been confusing. But consumers looking for coverage at the start of open enrollment on Wednesday face an especially baffling experience, and this year, they will have less time and less help to reach a decision because of funding cuts and rule changes.
Insurance exchanges already battered by years of premium increases and insurer exits were thrown into further disarray by President Trump's decision this month to end federal payments that insurers use to offset discounted health plans for lower-income Americans. Insurance companies have tried to make up the difference for those payments in ways that vary state to state and insurer by insurer — and are often baffling to the ordinary consumer.
In some states, such as Maryland and Utah, insurance companies are loading increases onto silver on-exchange plans only. Other states are spreading the increases more broadly.
"We call it an 'Alice in Wonderland' year, because things are upside down, things are very different," said Jason Stevenson, education and communications director at the nonpartisan Utah Health Policy Project, which helps Utahans access health insurance. "They're not following the normal laws of insurance physics."
Silver plans — mid-level plans that aren't too expensive or too bare-bones — will see big premium hikes in many states as insurance companies try to compensate for the loss of federal subsidies that helped underwrite those plans. In some cases, that could make silver plans more expensive even than gold plans, which provide more generous coverage.
People like the Purvances who pay full price for their insurance will likely be unable to avoid paying more for their plans — which could discourage people from signing up. Robert Laszewski, a health policy consultant, said that insurance companies expect 20 percent of those who pay full price for their coverage to leave the market over the next year. One carrier described the situation to him in stark terms: "Our unsubsidized market is melting."
Meanwhile, the lower-income Americans who would seem to be most at risk from Trump's decision to end the federal payments to insurers will largely be sheltered from paying more. They may even be able to pay very low premiums for minimal plans next year because of a second kind of federal subsidy, premium tax credits.
But while $0 premiums may seem great, the plans typically carry giant deductibles that could catch people by surprise — and be far worse than their current coverage.
And there won't be simple, universal rules of thumb because the effects will vary state by state and insurer by insurer.
"For those who thought it was a story when, several years ago, there were start-up difficulties with the website, that's nothing compared with what we're going to see," said M. Gregg Bloche, a law professor at Georgetown University. "How can there not be chaos?"
Some of those most caught up in the confusion will be people like the Purvances, who pay full freight for their insurance. About 6.7 million Americans buy plans that comply with the Affordable Care Act without subsidies, and many of them will confront situations where the mid-level plans could be more expensive than more generous ones. They also may need to pay attention to whether they're buying on the marketplace or off, because prices could vary.
In Utah, where insurers made up the difference from losing cost-sharing reductions by increasing premiums for silver plans, people like the Purvances will need to comparison shop.
Premiums for a silver plan sold on the exchange in Utah will increase by 55 percent on average, while a silver plan sold off the exchange will increase by 23 percent, according to Tanji Northrup, the assistant insurance commissioner in the state.
"Everyone really does need to get out and shop around," Northrup said. "We have that same message every year, but it's so crucial in Utah's market for 2018 plans."
That's what Purvance plans to do. When Wednesday comes, she will look for a better deal, whether it is the same kind of plan she has now off-exchange or another one.
Purvance and her husband realize they are in a good position, relatively speaking. They are both healthy, with years of experience in buying individual insurance and grateful for the Affordable Care Act after being denied coverage for minor preexisting conditions in the past. But she's worried about whether others will get discouraged and give up when they see an outrageous price.
Just as shopping for a plan is about to get a lot more confusing, federal funds that help support "navigators" — groups that help people through the process — have been slashed.
Typically, Stevenson's organization, the Utah Health Policy Project, focuses on helping underserved Utahans sign up for insurance — lower-income people who may not have email accounts or speak English. This year, Stevenson thinks more people than ever — at all income levels — will need help. Meanwhile, the navigator funding for Take Care Utah, a network of nonprofits and brokers focused on helping people sign up, has been slashed from $740,000 last year to $290,000 for open enrollment in 2018.
Facing little help and the constant pronouncements that "Obamacare is dead" from Trump, some people might simply go without health insurance. Others may be discouraged by the attention to rising premiums. But people eligible for federal assistance in paying their premiums — those who make up to about $97,000 for a family of four — may not realize that their costs are likely to be about the same or even less than this year. Those 8.7 million Americans will also likely receive bigger premium tax credits, which could make shopping more counterintuitive, as Stevenson has found that, at least in Utah, many people will have the option of a $0 premium on a bare-bones plan — which would cover less and require giant deductibles.
Rebecca Yates, an insurance broker and owner of Ark Insurance Solutions in Utah, said that the flash of panic that people get when they receive a letter about their premium increasing happens every year but that this year will be worse.
"Those letters go out, and they are terrifying," Yates said. But because the Trump administration cut the open enrollment period and the resources for signing people up, navigators and brokers won't be able to reach as many people and help them through the process.
Camilla Kragius of Park City did what most experts hope consumers will do when she got a letter saying her premiums would be raised 25 percent next year. She called Yates to ask about options, which were relatively few because she does not qualify for federal assistance.
She was most enthusiastic about a possible way out: Trump's recent executive order to make it easier for associations of small businesses to offer health plans.
Trump's order could loosen the rules to allow small businesses to group together to negotiate health coverage, to avoid some of the Affordable Care Act's requirements.
The 47-year-old entrepreneur, who works as a strategic coach for businesses, realized she hadn't used her health insurance in seven years. Perhaps, she thought, an association of health-minded entrepreneurs could start their own association to buy cheaper plans customized to their needs.
She was disappointed to learn that the changes wouldn't be ready in time for January.
Kragius felt skeptical about the Affordable Care Act from the beginning and is disappointed that a solution won't come soon enough to help her next year.
"The health-care situation needs to be fixed, because we're on a trajectory that is not sustainable, economically," she said. "Someone needs to go in and shake up the whole system."